A modified feeding Roux-en-Y jejunostomy in the neurologically damaged child

Laparoscopic Roux-en-Y feeding jejunostomy as a long-term solution for severe feeding problems in children

Enteral feeding is a common problem in children with gastric emptying disorders. Traditional feeding methods in these patients often show a high rate of complications and maintenance issues. Laparoscopic Roux-en-Y feeding jejunostomy (LRFJ) has been described in a few patients as a minimal invasive option for enteral access in these children. The aim of this study is to evaluate the outcomes of the LRFJ procedure in our tertiary referral center. We conducted a retrospective case-series including all patients, aged 0-18 years old, that underwent a LFRJ procedure between August 2011 and December 2020 for the indication of oral feeding intolerance due to delayed gastric emptying. Outcomes evaluated were complications (short and long term) and parenteral satisfaction. In total, 12 children were identified that underwent LRFJ for the indication of oral feeding intolerance due to delayed gastric emptying. A total of 16 complications were noted in 8/12 patients (67%). Severity classified by Clavien-Dindo were grade I (n = 13), grade II (n = 1), and grade IIIB (n = 2). In 11/12 patients, parents were satisfied with the results.

CONCLUSIONS

Although minor complications after LRFJ are common in our patients, this technique is a safe solution in patients with gastric emptying disorders leading to a definitive method of enteral feeding and high parenteral satisfaction.

WHAT IS KNOWN

• Traditional tube feeding in children (duodenal, PEG-J-tubes) with severe delayed gastric emptying can be challenging with a high rate of complications and maintenance issues. • Open loop jejunostomy and Roux-en-Y jejunostomy are alternative, permanent methods of feeding but either invasive or are accompanied by severe complications. Little is known in the literature about laparoscopic Roux-en-Y feeding jejunostomy.

WHAT IS NEW

• Laparoscopic Roux-en-Y feeding jejunostomy is a permanent, safe and minimal invasive alternative option for enteral feeding in children with severe delayed gastric emptying..

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.

Assessment of the safety and efficacy of percutaneous laparoscopic endoscopic jejunostomy (PLEJ)

INTRODUCTION AND AIMS

Gastric feeding may not be possible in the neurologically impaired child with foregut dysmotility. Post-duodenal feeding can be crucial, thereby avoiding the need for parenteral nutrition. The aim of this study is to evaluate the technical success, complication and clinical outcome of our institution's technique in creating a jejunostomy using the percutaneous laparoscopic-endoscopic jejunostomy (PLEJ) technique.

METHODS

Retrospective review of all paediatric patients (<18) with PLEJ between January 2008 and April 2015 was conducted. Patients were identified using the electronic procedure code and clinic letters. Data were collected in regard to the procedure technical success, short and long-term complications and clinical outcomes.

RESULTS

Sixteen patients (age range, 2-17years) were identified. The procedure was successful in all cases. At a median follow up of 25months, eleven patients (68%) had significant improvement of their symptoms of feeding intolerance/aspirations and are permanently PLEJ fed and two (13%) were regraded to gastric feeds. Two patients moved from total parenteral nutrition to partial parenteral nutrition while on PLEJ feeds. All patients had experienced weight gain and either went up or maintained their weight centile. The only major complication was small bowel volvulus encountered in two patients with abnormal gastrointestinal anatomy requiring surgical intervention.

CONCLUSIONS

In our small case series, PLEJ placement was safe as it provides valuable visualization of the bowel loops intraabdominally. It is a technically feasible and successful approach for children requiring long-term jejunal feeding especially those with foregut dysmotility.

Long-term and 'patient-reported' outcomes of total esophagogastric dissociation versus laparoscopic fundoplication for gastroesophageal reflux disease in the severely neurodisabled child

AIM

Fundoplication has high failure rates in neurodisability: esophagogastric dissociation (TOGD) has been proposed as an alternative. This study aimed to compare the long-term and 'patient-reported' outcomes of TOGD and laparoscopic fundoplication (LapFundo).

METHODS

Matched cohort comparison comprises (i) retrospective analysis from a prospective database and (ii) carer questionnaire survey of symptoms and quality of life (CP-QoL-Child). Children were included if they had severe neurodisability (Gross Motor Function Classification System five) and spasticity.

RESULTS

Groups were similar in terms of previous surgery and comorbidities. The TOGD group was younger (22 vs. 31.5months, p=0.038) with more females (18/23 vs. 11/24, p=0.036). TOGD was more likely to require intensive care: operative time, length of stay and time to full feeds were all longer (p<0.0001). Median follow-up was 6.3 and 5.8years. Rates of complications were comparable. Symptom recurrence (5/24 vs. 1/23, p=0.34) and use of acid-reducing medication (13/24 vs. 4/23, p=0.035) were higher for LapFundo. Carer-reported symptoms and QoL were similar.

