Gastrojejunal Feeding Research Articles

Mo1181 Preoperative Evaluation Does Not Predict Risk of Conversion to Transpyloric Feeding in Gastrostomy Dependent Pediatric Patients

Background: Prior literature suggests that a proportion of pediatric patients undergoing gastrostomy tube (GT) placement, especially those with underlying neurologic disability, will require coversion to gastrojejunal (GJ) feeds. Limited literature exists as to whether preoperative assessments may predict which patients will go onto require GJ feeding. The goal of this study was to compare the preoperative evaluations between patients sucessfully maintained on gastrostomy feeds patients) versus patients who failed GT feeds and required conversion to transpyloric feeding (GJ patients). Methods: We identified patients at Boston Children's Hospital who underwent GT placement and ultimately required GJ feeding between 2006-2013. These patients were matched according to age, neurologic, and cardiac status with a cohort of patients who remained GT dependent. Preoperative characteristics of both groups were compared in order to identify risk factors for conversion to GJ feeding. Proportions were compared using Chi-square analyses. Results: 81 GJ patients (median (IQR): age 14 (4, 57.5) months; weight 8.8 (4.6, 15) kg) were matched with 81 GT patients (median (IQR): age 14 (4.5, 57) months; weight 8.5 (5.2, 14.3) kg). Median time from GT to GJ conversion was 8 (IQR 3, 16.5) months. No differences in comorbidities (neurologic or cardiac disease, prematurity, cancer, metabolic/genetic disorder, oropharyngeal malformation, or pulmonary disease) were found. No differences in preoperative gastrostomy evaluations were seen. Both groups had similar rates of nasogastric feeding trials (GT (60, 74.1%) vs GJ (58, 71.6%), p=0.7), upper GI series (GT (47, 58%) vs GJ (45, 55.6%), p=0.75), and modified swallow studies (GT (38, 46.9%) vs GJ (46, 56.8%), p=0.21). No differences in aspiration were seen with 22 GT patients (27.2%) having abnormal modified swallow studies compared to 29 GJ patients (35.8%, p=0.4). There were no differences

Gastrojejunal Feeding Tube Use by Gastroenterologists in a Pediatric Academic Center

Enteral feeding through gastrojejunal (GJ) tubes is an established method of nutrition for patients with feeding difficulty who do not tolerate intragastric feedings. The pediatric literature about the long-term outcome, safety, and complications of different GJ tubes and placement methods is lacking. Our study aims to provide information about indications, techniques, and long-term outcome of GJ tube use in children. Retrospective chart review for GJ tube placement procedures was used at our center for 10 years (1999-2009). Data collected included demographics, placement indications, underlying diagnosis, tube type, placement methods, complications, tube survival, and patient outcome. Thirty-three patients using GJ tubes were identified, with a total of 160 successful procedures documented (overall success rate of 97.6%). At initial placement, the mean age was 6 years (range 0.6-21.6) and the mean weight was 19.4 kg (range 6.6-72.2). Patients had a mean of 4.9 tubes placed per patient (range 1-20) during a follow-up of 26.8 months (range 0.4-115.3). The most common indications for replacement included accidental dislodgement, tube obstruction, coiling back into the stomach, and broken tube component. At the end of the study, 39% continued using GJ tubes, 30% were transitioned back to gastrostomy or oral feeds, and 15% underwent a surgical intervention. Long-term GJ tube use is possible and safe in children. Various feeding tubes and placement methods can be used by pediatric gastroenterologists to provide long-term jejunal feeds in children.

