Assessing Clinical Outcomes Post Modified Laparoscopic Gastrostomy in Children: a Case Control Study

Assessing Clinical Outcomes Post Modified Laparoscopic Gastrostomy in Children: a Case Control Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Assessing Clinical Outcomes Post Modified Laparoscopic Gastrostomy in Children: a Case Control Study Hussein Naji, Aafia Mohammed Farooq Gheewale, Ebtesam Safi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-728208/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Feb, 2022 Read the published version in BMC Surgery → Version 1 posted 15 You are reading this latest preprint version Abstract Background Gastrostomy has become a common surgical procedure within the pediatric population with feeding difficulties and nutritional issues. In the aims of improving clinical outcomes, this research targets to compare the rate of complications of two different laparoscopic techniques of a gastrostomy button placement in a pediatric population: A combination of modified U-stitches and seldinger technique laparoscopic gastrostomy (MLG) versus the standard laparoscopic gastrostomy (LG). Methods Eighty-nine children were recruited for this retrospective case control study that assesses the surgical outcomes of a novel MLG, being the cases to the standard LG in children which are the controls. The main outcome measure is the rate of postoperative complications encompassing dislodgement of gastrostomy button, leak around button, local infection, and development of granulation tissue post-surgery which is compared between the two population groups. Results The p-value of the study was shown to be 0.03 proving a statistical significance between the complication rates. Conclusion As a result, the modified U-stitches laparoscopic gastrostomy has a lower rate of complications in comparison to the standard laparoscopic gastrostomy making it a better technique for gastrostomy placement in children. Surgery General Surgery Laparoscopic gastrostomy Postoperative complications U suture technique Seldinger technique Button Children Figures Figure 1 Figure 2 Background Gastrostomy is a surgical procedure in which a feeding tube or a button is placed through the abdominal wall into the stomach in aims of long term nutritional support or administration of medications [ 1 ]. A gastrostomy is advised in patients that are unable to eat normally, for which the most common reasons are neurological causes, anatomical causes or obstruction of the esophagus. The determining factor of how long one is unable to eat poses different options for the patient; wherein general enteral feeding using a nasogastric tube is recommended when the patient is unable to eat normally for at least 7–14 days. Moreover, if the patient is unable to eat normally for more than 30 days, a gastrostomy as a recommendation goes higher up in the list [ 2 ]. With the advancement of minimal invasive surgeries, newer modifications and techniques have developed including percutaneous endoscopic gastrostomy, percutaneous radiologic gastrostomy and laparoscopic gastrostomies [ 3 ]. While all methods have varying complications, efforts in constantly improving patient outcome are being made. Gastrostomy has become more common and widely accepted over the years in both infants and children. The surgery is done for children with feeding difficulties, malnourishment and other complex medical conditions in which the patient requires long-term enteral nutrition which has its obvious advantages over parenteral nutrition. Percutaneous endoscopic gastrostomy (PEG) was first introduced in the 1980s and quickly gained popularity [ 4 ]. According to the European Society for Clinical Nutrition and Metabolism (ESPEN), gastrostomy tube is indicated in patients who require enteral feeding for more than 2 weeks [ 5 ]. The goal of this is to prevent significant weight loss, nutritional deficiencies, assist with growth in children and improve their quality of life. In addition to PEG and with ongoing advances, LG became more available. It is a minimally invasive procedure where the gastrostomy button can be placed directly (instead of a feeding tube), with shorter hospital stay, quicker recovery and fewer complications [ 3 ]. One meta-analysis study proved that the risk of major complications was higher in PEG than in LG with a 95% confidence interval of 1.90–7.81 and a p value < 0.0002, making it the preferred method for gastrostomy tube placement in children [ 6 ]. In addition, the risk of accidental gastro-enteric fistula development which occurs in 1.27% of PEG is much lower in LG [ 7 ]. The standard laparoscopy technique allows for easy placement of the gastrostomy with direct viewing and manipulation of the stomach yielding a minimized risk of unintentional visceral injury [ 8 ]. Before an LG procedure, the site of the gastrostomy is marked on the left upper quadrant below the costal margin to prevent pressure sores. The peritoneal cavity is opened through a sub-umbilical incision according to Hasson technique. Pneumoperitoneum is achieved by inflating carbon dioxide through the 5-mm umbilical port at a rate of 1-3L/min until an intra-abdominal pressure of 8–10 mmHg is obtained. Abdominal exploration is completed using a 5-mm (30-degree) telescope through the umbilical port. Another 5-mm port is then introduced under direct vision over the designated site for the tube placement. The gastric wall is then grasped with a 5-mm laparoscopic Babcock forceps and brought through the port site while simultaneously removing the trocar and decreasing the pneumoperitoneal pressure to 0 mmHg. Once exteriorized, the gastric wall is fixed to the anterior abdominal fascia with four sutures. The incision is sometimes enlarged up to an additional 1cm for placement of the sutures. A gastrostomy is opened at the center of the sutures by diathermy. A balloon gastrostomy button is then inserted over a probe. Pneumoperitoneum (10 mmHg) is recreated for control of the location of the button and the stomach. While all methods have varying complications, efforts in constantly improving patient outcomes are being made. In line with the continued regard towards improvement, a novel technique was introduced in our pediatric surgery department with a modified U-stitches laparoscopic gastrostomy. This modification consists of a combination of hidden U-stitches placed under direct vision of laparoscopy to anchor the stomach to the abdominal wall and using Seldinger technique to insert the gastrostomy button. The aim of this research is to compare the rate of complications of two different laparoscopic techniques of a gastrostomy button placement in a pediatric population: A combination of modified U-stitches and Seldinger technique laparoscopic gastrostomy versus the standard laparoscopic gastrostomy. The modified U-stitches technique applied to laparoscopic gastrostomy is expected to yield a decreased number of complications in comparison to the standard laparoscopic gastrostomy in children. Methods Operative technique/Procedure MLG Patient is positioned supine on the surgical table under anesthesia. A 5 mm camera port is used to