Access for Enteral Nutrition

Julia Zimmer and Michael W. L. Gauderer

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Naso-, Orogastric or Naso-, Oroenteric Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Gastrostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Choice of Procedure/Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Complications and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Gastrostomy Closure and Persistent Gastrocutaneous Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Jejunostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Choice of Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Postoperative Care and Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Conclusion and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

AbstractEnterostomies are key interventions in the man-agement of various surgical and nonsurgicalpediatric conditions. They are employed for feed-ing, decompression, or a combination of both.

A large palette of options is now available,the choice of procedure depending on the spe-cific indication, the experience of the manage-ment team and the available resources. If theaccess is primarily for long-term feeding, theoptimal kind must be carefully chosen, takinginto account the patients’ specific needs,comorbidities, habitus, and caretakers’ experi-ence. Ideally the choice is a team decision.Regular early and long-term follow-up areessential to assure optimal functionality andminimal morbidity.

J. Zimmer (*)Department of Paediatric Surgery, Hannover MedicalSchool, Hannover, Germanye-mail: zimmer.julia@mh-hannover.de

M.W.L. GaudererUniversity of South Carolina School of MedicineGreenville, Greenville, SC, USAe-mail: mgauderer@charter.net

# Springer-Verlag GmbH Germany 2018P. Puri (ed.), Pediatric Surgery,https://doi.org/10.1007/978-3-642-38482-0_19-1

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KeywordsEnteral nutrition � Enteral access � Nasogastrictube � Orogastric tube � Gastrostomy �Gastrojejunal access � Jejunal access �Enterostomy � Percutaneous endoscopicgastrostomy � Laparoscopic-assistedtechniques � Minimally invasive gastrostomy �Minimally invasive jejunostomy

Introduction

Enteral access is used for short-, intermediate-, orlong-term feeding, decompression, or a combina-tion of both. Direct enteral nutrition is indicatedwhen the patient’s food intake does not meet theneeds to support adequate growth and develop-ment and to treat malnutrition (Abdelhadi et al.2016; Vermilyea and Goh 2016). The advantagesof enteral feeding over parenteral nutrition arewell documented, notably the preservation ofessential gastrointestinal physiology, and theabsence of complications of intravenous access(Vermilyea and Goh 2016; Pang et al. 2017).

In the last three to four decades, remarkableprogress has been made in enteral access regardingindications, formulas, and, notably, the advent ofminimally invasive access techniques (Baker et al.2015; Ray et al. 2017). Although gastrostomies andjejunostomies were previously performed inpatients with major congenital anomalies of thegastrointestinal tract and abdominal wall, contem-porary indications are more likely to be for non-surgical conditions. Typically, these are childrenwith the inability to swallow secondary to centralnervous lesions (Fig. 1), or patients requiring feed-ing supplementation following trauma or chemo-therapy, chronicmalnutrition secondary to anorexiaand other conditions (Abdelhadi et al. 2016).

Naso-, Orogastric or Naso-, OroentericAccess

Naso- or orogastric or naso- or oroenteric tubesare well suited for short and intermediary use.They are usually employed from a couple ofweeks to a few months (Abdelhadi et al. 2016;

Ricciuto et al. 2015). In addition to nutrition, theseaccess devices allow the administration of medi-cation or fluids when needed (Fig. 2) (Abdelhadiet al. 2016; Irving et al. 2014). If properly placed,secured, and regularly flushed, naso- or orogastric

Fig. 1 Five-year-old with cystinosis demonstrating feed-ing on a teaching doll

Fig. 2 Premature infant with continuous nasoentericpump feeding

2 J. Zimmer and M.W.L. Gauderer

tubes generally decompress more effectively thangastrostomy tubes (Vermilyea and Goh 2016).

A plain abdominal X-ray is still the mostemployed method to verify proper tube position(Vermilyea and Goh 2016). However, there is anunderstandable hesitation in its use due to radia-tion exposure (Abdelhadi et al. 2016; Irving et al.2014). Other accepted methods are visual obser-vation of gastric aspirate or gastric pH testing,although these can be unreliable (Irving et al.2014). Furthermore, the use of proton pumpinhibitors or histamine 2 receptor antagonistsmay complicate pH testing (Vermilyea and Goh2016). The use of electromagnetic deviceand capnography is currently controversial(Abdelhadi et al. 2016; Gilbert and Burns 2012;Powers et al. 2011). Ultrasound has been pro-posed to verify tube placement in critically illchildren, but this technique is limited, becauseintragastric contents, mostly gas, make interpreta-tion difficult (Abdelhadi et al. 2016; Adams et al.2014). Because of the possibility of pitfalls, thetraditional, simple air insufflation and ausculta-tion is no longer recommended as the sole methodfor verification of placement (Vermilyea and Goh2016).

In nonendotracheal intubated children, themain early complication of nasoenteric tubeplacement is accidental catheter introduction intothe trachea. Long-term complications of thesetubes include poor securing with damage to thenose or lip, naso-oto-pharyngeal irritation andinfection, gastroesophageal reflux and aspiration,and esophageal and gastric mucosal erosion(Abdelhadi et al. 2016; Idowu et al. 2010; Kimet al. 2017; Vermilyea and Goh 2016). Fortu-nately, contemporary enteric tubes are highly bio-compatible, hydrophobic, lubricious, andminimally irritating. For neonates, infants, andsmall children, feeding tubes of sizes 5 and 8 Frare well suited. For decompression, they need tobe 8 Fr or larger, and not too long. In general,nasoenteric tubes are preferred over nasogastrictubes. However, in certain instances, such as pre-mature infants, orogastric tubes are used(Gauderer 2009).

