Gastrojejunostomy Tube Placement Research Articles

The effects of gastrojejunostomy tube placement on pulmonary and gastrointestinal complications following spinal fusion for neuromuscular scoliosis.

To evaluate whether preoperative conversion from a gastrostomy tube (G-tube) to a gastrojejunostomy tube (GJ-tube) decreases short-term postoperative aspiration pneumonia and gastrointestinal complications in children with neuromuscular scoliosis. We conducted a retrospective chart review from January 2006 to October 2021 of pediatric patients who had neuromuscular scoliosis and were fed with a G-tube before spinal fusion. Eligible patients were divided into two groups based on whether they were converted to a GJ-tube preoperatively. Preoperative characteristics and 30-day postoperative outcomes were compared between groups using Chi-square tests. Of 261 eligible patients, 205 were converted to a GJ-tube, while 56 underwent spinal fusion with a G-tube. Common complications following G-tube to GJ-tube conversion were feeding intolerance (25.2%), GJ-tube malfunction (17.7%), and at least one episode of vomiting (17.4%). Within 30 days of discharge, 12.5% of GJ-tube patients and 11.5% of G-tube patients experienced aspiration pneumonia (P = 0.85). The GJ-tube group received postoperative tube feeds 7 hours earlier than the G-tube group on average (51.6 h vs. 44.5 h, P = 0.02). Within 30 days of discharge, one (0.5%) patient from the GJ-tube group died of gastrointestinal complications unrelated to conversion and two (3.6%) patients in the G-tube group died from aspiration pneumonia (P = 0.12). Results suggest that there were no appreciable differences in outcomes between patients converted to a GJ-tube preoperatively compared to those who continued to use a G-tube. However, preoperative characteristics indicate that a higher number of complex patients were converted to a GJ-tube, indicating potential selection bias in this retrospective sample. Level of evidence: Level III.

Mid-to-long-term outcomes with image-guided placement of de novo low-profile gastrojejunostomy tubes in pediatric patients

ObjectiveDe novo low-profile gastrojejunostomy (GJ) tubes are advantageous in children that require prolonged supplemental nutrition. However, few institutions place these devices at the time of initial feeding tube placement. We aim to build upon our previously published initial experience with this procedure to study mid-to-long-term outcomes of pediatric patients who have had de novo, image-guided, percutaneous low-profile GJ tube placement. MethodsAll de novo, image-guided, percutaneous, low-profile GJ tube placements at a single children's hospital were retrospectively reviewed between May 2014 and March 2021. Technical parameters, including fluoroscopy time, tube size, technical success, and complications were recorded. Clinical data, including age, indication, weight gain and transition to gastric/oral feeds were analyzed. Results64 de novo low-profile GJ tubes were successfully placed in 65 patients (mean age: 4.6 years, median: 1, range: 0.2–19; mean pre-procedural weight: 16.8 kg, median: 8.2, range: 4.4–66.7). Average clinical follow-up 23.4 months (range: 0.1–75, median 10.4). Average weight gain was 6.1 kg. Average increase in weight percentile was 7.3%. 19 (19/64; 29.7%) patients had conversion from GJ to G tube. 11 (11/64; 17.2%) patients had their enteric tube removed completely. There were 7 minor complications (7/65; 10.7%), most common being excessive skin irritation (6/7) and 9 major complications (9/65; 13.8%), most common being tube dislodgment within the first 30 days (6/9). ConclusionsThese results further support that de novo, image-guided, percutaneous, low-profile GJ tube placement is technically feasible and efficacious in children requiring post-pyloric nutritional supplementation with a favorable safety profile.

Effect of post-pyloric Dobhoff tube retention during gastrojejunostomy for reduction of fluoroscopic time and radiation dose.

The purpose of this study was to determine whether retention of a post-pyloric Dobhoff tube (DHT) in position to serve as a visual guide through the pylorus during gastrojejunostomy (GJ) tube placement results in a reduction in fluoroscopy time, procedure time, and estimated radiation dose. A retrospective study evaluated patients who underwent GJ tube placement or gastric to GJ conversion from January 1, 2017, to April 1, 2021. Demographic and procedural data were collected, and results were evaluated using descriptive statistics and hypothesis testing through an unpaired Student's t-test. Of the 71 GJ tube placements included for analysis, 12 patients underwent placement with a post-pyloric DHT in position, and 59 patients underwent placement without a post-pyloric DHT in position. The mean fluoroscopy time and estimated radiation dose were significantly reduced in patients who underwent GJ tube placement with a post-pyloric DHT in position compared with those without (7.08 min vs. 11.02 min, P = 0.004; 123.12 mGy vs. 255.19 mGy, P = 0.015, respectively). The mean total procedure time was also reduced in patients who underwent GJ tube placement with a post-pyloric DHT in position compared with those who had no post-pyloric DHT, but this finding lacked statistical significance (18.55 min vs. 23.15 min; P = 0.09). Post-pyloric DHT retention can be utilized during GJ tube placement to reduce radiation exposure to both the patient and interventionalist.