access the peritoneum according to Hasson technique through a subumbilical incision. A 3-mm laparoscopic grasper is introduced directly in the upper left quadrant (between the umbilicus and the costal margin). The anterior wall of the stomach is grasped near the greater curvature away from the pylorus to avoid any gastric outlet obstruction. A 2:0 Vicryl (½ circle Taper Point Plus 44mm Needle) is used to place an anchoring U-stitch through the abdominal wall and then through the full thickness of the gastric wall under direct vision with laparoscopic guidance and lastly going outside through the abdominal wall. This U stitch is placed medial to the position of the grasper. Another U stitch is going to be placed in the same way but lateral to the position of the grasper. The grasper is then removed while the stomach is anchored by the 2 U stitches. A puncture needle (18-G) is inserted between the U stitches through the same opening on the abdominal wall that was used for the grasper and then pushed under direct laparoscopic vision through the gastric wall to the stomach (Fig. 1 a- 1 b). A guide-wire is then introduced through the puncture needle to the stomach. The needle is removed leaving only the guide-wire in place (Figs. 1 c- 1 e). A telescoping dilator with a built-in peel-way external sheath is slowly introduced over the guide-wire (according to Seldinger technique) in a step-by-step telescoping manner (Figs. 1 f- 1 h). After sufficient dilation, the dilator is removed and an over-the-wire stoma measuring device was inserted to determine the appropriate length of the gastrostomy button to be placed. Next, the dilator is reinserted and the peel-away external sheath is introduced into the gastric lumen. The dilator is then removed, leaving only the external sheath with the guide-wire in place. A suitable size balloon gastrostomy button with an appropriate length shaft is inserted into the external sheath over the guide-wire and the external sheath is slowly peeled off. The guide-wire is removed to leave only the gastrostomy button in place (Figs. 1 i- 1 j). Each U stitch is tied subcutaneously after pulling its 2 arms by a Mosquito artery forceps introduced in the subcutaneous space. The 2 U stitches will ensure fixation of the stomach to the abdominal wall while the button’s balloon will secure the button in its place and prevent its dislodgement. Data collection The study was approved by the Mediclinic Middle East Research and Ethics Committee (MCME.CR 161. MPAR. 2020) and Dubai Scientific Research Ethics Committee (DSREC), DHA (DSREC-01/2021_19). This is a retrospective analysis where data collected from the electronic medical records of all children who underwent laparoscopic gastrostomy button placement in a period of 8 years. The patients were divided into 2 groups depending on the type of surgical procedure. The first group (cases) consisted of 48 patients who were operated with the newly introduced modified laparoscopic gastrostomy (MLG) by integrating the hidden U stitches and Seldinger techniques for placement of the button. The second group (control) consisted of 41 patients who were operated with the standard laparoscopic gastrostomy button placement (LG). The demographic data (age, sex and weight of patients were studied together with indications for gastrostomy, comorbidities, operative time and post-operative complications including leakage, infection, granuloma formation and dislodgment of the button. The two groups were followed up for a period of one year (at 1, 6 and 12 months). Inclusion criteria: All children who underwent a laparoscopic gastrostomy tube placement in our pediatric surgery department during the study period were included. Exclusion criteria: Children who underwent placement of gastrostomy button or tube via an open surgical method or PEG. Children who needed a concomitant operation (like fundoplication) at the time of laparoscopic gastrostomy tube placement. Two patients who underwent a LG but failed to attend during the follow up as they left the country for good during the follow up period (after 3 weeks and 6 weeks following the surgery). Statistical Analysis Statistical analysis was conducted using Microsoft Excel. Our null hypothesis of this study is that there is no difference in complications between the two surgical techniques. The two variables consisted of the two surgical techniques under which five complications were compared. The complications described were dislodgement of button, leak around button, redness and discharge around the button, local infection that required admission, and development of granulation tissue as is shown in Table 2 . Percentages were yielded for each complication that reflects its rate for each surgical technique. With the application of data analysis on Microsoft Excel, we were able to find the p-value by using each variable on the x and y-axis separately. The modified U-stitches LG was inserted into the Y input range while the LG was inserted into the X input range. By using the t-test and Mann-Whitney test, the p-value as a result, is 0.03 which rejects the null hypothesis proving a statistical significance to the study. Furthermore, the standard error is 0.07 which positively reflects on the sample population of this study, denoting a more accurate representation of the wider population. Results A total number of 89 children were enrolled in the study. The median age was 1.5 years (ranged between 1 month to 17 years), with no major intraoperative complications. There were no procedure related deaths nor was there any necessity to switch to open surgery. The median operating time was 55 minutes for the LG and 56 minutes for the MLG as shown in Table 1 . The postoperative complications are summarized in Table 2 with the most common complication for both procedures being formation of granulation tissue as seen in 15 patients (31%) in group one versus 12 patients (29%) in group two. Leakage around the button was markedly less in the second group (4% versus 15 %). The overall rate of complications however was still less with the MLG group. This is proven with the p-value 0.03 (<0.5) resulting in a significant difference. While the study stands internally valid to its sample population, it also is externally valid with the evidence of a low standard error (0.07), denoting a close relationship between the sample and wider population. Table 1 Age of patients and the median operating time. Laparoscopic Gastrostomy (LG) Modified U-stitches LG No. of patients 41 48 Median age 1.5 years (range 1 month-17 years 1.5 years (range 1 month-14 years) Median operating time 55 minutes (range 46–94) 56 minutes (range 3-112) Controls: patients undergoing the standard laparoscopic gastrostomy Cases: patients undergoing the modified U stitch LG. Table 2 Summary of the postoperative complications of the two different procedures Complications Laparoscopic Gastrostomy (LG) Modified U-stitches LG Number of patients 41 48 Dislodgment of button 2 (5%) 1 (2%) Leak around button 6 (15%) 2 (4%) Redness and discharge 8 (20%) 12 (25%) Development of granulation tissue 12 (29%) 15 (31%) Local infection that required