Gastrostomy

Gastrostomy is the preferred choice for long-termenteral access because it is physiologic, well tol-erated, and permit both, continuous and bolusfeedings. Oral feedings and physiological activi-ties are not interfered with. Additional advantagesinclude, among others, the option for gastricventing and the administration of nonpalatablediets and medications. Although well toleratedand essential in the management of numerouspediatric conditions, gastrostomies have, never-theless, a long list of potential early and late com-plications (Adams et al. 2014; Baker et al. 2015;Campwala et al. 2015; Friedman et al. 2004;Landisch et al. 2016; Naiditch et al. 2010).

Historical Perspective

Gastrostomy is one of the oldest abdominal oper-ations in continuous use. Few procedures havechallenged the creativity of surgeons more thanthis seemingly simple conduit between the gastricmucosa and the surface of the abdominal wall.Figure 3 illustrates the evolution of gastric accesssince the mid-nineteenth century (Gauderer andStellato 1986).

Indications

Esophageal AbnormalitiesWith contemporary approaches to esophagealatresia repair, a gastrostomy is no longer routinelyemployed. It is indicated in cases of esophagealatresia without fistula, difficult repairs, stagingprocedures, and when the child has associatedanomalies that may interfere with feeding.Gastrostomies are also needed in cases of severeesophageal stricture, such as those secondary toingestion of caustic substances (Gauderer 2011).

Duodenal ObstructionDuodenal obstruction is usually associated withproximal duodenal dilatation, atony, and gastricdilatation. If prolonged gastric decompression isanticipated, a fine silicone rubber catheter can be

Access for Enteral Nutrition 3

placed alongside a gastrostomy catheter, acrossthe anastomosis and into the proximal jejunumduring the initial procedure (Gauderer 2011).Although these tubes are sometimes difficult toplace and maintain, this simple and time-honoredtechnique can decrease or eliminate the need forparenteral nutrition.

Major Abdominal Wall DefectsSurgical repair of gastroschisis , and occasionallyother major abdominal wall defects, is usuallyfollowed by a prolonged ileus. Althoughdecompressive gastrostomies are not routinelyindicated, they can be helpful in patients withgastroschisis and associated atresia, particularlythose requiring long-term continuous feeding(Gauderer 2011).

Short-Gut SyndromeInfants who have lost over 50% of their smallbowel have profound alteration of gastrointestinalphysiology. Initial gastric hypersecretion mayrequire prolonged drainage. As the remainingintestine undergoes adaptive changes, continuousenteral feedings become necessary. As this latter

process can be fairly lengthy, direct gastric accessvia gastrostomy is desirable (Gauderer 2011).

Other Surgical PathologiesIn any condition in which a prolonged ileus orpartial luminal occlusion (e.g., complicated meco-nium ileus, small bowel Hirschsprung’s disease)is anticipated or in whom a complex feeding reg-imen is likely (e.g., those with intestinallymphangiectasia), a gastrostomy can facilitatemanagement (Gauderer 2011).

“Nonsurgical” PathologiesThis is, by far, the most common indication forplacement of a gastrostomy in contemporary prac-tice. It often becomes necessary in the care ofpatients with failure to thrive, malignancies, trauma,and/or inability to swallow, as well as those needingfeeding supplementation, nonpalatable medications,and chronic malabsorption syndromes. Because theneurologically impaired children frequently haveforegut dysmotility and gastroesophageal reflux, inaddition to swallowing difficulties, anti-reflux pro-cedures are at times added to gastrostomies(Gauderer 2011). However, this topic continues tobe the subject of significant controversy, given the

Fig. 3 Evolution of gastrostomy in chronological order ofdevelopment. From Gauderer and Stellato (1986, p. 662).Type 1: (a) gastric fistula secondary to gastrotomy (1635).Type 2: formation of a gastric cone, (b) through the inci-sion (1846, by Sedillot and Fenger), and (c) through acounterincision (1890, by Ssabanejev). Type 3: formationof a channel from the anterior gastric wall, (d) catheterparallel to stomach (1891), and (e) catheter perpendicular

to stomach (1894). Type 4: formation of a tube from thegastric wall, (f) without valve (1901) and (g) with valve(1899). Type 5: (h) formation of a tube from small or largebowel (1906). Type 6: (i) gastrostomy without celiotomy(percutaneous endoscopic) (1980). (j and k) contemporarygastrostomy with two low-profile devices, the originalbutton and a balloon-type device

4 J. Zimmer and M.W.L. Gauderer

morbidity of anti-reflux procedures and the avail-ability of effective medications (Barnhart 2016;Gantasala et al. 2013; Kakade et al. 2015). In gen-eral, gastrostomy and gastrojejunostomy proceduresin neurologically impaired and chronically ventila-tor dependent infants and children have as signifi-cant risk of postoperative complications, morbidityand mortality (Chatwin et al. 2013; Liu et al. 2013).