Impact of gastro-jejunostomy tube in lung transplant patients: a propensity-matched analysis.

During the postoperative phase of lung transplantation, the surgical creation of a gastro-jejunostomy (GJ) may be deemed necessary for patients with severe oesophageal dysmotility, prolonged oral intake difficulties stemming from use of a ventilator or marked malnutrition. We explored the effects of postoperative GJ tube on survival and bronchiolitis obliterans syndrome in lung transplant recipients. We retrospectively reviewed all lung transplants performed at our institution between 2011 and 2022. Propensity score matching was performed to match patients who required a GJ tube with control patients on a 1:1 ratio. The preoperative, operative and postoperative outcomes of the patients were evaluated. After propensity score matching, 193 patients with GJ were compared to 193 patients without GJ. Patients with GJ had significantly higher rates of delayed chest closure (P = 0.007), and postoperative dialysis (P = 0.016), longer intensive care unit stays (P < 0.001), longer ventilator duration (P < 0.001), higher rates of pneumonia (P = 0.035) and higher rates of being treated for acute cellular rejection within 1 year of transplant (P = 0.008). Overall survival and freedom from bronchiolitis obliterans syndrome were not found to be significantly different between the matched groups (P = 0.09 and P = 0.3). GJ tube placement during the postoperative phase of lung transplantation did not compromise patient survival or freedom from bronchiolitis obliterans syndrome although the results reflect more difficult and complicated cases. This study indicates that the GJ tube may be a useful option for enteral feeding.

S3534 A Unique Presentation of Gastrinoma Complicated by Duodenal Perforation

Introduction: Neuroendocrine tumors are uncommon neoplasms with multiple different characteristics. They can be benign but also proliferate into malignant tumors with different pathological scenarios such as intestinal obstruction/ intraluminal mass. Gastrinomas are type of NET originating from pancreatic islet cells but can also arise from gastrin-producing cells in the duodenum. We present a case of gastrinoma, in which clinical period was complicated by small bowel perforation. Case Description/Methods: A 55-year-old lady with no significant past medical presented with complaints of abdominal pain, diarrhea and nausea/vomiting that was uncontrolled with symptomatic management. The patient underwent an EGD that showed esophagitis, gastritis, and duodenitis, and she was transferred to our facility for further work-up. She underwent a workup for Zollinger Ellison Syndrome in view of persistent symptoms. Her gastrin level came back elevated at 4,180 pg/ml after her medications were stopped to get the correct lab readings. A nuclear scan was scheduled for the patient to localize the gastrinoma lesion, but suddenly the patient became altered, hypotensive, and developed an acute abdomen. On further investigation with CT scan of the abdomen, patient was found to have pneumoperitoneum, secondary to bowel perforation. She underwent an emergent exploratory laparotomy, was found to have large perforations of the 3rd, 4th portion of the duodenum and several small perforations throughout the small bowel. A Para duodenal lymph node was taken and sent for pathology. Pathology revealed a well-differentiated neuroendocrine tumor: histological subtype gastrinoma. The patient underwent duodenal resection, gastrojejunostomy, cholecystectomy and feeding tube placement. Post-op period was complicated by patient having persistent dysphagia, initially to solids and progressed to have dysphagia to liquids as well. The patient underwent an EGD again which showed presence of esophageal stricture and had to undergo dilatation 6 times in a span of 2 months for symptom relief. She follows up with oncology and gastroenterology regularly and is scheduled to get a PET scan soon to rule out metastasis. (Figure) Discussion: Gastrinomas manifest with peptic ulcer disease symptoms but some patients present with diarrhea. Serum gastrin levels of > 1000 pg/ml with symptoms is diagnostic of gastrinoma. A secretin provocative test is used for diagnosis if gastrin levels are < 1000 pg/ml. As clinicians, we must be aware of the complications of gastrinoma.Figure 1.: Histopathological slides.