Combined Laparoscopic-Endoscopic Placement of Primary Gastrojejunal Feeding Tubes in Children: A Preliminary Report

Placement of a primary gastrojejunal tube (GJT) can be technically challenging and often requires an open procedure to negotiate the tube past the duodenal sweep into the jejunum. The alternative approach is to first place a gastrostomy tube (GT), which is then changed to a GJT under endoscopic or fluoroscopic guidance after waiting 6-8 weeks to allow the stoma to mature. We report a case series of primary GJT placement using a combined laparoscopic-endoscopic approach. We retrospectively reviewed patients who underwent a combined laparoscopic-endoscopic primary GJT placement. Patients' demographics and relevant clinical information were analyzed. Six patients (4 male, 2 female) were identified. The median age at the time of operation was 30.2 months (range, 28 days-10 years). Five GJTs were successfully placed laparoscopically/endoscopically, and one procedure was converted to open. The mean operative time was 84 minutes (range, 63-102 minutes). Postoperative abdominal radiography confirmed post-pyloric tube position in all patients. Feedings were initiated on the first postoperative day. One intraoperative complication required conversion to an open procedure. No patients developed postoperative complications. Laparoscopic-endoscopic primary GJT placement is technically feasible and an excellent alternative in patients who require transpyloric feeding access.

Pneumatosis in Post-Whipple Patients

Pneumatosis intestinalis (PI) is the finding of air in the wall of the intestine. Clinical significance ranges from an incidental radiologic finding to an indicator of life-threatening disease requiring surgical intervention. We report the incidence and consequence of PI in a 7-year, single-surgeon, retrospective review. Data from demographics, imaging, and outcomes were analyzed. Two-tailed Fisher's exact test was performed to analyze the difference between groups. A total of 214 patients underwent a Whipple procedure with a routinely placed feeding tube during this period. Most had a gastrojejunal feeding tube, 80.4 per cent. Thirteen patients developed PI. Overall reoperation rate was nine of 201 versus four of 13 in the PI group (P<0.02). Three patients taken back to the operating room with peritonitis and PI had a necrotic bowel. A fourth patient was taken to surgery for unrelenting upper gastrointestinal bleeding. The remaining nine were managed nonoperatively with resolution of PI. The 90-day death rate in those without PI was 2.9 per cent versus 23.3 per cent with PI (P<0.02). Isolated PI can be managed nonoperatively; however, in the presence of peritonitis, it is a strong predictor of lethal complications.

Gastroesophageal Reflux

Gastroesophageal Reflux

One‐step Percutaneous Gastrojejunostomy in Early Infancy

In certain conditions that obviate the use of gastric feedings, the insertion of a jejunal feeding tube via gastrostomy constitutes an alternative to jejunostomy but requires a preexisting gastrostomy. Our aim was to assess a new technique of 1-step gastrojejunal tube insertion through a de novo gastrostomy. A total of 3 infants between 3 and 7 months old and weighing between 4.1 and 5.4 kg had a gastrojejunal feeding tube inserted using a 16-CH French introducer percutaneous endoscopic gastrostomy kit and a transgastric-jejunal feeding tube. No technical difficulties occurred and the gastrojejunal feeding tube was placed successfully in the 3 patients, the total procedure lasting 15 to 20 minutes. Enteral feeding was started within 4 to 6 hours of the procedure. Neither immediate (<24 hours) nor late complications related to the gastrojejunostomy occurred. Nissen fundoplication was performed in 2 of our patients at 12 and 15 months of age, respectively. The gastrojejunostomy tube was still in place in the third patient at age 15 months. Our first experience suggests that 1-step endoscopic placement of a transgastric-jejunal feeding tube without a preexisting gastrostomy tract is feasible in young and low-weight infants.

Percutaneous gastrojejunostomy in children: efficacy and safety

Transgastric jejunal intubation via gastrostomy (GJ) can be indicated when enteral nutrition via gastrostomy is not possible. Between 2001 and 2008, the authors prospectively assessed the outcomes in 29 patients...

An Unexpected Cause of Emesis

A 23-month-old boy presented to a tertiary care Emergency Department with a 2-day history of non-bilious, non-bloody emesis and fever. The child had global developmental delay, obstructive sleep apnea, sensorineural hearing loss, vesicoureteric reflux, and gastroesophageal reflux requiring gastrojejunal (GJ) feeding. He had a mild cough with no rhinitis and no history of diarrhea. There was no history of sick contacts or recent travel. Medications included domperidone, omeprazole, and co-trimoxazole for urinary tract infection prophylaxis.