Choice of Procedure/Technique

A wide variety of gastrostomy techniques areavailable. There are three basic types (Gauderer2006, 2011; Gauderer and Stellato 1986):

(A) Formation of a serosa-lined channel from theanterior gastric wall to the skin surfacearound a catheter. The catheter is placed inthe stomach and exits either parallel or verti-cally to the gastric serosa.

(B) Formation of a tube or conduit from a fullthickness gastric wall flap to the skin surface.

(C) Percutaneous techniques, in which the intro-duced catheter holds the gastric and abdomi-nal walls in apposition, with or without theaid of special fasteners.

With certain modifications, each of thesemethods can be performed employing minimallyinvasive approaches. Table 1 demonstrates themost commonly used gastrostomies and theircharacteristics.

The open “Stamm” technique is themost widelyemployed gastrostomy with laparotomy and can beused for children of all sizes, either as an isolatedintervention, or when employed in conjunctionwith another intra-abdominal procedure. For theplacement of the standard gastrostomy tube or askin-level device, general anesthesia is preferredbecause abdominal wall relaxation is required.After the tract is well healed, this stoma is suitablefor the passage of dilators or guidewires in childrenwith esophageal strictures. The construction of agastric wall tube is difficult in young children and isnot appropriate for newborns.

The first gastrostomy without laparotomy wasthe percutaneous endoscopic gastrostomy (PEG),

initially developed for high-risk pediatric patients(Gauderer et al. 1980). Eventually, it becameknown as the “pull” technique. The procedurehas been employed in children of all ages, includ-ing neonates, usually for the purpose of long-termenteral feeding (Beres et al. 2009; Lalanne et al.2014; Srinivasan et al. 2009; Wilson and Oliva-Hemker 2001).

Although there is no need for abdominal wallrelaxation, general endotracheal anesthesia isemployed in this age group so that the airway isprotected from compression during endoscopy. Theprocedure is very short and there is no postoperativeileus, no potential for bleeding or wound disruptionand only minimal interference with subsequentinterventions on the stomach, such as afundoplication (Gauderer 2009). The main disad-vantage of this and other pure endoscopic tech-niques is that the virtual space between thestomach and the abdominal wall cannot be visual-ized. This shortcoming can be overcome by theaddition of laparoscopic control (Croaker andNajmaldin 1997; Stringel et al. 1995). Although inthe typical PEG a long tube is initially employed, aprimary insertion of a skin-level device is also pos-sible (Ferguson et al. 1993; Novotny et al. 2009).

Several other methods of gastrostomy withoutlaparotomy have been introduced (Gauderer2009). The percutaneous endoscopic “push” tech-nique is performed with the aid of needle-deployed gastric anchors or “T” fasteners,followed by the Seldinger method of guide wireintroduction. Progressive tract dilatations andinsertion of a long tube or skin-level gastrostomydevice follow (Robertson et al. 1996). A similarapproach is used by interventional radiologistsand found to be suitable for even very smallstomachs (Cahill et al. 2001; Aziz et al. 2004).

In the last two decades, other minimally invasiveapproaches, such as laparoscopically aided tech-niques have been introduced. These are essentiallyexpansions of the above methods, significantlyincreasing the choices of gastric access techniquesavailable to surgeons managing infants (Humphreyand Najmaldin 1997; Rothenberg et al. 1999).

Recent comparative studies regarding efficacy,outcome, and complications of the differenttechniques have been published, favoring

Access for Enteral Nutrition 5

laparoscopic procedures (Akay et al. 2010; Bakeret al. 2015; Franken et al. 2015; Landisch et al.2016; Liu et al. 2013; Merli et al. 2016; Petrosyanet al. 2016). However, in the adult population, theoriginal PEG remains, by far, the procedure ofchoice. For infants with an abnormal epigastricanatomy, in whom the above techniques are diffi-cult or impossible to perform, a hybrid procedureemploying a mini-laparotomy and the PEG prin-ciple was developed (Gauderer 2008).

Open TechniqueThe child is placed on the table with a small rollbehind the back. A nasogastric tube is inserted fordecompression and to help identify the stomach.A small transverse incision is made over the leftupper rectus abdominis muscle (Fig. 4). This inci-sion should be neither too high, because it wouldbring the catheter too close to the costal margin,nor too low, avoiding the colon and the smallbowel. A short vertical incision is an alternative.However, this approach is less desirable because

Table 1 Comparison of the most commonly used gastrostomies. From Gauderer (2009, p. 371)

Serosa-linedchannels

Gastrictubes

Percutaneousendoscopictechniques

Percutaneousimaging guided“radiological”techniques

Laparoscopic andlaparoscopicallyassisted techniques

Catheter/stoma devicecontinuously in use

Yes No Yes Yes Yes

Laparotomy Yes Yes No No No

Laparoscopicallyfeasible

Possible Yes Yes N/A Yes

Need for gastricendoscopy

No No Yes No No

Need for abdominalrelaxation duringoperation

Yes Yes No No Yes and insufflation

Procedure time Short Moderate Very short Short Short

Postoperative ileus Yes Yes No No Some

Potential for bleeding Yes Yes Remote Remote Small

Potential for wounddehiscence/hernia

Yes Yes No No No

Potential for earlydislodgement ofcatheter

Yes No Rare Yes Small

Potential for gastricseparation

Possible Possible Yes Yes Possible

Potential for infection Yes Yes Yes Yes Yes

Potential forgastrocolic fistula

Low No Yes Low Low

Incidence of externalleakage

Moderate Significant Low Low Low

“Permanent” No Yes No No No

Suitable for passage ofdilators for esophagealstricture

Yes No No No Possible

Limited diameter ofcatheter

No N/A No Yes No

Interferes with gastricreoperation (e.g.,fundoplication)