Adjunctive techniques for percutaneous enteral access in children: a pictorial review.

Primary percutaneous gastrostomy and gastrojejunostomy tube placements are fundamental procedures performed in pediatric interventional radiology, with both antegrade and retrograde techniques described. In pediatric patients, however, challenges may arise due to smaller patient size and anatomical variations. Several adjunctive techniques may facilitate safe percutaneous access in the setting of a limited percutaneous gastric access window. These include the intra-procedural use of cone beam computed tomography (CT), percutaneous needle decompression in the setting of distended air-filled bowel interposed between the stomach and abdominal wall, post-pyloric balloon occlusion to facilitate gastric distension, ultrasound-guided gastric puncture, and intra-gastric contrast-enhanced ultrasound (ceUS) to define the relationship of the gastric wall and the anterior abdominal wall. Adjunctive techniques may increase successful primary percutaneous gastroenteric tube placement and may improve operator confidence in safe placement.

Abstract No. 99 Financial reimbursement in interventional radiology procedures: multicenter analysis within the Americas

To compare financial reimbursement costs related to interventional radiology procedures (IRP) across USA, Canada (Ontario) and Brazil Medicare Billing (based on RVU and CPT codes) obtained from a single institution was considered as the primary database for US billing. USA Procedure Reimbursement Fees (PRF) included billings in NON FAC PAR, NON FAC NON PAR, NON FAC LC, FAC PAR, FAC NON PAR and FAC LC categories. However, NON FAC PAR fees were utilized as a US Standard baseline for comparison with Ontario and Brazil. Brazilian private PRF were obtained from a single institution. Canadian billings were obtained from a single institution in Ontario (OHIP Database). Equivalency factor for standardization of PRF included the pre-COVID cost of living adjusted income (using proportionate household disposable income as a basis) and pre-COVID foreign exchange rate for each country (February 2020), relative to USA. All currency values were presented in US dollar equivalent. 32 of 45 procedures met inclusion criteria with PRF present for each country. Procedures with fees not available in 1 or more countries were excluded. Brazil-USA: 19 (59%) procedures demonstrated an average of 66% lower fees in Brazil as compared to USA. Some of these procedures include varicocele embolization, portal vein embolization, uterine fibroid embolization, Gastrojejunostomy tube placement and IVC filter placement. Only 12 (37%) procedures demonstrated an average of 219% higher fees in Brazil as compared to USA. Canada-USA: 22 (69%) procedures were underpaid in Ontario (-95% to -19%). Some of these procedures include biliary stent insertion, CT-guided visceral biopsy, port insertion, cholecystostomy tube, carotid stenting, hepatic radiofrequency ablation, thoracocentesis, mesenteric stenting and suprapubic catheter insertion. 1 (3%) procedure was similar in PRF (variance within ±5%). Variable PRF across nations has resulted in relatively low reimbursement fees in Brazil and Canada. Based on cost-of-living adjusted income and foreign exchange rate, a PRF reform is needed, in order to standardize IRP fees in Brazil, Canada and USA.

A68 DISTAL MIGRATION OF A PERCUTANEOUS GASTROJEJUNAL DUODOPA INFUSION TUBE DUE TO BEZOAR FORMATION AT THE JEJUNAL TUBE TIP

