Interpreting evidence on percutaneous endoscopic gastrostomy versus laparoscopic gastrostomy in children

We read with interest the recent systematic review and meta-analysis by Cassaro et al.1 addressing a clinically relevant question: the comparative safety of percutaneous endoscopic gastrostomy (PEG) and laparoscopic techniques for pediatric gastrostomy. However, several issues warrant cautious interpretation. Most included studies were non-randomized, and many were retrospective. Under the GRADE framework, such evidence typically starts at low certainty and is often downgraded for inconsistency or imprecision.2 Several outcomes were rated as high certainty, yet the rationale for upgrading, despite heterogeneity and wide confidence intervals, was not clearly explained. Although ROBINS-I was applied, all studies were classified as moderate risk without detailed domain-level justification. Given the likelihood of confounding by indication (e.g., anatomical considerations or prior surgery influencing technique choice), greater transparency would strengthen confidence in these judgments and clarify their impact on GRADE ratings.2, 3 For some key outcomes, heterogeneity was substantial (e.g., I² values ranged from 76% to 99%). While pooling is not inherently inappropriate, a clearer discussion of potential sources of variability and additional analyses is needed.2 Several pooled estimates show extremely wide confidence intervals, particularly for secondary outcomes such as operative time and time to first feed. These outcomes were analyzed using odds ratios, which are not optimal for continuous variables. Finally, concluding that “laparoscopic techniques are safer and PEG should be reserved for cases where laparoscopy is contraindicated”1 may overstate the certainty of the evidence. A more cautious interpretation, emphasizing the need for high-quality prospective data, would better reflect the acknowledged limitations. The authors declare no conflicts of interest.