admission 2 (5%) 2 (4%) Discussion Laparoscopic gastrostomy has many overall advantages for children who require long-term enteral nutrition. The surgeon has a better visual field thereby lowering the risk of perforation of hollow viscous and vascular injury. Laparoscopic visualization avoids accidental gastro-enteric fistula formation which is encountered in 1.27% of PEG [ 7 ]. Placement of a button directly is very helpful to the patient and much easier to handle than tube gastrostomy. The rate of postoperative complications were significantly less in the MLG group particularly leakage around the button and dislodgment of the button making this modified technique an enhanced surgical option for gastrostomy placement. The U sutures fixate the stomach to the abdominal wall in an efficient way with minimal handling of the gastric tissue as the stomach remained inside the abdomen all the time and never needed to be exteriorized. The same stitches will be buried under the subcutaneous tissues later on giving wonderful cosmetic results; particularly with the use of a 3 mm incision on the abdominal wall and then introducing the dilators according to Seldinger technique with minimal damage to the tissues. This soft handling of tissues and small incision is the reason for reduction of leakage around the button. This modified technique of gastrostomy is simple, effective and takes approximately the same operative time as the standard surgery. Improving quality of life after surgeries is an ongoing goal for surgeons; hence placement of the button directly with minimal complication rate and providing a good cosmetic result is giving an advantage of MLG over the standard LG. Conclusions MLG is a less invasive surgical procedure compared to the standard LG with a significant decrease in post-operative complications in the studied sample. The modified laparoscopic gastrostomy technique (MLG); a combination of U stitches and Seldinger technique, used in this study is safe and has proven to be advantageous in terms of excellent fixation of the stomach to the abdominal wall with minimal handling of stomach and favorable cosmetic results. Abbreviations MLG: Modified U-stitches and seldinger technique laparoscopic gastrostomy LG: laparoscopic gastrostomy PEG: Percutaneous endoscopic gastrostomy ESPEN: European Society for Clinical Nutrition and Metabolism Declarations Ethics approval and consent to participate Individual patient consent was waived due to the study being a retrospective study. The study was approved by the DHA (CP_7.1.02_F02) and MCME ethical committee (MCME. R 161. MPAR. 2020) Regional Ethics Review Board (reference No. 2011/1234-31/4). All patient information will remain anonymous hence this study doesn’t pose any serious ethical considerations. Consent for publication Individual patient consent was waived due to the study being a retrospective study Availability of Data and Materials Due to patient confidentiality, data is not publicly available Competing Interests The authors declare no conflict of interest. Funding This research received no external funding. Author Contributions Conceptualization, H.N.; methodology, HN, A and E.; validation, H.N.; formal analysis, A and E. and H.N.; data curation A and E. and H.N.; writing—original draft preparation, A and E and H.N.; writing—review and editing, A and E. and H.N.; supervision, H.N.; All authors have read and agreed to the published version of the manuscript.” Acknowledgements Not applicable References Merli L, De Marco E, Fedele C, Mason E, Taddei A, Paradiso F et al. Gastrostomy Placement in Children: Percutaneous Endoscopic Gastrostomy or Laparoscopic Gastrostomy?. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques [Internet]. 2016 [cited 7 June 2021];26(5):381-384. Available from: https://journals.lww.com/surgical-laparoscopy/Fulltext/2016/10000/Gastrostomy_Placement_in_Children__Percutaneous.8.aspx Lo¨ser C, Aschl G, He´buterne X, Mathus-Vliegen E, Muscaritoli M, Niv Y et al. Consensus Statement; ESPEN guidelines on Artificial enteral nutrition - percutaneous endoscopic gastrostomy (PEG). Clinical Nutrition [Internet]. 2005 [cited 7 June 2021];24(5):848-861. Available from: https://www.clinicalnutritionjournal.com/article/S0261-5614(05)00106-8/pdf McSweeney M, Smithers C. Advances in Pediatric Gastrostomy Placement. Gastrointestinal Endoscopy Clinics of North America [Internet]. 2016 [cited 7 June 2021];26(1):169-185. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1052515715000902?via%3Dihub Glasson E, Wong K, Leonard H, Forbes D, Ravikumara M, Mews C et al. Evolving Trends of Gastrostomy Insertion Within a Pediatric Population. Journal of Pediatric Gastroenterology & Nutrition [Internet]. 2018 [cited 7 June 2021];67(5):e89-e94. Available from: https://journals.lww.com/jpgn/Fulltext/2018/11000/Evolving_Trends_of_Gastrostomy_Insertion_Within_a.9.aspx Rahnemai-Azar A, Rahnemaiazar A, Nagshizadian R, Kurtz A, Farkas D. Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World Journal of Gastroenterology [Internet]. 2014;20(24):7739. Available from: https://www.wjgnet.com/1007-9327/full/v20/i24/7739.htm Sandberg F, Viktorsdóttir M, Salö M, Stenström P, Arnbjörnsson E. Comparison of major complications in children after laparoscopy-assisted gastrostomy and percutaneous endoscopic gastrostomy placement: a meta-analysis. Pediatric Surgery International [Internet]. 2018 [cited 7 June 2021];34(12):1321-1327. Available from: https://link.springer.com/article/10.1007/s00383-018-4358-6 Lantz M, Hultin Larsson H, Arnbjörnsson E. Literature Review Comparing Laparoscopic and Percutaneous Endoscopic Gastrostomies in a Pediatric Population. International Journal of Pediatrics [Internet]. 2010;2010:1-4. Available from: https://www.hindawi.com/journals/ijpedi/2010/507616/ Jones V, La Hei E, Shun A. Laparoscopic gastrostomy: the preferred method of gastrostomy in children. Pediatric Surgery International [Internet]. 2007;23(11):1085-1089. Available from: https://link.springer.com/article/10.1007%2Fs00383-007-2015-6 Cite Share Download PDF Status: Published Journal Publication published 21 Feb, 2022 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Major revision 16 Nov, 2021 Review # 4 received at journal 08 Nov, 2021 Review # 3 received at journal 03 Nov, 2021 Reviewer # 5 agreed at journal 24 Oct, 2021 Reviewer # 4 agreed at journal 24 Oct, 2021 Reviewer # 3 agreed at journal 23 Oct, 2021 Review # 2 received at journal 22 Oct, 2021 Review # 1 received at journal 22 Oct, 2021 Reviewer # 2 agreed at journal 09 Oct, 2021 Reviewer # 1 agreed at journal 18 Sep, 2021 Reviewers invited by journal 15 Sep, 2021 Editor assigned by journal 12 Sep, 2021 Submission checks completed at journal 17 Jul, 2021 Editor invited by journal 11 Jul, 2021 First submitted to journal 06 Jun, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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A gastrostomy is advised in patients that are unable to eat normally, for which the most common reasons are neurological causes, anatomical causes or obstruction of the esophagus. The determining factor of how long one is unable to eat poses different options for the patient; wherein general enteral feeding using a nasogastric tube is recommended when the patient is unable to eat normally for at least 7\u0026ndash;14 days. Moreover, if the patient is unable to eat normally for more than 30 days, a gastrostomy as a recommendation goes higher up in the list [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith the advancement of minimal invasive surgeries, newer modifications and techniques have developed including percutaneous endoscopic gastrostomy, percutaneous radiologic gastrostomy and laparoscopic gastrostomies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While all methods have varying complications, efforts in constantly improving patient outcome are being made.