No Yes No No No

Suitable for infants Yes No Yes Yes Yes

6 J. Zimmer and M.W.L. Gauderer

the linea alba is the thinnest area of the abdominalwall. Fascial layers are incised transversely andthe rectus muscle retracted or transected. Whenidentification of the stomach is not immediate,downward traction of the flimsy greater omentumreadily allows visualization of the transversecolon and stomach (Gauderer 2011).

The site of the gastrotomy placement on theanterior gastric wall is critical in infants. A posi-tion midway between the pylorus and the esoph-agus is chosen. The site should be neither toohigh, because this would interfere with afundoplication, should one be needed in thefuture, nor too low, because stomas at the levelof the antrum are prone to leakage and pyloricobstruction by the catheter. The surgeon must notplace the catheter too close to the greater curva-ture, to avoid the so-called gastric pacemaker andto minimize the potential for gastrocolic fistula(Gauderer and Stellato 1986).

The anterior gastric wall is lifted with two guysutures (4-0 silk) at the site of the stoma, ensuringthat the posterior wall is not included. A concen-tric purse-string suture (4-0 synthetic, absorbablematerial) is placed (Fig. 5). The gastrotomy, at thecenter of the purse-string, is made sharply throughthe serosa and muscular wall of the stomach(Gauderer 2011).

A small hemostat is introduced to confirmaccess into the gastric lumen. We prefer amushroom-type catheter (de Pezzer), sizes12–14 Fr. gauge, for neonates. The mushroomhead of the catheter is stretched with a short styletto allow atraumatic introduction into the stomach(Fig. 5). The purse-string is tied to invert theseromuscular gastric wall around the tube(Fig. 5). Other suitable catheters are the Malecotor the “T tube,” but both have the disadvantage ofbecoming more easily dislodged. However, ashort “T tube” is useful if the stomach is verysmall. Long balloon-type catheters, which mayrupture, also have a greater propensity for distalmigration into the small bowel. Skin-level devices(buttons or balloon-type) may be inserted duringthe operation, instead of the traditional long tubes(Gauderer et al. 1984, Gauderer 2006). The exitsite for the catheter should be through themid-portion of the rectus muscle about 1–2 cmabove or below the laparotomy incision (Figs. 6and 7). Although some surgeons bring the catheterout by way of the primary abdominal incision,wound complications that may occur in this set-ting tend to be more complex (Gauderer andStellato 1986). Once the exit site is chosen, theanterior gastric wall is secured to the posterioraspect of the anterior abdominal wall with fourequidistant sutures or, as illustrated, with a con-tinuous suture of double-ended 4-0 syntheticmonofilament thread (Wilson and Oliva-Hemker2001) (Fig. 7). The catheter position is tested byinjecting and aspirating saline. Gentle traction onthe catheter assures that its intragastric position ismaintained (Gauderer 2011).

The posterior rectus sheath is closed with arunning suture of 4-0 absorbable, synthetic mate-rial. The anterior rectus sheath is approximatedwith interrupted sutures of the same material. Thesubcutaneous layer is closed with a couple of 5-0

Fig. 4 Gastrostomy incision and catheter exit site. Analternative is a short vertical midline incision. FromGauderer (2011, pp. 458–9)

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or 6-0 synthetic, absorbable sutures. The skin canbe approximated with either interrupted or contin-uous 5-0 or 6-0 subcuticular sutures. Adhesivestrips cover the incision. The catheter is firmlysecured with two sutures of 3-0 or 4-0 syntheticmonofilament thread. These sutures are removedafter 1 week and a small cross-bar is placedloosely to prevent distal catheter migration.Occlusive dressings are not used after the firstcouple of postoperative days. Conversion of along tube to a “button” can be performed after afirm adherence between gastric and abdominalwall is established (Gauderer 2011).

Percutaneous Endoscopic GastrostomyThe PEG technique (“Pull”-PEG), as initiallydescribed (Gauderer et al. 1980), is applicable inchildren of all sizes. The procedure must, how-ever, be done with great precision and endoscopicskill. PEG incorporates these basic elements(Gauderer 2011):

Fig. 5 Gastrotomy site on the anterior gastric wall. Thetraction guy suture and the purse-string suture are depicted.Introduction of a de Pezzer catheter. From Gauderer (2011,pp. 458–9)

Fig. 6 The purse-string suture is tied. Partial placement ofthe continuous monofilament suture, used to anchor thestomach to the anterior abdominal wall. The catheter isbrought out through the counterincision. From Gauderer(2011, pp. 458–9)

Fig. 7 The continuous monofilament suture placement iscontinued anteriorly and then tied, providing a 360� fixa-tion of the stomach to the anterior abdominal wall with awatertight seal. From Gauderer (2011, pp. 458–9)

8 J. Zimmer and M.W.L. Gauderer

– Gastroscopic insufflation brings the stomachinto apposition to the anterior abdominal wall(Fig. 8).