Should fundoplication be added at the time of gastrostomy placement in patients who are neurologically impaired?

Background/Purpose Patients who have advanced neurologic impairment (NI) and require gastrostomy placement (GP) frequently have symptomatic gastroesophageal reflux. We investigated the outcomes of GP without fundoplication in patients who had NI. Methods This was a retrospective review of 54 patients with NI (median, 7 years; range, 1-18 years) undergoing GP alone. The operative criteria included medically controllable or no reflux symptoms. The patients were divided into 2 groups based on the percentage of total esophageal time with a pH less than 4.0 (reflux index, or RI): group I (GI, n = 33), RI less than 5.0% (median age, 6 years; range, 2-15 years); group II (GII, n = 21), RI 5.0% or greater (median age, 10 years; range, 1-18 years). Data are expressed as medians and ranges. Results Nutritional management was successfully conducted after GP with or without the administration of lansoprazole, famotidine, or rikkunshito in all but 2 patients. One GI patient with alpha-thalassemia required fundoplication, and one GII patient with Cockayne syndrome required gastrojejunal tube feeding. The RI increased significantly in GI patients (2.1% [0%-4.8%] vs 4.5% [0.2%-11.4%], P = .004), whereas it decreased significantly in GII patients (11.2% [5.9%-41.6%] vs 9.8% [1.05-26.6%], P = .04). Conclusion Gastroesophageal reflux and related symptoms rarely deteriorate to require additional treatment after GP in patients with NI. Gastrostomy placement is a less invasive and effective procedure for improving the quality of life in those patients.

W1078 Should Fundoplication Be Added at the Time of Gastrostomy Placement in Profoundly Handicapped Patients With Dysphagia?

Background: Handicapped patients with advanced neurological impairment and dysphagia require gastrostomy feeding and are associated with gastroesophageal reflux disease (GERD). Concurrent fundoplication is often recommended at the time of gastrostomy placement (GP) in those patients because of avoiding long-term anti-reflux medication or preventing future reflux symptoms. Fundoplication has recently been thrown doubts about its indication in those patients because of unignorable complications and the high incidence of recurrence of GERD. It was aimed in this study to conduct a retrospective review of the outcome of handicapped patients with GP alone. Methods: The subjects consisted of 60 profoundly handicapped patients requiring tube feeding, aged 1 yr to 33 yrs (median 9 yrs), who underwent GP alone. The operative criteria included no or medically controllable reflux symptoms. Operative procedure was laparoscopic in 53 and open in 7. They were divided into two groups based on % esophageal total time pH<4.0 (reflux index:RI) evaluated with preoperative 24-hour esophageal pH monitoring; Group I (GI, n=37): RI<5.0 %, median age 7 yrs (2yrs-33 yrs), Group II (GII, n=23): RI≥5.0 %, median age 11yrs(1yr -21 yrs). Postoperative pH monitoring was performed in 26 GI patients and 20 GII. Follow-up period ranged 2 yrs to 8 yrs(median 4 yrs). Data are expressed as medians and ranges. Results: Postoperative medical management of GERD succeeded in 3 of 4 GI patients and 12 of 13 GII with lansoprazole, famotidine, and a herbal medicine, rikkunshito. A GI patient with chromosomal anomaly required fundoplication after GP because of intractable emesis. A GII with Cockayne Syndrome required gastrojejunal continuous feeding because of emesis and diarrhea. Other patients were successfully nourished with gastrostomy bolus feeding. Respiratory symptoms were ameliorated in a GI patient and 3 GII presumably due to the removal of stimulation by nasogastric tubes. Chronic gastric volvulus was corrected in 4. The postoperative RI increased significantly in GI patients (2.0% [0%-4.8%] vs. 4.1%[0.2%11.9%], P=0.002), whereas decreased significantly in GII (11.8% [5.9%-67.2%] vs. 9.7%[1.0%-68.7%], P=0.048). Conclusions: Reflux symptoms and pathological esophageal acid exposure rarely deteriorate after GP in profoundly handicapped patients with dysphagia. GP alone is a less invasive and effective procedure to improve the quality of life in those patients. Concomitant fundoplication is unnecessary in most of them with adequate medical control of reflux symptoms.

