Curr Gastroenterol Rep (2011) 13:293–299
DOI 10.1007/s11894-011-0189-5
Outcomes of Percutaneous Endoscopic Gastrostomy
in Children
John E. Fortunato & Carmen Cuffari
Published online: 17 March 2011
# Springer Science+Business Media, LLC 2011
Abstract Percutaneous endoscopic gastrostomy (PEG) is a
relatively safe and minimally invasive surgical method for
providing enteral access in children. In pediatrics, the
indications for PEG placement frequently include malnutri-
tion or failure to thrive, as well as oropharyngeal dysphagia,
especially in children with neurological impairment (NI). The
risk for postoperative complications is low. However, among
children with NI, gastroesophageal reflux disease (GERD)
may necessitate fundoplication prior to gastrostomy tube
placement. Preoperative pH probe testing has not been shown
to be an effective screening tool prior to PEG placement
among patients with GERD. Laparoscopic gastrostomy tube
insertion was introduced in pediatric patients in an attempt to
decrease complications associated with PEG. Although out-
comes were reported to be similar to or better than PEG
alone, future comparative studies are needed to better define
the optimal patient demographic for this technique.
Keywords Percutaneous endoscopic gastrostomy .
Children . Outcomes
C. Cuffari
Department of Pediatrics, Division of Pediatric Gastroenterology
and Nutrition, The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
J. E. Fortunato
Department of Pediatrics,
Division of Pediatric Gastroenterology and Nutrition,
The Wake Forest University School of Medicine,
Winston-Salem, NC, USA
J. E. Fortunato (*)
Department of Pediatrics, Division of Pediatric Gastroenterology
and Nutrition, Wake Forest University School of Medicine,
Medical Center Boulevard,
Winston-Salem, NC 27157, USA
e-mail: jfortuna@wfubmc.edu
Introduction
The enteral route remains the most practical means of
providing nutrition in patients with a functional gastro-
intestinal tract but an inability to take food orally.
Although enteral nutrition can be accomplished simply
by means of either a nasogastric or nasojejunal tube,
these conduits are fraught with an increased risk of
aspiration, displacement, and mechanical failure [1]. In
comparison, percutaneous endoscopic gastrostomy (PEG)
provides enteral access that is much more conducive to
long-term (>3 months) use. Although PEG requires
surgical placement, the procedure is often performed by
the pediatric gastroenterologist, and is considered less
invasive than traditional surgical gastrostomy. Further-
more, the complication rate with PEG is lower (4–13.6%)
than with Stamm gastrostomy (24%) [2–5].
PEG was introduced in 1980, and has become an
effective method to establish gastrostomy tube feeds [6].
It is estimated that 11,000 PEGs are performed annually in
US children [7, 8•]. Historically, most of the early patients
in whom PEG was performed were children with an
inability to swallow. Over time, the indications have
broadened to include patients with oropharyngeal anatomic
abnormalities, as well as malnutrition and feeding problems
related to conditions such as metabolic disorders, cystic
fibrosis, cardiac disease, malignancy, or neurological
impairment (NI) [8•]. The distribution of principal diagno-
ses and indications for PEG placement observed over
11 years at the Johns Hopkins Children’s Center are shown
in Table 1 [8•]. Although most studies have shown that
PEG can be performed safely in the pediatric patient
population, the existence of concurrent pathological gastro-
esophageal reflux (GER), especially among children with
NI, has warranted special consideration.
294
Table 1 Principal diagnoses for
pediatric patients undergoing Diagnosis
percutaneous endoscopic gas-
trostomy at the Johns Hopkins Neurologic impairment
Children’s Center from 1994 Diagnosis not defined
to 2005 Chronic lung disease
Metabolic/genetic syndrome
Cardiac anomalies
Cystic fibrosis
Malignancy
Oropharyngeal anatomic malformation
Superior mesenteric artery syndrome
Chronic vomiting
(Adapted from Fortunato et al. Muscular dystrophy
[8].)
The objective of this review is to examine the global
experience in performing PEGs in the pediatric patient
population. The difference in outcomes between surgical
gastrostomy and PEG also is discussed. This review
addresses the influence of GERD, both preoperatively and
postoperatively, on clinical outcome, and the need for
preoperative diagnostic testing, especially among the
neurologically impaired. Lastly, special consideration is
given to the technical limitations associated with
performing PEGs in infants with significant prematurity
[2–4, 9, 10].
Outcomes of Open Surgical, Percutaneous Radiologic,
Laparoscopic, and PEG
Until the early 1980s, surgically placed feeding tubes were
the only feasible means for feeding patients who could not
maintain adequate oral intake. Since that time, less invasive
methods—including laparoscopically placed gastrostomy,
percutaneous radiologic gastrostomy, and PEG—have been
successfully introduced as alternatives. The best technique
in children remains uncertain.
