Gastrojejunostomy tube complications - A single center experience and systematic review

Complication Rates and Variability in Gastrojejunostomy Tube Usage in Infants and Children

BACKGROUND

Gastrojejunostomy tube (GJT) placement is commonly performed for enteral access and post-pyloric feeding in children with gastric feeding intolerance. Prior studies have suggested the risk of surgical complications is elevated in infants compared to older children. We aim to characterize GJT usage in children and investigate the risk factors for postoperative complications through two national databases.

METHODS

We performed a multi-institutional retrospective cohort study on children who underwent GJT placement utilizing two national databases, the Pediatric American College of Surgeons National Surgical Quality Improvement Program (Ped-NSQIP) and the Pediatric Health Information System (PHIS). Analyses were performed within each cohort separately to determine differences in outcomes between infants (<1 year of age) and non-infants (≥1 year of age). Multivariable logistic regression was performed to determine associations with postoperative complications.

RESULTS

Infants did not have an increased rate of surgical complications compared to non-infants in the Ped-NSQIP cohort (26.9 % vs. 29.0 %, p = 0.84) or PHIS cohort (35.3 % vs. 30.7 %, p = 0.07). There was an increased risk of complications in African American infants (OR 1.93, 95 % CI 1.01-3.67) and non-infants (OR 1.64, 95 % CI 1.27-2.10) and for urgent procedures or emergent procedures in both infants and non-infants (OR 5.42-6.46 and OR 2.12-2.61, respectively). GJT placement and complication rates significantly varied across institutions.

CONCLUSION

We demonstrate substantial but similar overall complication rates of GJT placement between infants and non-infants. These findings suggest age alone should not negate placement of GJTs when indicated for enteral access in children.

LEVEL OF EVIDENCE: 3

TYPE OF STUDY

Multi-institutional, retrospective, cohort study.

Enteral access and reflux management in neonates with severe univentricular congenital heart disease: literature review and proposed algorithm

Neonates with severe congenital heart disease undergoing surgical repair may face various complications, including failure to thrive. Feeding tube placement and fundoplication are often performed to combat poor growth in neonates. With the variety of feeding tubes available and controversy surrounding when fundoplication is appropriate, there is no current protocol to determine which intervention is necessary for this patient population. We aim to provide an evidence-based feeding algorithm for this patient population. Initial searches for relevant publications yielded 696 publications; after review of these studies and inclusion of additional studies through external searches, a total of 38 studies were included for qualitative synthesis. Many of the studies utilized did not directly compare the different feeding modalities. Of the 38 studies included, five studies were randomized control trials, three studies were literature reviews, one study was an online survey, and the remaining twenty-nine studies were observational. There is no current evidence to suggest that this specific patient population should be treated differently regarding enteral feeding. We propose an algorithm to assist optimal feeding for neonates with congenital heart disease. Conclusion: Nutrition remains a vital component of the care of neonates with congenital heart disease; determining the optimal feeding strategy for these patients can be approached like other neonates.

Jejunal Feeding by Gastrojejunal Tube in Pediatric Refractory Gastroesophageal Reflux Disease

OBJECTIVES

The objective of this study is to determine whether jejunal nutrition by gastrojejunal tube (GJT) could be a therapeutic option for refractory gastroesophageal reflux disease (GERD), avoiding further antireflux surgery.

METHODS

A monocentric retrospective study was conducted for all children <18 years who underwent GJT placement to treat GERD. We collected data at the first GJT placement, 5 months after last GJT withdrawal, and at the end of the follow-up (June 2021).

RESULTS

Among 46 GERD patients with 86 GJT, 32 (69.6%) and 30 (65.2%) avoided antireflux surgery 5 and 28 months, respectively, after the definitive GJT removal. Five months after GJT removal, discharge from hospital, transition to gastric nutrition, GERD complications, and treatment were significantly improved. Median age and weight at the first GJT placement were 7 months and 6.8 kg. Patients had digestive comorbidities or complicated GERD in 69.6% and 76.1% patients, respectively. The median duration of jejunal nutrition using GJT was 64.5 days. GJT had to be removed in 63 (75.9%) cases for technical problems.

CONCLUSIONS

Jejunal nutrition by GJT could be an alternative to antireflux surgery avoiding sustainably antireflux surgery in most of complicated GERD patients. The high frequency of mechanical complications raises that these devices should be technically improved.

