World Journal of Pediatrics (2019) 15:12–16

https://doi.org/10.1007/s12519-018-0206-y

REVIEW ARTICLE

Complications in children with percutaneous endoscopic gastrostomy

(PEG) placement
Brigitta Balogh1   · Tamás Kovács1 · Amulya Kumar Saxena2

Received: 24 April 2018 / Accepted: 29 October 2018 / Published online: 19 November 2018
© Children’s Hospital, Zhejiang University School of Medicine 2018

Abstract
Introduction  The aim of this study was to analyze the complication rates and mortality in association with different opera-
tive techniques of percutaneous endoscopic gastrostomy (PEG), age, underlying diseases and other risk factors. Moreover,
analysis of the indications of PEG insertion and the underlying comorbidities was also performed.
Methods  This study performs a literature analysis of PEG-related complications in children. Literature was searched on
­PubMed® (1994–2017) using terms “percutaneous endoscopic gastrostomy”, “complications”, “mortality” and “children”.
Results  Eighteen articles with 4631 patients were analyzed. The mean age was 3 years (0–26 years). Operative techniques
were: pull technique in 3507 (75.7%), 1 stage PEG insertion in 449 (9.7%), introducer technique in 435 (9.4%), image-guided
technique in 195 (4.2%) and laparoscopic-assisted PEG in 45 (1.6%). Most frequent indications for PEG insertion were
dysphagia (n = 859, 32.6%), failure to thrive (n = 723, 27.5%) and feeding difficulties (n = 459,17.4%). Minor complications
developed in n1518 patients (33%), including granulation  (n = 478, 10.3%), local infection (n = 384, 8.3%) and leakage
(n = 279, 6%). In 464 (10%) patients, major complications occurred; the most common were systemic infection (n = 163, 3.5%)
and cellulitis (n = 47, 1%). Severe complication like perforation occurred in less than 0.3%. Patients with lethal outcomes
(n = 7, 0.15%) had severe comorbidities; and the cause of mortality was sepsis in all cases. Prematurity or young age did not
affect complication rate. Patients with ventriculoperitoneal (VP) shunt had higher risk of major complications. In high-risk
patients, laparoscopic-assisted PEG insertion had less major and severe complication than traditional pull technique.
Conclusions  PEG is a safe operative technique; although minor complications are relatively common and occur in up to 1/3 of
patients, there is a fairly low rate of severe complications. Two-thirds of PEG patients have at least one comorbidity. Patients
with VP shunt have higher risk of major complications. In high-risk patients, laparoscopic-assisted PEG is recommended.

Keywords  Children · Complications · Percutaneous endoscopic gastrostomy

Introduction

Childhood is a very dynamic period in growth and develop-

ment during which the body needs a lot of different micro-
and macronutrients. Long-term eating disorders, dysphagia,
Electronic supplementary material  The online version of this malabsorption or maldigestion can lead to severe malnu-
article (https​://doi.org/10.1007/s1251​9-018-0206-y) contains trition. Long-term enteral access, such as gastrostomy, is
supplementary material, which is available to authorized users.
indicated if nutritional supplement is needed for longer than
* Brigitta Balogh 4–6 weeks. Percutaneous endoscopic gastrostomy (PEG)
[email protected] was first described in 1980 by Gauderer and this is the glob-
1
ally used technique for permanent enteral feeding in patients
Division of Pediatric Surgery, Department of Pediatrics,
with eating disabilities [1]. Since then, various techniques
University of Szeged, Korányi fasor 14‑15, Szeged 6725,
Hungary for gastrostomy insertion have been developed.
2 In the last three decades, various variants of less invasive
Department of Pediatric Surgery, Chelsea Children’s
Hospital, Chelsea and Westminster NHS Fdn Trust, Imperial PEG techniques have evolved and different techniques have
College London, London, UK different spectrum of outcomes. The rate of complications

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World Journal of Pediatrics (2019) 15:12–16 13