Compared with PEG, surgical gastrostomy is generally
associated with higher morbidity and mortality in most
adult series [11, 12]. However, some studies do not confirm
these results, demonstrating comparable complication rates
[13]. PEG is faster to perform in most cases, requiring
fewer medical resources, decreased hospitalization time,
and less delay in starting feeds postoperatively [14]. When
separated into minor versus major complications, open
gastrostomy placement appears to be associated mainly
with minor complications (eg, tube leaks and wound
infections), which are less frequent with PEG (43–33%,
respectively), in one series [15]. Major complications were
similar (14–17%, respectively) between open gastrostomy
and PEG. In children, no significant difference was
observed between open gastrostomy and PEG when
Curr Gastroenterol Rep (2011) 13:293–299
No. of patients (% of all diagnoses)
322 (35%)
202 (22%)
152 (16%)
96 (10%)
61 (7%)
35 (4%)
30 (3%)
15 (2%)
6 (<1%)
4 (<1%)
3 (<1%)
comparing cost-effectiveness, indications for gastrostomy
placement, or morbidity [16]. A preoperative diagnosis of
dysphagia may lengthen hospital stay in patients undergo-
ing PEG [8•].
About the same time PEG was first performed, another
method of placing a feeding gastrostomy, known as
percutaneous nonendoscopic or radiological gastrostomy,
was introduced [17]. Radiological gastrostomy has similar
benefits to PEG, including ease of insertion and low major
complication rates, with the advantage of introducing an
uncontaminated catheter through the abdominal wall. In
contrast, radiologically placed tubes were observed to
exhibit higher clogging rates and overall inferior tube
function rates after replacement [15]. In children, major
complications were uncommon in patients undergoing
either radiologic gastrostomy or PEG, but they were more
frequent in the radiological group [18•]. Minor complica-
tions were also significantly higher for radiologically
placed gastrostomies.
The increasing use of laparoscopy to perform surgical
techniques in a less invasive manner has introduced an
alternative for performing gastrostomy without the need for
laparotomy. When conditions such as obstruction of the
upper gastrointestinal tract, prior abdominal surgery, or
anatomic conditions (eg, hepatomegaly) exist, PEG may
not be a feasible option. Although most adult series agree
that laparoscopic gastrostomy placement is a good choice
for patients who are not candidates for PEG, PEG remains
the initial procedure of choice for placement of a gastro-
stomy [14, 19, 20]. For example, Bankhead et al. [14],
when comparing laparoscopic gastrostomy to PEG and
open gastrostomy, showed that laparoscopic gastrostomy
had the highest morbidity of the three techniques.
In pediatric patients, the laparoscopic technique of
gastrostomy tube insertion was used in an attempt to
decrease complications associated with PEG. Laparoscopic
gastrostomy has the advantages of direct visualization of
the tube’s placement into the stomach and of the stomach’s
Curr Gastroenterol Rep (2011) 13:293–299
having been secured to the abdominal wall with sutures in
the event of tube dislodgment [21]. Outcomes were
reported to be similar to that of PEG insertion, with the
exception of an increased rate of hollow organ injury in the
PEG group in one study (3% vs 0%) [22]. In another report,
PEG operative time was shorter than the laparoscopic
approach, with similar intraoperative complication rates,
but was associated with more serious postoperative com-
plications necessitating a higher rate of return to the
operating room for complications (19.4% for PEG vs
8.7% for laparoscopic gastrostomy) [23•]. These complica-
tions included significant stomal problems, intraperitoneal
leak after tube exchange, early tube dislodgement, gastric
separation, late gastrocolonic fistula, gastrocutaneous fistu-
la, colonic perforation, and pneumoperitoneum. The find-
ings in these retrospective studies underscore the need for
well-designed, randomized trials comparing PEG to lapa-
roscopic gastrostomy in pediatric patients matched not only
for age and sex, but also for weight and underlying disease.
Neurological Disorders
Neurological impairment is the most common indication for
PEG in children and adults, because these patients are at
higher risk of becoming chronically malnourished [24, 25].
This situation is likely attributable to decreased oral intake,
possibly from lack of oropharyngeal coordination or
dysphagia. PEG is a feasible option, particularly in the
setting of a multidisciplinary clinic, and was shown to
significantly reduce feeding time, choking events, and
incidence of pulmonary infections in these patients [26,
27]. In several series, mortality and major complications,
such as tract dehiscence, gastrocolonic fistula, volvulus,
peritonitis, or gastrointestinal bleeding, are rare after PEG
in children with NI [8•, 9, 28, 29]. Most minor complica-
tions are related to gastrostomy wound infections, granulo-
mas, or leakage from the tube [27]. Although major
complications do not seem to differ between NI and non-
NI children, those with NI may have a higher incidence of
long-term wound infections [8•]. In NI patients, PEG was
also shown to have favorable outcomes in comparison to
Stamm gastrostomy, with decreased 30-day and 1-year
mortality, need for reoperation for bleeding, and incidence
of fundoplication [30].
