Journal of Pediatric Gastroenterology & Nutrition:
Michaud, Laurent; Robert-Dehault, Amélie; Coopman, Stéphanie; Guimber, Dominique; Turck, Dominique; Gottrand, Frédéric
Division of Gastroenterology, Hepatology and Nutrition, and Reference Centre for Congenital and Malformative Oesophageal Diseases, Department of Paediatrics, Jeanne de Flandre Children's Hospital and Faculty of Medicine, University Lille 2, Lille, France.
Address correspondence and reprint requests to Laurent Michaud, MD, Département de Pédiatrie, Unité de Gastro-entérologie, Hépatologie et Nutrition, Hôpital Jeanne de Flandre, Avenue Eugène Avinée, 59037 Lille, France (e-mail: firstname.lastname@example.org).
Received 5 December, 2011
Accepted 30 January, 2012
The authors report no conflicts of interest.
ABSTRACT: 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.
Most patients requiring long-term enteral nutritional support can be successfully fed via a percutaneous or surgical gastrostomy tube (1); however, enteral nutrition via a gastrostomy tube may be impossible, even with a functional lower gastrointestinal tract, because of severe gastroesophageal reflux disease and/or delayed gastric emptying and/or antropyloric dysmotility. Under these rare circumstances, treatment options include percutaneous or surgical jejunostomy tube placement and surgical interventions such as Nissen fundoplication or total esophagogastric disconnection (Bianchi intervention) (2–4). Insertion of a jejunal feeding tube via a preexisting gastrostomy constitutes an alternative to jejunostomy or other surgical options, but requires a gastrostomy placement performed under general anesthesia at least 2 months earlier to ensure a mature gastrostomy tract and avoid the risk of gastric dislodgment. We report a technique of 1-step gastrojejunal tube insertion through a de novo gastrostomy performed in young infants.
Three infants (ages between 3 and 7 months; weight between 4.1 and 5.4 kg) were hospitalized from birth for severe feeding difficulties and failure to thrive. They were selected to receive jejunal feeding because enteral nutrition via a nasogastric tube failed and became hazardous due to of the presence of severe and persistent gastroesophageal reflux disease. After multidisciplinary discussion, Nissen fundoplication or esophagogastric disconnection was contraindicated because of low weight and associated disease (congenital heart disease: n = 2; Noonan syndrome: n = 1).
The placement of the gastrojejunal feeding tube was performed using a push technique in the operating room under general anesthesia. The patients’ parents gave informed consent for this procedure. Prophylactic antibiotics (kefandol, intravenously) were given before the procedure. A Mic-Key 16-CH French introducer percutaneous endoscopic gastrostomy (PEG) kit and a transgastric-jejunal feeding tube (Kimberly-Clark, Roswell, GA) were used. A gastropexy was first performed under endoscopic control: the gastric wall was fixed to the anterior abdominal wall using 3 T-fasteners inserted in a 1- to 1.5-cm triangular configuration. The puncture site at the center of the gastropexy pattern was identified under endoscopic guidance. A trocar and a guidewire were then introduced into the stomach to create the stoma tract. The dilators were advanced over the guidewire and allowed to dilate the stoma tract to the desired size (6 mm). A neonatoscope (5.8 mm diameter; Olympus N 30, Tokyo, Japan) was introduced through the gastrostomy site into the dilator through the peel-away sheath (Fig. 1). The pylorus was catheterized, with progressive advancement of the endoscope as far as possible into the jejunum. A guidewire was then inserted through the operating channel of the endoscope with subsequent removal of the latter. With the wire remaining in place, a 16-F, 15-cm-long transgastric gastrojejunostomy feeding tube was passed into the jejunum under fluoroscopy. The position of the gastrojejunal feeding tube was checked radiologically (Fig. 2).
No technical difficulties occurred and the gastrojejunal feeding tube was placed successfully in all 3 patients. The time required to perform the whole procedure ranged from 15 to 20 minutes. Enteral feeding was started within 4 to 6 hours of the procedure. In parallel with jejunal feeding, the gastric tube was used for gastric decompression and drug administration in 2 patients.
No immediate (<24 hours) or late complication related to the gastrojejunostomy occurred. Nissen fundoplication was performed in 2 of the patients at 12 and 15 months of age, respectively. The gastrojejunostomy tube was still in place in the third patient at age 15 months and jejunal nutrition remained well tolerated.
Our first 3 cases demonstrate that 1-step endoscopic placement of a transgastric jejunal feeding tube without a preexisting gastrostomy tract is feasible in young infants presenting with underweight.
The 3 patients reported here were considered poor candidates for antireflux surgery or esophagogastric disconnection and therefore were selected for a jejunostomy. The most commonly used methods of placing a surgical jejunostomy are catheter placement via either a Witzel or Roux-en-Y jejunostomy. Both methods represent a long-term solution for postpyloric access, but surgical jejunostomy has its own set of complications. Like gastrojejunal tubes, these tubes may become dislodged or blocked. They are more easily replaced than gastrojejunal tubes once a mature fistula has developed from bowel to skin; however, the Roux jejunostomy has been associated with stromal prolapse and bile leakage (5).
Nonsurgical approaches to postpyloric access have been developed, including percutaneous endoscopic jejunostomy or fluoroscopically assisted placement of a percutaneous jejunostomy tube; however, these techniques have several technical difficulties especially in young children, including the application of reinforcers to secure and stabilize the jejunal limb to the anterior abdominal wall for ultimate jejunostomy tube insertion. Since its first description by Gottfried and Plumser in 1984, gastrojejunal feeding has been more widely used, especially when enteral nutrition via gastrostomy fails. Gastrojejunal tubes are superior to nasojejunal tubes in terms of patient comfort and minimization of activity limitation. In parallel with jejunal feeding, the gastric tube can be used for decompression and drug administration; however, this technique requires the presence of a preexisting gastrostomy to allow the tube to be placed through a mature gastrostomy tract (6,7).
Our technique allows the introduction of a neonatoscope through a de novo gastrostomy orifice after gastropexy during the same anesthesia time, with subsequent insertion of the gastrojejunal feeding tube. The main advantages over the “classical” 2-step procedure are being able to start jejunal feeding immediately and the saving of 1 episode of general anesthesia in fragile infants. It appears safe to perform and, based on our preliminary experience, could constitute a bridge to Nissen fundoplication at a later age after improvement of nutritional status and resolution of comorbidities.
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