of pediatric PEGs varies widely in the literature, ranging Group-3 uses the introducer technique, when gastric
from 4 to 44% [2]. There is no recent study that analyzes the tube is inserted through a percutaneous puncture to avoid
preoperative risk factors for postoperative short- and long- its passage through the mouth. Long curved needles are
term complications. The aim of this study was to analyze the used for two parallel gastropexy stitches under gastro-
complication rates and mortality in association with different scopic assistance. These stitches provide the fixation of
operative techniques of PEG, age, underlying diseases and the anterior wall of the stomach. The metal trocar designed
other risk factors. Moreover, analysis of the indications of for PEG is inserted through a percutaneous incision. The
PEG insertion and the underlying comorbidities was also sheath is removed and the balloon of the gastric tube is
performed. According to the ESPGHAN (European Society inflated. This technique prevents peristomal infections and
for Pediatric Gastroenterology, Hepatology and Nutrition) pharyngoesophageal tumor implantations [5, 6].
guidelines, the complications were divided into early or late, Group-4 had image-guided PEG insertion using biplane
and minor or major [3]. fluoroscopy. Oral barium sulfate suspension is given to the
patient the night before the procedure for localization of
the colon. Ultrasonography is used for visualization of the
liver. A snare is passed orally and a guide wire is inserted
Methods
in the stomach under fluoroscopic guidance and withdrawn
through the mouth. A snare catheter is pulled in a retro-
Literature was searched on ­PubMed® using terms “percuta-
grade fashion from the abdominal wall to the mouth, and
neous endoscopic gastroscopy”, “children”, “complications”
finally the PEG is pulled down through the esophagus [7].
and “mortality”. Eighteen articles were published between
Laparoscopic assistance is used in Group-5. A scope
1994 and 2017 about the complications of different PEG
is introduced through an umbilical port site. If the stom-
techniques. Altogether, data from 4631 patients were col-
ach is visualized, a 5 mm port is placed in the left upper
lected and analyzed in this study. Surgical techniques were
quadrant. The stomach is grasped with a Babcock forceps
divided into five different groups. Group-1 had the origi-
and pulled up directly to the abdominal wall. A full thick-
nal pull technique, Group-2 had one-stage PEG insertion,
ness gastric traction stitch is performed. After placing two
Group-3 had introducer technique, Group-4 had image-
anchoring fascial sutures and a purse-string suture, the bal-
guided technique and the last group Group-5 had laparo-
loon gastrostomy tube is inserted through a small incision
scopic-assisted PEG insertion.
and the sutures are tied [8, 9].

Surgical techniques

Group-1, the original pull technique described by Gauderer Results

was utilized [1]. In this technique, during gastroscopy a
puncture site is determined above the inflated stomach. The PEG insertions were performed in 4631 patients (2441
correct insertion site is midway between the umbilicus and males, 1945 females and 245 unknown). The median age
the junction of the costal margin and the left mid-clavicular of the patients was 3 years (newborns—26 years). Indi-
line [3]. A needle is inserted followed by a trocar through cations for PEG were reported in 2632 (56.8%) patients.
the abdominal wall into the stomach. While the trocar is Most common indications for gastrostomy were inability
withdrawn, the sheath stays in situ. The guide wire is passed to swallow or dysphagia in 859 (32.6%), failure to thrive
through the sheath and retrieved out through the mouth. The in 723 (27.5%), feeding difficulties in 459 (17.2%), aspira-
gastrostomy tube is looped to the end of the guide wire that tion in 201 (7.63%) and poor weight gain in n = 158 (6%).
is pulled back into and out of the stomach until the bumper (Suppl. Table 1).
comes to lie on the anterior gastric wall. If the tube is in the About 60–70% of the children had at least one comor-
right position, it is cut down and the adapter plug is inserted bidity. A total of 1777 (38.4%) patients had impaired
[4]. neurologic status and 704 (15.2%) had oncologic condi-
Group-2, one-stage PEG button insertions are performed, tions. Metabolic, respiratory, cardiac and neuromuscular
which is a similar procedure to the pull technique described disorders were also common among these patients (Suppl.
by Gauderer except for the final step. The design of the tube Table 2).
allows the button part of the PEG to be hidden inside the Prematurity, thoraco-abdominal deformity, previous
introducer part of the PEG. Once this sheath is peeled off, abdominal surgery, peritoneal dialysis (PD) catheter and
the flanges of the button are deployed and the cap is placed ventriculo-peritoneal (VP) shunt were the most frequently
on it. The second anesthesia for PEG change to PEG button mentioned risk factors for complications during the PEG
can be avoided with this technique [2, 5]. insertion procedure (Suppl. Table 3).