Prophylactic antireflux procedures are not necessary in neurologically impaired children undergoing gastrostomy placement

PURPOSE

Fundoplication is frequently used in children with neurologic impairment even in the absence of reflux due to concerns for future gastric feeding intolerance, but supporting data are lacking. We aimed to determine the incidence of secondary antireflux procedures (fundoplication or gastrojejunostomy (GJ)) post gastrostomy tube (GT) placement in children with and without neurologic impairment.

METHODS

Children under 18 undergoing a GT placement without fundoplication between 2010 and 2020 were identified utilizing the PearlDiver Mariner national patient claims database. Children with a diagnosis of cerebral palsy or a degenerative neurologic disease were identified and compared to children without these diagnoses. The incidence of delayed fundoplication or conversion to GJ were compared utilizing Kaplan-Meier and Cox proportional hazards regression analyses.

RESULTS

A total of 14,965 children underwent GT placement, of which 3712 (24.8%) had a diagnosis of neurologic impairment. The rate of concomitant fundoplication was significantly higher among children with a diagnosis of neurologic impairment as compared to those without (9.3% vs 6.4%, p < 0.001). While children with neurologic impairment had a significantly higher rate of fundoplication or GJ conversion at 5 years compared to children without (12.6% [95% confidence interval (CI): 11.4%-13.8%] vs 8.6% [95% CI 8.0%-9.2%], p < 0.001), the overall incidence remained low.

CONCLUSION

Although children with neurologic impairment have a higher rate of requiring an antireflux procedure or GJ conversion than other children, the overall rate remains less than 15%. Fundoplication should not be utilized in children without clinical reflux on the basis of neurologic impairment alone.

Weighted Tip Extensions Result in Fewer Gastrojejunostomy Tube Migrations and Increase Tube Lifespan

PURPOSE

To investigate the safety and efficacy of attaching a weighted extension to the distal aspect of prefabricated gastrojejunostomy (GJ) tubes, and to determine whether this alteration reduces the occurrences of tip reflux into the esophagus or stomach.

MATERIALS AND METHODS

This retrospective 1-way crossover study included 64 GJ tubes in 15 patients placed by multiple operators in the interventional radiology department at a single institution from July 1, 2019, to December 1, 2021. Patients were selected for a weighted tip extension if they required a GJ tube exchange because of the distal tip refluxing into the stomach or esophagus and were aged ≥18 years. These modified GJ tubes were prepared by cutting the distal end of a nasojejunal tube to a length of 10-15 cm and suturing to the distal aspect of the GJ tube.

RESULTS

Of the 64 tubes studied, 37 had a weighted tip extension. The unmodified GJ tubes had a mean lifespan of 34.3 days, which was significantly shorter than the weighted tips (92.8 days; t test P = .001). There was 1 limited adverse event of abdominal pain and spasms that resolved after exchange with a shorter weighted extension.

CONCLUSIONS

This study suggests that for patients who require a GJ tube replacement because of the tip refluxing proximally into the stomach or esophagus, the addition of a 10-15-cm weighted extension to the distal end of the GJ tube is safe and significantly improves the lifespan of the enteric tube.

Routine Elective Gastrojejunostomy Tube Changes Are Associated With Reduced Tube Complications and Radiation Exposure

Gastrojejunostomy tubes (GJTs) can be a long-term solution for patients with intragastric feeding intolerance. Our retrospective study of 101 patients correlates the frequency of routine and urgent GJT changes, as well as complications and radiation exposure. Over a 2.75-year median duration, 60%, 33%, and 28% of patients had >1 episodes of a tube dislodgement/malpositioning, blockage, or leakage, respectively. Aspiration pneumonia hospital admission was required for 23% of patients. Patients with <1 routine tube change/year had more urgent changes/year (3.0) compared to patients with 1-2 (1.2) or >2 (0.8) routine yearly change. These patients required more frequent sedation for tube placement (21% vs 4.7%, P = 0.03) and experienced greater annual radiation exposure (9599 vs 304.5 and 69.1 μGym 2 , P = 0.01 and 0.008, respectively). Overall, aiming for a routine tube change at least every 6-12 months is associated with fewer urgent changes and complications as well as reduced radiation exposure and sedation requirements.

Postpyloric Feeding Access in Infants and Children: A State of the Art Review

Achieving postpyloric feeding access is a clinical challenge faced by the pediatric gastroenterologist in everyday practice. Currently, there is limited literature published on the topic. This article provides a practical summary of the literature on the different methods utilized to achieve postpyloric feeding access including bedside, fluoroscopic, endoscopic and surgical options. Indications and complications of these methods are discussed as well as a general approach to infants and children that require intestinal feeding.