CONCLUSIONS

TOGD had similar efficacy to LapFundo (with suggestion of lower failure), with comparable morbidity and carer-reported outcomes. However, TOGD was more 'invasive,' requiring longer periods of rehabilitation. Families should be offered both procedures as part of comprehensive preoperative counseling.

Management of small bowel volvulus around feeding Roux-en-Y limbs

BACKGROUND

Patients' inability to take oral nutrition calls for alternative feeding. In selected pediatric patients, traditional feeding tubes are not tolerated and jejunal feeding tubes can be obstructive. One option is a Roux-en-Y feeding limb. Our institution noted complications secondary to small bowel volvulus around this limb. Goals of this study were to review patients who experienced volvulus after Roux-en-Y creation, and to identify factors contributing to this complication.

METHODS

Institutional review board approval was obtained for a retrospective chart review. 25 patients were identified as having a Roux-en-Y jejunal feeding limb. Five developed volvulus. Factors documented included age, time to complication, revision, and outcome.

RESULTS

Average age at limb creation was not statistically significant between those with or without volvulus. Mean time to obstruction was 228 +/- 117 days post-limb creation. Average limb length was 18.7 +/- 7 cm in patients with volvulus, 14 +/- 2.3 cm in patients without. 3 of 5 patients presenting with volvulus were discharged home after revision; two patients died.

CONCLUSION

There is no definitive way to prevent small bowel volvulus around Roux-en-Y feeding limbs. No predictors of volvulus were identified. Once revised, no recurrences were observed. While this complication is uncommon, it has potentially catastrophic outcomes requiring early intervention.

Button-loop feeding jejunostomy

INTRODUCTION

Post-pyloric feeding via a surgical jejunostomy allows for enteral nutrition in patients that cannot receive oral or gastric feeding. Regardless of the technique used to create a jejunostomy, complications such as tube dislodgement, jejunostomy closure, or bowel obstruction can occur.

SURGICAL TECHNIQUE

We present a simple and efficient jejunostomy technique that does not require a sewn anastomosis and employs an easily exchangeable feeding button.

Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case-control study

BACKGROUND/PURPOSE

Recurrent gastroesophageal reflux disease (rGERD) is a common problem after fundoplication. Previous studies attempting to identify risk factors for rGERD have failed to control for confounding variables. The purpose of this study was to identify significant risk factors for rGERD after controlling for potential confounding variables.

METHODS

A retrospective, matched case-control study was conducted at a tertiary children's hospital. Cases (n = 116) met 1 of these criteria: reoperation for rGERD, symptomatic rGERD (confirmed by upper gastrointestinal series, esophagogastroduodenoscopy, or pH monitoring), or postoperative reinstitution of antireflux medication for more than 8 weeks. Controls (n = 209) were matched for surgeon, approach (laparoscopic/open), technique (partial/complete), and approximate operative date. Univariate and multivariable associations were analyzed by conditional logistic regression.

RESULTS

Significant risk factors for rGERD were age of less than 6 years (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7-7.5), preoperative hiatal hernia (OR, 3.2; 95% CI, 1.4-7.3), postoperative retching (OR, 5.1; 95% CI, 2.6-10.0), and postoperative esophageal dilatation (OR, 10.8; 95% CI, 1.8-65.4). Interestingly, significant association was not found between neurologic impairment and rGERD after controlling for potential confounding variables.

CONCLUSION

Age of less than 6 years, preoperative hiatal hernia, postoperative retching, and postoperative esophageal dilatation are independently associated with increased risk of rGERD. Neurologic impairment alone does not increase the risk of developing rGERD.

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.

Esophagogastric dissociation in the neurologically impaired: an alternative to fundoplication?

BACKGROUND/PURPOSE

Gastroesophageal reflux is common in children with severe neurological impairment. Fundoplication may produce symptomatic improvement but has a high failure rate. Esophagogastric dissociation (EGD) is an alternative procedure for treatment of gastroesophageal reflux. The aim of this study is to evaluate the results of EGD in our institution and compare them with a neurologically matched group of children who had Nissen fundoplication.

METHODS

Twenty consecutive patients who had EGD were retrospectively evaluated and the results were compared with a neurologically matched group of 20 consecutive patients who had Nissen fundoplication.

RESULTS

Twenty patients had EGD, 17 as a primary procedure. There was no operative mortality but 5 have died of other causes. Resolution of reflux-associated symptoms occurred in all patients. Of the 15 survivors, 5 remain on antireflux medication. Twenty patients had fundoplication. There was no operative mortality, but 8 patients have died of other causes. Failure occurred in 5 patients necessitating further surgery. Of the 10 unreoperated survivors, 6 remain on antireflux medication.