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14 World Journal of Pediatrics (2019) 15:12–16

Complications however, all the patients with lethal outcomes (n = 7) had
severe comorbidities and died due to severe outcomes
Several procedures of PEG insertion techniques exist to of general conditions such as sepsis (n = 6) or cachexia
prevent the higher risk of complications. Among the exam- (n = 1). There was no association between mortality and
ined 4631 patients, 1518 had minor complications. The the operative technique (Suppl. Table 6).
most common minor complications were superficial and of
infectious origin: granulation tissue (n = 478,10.3%), local
infection (n = 384, 8.3%), external leakage (n = 279, 6%) and Laparoscopic versus original pull insertion
skin erosion or erythema (n = 188, 4.1%). Unplanned tube
removal after postoperative period occurred in 65 cases, tube Two studies compared the major complications rate after
migration and obstruction developed in 2%. Less common laparoscopic and original PEG insertion technique in high-
complications are described in Suppl. Table 4. risk patients. All these patients had at least one severe
Major complications developed in 464 (10%) patients. comorbidity; the most important comorbidities were neu-
Almost 50% of the major complications were related to rologic disorders, previous abdominal surgeries, VP shunts
infections. Systemic infections occurred in 163 (3.5%) and PD catheters. There were 541 patients in the original
patients which were treated with intravenous antibiotics. pull technique group and 45 patients in the laparoscopic-
Cellulitis, peritonitis, sepsis or wound dehiscence was assisted group [8]. In the first group, the most common
noticed in 1.5%. Pneumoperitoneum was observed  in 34 major complications were buried bumper, granulation,
(0.7%) patients. Asymptomatic pneumoperitoneum can peritonitis and gastrocolic fistula. Altogether, 12.6% of
occur without intestinal perforation as a result of the pro- the high-risk patients had major complications in the first
cedure; however,esophagus or bowel perforations were group. In the laparoscopic group, only 4.4% patients with
noticed in 13 patients (0.3%). Gastrocolic fistulas were severe comorbidities had major complications. One patient
found in  21 patients (0.45%). Buried bumper, intraab- had peritonitis and one child had gastrocutaneous fistula
dominal bleeding and ileus were detected in 1% (Suppl. after the removal of the PEG. According to this report
Table 5). [8], the complication rate is higher in patients with VP
shunt, hepatomegaly, PD catheter, esophageal stenosis,
Mortality coagulopathy and in infants weighing less than 2 kg. Age,
mental retardation, scoliosis, previous abdominal surgery
Literature was also searched for mortality within few and severe constipation are not risk factors for major com-
weeks of insertion in different insertion techniques; plications (Table 1).

Table 1  Comparison of original and laparoscopic-assisted percutaneous endoscopic gastrostomy (PEG)

Variables Number of patients Comorbidities Complications (n) Conclusions
(n)

Pull technique 541 Neurologic Buried bumper (11) Higher risk of

Oncologic Gastrocolic fistula (8) complications
Gastrointestinal Granulation (8) Significant:
VP shunt Peritonitis (8)  VP shunt
Hepatomegaly Gastrocutan fistula (5) Not significant, but
PD catheter Tube migration (4) higher:
Coagulopathy Infection (4)  Hepatomegaly
Bleeding (3)  PD catheter
Pneumonia (1) Esophageal stenosis
Esophagus perforation (1)  Coagulopathy
Miscellaneous (15)  Infant < 2 kg
Laparoscopic-assisted 45 Neurologic Peritonitis (1) No risks:
PEG VP shunt Gastrocutan fistula (1)  Age < 1 y
Previous abdominal surgery  Mental retardation
Hepatomegaly  Scoliosis
Extreme kyphoscoliosis  Previous surgery
Colon interposition  Constipation
Situs inversus  0% conversion

PD peritoneal dialysis, VP ventriculo-peritoneal

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World Journal of Pediatrics (2019) 15:12–16 15