Gastrojejunal (GJ) tube feeding: developing a service and evaluating associated complications in a paediatric surgical centre

INTRODUCTION

Gastrojejunal (GJ) tubes are becoming an established alternative method of delivering nutrition to children who do not tolerate gastric feeding. However, there is limited literature surrounding patient outcomes, the longevity of tubes or complications. We aim to highlight the development and evaluation of a service to provide children with GJ tube feeding.

MATERIALS AND METHODS

A retrospective case-note review of children either undergoing an initial gastrostomy to gastrojejunal tube conversion or gastrojejunal tube replacement in our tertiary paediatric surgical centre between January 2015 and June 2018.

RESULTS

134 GJ feeding tubes were placed in 33 neurologically impaired children with a median age of 4.9 years (8 months-17 years) having a median 4 tube placements per child (1-11) within the study period. All tubes were 14 or 16 Fr 'AMT G-JET' tubes with a median replacement time of 174.9 days (13-504 days). The most common indication was foregut dysmotility in children with global developmental delay. The complication rate was 34.3% (46 tubes). In the study period, 2 patients (6.1%) reverted to oral feeding, 6 patients (18.2%) to gastric feeding and 25 children (75.7%) continued with jejunal feeding. No child required fundoplication. There were no procedure-related mortalities or mortality.

CONCLUSIONS

GJ tube feeding is an effective and safe method of managing children with foregut dysmotility. Many patients do not require permanent jejunal feeding, and thus the reversibility of this method is an asset. A dedicated team is needed to co-ordinate tube replacements and provide efficient long-term jejunal feeding.

LEVEL OF EVIDENCE

IV.

Endoscopic Gastrojejunostomy in Infants and Children

OBJECTIVE

To evaluate the feasibility of endoscopic gastrojejunal tube (GJT) placement in infants and children.

STUDY DESIGN

All children undergoing endoscopic GJT placement between January 2010 and December 2019 were included in this single-center retrospective study. Difficulties with and failure of GJT placement, complication rates, and device longevity, efficacy, and duration were assessed.

RESULTS

A total of 107 children, median age 10 months (IQR, 5.0-23.0 months) and median weight 6.6 kg (IQR, 5.3-9.5 kg), underwent endoscopic GJT placement using the gastric stoma to introduce the endoscope (one step: n = 36 of 107; 33.6%). Endoscopic placement was successful in 99%. Eight periprocedure complications occurred, including 1 pneumoperitoneum requiring exsufflation, 2 acute pulmonary hypertension episodes leading to death in 1 case, and 5 episodes of bronchospasm. Minor complications were frequent and mostly mechanical (79%), whereas major complications were rare (5.6%): intussusception (n = 4), intestinal perforation (n = 1), and pneumoperitoneum (n = 1). Ten patients died. Of the 97 patients who lived, 85 (87%) were weaned from jejunal feeding at a median of 179 days (IQR, 69-295 days) after initiation. Among them, 30 (35.2%) required fundoplication. Weight for age z-score was significantly higher at weaning.

CONCLUSIONS

GJT placement is feasible in children, even low-weight infants. Complications are frequent but are mostly minor.

Is Roux-en-Y Feeding Jejunostomy a Safe and Effective Operation in Children? A Systematic Review Exploring Outcomes

OBJECTIVES

Roux-en-Y jejunostomy (REYJ) may establish feeding in children with foregut dysmotility or severe gastro-esophageal reflux disease (GERD). Nevertheless, concerns have been raised about safety and efficacy. We, therefore, evaluated outcomes of REYJ by systematic review to determine if this was a satisfactory option for achieving enteral autonomy in children with complex nutritional needs.

METHODS

A PRISMA-adherent systematic review was conducted of studies reporting children undergoing feeding REYJ. Two authors performed processes independently; the senior author resolved disagreements. Embase, CINAHL and Medline were searched (inception-01/21). Additional databases, references, and 'grey' literature were searched. Methodological Index for Non-randomized Studies (MINORS) and a bespoke system assessed methodological quality.

RESULTS

Of 362 articles, 10 met eligibility criteria (9 retrospective series; 1 conference proceeding). Unpublished data were also attained. Interobserver agreement for MINORS (kappa = 0.47) and bespoke scoring (kappa = 0.58) were moderate. After consensus, median MINORS score was 37.5% (IQR 6.3%) and bespoke 50% (IQR 20.8%), indicating poor methodological quality. One hundred sixty-four patients were reported (age range: 2 months to 19 years). Time to full feeds and length of stay were inadequately reported but most achieved enteral autonomy. No studies reported patient/caregiver-questionnaires. Seventy-six complications were documented (Clavien-Dindo grading was infeasible). Morbidity included peristomal leakage (N = 26), internal hernia/volvulus (N = 8), and SSI (N = 7). Thirty-eight patients died (2 procedure-attributable) during follow-up (range: 1 month to 15 years).