\u003c/p\u003e \u003cp\u003eGastrostomy has become more common and widely accepted over the years in both infants and children. The surgery is done for children with feeding difficulties, malnourishment and other complex medical conditions in which the patient requires long-term enteral nutrition which has its obvious advantages over parenteral nutrition. Percutaneous endoscopic gastrostomy (PEG) was first introduced in the 1980s and quickly gained popularity [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. According to the European Society for Clinical Nutrition and Metabolism (ESPEN), gastrostomy tube is indicated in patients who require enteral feeding for more than 2 weeks [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The goal of this is to prevent significant weight loss, nutritional deficiencies, assist with growth in children and improve their quality of life.\u003c/p\u003e \u003cp\u003eIn addition to PEG and with ongoing advances, LG became more available. It is a minimally invasive procedure where the gastrostomy button can be placed directly (instead of a feeding tube), with shorter hospital stay, quicker recovery and fewer complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. One meta-analysis study proved that the risk of major complications was higher in PEG than in LG with a 95% confidence interval of 1.90\u0026ndash;7.81 and a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.0002, making it the preferred method for gastrostomy tube placement in children [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In addition, the risk of accidental gastro-enteric fistula development which occurs in 1.27% of PEG is much lower in LG [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe standard laparoscopy technique allows for easy placement of the gastrostomy with direct viewing and manipulation of the stomach yielding a minimized risk of unintentional visceral injury [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Before an LG procedure, the site of the gastrostomy is marked on the left upper quadrant below the costal margin to prevent pressure sores. The peritoneal cavity is opened through a sub-umbilical incision according to Hasson technique. Pneumoperitoneum is achieved by inflating carbon dioxide through the 5-mm umbilical port at a rate of 1-3L/min until an intra-abdominal pressure of 8\u0026ndash;10 mmHg is obtained. Abdominal exploration is completed using a 5-mm (30-degree) telescope through the umbilical port. Another 5-mm port is then introduced under direct vision over the designated site for the tube placement. The gastric wall is then grasped with a 5-mm laparoscopic Babcock forceps and brought through the port site while simultaneously removing the trocar and decreasing the pneumoperitoneal pressure to 0 mmHg. Once exteriorized, the gastric wall is fixed to the anterior abdominal fascia with four sutures. The incision is sometimes enlarged up to an additional 1cm for placement of the sutures. A gastrostomy is opened at the center of the sutures by diathermy. A balloon gastrostomy button is then inserted over a probe. Pneumoperitoneum (10 mmHg) is recreated for control of the location of the button and the stomach.\u003c/p\u003e \u003cp\u003eWhile all methods have varying complications, efforts in constantly improving patient outcomes are being made. In line with the continued regard towards improvement, a novel technique was introduced in our pediatric surgery department with a modified U-stitches laparoscopic gastrostomy. This modification consists of a combination of hidden U-stitches placed under direct vision of laparoscopy to anchor the stomach to the abdominal wall and using Seldinger technique to insert the gastrostomy button.\u003c/p\u003e \u003cp\u003eThe aim of this research is to compare the rate of complications of two different laparoscopic techniques of a gastrostomy button placement in a pediatric population: A combination of modified U-stitches and Seldinger technique laparoscopic gastrostomy versus the standard laparoscopic gastrostomy. The modified U-stitches technique applied to laparoscopic gastrostomy is expected to yield a decreased number of complications in comparison to the standard laparoscopic gastrostomy in children.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv class=\"Section2\" id=\"Sec6\"\u003e\n \u003ch2\u003eOperative technique/Procedure MLG\u003c/h2\u003e\n \u003cp\u003ePatient is positioned supine on the surgical table under anesthesia. A 5 mm camera port is used to access the peritoneum according to Hasson technique through a subumbilical incision. A 3-mm laparoscopic grasper is introduced directly in the upper left quadrant (between the umbilicus and the costal margin). The anterior wall of the stomach is grasped near the greater curvature away from the pylorus to avoid any gastric outlet obstruction. A 2:0 Vicryl (\u0026frac12; circle Taper Point Plus 44mm Needle) is used to place an anchoring U-stitch through the abdominal wall and then through the full thickness of the gastric wall under direct vision with laparoscopic guidance and lastly going outside through the abdominal wall. This U stitch is placed medial to the position of the grasper. Another U stitch is going to be placed in the same way but lateral to the position of the grasper. The grasper is then removed while the stomach is anchored by the 2 U stitches. A puncture needle (18-G) is inserted between the U stitches through the same opening on the abdominal wall that was used for the grasper and then pushed under direct laparoscopic vision through the gastric wall to the stomach (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003ea-\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eb). A guide-wire is then introduced through the puncture needle to the stomach. The needle is removed leaving only the guide-wire in place (Figs. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003ec-\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003ee). A telescoping dilator with a built-in peel-way external sheath is slowly introduced over the guide-wire (according to Seldinger technique) in a step-by-step telescoping manner (Figs. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003ef-\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eh). After sufficient dilation, the dilator is removed and an over-the-wire stoma measuring device was inserted to determine the appropriate length of the gastrostomy button to be placed. Next, the dilator is reinserted and the peel-away external sheath is introduced into the gastric lumen. The dilator is then removed, leaving only the external sheath with the guide-wire in place. A suitable size balloon gastrostomy button with an appropriate length shaft is inserted into the external sheath over the guide-wire and the external sheath is slowly peeled off. The guide-wire is removed to leave only the gastrostomy button in place (Figs. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003ei-\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003ej). Each U stitch is tied subcutaneously after pulling its 2 arms by a Mosquito artery forceps introduced in the subcutaneous space. The 2 U stitches will ensure fixation of the stomach to the abdominal wall while the button\u0026rsquo;s balloon will secure the button in its place and prevent its dislodgement.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003ch2\u003eData collection\u003c/h2\u003e\n \u003cp\u003eThe study was approved by the Mediclinic Middle East Research and Ethics Committee (MCME.CR 161. MPAR. 2020) and Dubai Scientific Research Ethics Committee (DSREC), DHA (DSREC-01/2021_19). This is a retrospective analysis where data collected from the electronic medical records of all children who underwent laparoscopic gastrostomy button placement in a period of 8 years. The patients were divided into 2 groups depending on the type of surgical procedure.\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003e\n \u003cp\u003eThe first group (cases) consisted of 48 patients who were operated with the newly introduced modified laparoscopic gastrostomy (MLG) by integrating the hidden U stitches and Seldinger techniques for placement of the button.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eThe second group (control) consisted of 41 patients who were operated with the standard laparoscopic gastrostomy button placement (LG).\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eThe demographic data (age, sex and weight of patients were studied together with indications for gastrostomy, comorbidities, operative time and post-operative complications including leakage, infection, granuloma formation and dislodgment of the button. The two groups were followed up for a period of one year (at 1, 6 and 12 months).\u003c/p\u003e\n \u003cp\u003eInclusion criteria:\u003c/p\u003e\n \u003cp\u003eAll children who underwent a laparoscopic gastrostomy tube placement in our pediatric surgery department during the study period were included.\u003c/p\u003e\n \u003cp\u003eExclusion criteria:\u003c/p\u003e\n \u003col\u003e\n \u003cli\u003e\n \u003cp\u003eChildren who underwent placement of gastrostomy button or tube via an open surgical method or PEG.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eChildren who needed a concomitant operation (like fundoplication) at the time of laparoscopic gastrostomy tube placement.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eTwo patients who underwent a LG but failed to attend during the follow up as they left the country for good during the follow up period (after 3 weeks and 6 weeks following the surgery).\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ol\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eStatistical analysis was conducted using Microsoft Excel. Our null hypothesis of this study is that there is no difference in complications between the two surgical techniques. The two variables consisted of the two surgical techniques under which five complications were compared. The complications described were dislodgement of button, leak around button, redness and discharge around the button, local infection that required admission, and development of granulation tissue as is shown in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Percentages were yielded for each complication that reflects its rate for each surgical technique. With the application of data analysis on Microsoft Excel, we were able to find the p-value by using each variable on the x and y-axis separately. The modified U-stitches LG was inserted into the Y input range while the LG was inserted into the X input range. By using the t-test and Mann-Whitney test, the p-value as a result, is 0.03 which rejects the null hypothesis proving a statistical significance to the study. Furthermore, the standard error is 0.07 which positively reflects on the sample population of this study, denoting a more accurate representation of the wider population.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total number of 89 children were enrolled in the study. The median age was 1.5 years (ranged between 1 month to 17 years), with no major intraoperative complications. There were no procedure related deaths nor was there any necessity to switch to open surgery. The median operating time was 55 minutes for the LG and 56 minutes for the MLG as shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The postoperative complications are summarized in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e with the most common complication for both procedures being formation of granulation tissue as seen in 15 patients (31%) in group one versus 12 patients (29%) in group two. Leakage around the button was markedly less in the second group (4% versus 15 %).\u003c/p\u003e\n\u003cp\u003eThe overall rate of complications however was still less with the MLG group. This is proven with the p-value 0.03 (\u0026lt;0.5) resulting in a significant difference. While the study stands internally valid to its sample population, it also is externally valid with the evidence of a low standard error (0.07), denoting a close relationship between the sample and wider population.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAge of patients and the median operating time.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLaparoscopic Gastrostomy (LG)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eModified U-stitches LG\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo. of patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5 years (range 1 month-17 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5 years (range 1 month-14 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian operating time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 minutes (range 46\u0026ndash;94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56 minutes (range 3-112)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eControls: patients undergoing the standard laparoscopic gastrostomy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCases: patients undergoing the modified U stitch LG.