Abstract Background Continuous intestinal infusion of levodopa/carbidopa intestinal gel (LCIG) for the treatment of advanced Parkinson’s Disease (PD) leads to less variability in plasma drug levels and improved symptom control. Percutaneous Gastrojejunostomy (PEG-J) tube placement has a high placement success rate; however, delayed tube malfunctions occur in approximately 58% of cases within two years. A rare complication is bezoar formation at the jejunal tube tip. Aims To present a case of bezoar formation at the jejunal tip of a PEG-J tube that caused distal migration of the tube with gastroduodenal ulceration and required surgical extraction. Methods Full chart review was conducted including clinical notes, laboratory results, radiographic imaging, endoscopy reports, and surgical reports. A relevant literature review was conducted. Results A 57-year-old male with severe PD underwent endoscopic guided PEG-J tube insertion for continuous infusion of LCIG; intestinal administration was effective for symptom control. Two years later, he noted that the gastric tube had retracted approximately 15 cm into the stoma without external manipulation of the apparatus. Attempts to externally pull the tube back into position were unsuccessful. The patient underwent Gastroscopy (EGD) with fluoroscopy. Contrast was used to confirm placement of the jejunal tip within the jejunum, but also showed migration of the gastric tip into the duodenum. A gastroscope was used to reposition the gastric tube in the stomach; the jejunal tube was visualized to be under traction. The bumper on the apparatus was re-positioned and external tape was used to further secure the apparatus and prevent migration. A month later the tube had migrated again; repeat EGD showed the jejunal tube to be under traction with some resultant ulceration of the pyloric channel and duodenal bulb where the tube had been pressing against the mucosa. The jejunal tube could not be pulled back and appeared to be fixed distally. A CT scan was obtained to assess for complications and a coiled tip was seen in the proximal jejunum. Surgical extraction of the malfunctioning tube was required. At laparotomy, the coiled tip of the feeding tube was successfully removed via enterotomy. The tube tip had coiled around itself and was encased with food materials, creating a large bezoar that was being pulled distally by peristalsis. The patient subsequently underwent insertion of a new GJ tube for ongoing administration of LCIG and has been doing well since. Conclusions Bezoar formation at the jejunal tip of LCIG PEG-J tubes is a rare complication and can lead to distal migration and traction related gastroduodenal ulceration. Surgical removal may be required. Funding Agencies None

An Unusual Case of Thiamine Deficiency in a Total Parenteral Nutrition-Dependent Child Secondary to Munchausen by Proxy

An Unusual Case of Thiamine Deficiency in a Total Parenteral Nutrition-Dependent Child Secondary to Munchausen by Proxy

Primary gastrojejunostomy tube placement using laparoscopy with endoscopic assistance: A novel technique

BackgroundGastrojejunostomy (GJ) tubes are commonly used to provide postpyloric enteral nutrition in pediatric patients who cannot tolerate gastric feeds. Most techniques depend on a preexisting gastrostomy tube (GT) site to convert to a gastrojejunostomy. Several minimally invasive techniques have been described; however, their risk profile varies widely. Description of the operative techniqueWe present a technique for primary laparoscopic GJ tube placement that minimizes the risk of hollow viscus injury and the use of fluoroscopy through endoscopic assistance. ResultsEleven GJ tubes were placed using this technique in patients ranging from 5 months to 17 years of age and weighing 6.3 to 46.0 kg. Endoscopy through the gastrostomy site allowed direct visualization of wire and tube placement. There were no intraoperative or postoperative complications within 30 days of operation. Use of fluoroscopy was limited with minimal total radiation exposure. ConclusionThe described technique of laparoscopic primary gastrojejunostomy tube placement with endoscopic assistance was associated with a low complication rate and minimal use of fluoroscopy. Level of evidenceIV

Percutaneous Gastrojejunostomy Tube Insertion in Patients with Surgical Gastrojejunal Anastomoses: Analysis of Success Rates and Durability

Patients with a gastrojejunal anastomosis pose challenging anatomy for percutaneous gastrojejunostomy (GJ)-tube placement. A retrospective review of 24 patients (mean age 67.8 years, 13 males) with GJ anastomoses who underwent attempted GJ tube placement revealed infeasible placement in 6 patients (25%) due to an inadequate window for puncture. When a gastric puncture was achieved, GJ tube insertion was technically successful in 83% (15/18) of attempts, resulting in an overall technical success rate of 63% (15/24). The most common tube-related complication was the migration of the jejunal limb into the stomach, which occurred in 40% (6/15) of successful cases. No major procedure related complications were encountered.

Metoclopramide Reduces Fluoroscopy and Procedure Time during Gastrojejunostomy Tube Placement: A Placebo-Controlled Trial