– With the stomach apposed to the abdominalwall, a cannula is introduced percutaneouslyinto the gastric lumen under direct endoscopicguidance (Fig. 8).

– The cannula serves as access to introduce aguide wire, which is then withdrawn out ofthe patient’s mouth with the gastroscope(Figs. 8 and 9). A tract is thus established.

– A PEG catheter with a tapered end is attachedto the oral end of the guide wire and pulled in aretrograde fashion until it assumes its finalposition, keeping the stomach firmly, but nottoo tightly, apposed to the abdominal wall(Fig. 10).

Although there are multiple variations of theoriginal PEG technique (Croaker and Najmaldin1997; Ferguson et al. 1993; Gauderer et al. 1980;Gauderer and Stellato 1986; Novotny et al. 2009;Robertson et al. 1996; Stringel et al. 1995) andseveral types of catheters, one must be cautious,because most of these are not suitable for use ininfants. We employ a 16 Fr. Gauge (or smaller)commercially available silicone rubber pediatricPEG catheter. Larger, stiffer catheters, or thosewith a stiff, noncollapsible inner retainer, can eas-ily tear the infant’s esophagus (Gauderer 2011).

A single dose of an i.v. broad-spectrum antibi-otic is administered at the outset. The childremains in the supine position throughout theprocedure. The abdomen is cleansed and sterilelydraped. Gastroscopy is performed with the

Fig. 8 Percutaneousendoscopic gastrostomy(PEG). Insufflation of airthrough the endoscope toapproximate the stomach tothe abdominal wall anddisplace the colon caudally.Digital pressure is appliedto the proposed gastrostomysite, which usuallycorresponds to the areawhere transillumination isbrightest. Transilluminationand clear visualization of ananterior gastric wallindentation are key points.Drawn of long-lasting localanesthetic into a syringe andinjection of the proposedPEG. The needle isadvanced further, andcontinuous aspirationpressure is applied to theplunger. Air aspirationshould only occur when thetip of the needle enters thegastric lumen. FromGauderer (2011, pp. 460–1)

Access for Enteral Nutrition 9

smallest pediatric gastroscope available. Thescope is inserted and advanced slowly into thestomach, at which point the light is seen throughthe left upper quadrant abdominal wall. With thegastroscope in place, insufflation distends thestomach, apposes it against the anterior abdominalwall, and displaces the colon downward. Whenthe room lights are dimmed, the gastric contour isclearly visible, particularly in small children.

The preferred gastrostomy site is over themid-portion of the left rectus muscle. Digital pres-sure is exerted at this site, and this is seen by theendoscopist as a “polypoid lesion” or “mound” onthe anterior gastric wall (gastric transilluminationand endoscopically visualized digital indentationof the stomach are the most important factors insafe PEG placement). The endoscopist then placesan endoscopic polypectomy snare around thisinvagination of the anterior gastric wall. Digitalpressure is released and a 0.5–0.7 cm skin incision

is made. A hemostat with slightly opened prongsis placed in the incision, recreating andmaintaining the intragastric “mound” (Fig. 9).Through this incision and through the prongs ofthe hemostat, a 16-gauge, smoothly tapered,i.v. cannula and needle are thrust through abdom-inal and gastric walls under endoscopic visualiza-tion. This should be performed quickly to avoiddisplacing the stomach from the abdominal wall.The snare, if properly positioned initially, will bearound the advancing cannula. If not, it can bemaneuvered to encircle the cannula. A long,monofilament synthetic suture or a plastic-covered steel guide wire is then advanced throughthe cannula and grasped by the snare (Fig. 10). Ifthere is difficulty with the snare, a biopsy oralligator-type forceps may be used. As the gastro-scope and snare are withdrawn, the suture isbrought out of the patient’s mouth (Fig. 10). Thepreviously selected PEG catheter is thenconnected to the suture outside the patient’smouth and both suture and catheter are coatedwith a water-soluble lubricant. Traction on theabdominal portion of the suture or guide wirepulls the catheter in a retrograde fashion, throughthe mouth, esophagus, and stomach, and acrossthe abdominal wall (Fig. 11). The gastroscope isreintroduced to verify the catheter position underdirect vision. While re-endoscopy might theoreti-cally be unnecessary, we believe it adds safety tothe procedure (Gauderer 2011).

Fig. 9 A small incision is made and a Kelly-type hemostatis applied to maintain the intragastric indentation. Theendoscopist places the polypectomy snare around the“mound”; the cannula is introduced between the slightlyspread prongs of the hemostat and then thrust through theabdominal and gastric walls into the open snare. The snareis partially closed but not tightened around the cannula.From Gauderer (2011, pp. 460–1)

Fig. 10 The needle is removed and the guide wireinserted. The polypectomy snare (alternatively alligatoror biopsy forceps) grasps the guide and exit it through themouth. From Gauderer (2011, pp. 460–1)

10 J. Zimmer and M.W.L. Gauderer

Traction on the catheter is continued until theinner catheter retainer or “dome” loosely touchesthe gastric mucosa (Fig. 11). Markings on the com-mercially available catheters, or markings added totubes without marks, are helpful in indicating thefinal position of the tube. The external cross-bar isthen placed (Fig. 10). Excessive pressure by theexternal cross-bar on the abdominal wall will pro-duce pressure necrosis and eventual catheter extru-sion, and should be avoided. The tapered catheterend is cut off and a connector attached. Tape is usedfor temporary catheter immobilization. The cathe-termay be converted to a skin-level device by usingthe external port valve at any time. To replace thePEG catheter with a “button” or balloon-type skin-level device, we find it is prudent to wait until firmadhesions between the stomach and abdominalwall are established. This may take 1–3 months orlonger (Gauderer 2011).