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSummary of the postoperative complications of the two different procedures\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLaparoscopic Gastrostomy (LG)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eModified U-stitches LG\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDislodgment of button\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeak around button\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRedness and discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDevelopment of granulation tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocal infection that required admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eLaparoscopic gastrostomy has many overall advantages for children who require long-term enteral nutrition. The surgeon has a better visual field thereby lowering the risk of perforation of hollow viscous and vascular injury. Laparoscopic visualization avoids accidental gastro-enteric fistula formation which is encountered in 1.27% of PEG [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Placement of a button directly is very helpful to the patient and much easier to handle than tube gastrostomy.\u003c/p\u003e \u003cp\u003eThe rate of postoperative complications were significantly less in the MLG group particularly leakage around the button and dislodgment of the button making this modified technique an enhanced surgical option for gastrostomy placement.\u003c/p\u003e \u003cp\u003eThe U sutures fixate the stomach to the abdominal wall in an efficient way with minimal handling of the gastric tissue as the stomach remained inside the abdomen all the time and never needed to be exteriorized. The same stitches will be buried under the subcutaneous tissues later on giving wonderful cosmetic results; particularly with the use of a 3 mm incision on the abdominal wall and then introducing the dilators according to Seldinger technique with minimal damage to the tissues. This soft handling of tissues and small incision is the reason for reduction of leakage around the button.\u003c/p\u003e \u003cp\u003eThis modified technique of gastrostomy is simple, effective and takes approximately the same operative time as the standard surgery. Improving quality of life after surgeries is an ongoing goal for surgeons; hence placement of the button directly with minimal complication rate and providing a good cosmetic result is giving an advantage of MLG over the standard LG.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eMLG is a less invasive surgical procedure compared to the standard LG with a significant decrease in post-operative complications in the studied sample. The modified laparoscopic gastrostomy technique (MLG); a combination of U stitches and Seldinger technique, used in this study is safe and has proven to be advantageous in terms of excellent fixation of the stomach to the abdominal wall with minimal handling of stomach and favorable cosmetic results.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMLG: Modified U-stitches and seldinger technique laparoscopic gastrostomy\u003c/p\u003e\n\u003cp\u003eLG: laparoscopic gastrostomy\u003c/p\u003e\n\u003cp\u003ePEG: Percutaneous endoscopic gastrostomy\u003c/p\u003e\n\u003cp\u003eESPEN: European Society for Clinical Nutrition and Metabolism\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndividual patient consent was waived due to the study being a retrospective study. The study was approved by the DHA (CP_7.1.02_F02) and MCME ethical committee (MCME. R 161. MPAR. 2020) Regional Ethics Review Board (reference No. 2011/1234-31/4). All patient information will remain anonymous hence this study doesn\u0026rsquo;t pose any serious ethical considerations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndividual patient consent was waived due to the study being a retrospective study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to patient confidentiality, data is not publicly available\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, H.N.; methodology, HN, A and E.; validation, H.N.; formal analysis, A and E. and H.N.; data curation A and E. and H.N.; writing\u0026mdash;original draft preparation, A and E and H.N.; writing\u0026mdash;review and editing, A and E. and H.N.; supervision, H.N.; All authors have read and agreed to the published version of the manuscript.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMerli L, De Marco E, Fedele C, Mason E, Taddei A, Paradiso F et al. Gastrostomy Placement in Children: Percutaneous Endoscopic Gastrostomy or Laparoscopic Gastrostomy?. Surgical Laparoscopy, Endoscopy \u0026amp; Percutaneous Techniques [Internet]. 2016 [cited 7 June 2021];26(5):381-384. Available from:\u0026nbsp;\u003ca href=\"https://journals.lww.com/surgical-laparoscopy/Fulltext/2016/10000/Gastrostomy_Placement_in_Children__Percutaneous.8.aspx\"\u003ehttps://journals.lww.com/surgical-laparoscopy/Fulltext/2016/10000/Gastrostomy_Placement_in_Children__Percutaneous.8.aspx\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLo\u0026uml;ser C, Aschl G, He\u0026acute;buterne X, Mathus-Vliegen E, Muscaritoli M, Niv Y et al. Consensus Statement; ESPEN guidelines on Artificial enteral nutrition - percutaneous endoscopic gastrostomy (PEG). Clinical Nutrition [Internet]. 2005 [cited 7 June 2021];24(5):848-861. Available from:\u0026nbsp;\u003ca href=\"https://www.clinicalnutritionjournal.com/article/S0261-5614(05)00106-8/pdf\"\u003ehttps://www.clinicalnutritionjournal.com/article/S0261-5614(05)00106-8/pdf\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMcSweeney M, Smithers C. Advances in Pediatric Gastrostomy Placement. Gastrointestinal Endoscopy Clinics of North America [Internet]. 2016 [cited 7 June 2021];26(1):169-185. Available from:\u0026nbsp;\u003ca href=\"https://www.sciencedirect.com/science/article/abs/pii/S1052515715000902?via%3Dihub\"\u003ehttps://www.sciencedirect.com/science/article/abs/pii/S1052515715000902?via%3Dihub\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGlasson E, Wong K, Leonard H, Forbes D, Ravikumara M, Mews C et al. Evolving Trends of Gastrostomy Insertion Within a Pediatric Population. Journal of Pediatric Gastroenterology \u0026amp; Nutrition [Internet]. 2018 [cited 7 June 2021];67(5):e89-e94. Available from:\u0026nbsp;\u003ca href=\"https://journals.lww.com/jpgn/Fulltext/2018/11000/Evolving_Trends_of_Gastrostomy_Insertion_Within_a.9.aspx\"\u003ehttps://journals.lww.com/jpgn/Fulltext/2018/11000/Evolving_Trends_of_Gastrostomy_Insertion_Within_a.9.aspx\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRahnemai-Azar A, Rahnemaiazar A, Nagshizadian R, Kurtz A, Farkas D. Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World Journal of Gastroenterology [Internet]. 2014;20(24):7739. Available from:\u0026nbsp;\u003ca href=\"https://www.wjgnet.com/1007-9327/full/v20/i24/7739.htm\"\u003ehttps://www.wjgnet.com/1007-9327/full/v20/i24/7739.htm\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eSandberg F, Viktorsd\u0026oacute;ttir M, Sal\u0026ouml; M, Stenstr\u0026ouml;m P, Arnbj\u0026ouml;rnsson E. Comparison of major complications in children after laparoscopy-assisted gastrostomy and percutaneous endoscopic gastrostomy placement: a meta-analysis. Pediatric Surgery International [Internet]. 2018 [cited 7 June 2021];34(12):1321-1327. Available from:\u0026nbsp;\u003ca href=\"https://link.springer.com/article/10.1007/s00383-018-4358-6\"\u003ehttps://link.springer.com/article/10.1007/s00383-018-4358-6\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eLantz M, Hultin Larsson H, Arnbj\u0026ouml;rnsson E. Literature Review Comparing Laparoscopic and Percutaneous Endoscopic Gastrostomies in a Pediatric Population. International Journal of Pediatrics [Internet]. 