Discussion [15]. In this method, anesthesia is not required for change or

removal [16]. The introducer technique had the advantage
Percutaneous endoscopic gastrostomy is the most wide- of avoiding the oral passage, so these patients had less peri-
spread technique for enteral feeding of patients with dyspha- stomal infections. Campoli et al. reported 0.2% peristomal
gia, feeding difficulties or nutritional absence. The original infection rate with the introducer technique even without
technique described by Gauderer has many modifications using prophylactic antibiotics [6].
[1]. This study analyzed the risk factors for different minor Two articles compared the outcomes after the original
and major complications. pull technique and laparoscopic-assisted PEG insertion in
high-risk patients. Vervloessem et al. reported 467 patients
(448 PEG, 19 laparoscopic-assisted PEG) with potential
Age, weight and maturity risk factors: age under 1 year, mental retardation, scolio-
sis, esophageal stenosis, hepatomegaly, upper abdominal
According to Szlagtys et al., PEG insertion is advisable as surgery, VP shunt, peritoneal dialysis or coagulopathy [8].
early as possible in patients with feeding disorders even in Normal PEG procedure had 12.6% major complications;
infancy if long-term enteral access is necessary, because however, there were no major complications in the 19 lapa-
better nourished children have less postoperative complica- roscopic-assisted PEG. Only VP shunt was a significant risk
tions [10]. At the time of intervention, younger patients had factor (P = 0.002) for major complications. Hepatomegaly,
lower prevalence of severe malnutrition than older children. coagulopathy, esophageal stenosis and peritoneal dialysis
Early nutritional supplementation is associated with better were possible risk factors; however, the number of patients
outcome [10]. were low. Zamakhshary et al. compared 26 laparoscopic
Young age is often mentioned as risk factor; however, and 93 original PEG procedures in high-risk patients [9]. In
McSweeney et al. found that age younger than 6 months the laparoscopic group, there was one major tube-specific
was significantly protective against major complications complication, a formula drainage around the tube and a non-
[11]. Children weighing < 4 kg had lower risk for major specific complication: a gastrocutaneous fistula. The overall
complications. In the same study, ASA (American Society complication rate was 7.7% in the laparoscopic group and
of Anaesthesiologists) III class had lower complication rate 14% in the standard PEG group with more severe complica-
than in ASAI-II and ASA IV–V groups. These patients were tions, for example transcolonic tube placement, peritonitis
hospitalized before PEG placement and had more intense or disruption of the gastrocutaneous tract. Landish et al.
postoperative monitoring. Lalanne et al. reported higher rate reported that significant major complications included a
of late complications in patients younger than 1 year. More 3.8% incidence of gastrocolic fistula among standard PEGs
than 60% of late complications were granulation tissue, (3.8% vs 0%, P= 0.04) and 7.6% early tube dislodgements
local erythema or leakage [12]. Another study found that among the laparoscopic group (0 vs. 7.6%, P = 0.01) [17].
there was no difference in outcomes in patients < 1 year [11]. According to McSweeney et al., the frequency of complica-
Forty infants with a mean gestational age of 29 weeks were tions decreased after the first year following PEG insertions
treated with PEG. Premature infants had similar minor and [2].
major complication rates as older children [13]. According
to an Italian multicentre study, age was not an independent Comorbidities and risk factors
variable influencing the factor of complications. However,
patients older than 5 years had significantly higher incidence McSweeney et al. found that patients with neurologic dis-
of intraoperative complications [14]. orders had less major complications, because they are usu-
ally hospitalized and are under increased supervision [2].
However, patients with VP shunt have higher risk during
Operative techniques PEG insertion [2]. Patients with VP shunt had a significantly
higher risk (p P = 0.07) for major complications. Oncologic
Nah et al. reported a new technique called image-guided patients without neurologic disorders or with failure to
PEG with easy insertion and avoidance of laparotomy inci- thrive had greater risk for a major complication. Accord-
sion [7]. Ultrasonography and fluoroscopy were used as ing to Fortunato’s data, neurologically impaired patients had
guidance in 331 patients. However, original PEG insertion elevated risk for wound infection; however, this population
had lower overall complication rate than the image-guided demonstrated greater weight gain after the PEG placement
procedure. [18]. Respiratory diseases were association with fewer early
One-step low-profile PEG insertion was used in 45 chil- complications according to Lalanne et al. [12]. Late com-
dren. Almost all patients had an upper gastrointestinal study plications were less frequent in patients with neurological
before the placement to evaluate anatomical abnormalities disorders and more frequent with digestive diseases. Eleven

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16 World Journal of Pediatrics (2019) 15:12–16