PurposeTo determine whether a single 10-mg intravenous dose of the promotility agent metoclopramide reduces the fluoroscopy time, radiation dose, and procedure time required for gastrojejunostomy (GJ) tube placement. MethodsThis prospective, randomized, double-blind, placebo-controlled trial enrolled consecutive patients who underwent primary GJ tube placement at a single institution from April 10, 2018, to October 3, 2019. Exclusion criteria included age less than 18 years, inability to obtain consent, metoclopramide allergy or contraindication, and altered pyloric anatomy. Average fluoroscopy times, radiation doses, and procedure times were compared using t-tests. The full study protocol can be found at www.clinicaltrials.gov (NCT03331965). ResultsOf 110 participants randomized 1:1, 45 received metoclopramide and 51 received placebo and underwent GJ tube placement (38 females and 58 males; mean age, 55 ± 18 years). Demographics of the metoclopramide and placebo groups were similar. The fluoroscopy time required to advance a guide wire through the pylorus averaged 1.6 minutes (range, 0.3–10.1 minutes) in the metoclopramide group versus 4.1 minutes (range, 0.2–27.3 minutes) in the placebo group (P = .002). Total procedure fluoroscopy time averaged 5.8 minutes (range, 1.5–16.2 minutes) for the metoclopramide group versus 8.8 minutes (range, 2.8–29.7 minutes) for the placebo group (P = .002). Air kerma averaged 91 mGy (range, 13–354 mGy) for the metoclopramide group versus 130 mGy (range, 24–525 mGy) for the placebo group (P = .04). Total procedure time averaged 16.4 minutes (range, 8–51 minutes) for the metoclopramide group versus 19.9 minutes (range, 6–53 minutes) for the placebo group (P = .04). There were no drug-related adverse events and no significant differences in procedure-related complications. ConclusionsA single dose of metoclopramide reduced fluoroscopy time by 34%, radiation dose by 30%, and procedure time by 17% during GJ tube placement.

3:18 PM Abstract No. 220 A randomized controlled trial of metoclopramide versus placebo to reduce fluoroscopy time during gastrojejunostomy tube placement

Gastrojejunostomy (GJ) tube placement is a common procedure performed to provide post pyloric nutritional support, but advancing a guidewire and the tube through the pylorus can be a tedious and time consuming step. The purpose of this study was to determine whether a single dose of the gastric promotility agent metoclopramide prior to GJ tube placement facilitates passage of the guidewire through the pylorus thus reducing fluoroscopy time. In this single-institution, randomized, double-blind, placebo-controlled trial, consecutive patients over 18 undergoing GJ tube placement were enrolled from April 9, 2018, to September 4, 2019. Patients unable to provide written consent or with metoclopramide allergy, altered pyloric anatomy (e.g., prior Whipple), long QT, extrapyramidal symptoms or seizure disorders were excluded. 51 patients were randomized to a single dose of metoclopramide 10 mg IV and 51 patients were randomized to placebo immediately prior to GJ tube placement. Balloon retained GJ tubes were placed using standard push technique. Fluoroscopy time, air kerma, and total procedure time were recorded. Groups were compared using t-tests and Fisher’s exact test. 43 of 51 patients (n = 33 males, mean age = 57) randomized to metoclopramide and 48 of 51 (n = 27 males, mean age = 54) randomized to placebo underwent GJ placement (P = 0.20). Mean fluoroscopy time to advance the guidewire from the stomach through the pylorus was 1.6 minutes (range, 0.3-10.1) in the metoclopramide group versus 4.2 minutes (range, 0.2-27.3) for placebo (P = 0.003). Mean total procedure fluoroscopy time was 5.8 minutes (range, 1.5-16.2) versus 8.7 minutes (range, 2.8-29.7) (P = 0.004). Mean air kerma was 90 mGy (range, 13-354) versus 124 mGy (range, 24-525) (P = 0.08). Mean total procedure time was 16.5 minutes (range, 8-51) versus 19.7 minutes (range, 6-53) (P = 0.07). There was no significant difference in the 30 day major complication rate (n = 1 in each group; P = 1.0). There were no drug related adverse events. A single dose of 10 mg metoclopramide immediately prior to GJ tube placement leads to a statistically significant reduction in fluoroscopy time by a factor of one third.

4:03 PM Abstract No. 225 Primary percutaneous pull-type gastrojejunostomy tube placement: a 5-year experience