2010;2010:1-4. Available from:\u0026nbsp;\u003ca href=\"https://www.hindawi.com/journals/ijpedi/2010/507616/\"\u003ehttps://www.hindawi.com/journals/ijpedi/2010/507616/\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJones V, La Hei E, Shun A. Laparoscopic gastrostomy: the preferred method of gastrostomy in children. Pediatric Surgery International [Internet]. 2007;23(11):1085-1089. Available from:\u0026nbsp;\u003ca href=\"https://link.springer.com/article/10.1007%2Fs00383-007-2015-6\"\u003ehttps://link.springer.com/article/10.1007%2Fs00383-007-2015-6\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopic gastrostomy, Postoperative complications, U suture technique, Seldinger technique, Button, Children","lastPublishedDoi":"10.21203/rs.3.rs-728208/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-728208/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eGastrostomy has become a common surgical procedure within the pediatric population with feeding difficulties and nutritional issues. In the aims of improving clinical outcomes, this research targets to compare the rate of complications of two different laparoscopic techniques of a gastrostomy button placement in a pediatric population: A combination of modified U-stitches and seldinger technique laparoscopic gastrostomy (MLG) versus the standard laparoscopic gastrostomy (LG).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eEighty-nine children were recruited for this\u003cstrong\u003e \u003c/strong\u003eretrospective case control study that assesses the surgical outcomes of a novel MLG, being the cases to the standard LG in children which are the controls. The main outcome measure is the rate of postoperative complications encompassing dislodgement of gastrostomy button, leak around button, local infection, and development of granulation tissue post-surgery which is compared between the two population groups.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe p-value of the study was shown to be 0.03 proving a statistical significance between the complication rates. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAs a result, the modified U-stitches laparoscopic gastrostomy has a lower rate of complications in comparison to the standard laparoscopic gastrostomy making it a better technique for gastrostomy placement in children.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Assessing Clinical Outcomes Post Modified Laparoscopic Gastrostomy in Children: a Case Control Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-07-19 17:11:05","doi":"10.21203/rs.3.rs-728208/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-11-17T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-11-09T00:00:00+00:00","index":4,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThe author described a modified laparoscopic gastrostomy in children in a cohort of 48 patients comparing follow up data and complication vs Laparoscopic Gastrostomy (LG). The article is well presented but reading the paper I recalled that the same procedure has been described previously in Pediatr Surg . 2021 Aug;56(8):1317-1321. doi: 10.1016/j.jpedsurg.2021.03.055. Epub 2021 Apr 5. where the author stated in the methods \"LBGs were inserted under direct vision by first placing 2-3 buried sutures between the abdominal wall and stomach and then inserting of the balloon gastrostomy device, either directly or using a Seldinger-type insertion kit into the stomach\". They stated that LBGs was performed in 277 patients Can you please clarified better how your technique is different from the one described in the previous article?* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interest**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2021-11-04T00:00:00+00:00","index":3,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThank you for the opportunity to revise the paper entitled \"Assessing clinical outcomes post modified laparoscopic gastrostomy in children: A case control study \" it is a retrospective case control evaluation of postoperative results of a cohort of pediatric patients submitted to inguinal gastrostomy tube insertion via laparoscopic or modified laparoscopic approach. I would like to congratulate with authors for their results and excellent effort in this analysis. The paper according to MINORS (K. Slim ANZ J Surg . 2003 Sep;73(9):712-6. doi: 10.1046/j.1445-2197.2003.02748.x.) has a score of 14/24. The score is very low since the paper suffers from several bias: 1. the paper has a clear aim (2 point) 2. we are not aware if the patients enrolled are consecutive or not (0 points) 3. Data are not prospectively collected (0 points) 4. The endpoints are insufficiently appropriated to the endpoint (1 points). 5. There are bias on the assesment technique of the endpoint (1 point) 6. The f-up period is well specified for each endpoint, (2 point) 7. It is well stated the loss to f-up rate (2 point) 8. The study size is not prospectively calculated (0 point) 9. The control group could be considered adequate (2 points) 10. The groups are comparable (2 points) 11. There is baseline equivalence of groups (2 points) 12. Statistical analysis could be extensively improved (0 points) Title: The title is informative in relation to the type of article, case control Abstracts: results did not clarify anything and did not contain variables from which you obtain the p value. Background: is very redundant with repetition of information . Methods were clearly stated. The Results: you did not identify variables from which you obtain your results.. Discussion: Must be revised after revision of results . Language: the article needs important refinements by a mother tongue expert In conclusion the paper lacks a robust methodology and is merely a retrospective case series organized by surgical technique, there is no clue of a protocol is just observation, the perioperative results are sufficiently documented) but the statistical analysis cannot show the significance of the results. The results section is redundant and the discussion is poorly oriented on study results explanation, instead largely relies on authors impressions. For those reasons the paper should undergo at least profound revision that still could be insufficient for a final acceptance.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **'I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2021-10-25T01:00:00+00:00","index":5,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-10-25T00:00:00+00:00","index":4,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-10-24T00:00:00+00:00","index":3,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-10-23T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nThe authors report the differences between two different techniques for gastrostomy. Enclosed please find my detailed comments regarding the article. Abstract: AUTHORS: „The p-value of the study was shown to be 0.03 proving a statistical significance between the complication rates.