CONCLUSIONS

Esophagogastric dissociation is an effective antireflux procedure when compared with fundoplication. It has a lower failure rate. We recommend EGD as a primary procedure in selected children with severe neurological impairment.

Laparoscopic Roux-en-Y Feeding Jejunostomy: A New Minimally Invasive Surgical Procedure for Permanent Feeding Access in Children with Gastric Dysfunction

Long-term feeding access in children with foregut dysfunction has traditionally been achieved by gastrostomy tube placement with or without fundoplication. Alternatives after failed procedures have included re-do fundoplication, transpyloric gastrojejunal tube placement, loop jejunostomy (open or laparoscopic), and open Roux-en-Y jejunostomy. We describe a new technique, laparoscopic Roux-en-Y feeding jejunostomy (LRFJ), which offers a minimally invasive option in providing long-term enteral access to these children. Five children, ages 10 months to 9 years (mean age, 3.4 years), weighing 8.8 to 15.2 kilograms (mean weight, 12.3 kg), underwent LRFJ. Four children had mental retardation/cerebral palsy. In 3 children, LRFJ was the only intra-abdominal procedure performed. No technical complications related to the procedure were observed. Mean operative time was 98 minutes in the children in which LRFJ was the only procedure performed. Enteral feeds were typically begun by postoperative day (POD) 5. Follow-up has ranged from 12 to 30 months (mean follow-up, 23 months). All 4 survivors remain on full jejunal feedings and are doing well. One child developed stomal stenosis requiring dilatation. In summary, LRFJ can be performed safely in children with gastric dysfunction, may be performed in conjunction with a variety of other laparoscopic procedures, and offers a new option for nutritional access in this challenging pediatric population.

The failed fundoplication

Fundoplication is the standard surgical approach to gastroesophageal reflux (GER) in a child. Although successful in many patients, there is a significant risk of complications and failure, especially in high-risk patients such as those with certain types of associated anomalies, diffuse motility disorders, chronic pulmonary disease, neurologic impairment, and young infants. Fundoplication failure can take the form of persistent reflux-related symptoms, symptoms that are caused by complications of the surgery, or anatomic problems such a para-esophageal hernia or migration of the wrap into the mediastinum. The most effective strategy for treatment of the child undergoing fundoplication is to prevent failure by careful patient selection, individualization of the operation based on the patient's anatomy and physiology, and meticulous attention to the technical details of the operation. Options for the child with a failed fundoplication include medical management, jejunal feeding using a percutaneous tube or a Roux-en-Y jejunostomy, revision of the fundoplication, or esophagogastric dissociation. If the fundoplication is to be revised, the same principles of patient selection, individualization of the operation, and attention to technique must be used to optimize the chance of success. The primary goal in the treatment of GER is to improve quality of life for the patient and the family.

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 is an alternative when antireflux surgery fails, or is hazardous or inappropriate.

AIMS

To review experience of gastrojejunal (G-J) feeding over six years in two regional centres in the UK.

METHODS

Retrospective review of all children who underwent insertion of a G-J feeding tube.

RESULTS

There were 18 children, 12 of whom were neurologically impaired. G-J tubes were inserted at a median age of 3.1 years (range 0.6-14.7) because of persistent symptoms after Nissen fundoplication (n = 8) or symptomatic GOR where fundoplication was inappropriate. Four underwent primary endoscopic insertion of the G-J tube; the remainder had the tube inserted via a previous gastrostomy track. Seventeen showed good weight gain. There was one insertion related complication. During a median follow up of 10 months (range 1-60), four experienced recurrent aspiration, bilious aspirates, and/or diarrhoea. There were 65 tube related complications in 14 patients, necessitating change of the tube at a median of 74 days. Jejunal tube migration was the commonest problem. Five died from complications of their underlying disease.

CONCLUSIONS

Although G-J feeding tubes were inserted safely and improved nutritional status, their use was associated with a high rate of morbidity. Surgical alternatives such as an Roux-en-Y jejunostomy may be preferable.

Nutritional support at home and in the community

Technical developments in feeding, together with the growth of support structures in the community has lead to a steady increase in the number of children receiving home enteral tube feeding and home parenteral nutrition. In many cases the adverse nutritional consequences of disease can be ameliorated or prevented, and long term parenteral nutrition represents a life saving intervention. Careful follow up of children receiving home nutritional therapy is necessary to establish the ratio of risks to benefits. A considerable burden is sometimes placed on family or other carers who therefore require adequate training and ongoing support. The respective responsibilities of different agencies relating to funding and support tasks require more clear definition.