Jejuno-jejunal intussusception caused by a percutaneous endoscopic gastrojejunostomy tube in a pediatric patient: A case report

RATIONALE

Although percutaneous endoscopic gastrojejunostomy (PEG-J) tubes are believed to reduce the side effect of aspiration, cautious catheter management is required. Intussusception is a serious complication of these tubes.

PATIENT CONCERNS

A 7-year-old boy bedridden with hypoxic encephalopathy owing to drowning at the age of 1 year was admitted our hospital with urinary retention for 1 month. At the age of 4 years, a PEG-J tube was inserted. Concomitant with hyperaldosteronemia, an intestinal intussusception from the duodenum to the jejunum was observed via computed tomography (CT). The patient's condition worsened dramatically; gastrointestinal perforation was suspected, and laparotomy was performed.

DIAGNOSIS

Jejuno-jejunal intussusception.

INTERVENTIONS

Open surgery was performed to release the intussusception. By assessing the reduced intestinal tract, the intussusception starting from a 50 cm portion from the Treitz ligament had been extended to 100 cm from the Treitz ligament. The oral side jejunum was dilated. No evidence of intestinal perforation or strangulated ileus was observed, and the intussusception was manually remediable.

OUTCOMES

Preoperative CT examination showed intussusception from the duodenum to the jejunum. Laparotomy showed intussusception on the anal side of the Treitz ligament. With regard to the CT findings associated with the progression of intussusception to the duodenal site, as a result of the telescope phenomenon extending to the duodenum due to the relaxation of the Treitz ligament through repeated intussusception, it was considered that CT examination revealed intussusception extending from the jejunum to the duodenum of oral side. After 3 postoperative weeks, the patient was finally able to return home.

LESSONS

If the ileus is observed during the insertion of a PEG-J, clinicians should consider the possibility of intussusception even in the duodenum.

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%).

Preoperative Evaluation Is Not Predictive of Transpyloric Feeding Conversion in Gastrostomy-dependent Pediatric Patients

OBJECTIVES

Limited literature exists as to whether preoperative gastrostomy (GT) evaluation may predict which patients will go onto require gastrojejunostomy (GJ) tube feeding. The goal of this study was to compare the preoperative evaluations between patients maintained on GT feeds versus patients who required conversion to GJ feeds.

METHODS

We identified patients at Boston Children's Hospital who underwent GT tube placement and required GJ feeding between 2006 and 2012. GT patients were matched according to age, neurologic, and cardiac status with GJ-converted patients. Preoperative characteristics, rates of total hospitalizations, and respiratory-related admissions were reviewed.

RESULTS

A total of 79 GJ patients (median interquartile range (IQR): age 15 (4.3, 55.7) months; weight 8.8 (4.6, 14.5) kg) were matched with 79 GT patients (median (IQR): age 14.6 (4.7, 55.7) months; weight 8.5 (5, 13.6) kg). Median time from GT to GJ conversion was 8 (IQR 3, 16) months. Both groups had similar rates of successful preoperative nasogastric feeding trials (GT (84.5%) versus GJ (83.1%), P = 1.0), upper gastrointestinal series (GT (89.1%) versus GJ (93.2%), P = 0.73), abnormal videofluoroscopic swallow studies (GT (53.8%) versus GJ (62.2%), P = 0.4), and completion of gastric emptying studies (GT (10.1%) versus GJ (5.1%), P = 0.22). No differences were seen in preoperative hospitalization rates (P = 0.25), respiratory admissions (P = 0.36), although GJ patients had a mean reduction in the number of hospitalization of -1.5 ± 0.5 days, P < 0.001, after conversion.

CONCLUSIONS

No differences in preoperative patient characteristics or diagnostic evaluations were seen in GT fed versus GJ converted patients. GJ patients did experience an overall decrease in total admissions after GJ conversion.

Analysis of risk factors contributing to morbidity from gastrojejunostomy feeding tubes in children

PURPOSE

The purpose of this study was to define morbidity from gastrojejunostomy tube (GJT) placement in children.

METHODS

A retrospective single-center 5-year review of GJT placement in children was performed. Age, weight, prior surgery, indication, type of GJT, and complications (GJT replacement, wound complications, and perforation) were recorded. Logistic regression for morbidity was performed.