To evaluate outcomes of primary percutaneous pull-type gastrojejunostomy placement and make comparison with conventional balloon-retained devices. Over a 5-year period, from January 2014 to December 2018, a total of 68 adult patients underwent primary placement of a percutaneous gastrojejunostomy (GJ) tube. A push-type (balloon-retained) GJ was placed in 57, and a pull-type (mushroom retained) device with immediate jejunal tube extension was placed in 11. Records were reviewed for procedure indication, technical success, fluoroscopy time, immediate- and short-term complications, as well as jejunal tip migration. Indications for primary GJ placement were aspiration or risk of (n = 36), feed intolerance (n = 15), gastroparesis or gastric outlet obstruction (n = 12), and the simultaneous need for venting gastrostomy and jejunal feeding (n = 5). Technical success was noted in all 68 patients. Average fluoroscopy time did not differ between push-type (12.5 min ± 8.0) and pull-type (12.2 min ± 3.1) techniques (P = 0.89). Retrograde migration of the jejunal tip into the stomach was identified in six patients (11%) for a total of eight instances in the push-type group, compared to three patients (27%) for a total of 14 instances in the pull-type group, though this was not statistically significant (P = 0.13). Major complications were identified in four push-type patients (all hemodynamically significant bleeding events), and none of the pull-type patients. Primary placement of balloon-retained gastrojejunostomy and mushroom-retained gastrostomy with immediate jejunal extension have high technical success rates, similar average procedural time and incidence of jejunal tip migration.

Surgical Interventions for Infant and Childhood Gastroesophageal Reflux Disease

Gastroesophageal reflux (GER) is a common condition in infants, thought to be the result of transient lower esophageal sphincter relaxations which occur independent of swallowing.&nbsp; Most cases of GER are physiologic and generally resolve by early childhood. Gastroesophageal reflux disease (GERD) is diagnosed when symptoms persist or complications such as aspiration or esophagitis develop.&nbsp; Currently there is wide practice variation in the surgical treatment of severe infant and childhood reflux with multiple acceptable surgical approaches chosen based on individual disease characteristics as well as surgeon preference.&nbsp; In this review article we discuss the use of laparoscopic fundoplication, gastrojejunostomy and jejunostomy tube placement to mitigate the symptoms of GERD. &nbsp;Although these minimally invasive techniques have greatly advanced treatment in infants and children, a paucity of data exists comparing outcomes of each technique, resulting in a lack of consensus on best technique.&nbsp; Surgical approach to GERD treatment is an important area of research that needs further investigation.

Hybrid Approach of Endoscopic and Fluoroscopy-Guided EndoVive® Gastrojejunostomy Tube Placement for Patients with Esophageal Perforations

Hybrid Approach of Endoscopic and Fluoroscopy-Guided EndoVive® Gastrojejunostomy Tube Placement for Patients with Esophageal Perforations

2626 A Curious Case of Gastric Outlet Obstruction!

INTRODUCTION: The average lifetime risk of a woman developing breast cancer is 12%. Invasive lobular carcinoma (ILC), the second most common histologic type attributes to 10–15% of breast cancer diagnoses. Compared to invasive ductal carcinoma, ILC has a higher chance to metastasize liver, ovaries and even the gastrointestinal tract. We present a unique case of gastric outlet obstruction (GOO) as the initial presentation of metastatic ILC. Histologically, it can be challenging to delineate ILC from primary gastric adenocarcinoma. This was a rare case where the diagnosis was made via the comparison of the endoscopic biopsy with the patient’s previous lymph node pathology. CASE DESCRIPTION/METHODS: 75-year-old female with history of type 2 diabetes mellitus, and lobular carcinoma treated with a bilateral mastectomy and Anastrozole hormone therapy for 8 years presented with confusion and non-bilious, non-bloody vomiting for two weeks. Vitals indicated orthostatic hypotension and abdominal exam revealed a tender epigastrium without rigidity or guarding. Laboratory findings demonstrated severe contraction alkalosis. Abdominal CT with contrast depicted wall thickening in the second and third portion of the duodenum. Endoscopy revealed an infiltrative circumferential mass that stemmed from the antrum extending through to the proximal duodenum causing GOO. The morphological features of the duodenal mass were consistent with biopsy findings of the patient’s previous sentinel lymph node and mastectomy specimen. The diagnosis was further confirmed with immunostains, which were positive for estrogen receptor and mammoglobin, and negative for progesterone receptor and E-cadherin. Patient received robotic gastrojejunostomy tube placement. Her nutritional status improved and was started on chemotherapy. She had a complete metastatic workup which was unrevealing. DISCUSSION: ILC can metastasize later in life to the brain, ovaries and gastrointestinal tract. Isolated duodenal metastasis is limited to only a few case reports. It is theorized in the literature that lack of expression of the adhesion molecule, E-cadherin, may facilitate ILC’s permeation into tissues. This may contribute to metastasis of ILC with a predilection to gastrointestinal and gynecological sites, which generally occurs after a mean duration of 7 years. Our case is rare in that, the patient presented with GOO as the only initial manifestation of duodenal metastasis within 8 years of treatment of ILC without any other evidence metastatic spread.