CONCLUSIONS

Up to 50% patients experience complications after REYJ (often minor) with 23% patients dying during follow-up, often comorbidity-attributable. REYJ can achieve enteral autonomy although parents/caregivers of children should be counselled accordingly.

Cost evaluation of two types of gastrojejunal feeding tubes used in pediatric patients

BACKGROUND

Gastrojejunal tubes are important feeding devices for children with gastro-esophageal reflux, allowing medication and feeding into the small bowel, and allowing gastric venting to prevent reflux. As with many medical devices, there are multiple manufacturers and designs, including balloon-retained tubes and disc-retained tubes.

OBJECTIVE

This study evaluated the cost difference between these two types of gastrojejunal tube.

MATERIALS AND METHODS

We conducted a 3.5-year retrospective cost evaluation for all pediatric patients undergoing an insertion or change of gastrojejunal tube using a bottom-up micro-costing analysis. We calculated days between encounters and a subsequent cost per day for each patient.

RESULTS

A total of 187 children and adolescents were included, with an average age of 9.2 years. They underwent a total of 1,240 encounters, an average of 6.6 encounters per patient during the study period. A total of 82% of these encounters were related to balloon-retained tubes and 18% to disc-retained tubes. The most common reason for an encounter was a routine change (57%), with mechanical complications accounting for 31%. Disc-retained tubes had a longer period between encounters (117.5 days) than balloon-retained tubes (95 days; P=0.038). However, disc-retained tubes cost 6.9 British pound sterling (GBP) per day, which was significantly higher than balloon-retained tubes at 5.2 GBP per day (P<0.0001).

CONCLUSION

Despite being more expensive to purchase, balloon-retained tubes were noted to be the least costly device in a cost-per-day analysis.

Intussusception Caused by Percutaneous Endoscopic Gastrostomy With Jejunal Extension in Patients With Severe Motor and Intellectual Disabilities

The risk of intussusception related to percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) in patients with severe motor and intellectual disabilities (SMID) remains unknown. In a cross-sectional study, a review of 26 patients (mean age, 11.6 ± 6.4 years) with SMID who underwent PEG-J was performed. During the follow-up period, 6 of 26 (23%) patients developed intussusception. The median period from PEG-J to the onset of intussusception was 364 (range, 8-1344) days. No significant difference was observed in the Cobb angle between the intussusception and nonintussusception groups; however, body mass index at the time of PEG-J was significantly lower in the intussusception group. Intussusception related to PEG-J occurs relatively frequently in patients, and it is possibly attributable to factors such as deformity caused by undernutrition and weight loss. If enteral nutrition via PEG-J has been established, earlier enterostomy can be recommended because of the high risk of intussusception in patients with SMID.

What are the new guidelines and position papers in pediatric nutrition: A 2015-2020 overview

BACKGROUND

Nutrition related publications in pediatric population cover wide range of topics and therefore it is usually difficult for clinicians to get an overview of recent nutrition related guidelines or recommendations.

METHODS

The Special Interest Group (SIG) of Pediatrics of European Society for Clinical Nutrition and Metabolism (ESPEN) performed a literature search to capture publications in the last five years aiming to provide the latest information concerning nutritional issues in children in general and in specific diseases and to discuss progression in the field of pediatric nutrition evidence-based practice.

RESULTS

Eight major topics were identified as the most frequently reported including allergy, critical illness, neonatal nutrition, parenteral and enteral nutrition, micronutrients, probiotics and malnutrition. Furthermore, it was noted that many reports were disease focused or included micronutrients and were, therefore, represented as tables.

CONCLUSION

Overall, it has been shown that most reports on nutrition topics in pediatrics were systematic reviews or guidelines/position papers of relevant societies, but many of them basing the conclusion on a limited number of high-quality randomized controlled trials or large observational cohort studies.

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

BACKGROUND

Gastrojejunostomy (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 TECHNIQUE

We 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.

RESULTS

Eleven 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.

CONCLUSION

The 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 EVIDENCE

IV.