Enteral feeding via PEG is an effective means of
improving growth and nutritional status of children with
severe neurological disabilities. Sullivan et al. [31], in a
longitudinal, prospective, multicenter cohort study, demon-
strated significant increases in weight gain in children with
cerebral palsy, with median weight z-scores increasing from
−3 before PEG to −2.2 at 6 months and −1.6 at 12 months.
Nearly all parents also reported a perceived improvement in
295
their child’s health and quality of life after the tube was
placed [32]. However, a follow-up study the following year
examined the relatively low energy expenditure and high
body fat content of children with severe cerebral palsy,
highlighting the potential risk of overfeeding these children
[33]. This finding underscores the critical need for specific
dietary recommendations when considering gastrostomy in
NI patients, and the need for future studies to determine the
most optimal preoperative and postoperative nutritional
assessment.
Gastroesophageal Reflux Disease
The risk of GERD after PEG has been the subject of many
trials and remains controversial. Although a study by
Grunow et al. [34] suggested an increased incidence of
GER after PEG in 6 of 10 patients, based on esophageal pH
monitoring before and after PEG, only one required
fundoplication. Subsequent larger trials have had different
conclusions. A prospective study in 68 patients showed that
pH monitoring after PEG did not differ significantly from
results before PEG, with the exception of PEG tubes placed
in the antrum [35]. The study further described poor
correlation between clinical signs of GER and pH moni-
toring findings. These results are consistent with other
reports suggesting that PEG does not appear to precipitate
GERD [36, 37]. Interestingly, recent data have also raised a
concern regarding the association between a preoperative
history of dysphagia or aspiration on modified barium
swallow study and GERD, with 10.6% and 11.2%,
respectively, of these patients requiring fundoplication after
PEG [8•].
Patients with preexisting GERD or abnormal esophageal
pH study may require special attention, because these
patients may have a less favorable outcome from exacer-
bation of their symptoms after PEG [9, 38]. Sulaeman et al.
[9] showed that among 22 patients with normal preopera-
tive 24-hour pH monitoring, only one later required Nissen
fundoplication, compared to 7 of 24 with abnormal pH
before PEG. In contrast, in a series of 28 patients with an
abnormal pregastrostomy pH study, the majority of subjects
with symptomatic GERD (19 of 25 patients) improved after
PEG alone, which raises questions about the need for
preoperative pH testing and the need for concomitant
antireflux surgery [37].
The patient with NI or cerebral palsy deserves special
consideration because of the frequency of performing PEG
in these children. Increased GER is commonly seen in
patients with NI [39]. The evidence regarding an increase in
GER in children with NI after PEG is mixed: the clinical
severity of reflux was shown to increase in some studies,
but not in others [26, 37, 40, 41]. However, there seems to
296 Curr Gastroenterol Rep (2011) 13:293–299

be agreement that concomitant antireflux surgery should series to date, consisting of 747 patients, immediate postop-
not automatically be performed in these patients, and that erative complications were observed in 4% of patients, and
routine investigation for GER in asymptomatic children included wound infection, pneumoperitoneum, skin necrosis,
should be avoided [41]. Further diagnostic assessment and inability to place PEG, and, most seriously, gastric separation
antireflux surgery should be considered if symptoms (Table 2) [8•]. Postoperative complications noted after
progress after PEG [42]. The discrepancies among studies hospital discharge occurred in 20% of patients and were
underscore the need for future studies to determine both the mostly minor, related to wound infection or granuloma
clinical relevance of pH monitoring before PEG as well as formation. Only one major complication, gastrocolonic
the need for antireflux surgery in both neurologically fistula, occurred [8•]. Other series have reported complica-
normal and NI patients. tions such as gastrocolonic fistula, pneumoperitoneum,
duodenal hematoma, necrotizing fasciitis, gastric perforation,
intestinal obstruction, and catheter migration [2, 3]. Only
PEG in Infants two deaths have been reported, both in patients with
advanced cardiac disease from one pediatric series [2].
