A gastrostomy tube is used when a nasogastric tube is required for more than 1 month to provide sufficient nutrition when oral feeding is impossible.1 It is already well known that nutrition through gastrostomy tubes improves malnutrition status of children with neurodisabilities or oncologic conditions, has a positive effect on prognosis, and induces longer survival.2 Gastrostomy tube placement can be performed with upper gastrointestinal (UGI) endoscopy or surgical methods. Some centers have implemented radiological methods that use fluoroscopy instead of UGI endoscopy. Recently, pediatric endoscopists in Korea have been performing percutaneous endoscopic gastrostomy (PEG) using UGI endoscopy. In the past, PEG was mainly performed using the pull method, and it was recommended to use it initially. Complications such as infection and dislodgement have been reported to be higher than with the surgical method. Recently, some institutions choose to use the push method in children.34

With the implementation of laparoscopy, the disadvantages of conventional open surgery have greatly improved.5 To date, PEG methods using UGI endoscopes have been recommended as a better way to implement them without complications and are easier than other methods for pediatric gastrostomy tube placement. However, if PEG procedures are difficult due to structural problems of the stomach or if fundoplication is required due to gastroesophageal reflux disease (GERD), a surgical method is required.2 Although various methods for gastrostomy tube replacement such as the pull-method PEG, push-method PEG, open surgery, laparoscopic surgery, and radiological methods have been implemented, large complications are likely associated with the individual characteristics of patients rather than the procedure itself.

In this study, we aimed to investigate the performance status of pediatric PEG in South Korea and to report indications and appropriate methods for domestic situations. We also aimed to compare questionnaire variables according to different groups in order to examine associations between variables.

There are very few endoscopy centers in Korea where pediatric endoscopy is possible. The demand for pediatric gastrostomy is also not high compared to that of adults, but it is an important procedure from the perspective of the nutritional treatment of patients. Through this survey, we observed that although there are not many cases of pediatric gastrostomy in Korea, pediatric PEG and pediatric surgical gastrostomy (SG) are performed to a similar extent. Some centers perform PEG with the help of endoscopists from the Department of Internal Medicine, and very rarely perform gastrostomy by imaging. Gastrostomy can be performed in various ways because there is no treatment method that has enough advantages to give absolute priority. With the development of gastrostomy methods, there are fewer complications, and it can be performed without difficulty with less time and cost. Some studies have reported that gastrostomy was performed safely with the collaboration of endoscopists and surgeons, and that could decrease the risks for each method.6

Gastrostomy was performed using only SG until 1980. PEG was initiated by Ponsky, a surgeon specialized in adults, who developed the pull method. It is referred to as the pull method because the thread from the abdominal skin is removed from the mouth using an endoscope, and the gastrostomy tube is tied and then pulled outward from the abdomen and held in position.7 Although the procedure time is short owing to the simplicity of the method, it cannot be used if the esophagus is narrow because the gastrostomy tube passes through the mouth to the esophagus. In addition, it is associated with a risk of infection. Therefore, if a patient has a narrow esophagus or a high risk of infection, other methods should be considered first.28 In addition, the pull method requires the use of a gastrostomy tube made of a plastic bumper. In this survey, 70.4% of institutions were found to use high-profile plastic-based tubes, where the pull method was performed, and buried bumper syndrome occurred only in institutions using the pull method. Buried bumper syndrome occurs when the bumper digs into the abdominal wall and dislodgement occurs and is thought to be a consequence of the plastic bumper part of the tube rather than the procedure method.3

The push method uses an introducer that performs gastropexy from the abdominal skin and inserts and mounts the gastrostomy tube directly. EGD is performed, but because the gastrostomy tube does not pass through the mouth and esophagus, it can be performed even if the esophagus is narrow, and reduce the risk of infection, compared to the pull method.89 In this study, among the 7 out of 9 institutions that answered that the main method of implementation was the push method using an introducer, 7 institutions used the high-profile balloon-based tube from the time of the procedure, while 2 institutions used the low-profile balloon-based tube from the beginning. Although rare, using a balloon-based tube is more appropriate for preventing buried bumper syndrome.9 Some studies have reported that the bleeding rate is high in the push method, includes procedures such as gastropexy or introducers on the abdomen.10 However, a small-scale study comparing the pull and push methods in adults in Korea reported that there was no significant difference in infection or bleeding, and no buried bumper syndrome was reported.11 Another study comparing outcomes between primary gastrostomy tubes and buttons (G-tube and G-button) in pediatric patients reported that primary G-tube offers no significant advantage in overall, minor or major complications when compared to primary G-button.12 Large-scale studies comparing pull and push methods are required.

In this study, 61.3% of the procedures were performed together with fundoplication when required. SG is conducted when fundoplication is performed too or when PEG is expected to be difficult due to structural problems.2 SG may be advantageous for the operator because it is performed under general anesthesia. However, the duration of gastrostomy is relatively longer than that of PEG, and general anesthesia may cause dangerous situations depending on the patient’s general condition. In addition, the cost and recovery time after the procedure also has disadvantages compared with those of PEG.13 As in this survey, the priority consideration for pediatric gastrostomy procedures in Korea is PEG, and SG is selected in situations where PEG is difficult. SG has also been developed in a way that compensates for its limitations. Recently, laparoscopy has been used instead of open surgery, which leaves a large scar. However, fundoplication or gastrostomy using laparoscopy cannot shorten the procedure time or eliminate the need for general anesthesia, although a recent study reported that laparoscopic PEG may be safer than conventional PEG in high-risk pediatric patients with severe thoracoabdominal deformity, previous abdominal surgery, ventriculoperitoneal shunt, and abdominal tumors.1415 In addition, the difference in the procedures time depends more on the ability of the operator than on the procedure method. In this study, among the cases in which gastrostomy was performed again, there was a case in which the stormy site was placed too close to the pylorus, causing ballooning to interfere with gastric emptying. This may occur more often when open surgery is performed for gastrostomy in young children. Laparoscopy is more advantageous for site selection than open surgery. However, this complication can never occur in PEGs that focus on the stomach. Although the laparoscopic method is a recent trend in surgical procedures, it has inevitable disadvantages in terms of fundoplication. Fundoplication is a procedure in which the lower esophagus is wound around the muscle and tightened by the operator. Depending on the proficiency of the operator, reflux may continue because of tightening too loosely, and there may be cases where the liquids cannot be swallowed because of the tightening was too hard. Therefore, a recent study published in Korea reported that concomitant EGD during fundoplication was better than fundoplication alone regarding optimal tightness inside the esophagus.16

Compared to other countries, Korea has better access to pediatric endoscopy, and many pediatric endoscopy specialists are active in various parts of the country.17 According to the questionnaire data obtained in this study, it was observed that each center has implemented methods according to each hospital’s situation to reduce complications, procedure time, and costs. Thus, it was found that most centers did not have frequent complications and maintained the procedure method. Most of them recognized gastrostomy as an essential technique for children to improve the nutritional status of the patient, reduce the hospitalization rate, and impose great advantages on the clinical course.1819 Approximately 50% of the institutions used general anesthesia, which could be related to the sedation method of pediatric endoscopy. Most pediatric endoscopists are responsible for managing PEG and gastrostomy tubes. A 38.7% of the institutions did not consider fundoplication, and initially implemented PEG gastrostomy. For pediatric endoscopists, this survey showed that PEG is a safe procedure that should be considered as a first-line treatment. In addition, based on the results of this survey, a multicenter chart review of patients undergoing these procedures should be conducted.