RESULTS

142 children underwent 394 GJT placements at a median age of 2.7years (range 5 weeks-18years). The most common indications were failure to thrive (62%) and reflux (25%). Among the 296 GJT replacements, the most common reason was tube dislodgement (30%). Risk factors for replacement, which occurred at a median interval of 12 weeks (range 2days-2.4years), were peristomal complaint (OR=5.4, p=0.02) and prior GJT replacement (OR=1.8, p=0.03). In all, 7 (5%) jejunal perforations occurred at a median of 3 days (range 0-21 days) from GJT placement. Patients with perforation had a median weight of 4.6kg (range 3-11.2kg) and age of 3.9months (range 8 weeks-2.1years). Lower weight (p<0.01) and younger age (p=0.02) predicted perforation, with those weighing less than 6kg (OR=51.9, p<0.001) or younger than 6months (OR=28.6, p<0.01) at highest risk.

CONCLUSIONS

GJT placement has a significant risk of recurrent dislodgement and the highest risk of perforation in children weighing less than 6kg or younger than 6months. Alternate feeding options should be strongly considered in this vulnerable population.

Advances in Pediatric Gastrostomy Placement

Placement of gastrostomy tubes in infants and children has become increasingly commonplace. A historical emphasis on use of open gastrostomy has been replaced by less invasive methods of placement, including percutaneous endoscopic gastrostomy and laparoscopically assisted gastrostomy procedures. Various complications, ranging from minor to the more severe, have been reported with all methods of placement. Many pediatric patients who undergo gastrostomy tube placement will require long-term enteral therapy. Given the prolonged time pediatric patients may remain enterally dependent, further quality improvement and education initiatives are needed to improve long-term care and outcomes of these patients.

Gastrojejunal tube placement through an established gastrostomy via an endoscopic transgastric approach in a pediatric population

BACKGROUND AND AIMS

Gastrojejunal feeding tubes (GJTs) are typically converted from gastrostomy feeding tubes by interventional radiology in many pediatric centers to provide both postpyloric feeding and gastric decompression. Endoscopic transgastric GJT placement via an established gastric stoma can be performed without sedation and with minimal fluoroscopy but is relatively new in pediatrics with limited description. This study analyzed the success rate, adverse events, and technical issues associated with endoscopic GJT placement via a transgastric approach in pediatric patients at a large children's hospital.

METHODS

We retrospectively reviewed endoscopic GJT placements in pediatric patients performed over a 16-month period at the Children's Hospital of New York-Presbyterian, Columbia University Medical Center. Indication for GJT placement, patient demographic characteristics and medical history, use of sedation, fluoroscopy time, and procedural and postprocedural adverse events were assessed.

RESULTS

A total of 47 GJT placements were performed, all successful, in a patient cohort with a mean age of 8 years. The mean fluoroscopy time was 10 seconds, and sedation was used in 30% of placements. In 8 patients who had undergone GJT placement by endoscopy and interventional radiology, the fluoroscopy time was significantly reduced by using the endoscopic method (10 seconds vs 299 seconds, P = .001).

CONCLUSIONS

Endoscopic transgastric GJT placement via an established gastrostomy with fluoroscopic confirmation can be safely performed by pediatric gastroenterologists without sedation and with minimal radiation exposure.

Eliminating Rumination in Developmentally Disabled Children: A Case Report

Rumination is the effortless regurgitation of food, with subsequent spitting out or rechewing and reswallowing. In developmentally delayed children, rumination is a pleasurable, self-stimulating habit. For 3 years, we evaluated and treated 2 nonambulatory, nonverbal 4-year-old children who ruminated frequently while awake. The social isolation caused by a child covered in regurgitated food prompted caregivers of these children to find a solution. We hypothesized that rumination would cease if the stomach stayed empty of food. We intervened by placing gastrojejunostomy tubes and then initiated continuous drip jejunal tube feedings over 12 waking hours to reduce hunger; the children's oral diet was also stopped. In both cases, these changes reduced episodes of rumination to 3 to 5 times daily. To eliminate rumination, unpleasant tasting substances (N-acetylcysteine or cayenne pepper-based hot sauce) were given through the gastrostomy tube every 4 hours while the children were awake. Within 1 week of adding the unpalatable substances, rumination ceased. After 2 months of no rumination, 1 mother restarted oral feeding. There was no recurrence of rumination, and 3 months after gastrojejunal tube placement, the tube was removed. In 1 year of follow-up, rumination did not recur. The second mother was pleased with the outcome with jejunal feedings and chose not to resume oral feedings. These results showed that jejunal tube feeding in combination with insertion of unpalatable contents into the stomach eliminated rumination in these developmentally delayed children.