The PEG catheter can be used immediately afterinsertion, but some centers wait for 24 h or evenlonger before staring enteral feedings. However,

recent studies showed that early feedings (within3–6 h) are not associated with a higher complica-tion rate (Corkins et al. 2010; Jensen et al. 2017).

Minimally Invasive GastrostomiesThe application of laparoscopy to pediatricpatients expanded the number of options andincreased the safety of gastrostomy placement.In addition to the “open” gastrostomy and theconventional PEG, the insertion of a gastrostomydevice can be performed either as entirely withlaparoscopic assistance (LAP), or laparoscopiccontrol can be employed to assist with the PEGapproach (LA-PEG) (Baker et al. 2013, 2015;Georgeson 1998; Livingston et al. 2015; Patelet al. 2014; Stringel et al. 1995; Turial et al.2009; Vasseur and Reinberg 2015). Various stud-ies have demonstrated that laparoscopic controlsignificantly lower the risk of major complicationsin children (Baker et al. 2015; Merli et al. 2016;Petrosyan et al. 2016). Although radiologicallyassisted/guided gastrostomies belong to thisgroup, they will not be described here (Bakeret al. 2015; Merli et al. 2016; Petrosyan et al.2016).

Laparoscopically Assisted Gastrosto-mies Direct intra-abdominal visualization by alaparoscope adds safety to the minimally invasiveprocedures and allows for multiple variations forconstructing a gastrostomy (Croaker andNajmaldin 1997; Ferguson et al. 1993; Georgeson1993; Novotny et al. 2009; Robertson et al. 1996;Stringel et al. 1995). Several approaches have beendescribed. In addition to the videoscopically con-trolled PEG, the two most common methods areadaptations of the Stamm technique and modifica-tions of the “push” PEG (Livingston et al. 2015;Vasseur and Reinberg 2015). The authors’ prefer-ence is for the latter because, in order to place apurse-string suture through the exposed segment ofthe anterior gastric wall, the trocar site must besufficiently enlarged. This may predispose the siteto leakage. To temporarily anchor the stomach tothe abdominal wall, different approaches may beemployed, notably T-fasteners and U-stitches. Themost suitable site for the gastrostomy is selected inthe left upper quadrant and marked. A nasogastric

Fig. 11 The appropriate sized PEG catheter is attached tothe oral end of the guide wire and pulled in a retrogrademanner through the infant’s esophagus and stomach, andthen across the gastric and abdominal walls. The insetshows the position of the catheter at the end of the proce-dure. From Gauderer (2011, pp. 460–1)

Access for Enteral Nutrition 11

tube is inserted. Pneumoperitoneum is establishedin the child’s size-appropriate manner, a trocar isplaced at the umbilicus and the laparoscope isintroduced. A needle is pushed through the previ-ously marked abdominal wall site and the appro-priate relation between the anterior gastric wall andthe stoma site established. A small skin incision ismade and a 5 mm trocar inserted. A grasper isintroduced and the gastrostomy site on the anteriorgastric wall is lifted toward the parietal peritoneum(Fig. 12). A U-stitch is passed through the abdom-inal wall, through the anterior gastric wall, andback out through the abdominal wall. A secondU-stitch is passed parallel to the first one, 1–2 cmapart (Figs. 12–14). The sutures are lifted,maintaining the stomach in contact with theabdominal wall (Fig. 14). The grasper and thetrocar are removed. The stomach is insufflatedwith air through the nasogastric tube and a needleis inserted through the trocar site into the gastriclumen, between the two U-stitches. A Seldinger-type guide wire is passed through the needle intothe stomach (Fig. 13). The tract is dilated over theguide wire to the size required to insert either aFoley-type catheter or a balloon-type skin-level

device. These are placed over the same guidewire. Stiffening of the catheter shaft with a thinmetallic dilator is helpful. The previously placedU-stitches are tied over the wings of the “button”(Figs. 15 and 16). If a long tube is placed, a pair ofbolsters is employed. Care must be taken to avoidexcessive tension.

Numerous variations for constructing alaparoscopically controlled or aided gastrostomyhave been introduced. These include one or twotrocar techniques or micro-invasive strategies(Akay et al. 2010; Baker et al. 2013; Kawaharaet al. 2006; Patel et al. 2014; Turial et al. 2009):Large double U-stitch techniques have been mod-ified, e.g., replacement of U-stitches with a con-tinuous double U-stitch suture (Backman et al.2010), subcutaneous placement of absorbablestay-sutures (Antonoff et al. 2009), orlaparoscopically placed sutures to secure the stom-ach to the abdominal wall (Villalona et al. 2011).