W1079 Effect of Endoscopic Fundoplication With EsophyX Device on Proton Pump Inhibitors Usage in a Single Third Level Italian Care Center

Background: Handicapped patients with advanced neurological impairment and dysphagia require gastrostomy feeding and are associated with gastroesophageal reflux disease (GERD). Concurrent fundoplication is often recommended at the time of gastrostomy placement (GP) in those patients because of avoiding long-term anti-reflux medication or preventing future reflux symptoms. Fundoplication has recently been thrown doubts about its indication in those patients because of unignorable complications and the high incidence of recurrence of GERD. It was aimed in this study to conduct a retrospective review of the outcome of handicapped patients with GP alone. Methods: The subjects consisted of 60 profoundly handicapped patients requiring tube feeding, aged 1 yr to 33 yrs (median 9 yrs), who underwent GP alone. The operative criteria included no or medically controllable reflux symptoms. Operative procedure was laparoscopic in 53 and open in 7. They were divided into two groups based on % esophageal total time pH<4.0 (reflux index:RI) evaluated with preoperative 24-hour esophageal pH monitoring; Group I (GI, n=37): RI<5.0 %, median age 7 yrs (2yrs-33 yrs), Group II (GII, n=23): RI≥5.0 %, median age 11yrs(1yr -21 yrs). Postoperative pH monitoring was performed in 26 GI patients and 20 GII. Follow-up period ranged 2 yrs to 8 yrs(median 4 yrs). Data are expressed as medians and ranges. Results: Postoperative medical management of GERD succeeded in 3 of 4 GI patients and 12 of 13 GII with lansoprazole, famotidine, and a herbal medicine, rikkunshito. A GI patient with chromosomal anomaly required fundoplication after GP because of intractable emesis. A GII with Cockayne Syndrome required gastrojejunal continuous feeding because of emesis and diarrhea. Other patients were successfully nourished with gastrostomy bolus feeding. Respiratory symptoms were ameliorated in a GI patient and 3 GII presumably due to the removal of stimulation by nasogastric tubes. Chronic gastric volvulus was corrected in 4. The postoperative RI increased significantly in GI patients (2.0% [0%-4.8%] vs. 4.1%[0.2%11.9%], P=0.002), whereas decreased significantly in GII (11.8% [5.9%-67.2%] vs. 9.7%[1.0%-68.7%], P=0.048). Conclusions: Reflux symptoms and pathological esophageal acid exposure rarely deteriorate after GP in profoundly handicapped patients with dysphagia. GP alone is a less invasive and effective procedure to improve the quality of life in those patients. Concomitant fundoplication is unnecessary in most of them with adequate medical control of reflux symptoms.

Cap myopathy caused by a mutation of the skeletal alpha-actin gene ACTA1

Cap myopathy is a congenital myopathy with cap-like structures under the sarcolemma. Mutations in TPM2 and TPM3 genes have been reported in cap myopathy so far. We report a newborn boy with persistent profound weakness who required gastro-jejunal tube feeding, tracheostomy and life-long ventilation until he died at 5 years of age. Muscle biopsy at 5 weeks of age was uninformative. Repeat biopsy at 4.5 years revealed subsarcolemmally located caps that were immunopositive for alpha-actinin, actin and to some extent, desmin. EM confirmed loosely arranged thin filaments and paucity of thick filaments. Molecular analysis of ACTA1 gene identified a novel de novo Met47Val mutation. In addition to a new ACTA1 gene mutation, our case emphasizes the genetic heterogeneity of cap myopathy and its association with ACTA1 gene as well as the importance of repeat muscle biopsy in patients with undiagnosed muscle weakness.

Do Some Adolescents With Rumination Syndrome Have “Supragastric Vomiting”?

Do Some Adolescents With Rumination Syndrome Have “Supragastric Vomiting”?