The occlusion balloon reduction technique for de novo placement and salvage of malpositioned enteric tubes.

Nasoenteric, gastrojejunostomy, and jejunostomy tubes are methods of enteral nutrition in patients with functioning gastrointestinal tracts who cannot maintain adequate oral intake. Current placements; however, may be complicated by redundant wire and catheter loops within the stomach preventing operators from optimal feeding tube placement and predisposing patients to feeding tube prolapse. This report describes the occlusion balloon reduction technique for salvage of malpositioned tubes and placement of new enteric tubes in the setting of redundant loops. Five patients underwent the occlusion balloon reduction technique for jejunostomy (n = 3), gastrojejunostomy (n = 1), or nasojejunal tube placement (n = 1). All patients (n = 5) had redundant wires coiled within the stomach. In all patients (n = 5), a 9-French × 32mm × 120cm Coda balloon was inserted over the wire and passed into the small bowel. The balloon was inflated after which reduction of redundancy in the upper gastrointestinal tract was performed. Feeding tubes were then placed with tips in the distal jejunum. Technical success of the occlusion balloon reduction technique, successful placement of enteric tube, complications, and follow-up were recorded. The occlusion balloon reduction was technically successful in all patients (n = 5). Feeding tube placement was successful in all patients (n = 5). No minor or major complication occurred. Mean follow-up was 56days. The occlusion balloon reduction technique provides a method for reduction of redundant wire and catheter loops within the stomach during enteric tube placement or repositioning.

Impact of practice change on intestinal perforation risk for pediatric gastrojejunostomy tube placement

BackgroundGastrojejunostomy tubes (GJTs) have been associated with intestinal perforation in children <6 months or <6 kg. This study evaluated the impact of an institutional practice change recommending a new soft tip GJT for children <10 kg. MethodsWe performed a single-center review of GJT placements among children <10 kg before (1/1/2010–12/31/2013) and after (7/1/2014–12/31/2016) the practice change. Intestinal perforation, nasojejunal tube (NJT) for >30 days, and GJT replacement were assessed. ResultsSixty GJTs were placed in 35 children (54% male; 17.2±9.0 months old) after compared to 147 GJTs in 77 children (44% male, p=0.32; 14.1±11.8 months, p=0.08) before the practice change. Use of soft tip GJT was adhered to in 19 placements (32%). There were no intestinal perforations after the practice change (before: 6 (4.1%); p=0.11). NJT remained >30 days in 15 patients (65%) after the practice change (before: 13 (35%); p=0.02). Replacement was required for 53% with soft tip GJT and 18% with standard GJT (p=0.006). DiscussionA reduction in intestinal perforation with an institutional practice change may be explained by fewer GJT placements in high-risk children and longer length of NJT placement. Future protocols may consider age and size restrictions rather than alternative tube types. Type of studyTreatment study. Level of evidenceLevel III.

Survival and Health Care Use After Feeding Tube Placement in Children With Neurologic Impairment.

Children with neurologic impairment (NI) often undergo feeding tube placement for undernutrition or aspiration. We evaluated survival and acute health care use after tube placement in this population. This is a population-based exposure-crossover study for which we use linked administrative data from Ontario, Canada. We identified children aged 13 months to 17 years with a diagnosis of NI undergoing primary gastrostomy or gastrojejunostomy tube placement between 1993 and 2015. We determined survival time from procedure until date of death or last clinical encounter and calculated mean weekly rates of unplanned hospital days overall and for reflux-related diagnoses, emergency department visits, and outpatient visits. Rate ratios were estimated from negative binomial generalized estimating equation models adjusting for time and age. Two-year survival after feeding tube placement was 87.4% (95% confidence interval [CI]: 85.2%-89.4%) and 5-year survival was 75.8% (95% CI: 72.8%-78.4%). The adjusted rate ratio comparing weekly rates of unplanned hospital days during the 2 years after versus before tube placement was 0.92 (95% CI: 0.57-1.48). Similarly, rates of reflux-related hospital days, emergency department visits, and outpatient visits were unchanged. Unplanned hospital days were stable within subgroups, although rates across subgroups varied. Mortality is high among children with NI after feeding tube placement. However, the stability of health care use before and after the procedure suggests that the high mortality may reflect underlying fragility rather than increased risk from nonoral feeding. Further research to inform risk stratification and prognostic accuracy is needed.