Fig. 12 Laparoscopically assisted gastrostomy. After theestablishment of pneumoperitoneum, a trocar is inserted atthe gastrostomy site, a grasper is introduced, and the appro-priate portion of the anterior gastric wall is lifted. Place-ment of two sutures in the depicted manner. FromGauderer(2011, p. 462)

Fig. 13 Insufflation of the stomach with air through thenasogastric tube. Insertion of a needle through the trocarsite into the gastric lumen, between the two U-stitches. ASeldinger-type guide wire is passed through the needle intothe stomach. The tract is dilated over the guide wire to thesize required to insert either a Foley-type catheter or aballoon-type skin-level device or another low-profileaccess device. These are placed over the same guide wire.From Gauderer (2011, p. 462)

12 J. Zimmer and M.W.L. Gauderer

Laparoscopic-Assisted Percutaneous Endo-scopic Approach For optimal visualization ofthe structures, laparoscopy has been added to theconventional PEG in various techniques (Hassanand Pimpalwar 2011; Idowu et al. 2010; Living-ston et al. 2015; Nixdorff et al. 2010; Smithermanand Pimpalwar 2009).

The gastroscope is placed within the stomachand a laparoscopic port is introduced through theumbilicus. Pneumoperitoneum is achieveddepending on the patient’s age. A camera is intro-duced into the peritoneal cavity, the idealgastrostomy site is chosen, and a skin incision ismade for the abdominal wall exit site. Under directvisualization by both gastroscope and laparoscope,T-Fasteners are placed from the gastrostomy siteon the abdominal wall into the insufflated stomach.A needle is placed between the sutures from theabdominal incision into the stomach. A guide wireis then introduced. Under direct visualization anappropriate size dilator–peel away sheath is passedover this guide wire into the stomach. Guide wire

and dilators are removed. An appropriate sizeballoon-type button is introduced through thepeel away sheath. The latter is removed and theballoon is inflated with saline (usually 3–5 ml).The anchoring sutures are lifted outside and tiedsubcutaneously. Inspection with both gastroscopeand laparoscope ensures a proper gastrostomydevice placement (Livingston et al. 2015; Hassanand Pimpalwar 2011).

As a variation, besides the umbilical port twotransabdominally incisions can be made for laparo-scopic working instruments and only three suturesmay be placed around a proposed gastrostomy site(Smitherman and Pimpalwar 2009).

Although multiple variations exist andundoubtedly others will be described, the princi-ples are essentially the same: safe approximationof the stomach to the abdominal wall, protectionof adjacent organs, and comfortable, tension-freegastrostomy device placement.

Choice of Access DeviceThere are several types of commonly usedgastrostomy tubes. The “traditional” long cathe-ters are characterized by the mode of retention(semi-rigid intragastric portion and inflatableintragastric balloon). The skin-level devices or“buttons” are modifications in which theintragastric retention mechanism is similar tothose of the long tubes (Gauderer et al. 1984,Gauderer 2009). A comparison of the devices isshown in Table 2. Of the conventional, long tubes,the Foley or balloon catheters are the easiest toinsert, but have the disadvantage of balloon defla-tion leading to dislodgement (Gauderer 2009).Additionally, these catheters are prone to distalmigration with possible intestinal obstruction.The de Pezzer and PEG-type catheters are lessprone to dislodgement but are a little harder toinsert. The Malecot-type catheters, with its rela-tively soft winged tip, are easier to insert but alsomore prone to dislodgement (Gauderer 2009).

All types of catheters can be used for long-termcare, but skin-level devices are best suited for thispurpose (Fig. 17). The three most commonlyemployed skin-level devices are shown inFig. 18. The original button has the lowest

Fig. 14 Laparoscopic gastrostomy procedure, intra-abdominal view. U-sutures are placed. The sutures arelifted, maintaining the stomach in contact with the abdom-inal wall. Removal of grasper and trocar. Insufflation of thestomach. Insertion of a needle through the trocar site intothe gastric lumen, between the two U-stitches. A Seldinger-type guide wire is passed through the needle into thestomach. The tract is dilated over the guide wire to thesize required to insert either a Foley-type catheter or aballoon-type skin-level device.

Access for Enteral Nutrition 13

external profile and tends to last considerablylonger than the other devices. However, becausethe mushroom head is difficult to collapsecompletely, its insertion can be more painful.Although accidental connector dislodgement,after long-term use, could occur with earlymodels, this is not a problem with newer devices(Gauderer 2009). A combination PEG catheter-button for primary insertion is commerciallyavailable. However, judging the appropriate

button length prior to insertion may be difficultand once the button is deployed, it cannot bechanged (Gauderer 2009).

Contemporary balloon-type skin-level deviceshave the advantages of greater ease in the changingprocess and a feeding adapter that is more securelyconnected. Disadvantages include a shorter lifespan because of balloon deflation and a slightlytaller external profile. Additionally, the balloonoccupies more intragastric volume and in someearlier models the protruding tip produced erosionson the posterior gastric wall (Gauderer 2009).