Impact of Fundoplication Versus Gastrojejunal Feeding Tubes on Mortality and in Preventing Aspiration Pneumonia in Young Children With Neurologic Impairment Who Have Gastroesophageal Reflux Disease

Aspiration pneumonia is the most common cause of death in children with neurologic impairment who have gastroesophageal reflux disease. Fundoplications and gastrojejunal feeding tubes are frequently employed to prevent aspiration pneumonia in this population. Which of these approaches is more effective in preventing aspiration pneumonia and/or improving survival is unknown. The objective of this study was to compare outcomes for children with neurologic impairment and gastroesophageal reflux disease after either a first fundoplication or a first gastrojejunal feeding tube. This was a retrospective, observational cohort study of children with neurologic impairment who had either a fundoplication or gastrojejunal feeding tube between January 1997 and December 2005 at a tertiary care children's hospital. Main outcome measures were postprocedure aspiration pneumonia-free survival and mortality. Propensity analyses were used to control for bias in treatment assignment and prognostic imbalances. Of the 366 children with neurologic impairment and gastroesophageal reflux disease, 43 had a first gastrojejunal feeding tube and 323 underwent a first fundoplication. Median length of follow-up was 3.4 years. Children who received a first fundoplication had similar rates of aspiration pneumonia and mortality after the procedure compared with those who had a first gastrojejunal feeding tube, when adjusting for the treatment assignment using propensity scores. Aspiration pneumonia and mortality are not uncommon events after either a first fundoplication or a first gastrojejunal feeding tube for the management of gastroesophageal reflux disease in children with neurologic impairment. Neither treatment option is clearly superior in preventing the subsequent aspiration pneumonia or improving overall survival for these children. This complex clinical scenario needs to be studied in a prospective, multicenter, randomized control trial to evaluate definitively whether 1 of these 2 management options is more beneficial.

Reflux related hospital admissions after fundoplication in children with neurological impairment: retrospective cohort study

Objective To examine the impact of fundoplication on reflux related hospital admissions for children with neurological impairment.Design Retrospective, observational cohort study.Setting 42 children’s hospitals in the United States.Participants 3721 children...

P-069B 重症心身障害児における経胃瘻空腸チューブの管理留置とその検討(術式, 第44回日本小児外科学会学術集会)

P-069B 重症心身障害児における経胃瘻空腸チューブの管理留置とその検討(術式, 第44回日本小児外科学会学術集会)

Optimal enteral feeding in children with gastric dysfunction: surgical jejunostomy vs image-guided gastrojejunal tube placement

Purpose Long-term feeding access in children who fail initial gastrostomy is a management quandary. Although image-guided gastrojejunal feeding tube placement (IGJ) is becoming the access of choice in many centers, few studies have compared long-term results with surgical jejunostomy (SJ). The authors compare outcomes with these 2 techniques. Method A retrospective review of 20 children requiring jejunal feeding access after failing initial gastrostomy was done. Procedures were performed at a tertiary referral center by interventional radiologists (IGJ) or board-certified pediatric surgeons (SJ). Results Initially, patients underwent IGJ (n = 14) or SJ (n = 6). Image-guided gastrojejunal feeding tube placement patients required gastrostomy at an average age of 23.8 months, with conversion to IGJ an average of 17.2 months later. SJ patients required gastrostomy at average age of 16.2 months, with conversion to SJ 30.7 months later. Of 14 patients undergoing IGJ, 7 (50%) eventually required SJ because of recurring tube management issues. Thus, 13 patients ultimately had SJ, with 11 (85%) Roux-en-Y jejunostomies. Mean operating time for SJ was 158 minutes, with an average of 5.1 days to initiation of feeds, 11 days to full feeds, and 19.9 days to discharge (range, 3-66 days). Image-guided gastrojejunal feeding tube placement patients averaged 4.6 tube adjustments per year requiring fluoroscopic guidance. Surgical jejunostomy averaged 1.5 tube adjustments per year requiring outpatient hospital visits. Image-guided gastrojejunal feeding tube placement patients averaged 3.9 hospital d/y secondary to feeding tube management issues, whereas SJ patients averaged 1.4 hospital days per year. Conclusion In this group of children with long-term jejunal feeding access, half of those with IGJ eventually required SJ. Surgical jejunostomy required fewer adjustments and hospitalizations per year. Although initially more invasive than IGJ, SJ may provide more stable feeding access with fewer complications. This represents the first published report comparing long-term outcomes between IGJ and SJ.