Family mealtime behaviors in children who are tube fed and preparing to transition to oral eating: A comparison to other pediatric populations

This study examined differences in observed mealtime behaviors between children preparing to transition to oral feeding and children with various other chronic illnesses using a standardized measure of mealtime beaviors. The parent-child mealtime relationship can become strained due to problematic mealtime behaviors that limit food intake, as well as inadvertent reinforcement of disruptive behavior by caregivers. Frequency/rate of behaviors were compared between children with tube feeding (CwTF) and from previous studies of children with chronic illnesses using the Dyadic Interactive Nomenclature for Eating (DINE). Parents of CwTF used more coaxing, physical prompts, and reinforcement during meals, while parents of children with chronic illnesses used more direct commands and engaged in more parent talk. Findings support differences in parent-child mealtime interactions and eating behaviors across pediatric illness subgroups.

Botulinum Toxin as a Treatment for Feeding Difficulties in Young Children

OBJECTIVE

To determine the effectiveness of intrapyloric botulinum toxin injection (IPBI) for treatment of feeding disorders and associated gastrointestinal symptoms in very young children.

STUDY DESIGN

A single-center retrospective study of patients 2 months to 5 years old who received IPBI at Boston Children's Hospital from May 2007 to June 2019 was performed. Charts were reviewed for demographic data, comorbidities, symptoms leading to IPBI, oral and tube feeding data, symptom improvement after IPBI, and need for repeat injections. The primary outcome was symptom improvement at the first gastroenterology clinic visit following IPBI. Secondary outcomes included improvement in oral feeding, decreases in tube feeding, and need for repeat injections. The χ² or Fisher exact tests and multivariate logistic regression were used to identify factors associated with symptomatic improvement.

RESULTS

A total of 85 patients who received 118 injections were included in the final analysis; 57 patients (67%) had partial or complete improvement in symptoms after IPBI. Among the 55 patients with enteral tubes, there was an improvement in feeding, with more patients receiving at least some oral feeds after IPBI compared with before (26/55 vs 15/55; P = .004) and fewer patients receiving postpyloric feeds after IPBI compared with before (12/55 vs 21/55; P = .01). Twenty-six patients (31%) received repeat IPBI within 1 year, with only 6 patients receiving IPBI more than twice.

CONCLUSIONS

IPBI is safe and effective in young children. Children with enteral tubes show improvement in oral feeding and reduction in need for postpyloric feeding after IPBI.

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

BACKGROUND

Gastrojejunostomy 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.

METHODS

We 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.

RESULTS

Sixty 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).

DISCUSSION

A 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 STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Combined laparoscopic-fluoroscopic technique for primary gastrojejunostomy button tube placement

BACKGROUND

Gastrojejunostomy (GJ) tubes are frequently used to provide pediatric enteral nutritional support for pediatric patients. Various placement methods have been described, each with attendant advantages and disadvantages.

DESCRIPTION OF THE OPERATIVE TECHNIQUE

We present a technique for primary laparoscopic/fluoroscopic GJ button tube placement designed to avoid delay in placement of the jejunal limb, and difficulties associated with endoscopic-assisted and primary fluoroscopic placement.

RESULTS

There were 52 gastrojejunostomy button tubes placed via this technique in patients ranging from 3.8 to 90.3 kg in weight. Three postoperative complications were identified; one bowel perforation on postoperative day two, and two tube dislodgements within 30 days.

CONCLUSION

The described technique was uniformly effective and was associated with a low complication rate (5.8%).

Major complications of jejunal feeding in children

AIM OF THE STUDY

The aim of the study was to identify major gastrointestinal complications associated with direct jejunal feeding. We hypothesized that jejunal feeding may cause life-threatening surgical complications in a minority of patients.

METHODS

All patients undergoing jejunal feeding between 1/2008 and 1/2018 at a pediatric surgical unit were identified retrospectively. Data sought from records included demographics, comorbidities, indications, feeding strategies, adverse events, and follow-up. Major surgical complications were defined by Clavien-Dindo grade ≥ IIIb and involving the GI tract (excluding changes of jejunal tube).

MAIN RESULTS

197 patients were identified (110 female). Median age (IQR) at initiation of jejunal feeding months was 5.6 (6-164) months. 122 were neurologically impaired. The most frequent indications were: GERD/gastroparesis (n = 114), prophylaxis/treatment of Superior Mesenteric Artery (SMA) syndrome (N.B. our center is a national spinal deformity unit) (n = 47), congenital anomalies of aerodigestive anatomy (n = 17), and malignancy (n = 7). 125 patients were managed with nasojejunal feeding alone: gastrojejunal tube (n = 51) and via Roux-en-Y jejunostomy (n = 21). There were 14 significant gastrointestinal complications (n = 11 grade > IIIb) identified among 12 patients, of whom 8 required bowel resections, and 2 died as a result: nonmechanical bowel ischemia (n = 7), intussusception (n = 4), and volvulus (n = 3).

