Wadie George M, Lobe Thom E
University of Tennessee, Memphis, TN 38105, USA.
Semin Laparosc Surg. 2002 Sep;9(3):180-9.
We review our experience with gastrostomy techniques in neurologically impaired (NI) children, with or without a Nissen fundoplication. The records of 130 NI children who had a gastrostomy tube (GT) placed between January 1999 and October 2001 were reviewed. Data collected included: demographics, neurological status, operative time, time to first feed, postoperative stay, analgesic requirements, follow-up, mortality and complication rates. Open GTs were placed using the standard Stamm gastrostomy technique through a midline incision and were combined with a standard open Nissen fundoplication when indicated. Laparoscopic GTs were placed after institution of carbon dioxide pneumoperitoneum using a 2-port technique, a Mic-key G device of appropriate size and anchored to the anterior abdominal wall with 2 "U" stitches. The laparoscopic Nissen fundoplication (LNF) procedures were performed using a 5-port technique. Patients were divided into 4 groups: group I (n = 12) laparoscopic GT alone, group II (n = 44) open GT alone, Group III (n = 44) laparoscopic GT with LNF and Group IV (n = 30) open GT with Nissen fundoplication. Based on their similar characteristics, Groups I and II and Groups III and IV were compared together. Data were analysed using Student's t test, and internal review board approval was obtained. Patients ranged in age between 10 days and 17.7 years (mean 3.64 years). Their weight was between 1.2 and 63.4 kg (mean 12.8 kg). The compared groups showed similar characteristics with regard to age, weight, cause of mental impairment, and the reason for placement of the GT. The operative time for group III was significantly longer than that of group IV (P < 0.05). Time to first feed was significantly shorter for group I when compared to group II. The postoperative analgesic requirements were not statistically different. The overall short- and long-term complication rates were not statistically different when the related groups were compared, however, site-related complications and feeding problems were significantly less in group I compared to group II. Only 1 operative mortality occurred in group III. Follow-up showed less long-term morbidity and fewer complications with the laparoscopic GT compared to the open one as regard to admissions, surgery, and emergency department visits related to GT problems as well as frequency of GT change. Based on our experience, laparoscopic placement of a low-profile GT in NI children appears to be associated with less morbidity, permits earlier enteral nutrition, and has a cosmetic advantage. We believe that the laparoscopic technique should be the procedure of choice for GT placement in these children even when a Nissen fundoplication is deemed necessary.
我们回顾了在有或没有行nissen胃底折叠术的神经功能受损（NI）儿童中应用胃造口术的经验。回顾了1999年1月至2001年10月期间接受胃造口管（GT）置入的130例NI儿童的记录。收集的数据包括：人口统计学资料、神经状态、手术时间、首次喂养时间、术后住院时间、镇痛需求、随访情况、死亡率和并发症发生率。开放性GT采用标准的 Stamm 胃造口术经中线切口置入，必要时与标准开放性nissen胃底折叠术联合进行。腹腔镜GT在建立二氧化碳气腹后采用双孔技术置入，使用合适尺寸的Mic-key G装置，并用2针“U”形缝线固定于前腹壁。腹腔镜nissen胃底折叠术（LNF）采用五孔技术进行。患者分为4组：I组（n = 12）仅行腹腔镜GT，II组（n = 44）仅行开放性GT，III组（n = 44）行腹腔镜GT联合LNF，IV组（n = 30）行开放性GT联合nissen胃底折叠术。根据相似特征，将I组和II组、III组和IV组分别进行比较。采用学生t检验分析数据，并获得了内部审查委员会的批准。患者年龄在10天至17.7岁之间（平均3.64岁）。体重在1.2至63.4千克之间（平均12.8千克）。比较的各组在年龄、体重、智力障碍原因和GT置入原因方面具有相似特征。III组的手术时间明显长于IV组（P < 0.05）。I组的首次喂养时间明显短于II组。术后镇痛需求无统计学差异。相关组比较时，总体短期和长期并发症发生率无统计学差异，然而，I组与II组相比，与部位相关的并发症和喂养问题明显更少。III组仅发生1例手术死亡。随访显示，与开放性GT相比，腹腔镜GT在与GT问题相关的入院、手术和急诊科就诊以及GT更换频率方面，长期发病率更低，并发症更少。根据我们的经验，在NI儿童中腹腔镜置入低轮廓GT似乎发病率更低，能更早进行肠内营养，且具有美观优势。我们认为，即使认为有必要行nissen胃底折叠术，腹腔镜技术也应是这些儿童GT置入的首选方法。