The Limitations of Gastro-Jejunal (G-J) Feeding Tubes in Children: A 9-Year Pediatric Hospital Database Analysis

A gastro-jejunal (G-J) feeding tube is a safe and useful temporizing method of providing enteral access in children. Although G-J tubes are often used to obviate the need for a surgical jejunostomy, their long-term use is often associated with mechanical failure. To review the clinically effective durability of G-J feeding tubes in providing enteral access in children. We performed a retrospective review of 102 patients at the Johns Hopkins Children's Center from 1994-2003 whose underlying diagnosis necessitated the need for postpyloric enteral access. Long-term follow-up was obtained in 85 (48 M; 37 F) patients with a median (range) age of 2.0 (0.1-18.0) yr. The most common indication for G-J tube placement was gastroesophageal reflux with aspiration in 51 patients and feeding intolerance and vomiting in 19 patients. The mean (range) number of tube replacements was 2.2 (1-14) over a median (range) duration of follow-up of 39 (2-474) days. The indication for G-J tube replacement included: tube displacement (58), a clogged tube (41), and a cracked tube or ruptured balloon (35). In 52 cases, the cause for G-J tube replacement was undetermined. G-J feeding tubes are associated with the frequent need for tube maintenance and replacement and may not be the most feasible clinical option in providing long-term (>1 month) enteral access in children intolerant to gastrostomy tube feeds. Future studies are needed to develop innovative percutaneous jejunostomy tube placement techniques that facilitate long-term enteral access.

Limitations and uses of gastrojejunal feeding tubes

Background: Gastrostomy feeding is a well established alternative method to long term nasogastric tube feeding. Many such patients have gastro-oesophageal reflux (GOR) and require a fundoplication. A transgastric jejunal tube...

Intestinal arginine biosynthesis is crucial for maintaining arginine serum levels in sucklings

means for guiding placement of jejunal feeding tubes, its disadvantage has been in the need to transport the patient to the radiology suite, and the extent of radiation exposure. Herein, we describe a method of endoscopically assisted placement of gastrojejunal and nasojejunal feeding tubes in pediatric patients. Patients and Methods: In 1997, a total of 8 patients (7 male; 1 female) with a mean age (range) of 2.4 yrs (1.5-4yrs) required jejunal tube placement. Under general anesthesia, the patient received a single dose of intravenous metoclopramide (0.1mg/Kg). Silk sutures were tied at intervals along the tube, and the tube was advanced and stabilized by using biopsy forceps to grab the sutures. In a step-wise fashion the feeding tube was directed into the pylorns. Once in position, the guide-wire was carefully removed. Results: The indications for jejunal access included: post-operative gastroparesis in 5, and gastroesophageal reflux with oropharyngeal dysmotility in 3 patients. Over the course of one year, 6 patients had a total of 9 gastrojejunal feeding tubes successfully inserted by endoscopy. Three patients had to have their feeding tubes replaced for reasons unrelated to the initial placement after several months of usage. One of the 6 patients had their gastrojejunal feeding tube inserted after an unsuccessful 3 hour attempt by fluoroscopy. Of the remaining 2 patients, nasojejunal feeding tube placement was attempted and successful in one. The failure to insert the tube by endoscopic assistance was attributed to an unrecognized intestinal malrotation. All tubes had their positioning confirmed radiographically, and there were no complications. The overall success for endoscopio jejunal tube placement was 91%. Conclusions: Endoscopically assisted jejunal feeding tube placement is an effective and safe method of establishing a route for enteral nutrition in pediatric patients. Endoscopic placement of jejunal feeding tubes may be used as an initial method of enteric intubation and after an unsuccessful fluoroscopic attempt.