\" REV: This is not an adequate description of your results in the abstract. Even if you like to keep this sentence you would be required to state the type of test and the score you applied. I would like to read some information about the incidence of the different complications you looked for in the two groups here. Please revise. Background: REV: I am unhappy with the jovial way you formulate your sentences here. For instance: \"The determining factor of how long one is unable to eat poses different options for the patient; wherein general enteral feeding using a nasogastric tube is recommended when the patient is unable to eat normally for at least 7-14 days. Moreover, if the patient is unable to eat normally for more than 30 days, a gastrostomy as a recommendation goes higher up in the list [2].\" I would prefer something like: The choice of method for enteral feeding depends on the time of anorexia; while feeding via nasogastric tube is recommended for shorter periods up to 14 days, longer intervals may warrant placement of a gastrostomy.\" AUTHORS: \"Gastrostomy has become more common and widely accepted over the years in both infants and children. The surgery is done for children with feeding difficulties, malnourishment and other complex medical conditions in which the patient requires long-term enteral nutrition which has its obvious advantages over parenteral nutrition.\" REV: Double information - You have already mentioned this a couple of sentences before. AUTHORS: \"…gastrostomy tube is indicated in patients who require enteral feeding for more than 2 weeks…\" REV: See comment above. Methods: REV: You describe the technique for conventional placement twice; once in the background and once in the methods section. Please choose either (I would prefer the background section). REV: I do not understand your study design. You performed a retrospective study but operated the patients with the new technique first and then the \"controls\" with the older technique\"??? If this is a true retrospective study I would expect the old, established method first and then the new one. Please explain! REV: I am unhappy and will not accept your statistics! If you compare complication rates you have to use a statistics program like SPSS, SAS or other. If you are advanced you can enter your data to R. Typically you list the patients with their IDs and a grouping variable. You then list your complications as separate columns. In each column (e.g. spillage, infection, displacement…) a patient can have a result of either 0 (for no complication) or a 1 (complication) - as you cannot have half or almost or something else unless you used a scoring system (I would require you to use a validated scoring though). As this is nominal data a T- Test or Mann-Whitney-U-Test are wrong. You should perform the analysis with the overall complications (any complications or none) and then individually for your sections (dislodgement …). You can compare this kind of data with a Chi-Squared Test. Consequently (nominal, not metric data) it is wrong to calculate a standard error (can be used for normally distributed metric data only!). Please revise statistics and the results and/or consult statistician. REV: As your discussion and conclusion rely on your faulty statistics I would like you to revise these first and then resubmit your paper for further review. Availability of Data and Materials AUTHORS: \"Due to patient confidentiality, data is not publicly available\" REV: I strongly disagree. You can present anonymized data with patient age, gender and an ID. Especially with the faulty statistics you performed I would like to see the data and verify your tests before continuing my review. Figures REV: Figure 1 is blurry - please present acceptable images.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2021-10-23T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reject\nForm responses:\n---\n\nComments to Author:\n---\nThis is a retrospective study comparing outcomes between 2 techniques used for laparoscopic insertion of a gastrostomy tube in pediatric patients. 1) Intro: - description of the actual techniques should be in the methods section - need to check grammar - also should be clear they are describing the technique they use (ie I do not go sub umbilical but go transumbilical and routinely use pressures up to 15, not 8-10 depending on the size of the child), and some people use veress technique with STEP ports. There are many variations. - some people also do not put a full port at the GTube site, but just make a stab incision and pass the instrument into the abdomen directly to keep the defect smaller. - this should say GASTROTOMY is made not Gastrostomy is opened \"A gastrostomy is opened at the center of the sutures by diathermy\" 2) methods: this procedure described is NOT novel and was described many years ago and is standard approach for probably 50% of pediatric surgeons. J Laparoendosc Adv Surg Tech A . 2006 Dec;16(6):643-9. doi: 10.1089/lap.2006.16.643. U-stitch laparoscopic gastrostomy technique has a low rate of complications and allows primary button placement: experience with 461 pediatric procedures Charles J Aprahamian 1, Traci L Morgan, Carroll M Harmon, Keith E Georgeson, Douglas C Barnhart 3) results: when you say enrolled.. did you get consent? or were they selected just by chart review? -table needs massive revision. Should have p values in the table for each complication - no description of which complications actually needed intervention. Many would not describe mild leaking as a complication, but rather something expected. Redness that is not cellulitis and does not require abx is likewise probably not a complication 4) discussion:this technique is already extensively described in the literature and widely used. 5) conclusion: conclusion is definitely too strong based on a small retrospective study.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2021-10-10T00:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-09-19T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-09-16T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-09-13T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-07-17T14:07:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-07-12T00:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2021-06-07T00:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1c229f82-77cb-4de1-9e36-d3118bd6abdc","owner":[],"postedDate":"July 19th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":5827939,"name":"Surgery"},{"id":5827940,"name":"General Surgery"}],"tags":[],"updatedAt":"2022-02-22T09:51:05+00:00","versionOfRecord":{"articleIdentity":"rs-728208","link":"https://doi.org/10.1186/s12893-022-01515-0","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2022-02-21 09:51:05","publishedOnDateReadable":"February 21st, 2022"},"versionCreatedAt":"2021-07-19 17:11:05","video":"","vorDoi":"10.1186/s12893-022-01515-0","vorDoiUrl":"https://doi.org/10.1186/s12893-022-01515-0","workflowStages":[]},"version":"v1","identity":"rs-728208","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-728208","identity":"rs-728208","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}