CONCLUSION

This series highlights the major complications of jejunal feeding, including a significant yet underreported risk of gut compromise. Patients undergoing jejunal feeding had a 6.1% risk of developing major surgical complications (of note, 3.6% developed bowel ischemia of unknown etiology). Susceptible children were comorbid, fragile, and neurologically impaired. These findings should influence parental discussions and informed consent before embarking upon jejunal feeding.

LEVEL OF EVIDENCE

Level IV prognosis study.

Feeding tubes in children

PURPOSE OF REVIEW

A practical guide to different feeding tubes available for nutritional support in children, focused on indications, placement methods and complications.

RECENT FINDINGS

Enteral nutritional support refers to the delivery of nutrition into the gastrointestinal tract distal to the oesophagus. Different feeding tubes are available for exclusive or supplemental nutritional support in children who are unable to independently sustain their own growth, nutritional and hydration status. Gastric feeding is the first choice; however, jejunal feeding provides a good alternative route in the presence of contraindications or intolerance. Feeding tubes can be short or long term: nasogastric and nasojejunal tubes provide short-term nutrition support, gastrostomy and jejunostomy tubes, long-term enteral feeding. The latter are established surgically through the formation of a stoma, an artificial connection between gastric or jejunal lumen and the abdominal wall, performed either endoscopically (percutaneous endoscopic gastrostomy, percutaneous endoscopic gastrojejunostomy) or surgically (gastrostomy, direct jejunostomy). Awareness of different available options, technical considerations and potential risks will inform the decision-making process for an individual patient to ensure the correct balance between adequate enteral nutritional and unnecessary morbidity.

SUMMARY

Successful administration of nutrition support requires knowledge of the correct indication, route and specific functional details of the appropriate feeding tube.

Surgical jejunostomy and radiological gastro-jejunostomy tube feeding in children: risks, benefits and nutritional outcomes

PURPOSE

Radiologically inserted gastrojejunal tubes (RGJ) and surgical jejunostomy (SJ) are established modes of jejunal feeding. The aim of the study is to review nutritional outcomes, complications and the practical consideration to enable patients and carers to make informed choice.

METHODS

Retrospective review of patient notes with a RGJ or SJ in 2010, with detailed follow-up and review of the literature.

RESULTS

Both RGJ and SJ are reliable modes to provide stable enteral nutrition. Both have complications and their own associated limitations.

CONCLUSIONS

The choice has to be tailored to the individual patient, the social care available, the inherent medical disease and risk/benefit of repeated anaesthetic and radiation exposure. RGJ and SJ are important tools for nutritional management that achieve and maintain growth in a complex group of children. The risk and benefits should be reviewed for each individual patient.

How to Recognize, Avoid, or Get Out of Trouble in Pediatric Interventional Radiology

The average clinical practice of most interventional radiologists focuses on the care of adults (for practical purposes, defined as most patients over age 15). However, an increasing number of pediatric patients are being referred to Interventional Radiologists for evaluation and possible treatment. In some cases, these patients may not require significant deviation from the normal procedures of the lab (e.g., a 160 pound 14-year-old), although they may be designated as a pediatric patient by the anesthesia support team. In others, modifications must be made to ensure the safe and effective treatment of these patients (e.g., a 0.5 kg neonate). Unlike the specialty of adult interventional radiology (IR), pediatric interventional radiology (PIR) is relatively nascent. Like adult IR 10-15 years ago, PIR still competes for name recognition and even at the largest of pediatric medical centers, is involved in the political skirmishes that might make the most seasoned adult interventionalist smile (or cringe) in reminiscence. The field of PIR is growing rapidly and demands on these specialized practitioners are increasing. Some hospitals/centers have fellowship-trained Pediatric Interventional Radiologists who can attend to these patients, but others defer to the adult IR practitioners. Herein, we offer some thoughts on how to help the pediatric patient for our PIR and adult IR colleagues. These thoughts focus on preprocedural planning, optimizing intraprocedural success, and minimizing procedural morbidity. Throughout the process of preparing for a pediatric patient, it pays to recall the oft-recited mantra from medical school: "Kids are not just small adults."