PEDIATRIC SURGERY UPDATE ©

VOLUME 49 NO 02 AUGUST 2017

Gastrojejunostomy Tube

Gastrojejunostomy tube (GJT) insertion is a common procedure performed to provide postpyloric enteral nutrition in children and adults. GJT is an alternative to gastrostomy tubes when the stomach cannot be fed directly due to history of gastroparesis, gastroesophageal reflux, failed fundoplication, aspiration pneumonia or small capacity stomach (microgastria). GJT are placed via open laparotomy, endoscopic-assisted laparoscopy or fluoroscopic technique after a previous gastrostoma. Open, endoscopic and laparoscopic technique includes the used if intraoperative fluoroscopy. GJT tip placement should be placed distal to the third portion of the duodenum. All cases should have fluoroscopic contrast studies during insertion to demonstrate that no bowel perforation has occurred. Complications associated with the use of GJT include the need for tube replacement, peristomal granulation or leakage, recurrent symptoms of gastroesophageal reflux, intussusception and intestinal perforation. The most frequent reported complications are the need for tube replacement due to mechanical failure from tube fracture or balloon rupture, tube obstruction from clogging or tube displacement from complete removal or distal migration. Almost 75% of children require a return to the operating room for GJT replacement with a mean of two replacements per year. Children weighting less than 6 kilograms or younger than six months of age are at a higher risk of suffering an intestinal perforation with the use of GJT. The complication with the greatest potential morbidity is that related to intestinal perforation which can lead to death. The perforation occurs nears the ligament of Treitz and usually occurs within the first 30 days after insertion. This occurs due to the relative rigidity of the jejunal extension of the GJT which exerts radial pressure on the duodenojejunal junction in the area of the ligament of Treitz where the bowel makes a sharp turn. The smaller the child the smaller the bowel diameter and size. The tip causes pressure necrosis leading to perforation.

References:
1- Jaskolka D, Brown N, Cohen E, Mounstephen W, Connolly B: Evaluating the implementation of a quality improvement initiative: weekend gastrojejunostomy tube maintenance service in a tertiary pediatric center. Can Assoc Radiol J. 64(3):229-35, 2013
2- Crowley JJ, Hogan MJ, Towbin RB: Quality improvement guidelines for pediatric gastrostomy and gastrojejunostomy tube placement.  J Vasc Interv Radiol. 25(12):1983-91, 2014
3- Richards MK, Li CI, Foti JL, Leu MG, Wahbeh GT, Shaw D, Libby AK, Melzer L, Goldin AB: Resource utilization after implementing a hospital-wide standardized feeding tube placement pathway. J Pediatr Surg. 51(10):1674-9, 2016
4- Demehri FR, Simha S, Herrman E, Jarboe MD, Geiger JD, Teitelbaum DH, Gadepalli SK: Analysis of risk factors contributing to morbidity from gastrojejunostomy feeding tubes in children. J Pediatr Surg. 51(6):1005-9, 2016
5- Morse J, Baird R, Muchantef K, Levesque D, Morinville V, Puligandla PS: Gastrojejunostomy tube complications - A single center experience and systematic  review. J Pediatr Surg. 52(5):726-733, 2017
6- Onwubiko C, Weil BR, Bairdain S, Hall AM, Perkins JM, Thangarajah H, McSweeney ME, Smithers CJ: Primary laparoscopic gastrojejunostomy tubes as a feeding modality in the pediatric population. J Pediatr Surg. pii: S0022-3468(17)30333-0. doi: 10.1016/j.jpedsurg.2017.05.015, 2017

         Fetal Ovarian Torsion

*Edited by: Humberto Lugo-Vicente, MD, FACS, FAAP
P.O. Box 10426, Caparra Heights Station, San Juan, Puerto Rico 00922-0426
Tel (787)-999-9450 Fax (787)-720-6103 E-mail: TITOLUGO@COQUI.NET
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Pediatric Surgery Update ISSN 1089-7739
Last updated: September 2017