Few studies have examined PEG placement in infants [43, These data compare favorably to adult series, in which
44]. Previous guidelines have considered the lower limit of complications were observed in 10% to 15% of patients after
body weight for PEG insertion to be about 10 kg [45]. PEG, with severe complications, often requiring surgical
However, infants weighing between 2.3 and 3.5 kg have intervention, occurring in 3.8% to 5.1% [5, 47, 48].
safely tolerated PEG insertion using the standard pull In the study by Fox et al. [3], acute cellulitis at the
technique [44]. With laparoscopic video-assisted technique gastrostomy site was the most frequent complication after
now well established in pediatric patients, some investi- PEG, occurring in 7.3% of patients (compared to a total
gators have suggested its use for gastrostomy tube complication rate of 12.4%). The use of prophylactic
placement in these small, medically complex infants. A antibiotics has been well described, most recently in a
recent series demonstrated that the procedure was well meta-analysis that included 10 randomized, controlled trials
tolerated in infants less than 1 year of age weighing as little with a pooled total of 1,059 patients [49]. The study
as 2.6 kg, with no reported complications [46]. demonstrated a relative risk reduction of 62% (95% CI: 48–
72%) and absolute risk reduction of 15% (95% CI: 10–
19%) with the use of prophylactic antibiotics. Patients who
Complications received penicillin-based prophylaxis had similar rates of
wound infections compared to those receiving
Although PEG tube insertion is generally a safe procedure, cephalosporin-based prophylaxis. In addition, administra-
major and minor complications have been reported, with a tion of three versus one antibiotic dose did not result in
variable incidence in published pediatric series. In the largest further reducing the risk of infection. Current guidelines for
Table 2 Complications ob-
served in the immediate postop- Immediate postoperative complications No. of complications in 747 patients
erative period after percutaneous Major
endoscopic gastrostomy and af- Gastric separation 1
ter discharge in pediatric
Minor
patients at the Johns Hopkins
Children’s Center from 1994 to Wound infection 19
2005 Pneumoperitoneum 4
Skin necrosis 2
Technical inability to place percutaneous endoscopic gastrostomy 2
Postoperative complications after hospital discharge No. of complications in 682 patients
Major
Gastrocolonic fistula 1
Minor
Granuloma 69
Wound infection 63
Pressure necrosis 9
Wound infection and granuloma 8
Wound infection and necrosis 1
(Adapted from Fortunato et al. Granuloma and necrosis 1
[8].)
Curr Gastroenterol Rep (2011) 13:293–299
PEG insertion in children similarly recommend the use of
prophylactic antibiotics [50, 51]. The efficacy of single
dose versus multiple doses of antibiotics before PEG is not
clear. A recent prospective study using intravenous cef-
triaxone suggested that a single dose of antibiotic prophy-
laxis was just as effective as 48-hour prophylaxis using
multiple doses [52].
The influence of preoperative clinical factors on the risk
for complications after PEG is not entirely clear. This is
likely due in part to the heterogeneity of patient populations
among medical centers performing PEG, as well as to the
number of cases and experience of the gastroenterologist. In
children, preoperative conditions such as multisystem organ
failure, malignancy, NI, and AIDS have been shown to
increase the risk for complications after PEG in some
reports, regardless of age, weight, or nutritional status [3,
53, 54]. In the larger series, preoperative diagnosis,
indication for PEG (including failure to thrive, dysphagia,
insufficient oral intake, and medication access), prematuri-
ty, or NI did not influence postoperative complications.
However, preoperative dysphagia and aspiration identified
on modified barium swallow study and younger patient age
were associated with the need for PEG conversion to
fundoplication with gastrostomy [8•].
Conclusions
PEG is a relatively safe and minimally invasive method to
provide enteral feeding access in most children, and is
associated with minimal complications in most patients.
The indications for PEG placement are broad, but frequent-
ly include malnutrition or failure to thrive, as well as
dysphagia. Little evidence exists to suggest that PEG
precipitates GERD, but its impact on preexisting reflux
symptoms remains unclear. Although esophageal pH
monitoring may better quantify the degree of reflux in
patients than reported GER symptoms, its preoperative role
before gastrostomy tube placement is not well defined.
Because NI is the most common indication for PEG in
children and adults, these patients require special attention
before and after PEG placement. Although PEG is feasible
in these patients, particularly after a multidisciplinary team
evaluation, these patients often have a high incidence of
GERD, which may not be detected preoperatively. Al-
though concomitant fundoplication and gastrostomy are
generally not indicated initially in these patients, further
diagnostic assessment and antireflux surgery should be
considered if reflux symptoms progress after PEG. Finally,
the advent of minimally invasive laparoscopic surgery in
pediatric patients raises the question of what should be
considered the ideal method for obtaining enteral access in
children. Complications from laparoscopically placed gas-
297
trostomy tubes are very low when compared to PEG alone.
Future prospective studies are needed to better define the
optimal patient demographic best suited for each technique.
Disclosure Conflicts of interest: J.E. Fortunato—none; C. Cuffari—
none.
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