pediatric bone marrow-transplanted children were operated endoscopic gastrostomy in children and adolescents. J Pediatr Gas-
with PEG placement. Four patients were neutropenic during troenterol Nutr. 2015;60:131–41.
4. von Schnakenburg C, Feneberg R, Plank C, Zimmering M, Arbeiter
the procedure and all these patients had severe infection after K, Bald M, et al. Percutaneous endoscopic gastrostomy in children
the procedure. According to this study, significant neutro- on peritoneal dialysis. Perit Dial Int. 2006;26:69–77.
penia may be a contraindication for PEG placement [19]. 5. Evans JS, Thorne M, Taufiq S, George DE. Should single-stage
Several risk factors were analyzed for major complica- PEG buttons become the procedure of choice for PEG placement in
children? Gastrointest Endosc. 2006;64:320–4.
tions on 467 patients with PEG procedure. Only VP shunt 6. Campoli PM, Cardoso DM, Turchi MD, Ejima FH, Mota OM.
was found to be a significant risk factor [8]. Hepatomegaly, Assessment of safety and feasibility of a new technical variant of
coagulopathy, esophageal stenosis and peritoneal dialysis gastropexy for percutaneous endoscopic gastrostomy: an experience
were described as possible risk factors; however, age under with 435 cases. BMC Gastroenterol. 2009;9:48.
7. Nah SA, Narayanaswamy B, Eaton S, Coppi PD, Kiely EM, Curry
1 year, mental retardation, scoliosis, constipation and upper JI, et al. Gastrostomy insertion in children: percutaneous endoscopic
abdominal surgery were not related to complication rate. or percutaneous image-guided? J Pediatr Surg. 2010;45:1153–8.
Thoraco-abdominal deformity had a greater incidence of late 8. Vervloessem D, van Leersum F, Boer D, Hop WC, Escher JC, Mad-
complications such as decubitus or leakage [14]. ern GC, et al. Percutaneous endoscopic gastrostomy (PEG) in chil-
dren is not a minor procedure: risk factors for major complications.
Semin Pediatr Surg. 2009;18:93–7.
9. Zamakhshary M, Jamal M, Blair GK, Murphy JJ, Webber EM,
Skarsgard ED. Laparoscopic vs percutaneous endoscopic gastros-
Conclusions tomy tube insertion: a new pediatric gold standard? J Pediatr Surg.
2005;40:859–62.
At least 60–70% of the children with feeding difficulties 10. Szlagatys-Sidorkiewicz A, Borkowska A, Popińska K, Toporowska-
Kowalska E, Grzybowska-Chlebowczyk U, Wernicka A, et al. Com-
such as dysphagia or failure to thrive that qualify for PEG
plications of PEG are not related to age—the result of 10-year mul-
insertions have at least one comorbidity. Parents/caregivers ticenter survey. Adv Med Sci. 2016;61:1–5.
report that the gastrostomy is a great help for themselves and 11. McSweeney ME, Kerr J, Jiang H, Lightdale JR. Risk factors for
their child [20]. PEG is a safe operative technique for enteral complications in infants and children with percutaneous endoscopic
gastrostomy tubes. J Pediatr. 2015;166:1514–9.
feeding, with frequently observed minor complications and a
12. Lalanne A, Gottrand F, Salleron J, Puybasset-Jonquez AL, Guim-
low rate of major complications [21]. Patients with VP shunt ber D, Turck D, et al. Long-term outcome of children receiving
have higher risk of major complications. In case of high-risk percutaneous endoscopic gastrostomy feeding. J Pediatr Gastro-
patients, laparoscopic-assisted PEG is recommended. enterol Nutr. 2014;59:172–6.
13. Minar P, Garland J, Martinez A, Werlin S. Safety of percutaneous
endoscopic gastrostomy in medically complicated infants. J Pediatr
Author contributions  Concept and design: BB, TK, AKS. Acquisition
Gastroenterol Nutr. 2011;53:293–5.
of data, and analysis and interpretation of data: BB. Drafting the article
14. Fascetti-Leon F, Gamba P, Dall’Oglio L, Pane A, dé Angelis GL,
and revising it critically for important intellectual content: BB, TK,
Bizzarri B et al. Complications of percutaneous endoscopic gas-
AKS. Final approval of the version to be published: BB, TK, AKS.
trostomy in children: results of an Italian multicenter observational
study. Dig Liver Dis. 2012;44:655–9.
Funding  No financial or nonfinancial benefits have been received or 15. Pattamanuch N, Novak I, Loizides A, Montalvo A, Thompson J,
will be received from any party related directly or indirectly to the Rivas Y, et al. Single-center experience with 1-step low-profile per-
subject of this article. cutaneous endoscopic gastrostomy in children. J Pediatr Gastroen-
terol Nutr. 2014;58:616–20.
Compliance with ethical standards  16. Jacob A, Delesalle D, Coopman S, Bridenne M, Guimber D, Turck
D, et al. Safety of the one-step percutaneous endoscopic gastrostomy
button in children. J Pediatr. 2015;166:1526–8.
Ethical approval  This article does not contain any studies with human
17. Landisch RM, Colwell RC, Densmore JC. Infant gastrostomy out-
participants performed by any of the authors.
comes: the cost of complications. J Pediatr Surg. 2016;51:1976–82.
18. Fortunato JE, Troy AL, Cuffari C, Davis JE, Loza MJ, Oliva-
Informed consent  For this type of study formal consent is not required.
Hemker M, et al. Outcome after percutaneous endoscopic gastros-
tomy in children and young adults. J Pediatr Gastroenterol Nutr.
2010;50:390–3.
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