The third type is a device with a changeableexternal port-valve. The greatest advantage of thisconcept is that an originally placed longgastrostomy tube can be converted to a skin-level device by simply cutting the tube to thedesired length above the skin and placing thevalve in the shaft. The tract is not disturbed, thuseliminating the possibility of gastric separation.The conversion can be done either immediatelyafter the gastrostomy catheter insertion or anytime thereafter. The main disadvantage in the pre-sent model is late valve failure. However, if thisoccurs, the external port-valve is changed, again

Fig. 15 Laparoscopic placement of a balloon-type “button.” The previously placed U-stitches are tied over the “wings”of the skin-level device. From Gauderer (2011, p. 462)

Fig. 16 Laparoscopic procedure. Postoperative status.Small incision scars and the gastrostomy tube in place

14 J. Zimmer and M.W.L. Gauderer

without removal of the initially placed catheter(Gauderer et al. 1998). Because the valve can beapplied at any level on the shaft of the tube, thisskin-level device becomes specific for eachpatient. An additional advantage is that inventory

is markedly simplified as the need for multiplecatheter lengths is eliminated (Gauderer 2009).

The diameter of the long tubes and the skin-level devices depends on the size of the child andthe purpose of the gastrostomy. For infants and

Table 2 Comparison of most commonly used gastrostomy devices. From Gauderer (2009, p. 374)

PEG-type, de Pezzer,Malecot, T-tube

Foley(balloon type)

Skin-level (“button”type)

Suitable for initial insertion Yes Yes Yes

Suitable for decompression Yes Yes Yes

Tendency for accidental dislodgement orexternal migration

Moderate (with specialadaptor)

Moderate Very Low (exceptballoon type)

Tendency for internal (distal) migration Moderate High None

Tendency for peristomal leakage(particularly large tubes)

Moderate Moderate Low

Balloon deflation No Yes Yes, with balloon type

Reinsertion Easy to moderatelydifficult

Easy Easy to moderatelydifficult

Long-term (particularly ambulatorypatients)

Adequate Adequate Best suited

Overall complication rates Significant Significant Low

Fig. 17 Child with gastrostomy buttonFig. 18 The three main gastrostomy device groups. FromGauderer (2009, p. 374)

Access for Enteral Nutrition 15

small children, 12–16 F tubes are appropriate. Forolder children, sizes 18–20 F are well suited(Gauderer 2009).

Complications and Management

Although frequently considered a “simple” proce-dure, a gastrostomy has a considerable potential forearly and late morbidity, particularly among neo-nates (Farrelly and Stitelman 2016; Gauderer2011). Most of the common problems can be pre-vented with meticulous attention during placementand subsequent follow-up (Beres et al. 2009). Theuse of skin-level devices such as the originalgastrostomy button (Gauderer et al. 1984; Gaudererand Stellato 1986), the balloon-type versions, or theexternally placed port-valve has dramaticallydecreased the most common problems associatedwith older, long tubes. Many techniques, whether“open,” endoscopic, or laparoscopically aided, nowpermit the initial placement of one of these well-tolerated skin-level devices (Gauderer et al. 1998;Gauderer 2011).

Complications Related to OperativeTechnique

Separation of Stomach fromAbdominal Wall This most frequently occursafter early gastrostomy tube reinsertion, before afirm adhesion between gastric and abdominalwalls has occurred, but can also occur at anytime thereafter. During the attempt to replace adislodged catheter, the stomach is pushed awayfrom the abdominal wall; that displacement leadsto a partial or complete separation of the stoma. Ifnot recognized soon, severe peritonitis and deathmay result (Friedman et al. 2004; Gauderer 2011;Gauderer and Stellato 1986). To avoid this prob-lem, the stomach must be firmly anchored to theanterior abdominal wall and the catheter wellsecured to the skin, particularly with the opentechniques. In the event of early removal or dis-lodgement of the tube, the tract can be gentlyprobed and a thin Foley catheter inserted. Thismust be followed by injection of a radio-opaquecontrast material under fluoroscopy to assure an

intragastric position of the tube and absence ofintraperitoneal leakage. If there is any questionabout the position of the catheter, prompt explo-ration is necessary (Gauderer 2009).

Wound Separation, Dehiscence, and VentralHernia They are usually the result of technicalproblems after open procedures and carry highmorbidity and mortality rates (Gauderer 2009;Gauderer and Stellato 1986). Leakage from anenlarged incision can be life threatening(Gauderer 2009). Such mishaps can be minimizedby the use of appropriate, small incisions and bybringing the tube out through a counter-incision.

Hemorrhage Major bleeding is usually relatedto inadequate hemostasis at the time of catheterinsertion (Gauderer 2009). Gentle traction on thecatheter can control the bleeding, but (Friedmanet al. 2004) reoperation may become necessary.

Infection This complication can occur with anytype of gastrostomy (Beres et al. 2009; Friedmanet al. 2004; Gauderer and Stellato 1986; Goldinet al. 2016). Although usually limited to the skinand subcutaneous tissue, it can lead to full-thickness abdominal wall loss. Infections can usu-ally be avoided through the use of prophylacticantibiotic administration and a skin incision onlyslightly larger than the diameter of the tube(Gauderer 2011).

Injury to the Posterior Stomach Walland Other Organs The posterior gastric wallcan be damaged or perforated not only duringthe initial procedure but also later during catheterchange (Gauderer and Stellato 1986). Once thetube is introduced, air or saline should be injectedto test the tube’s position and function. Duringopen procedures, damage to the liver and spleencan occur through the improper use of retractorsor other instruments (Gauderer 2011). Thedistended colon may be mistaken for the stomach,particularly in patients with intra-abdominal adhe-sions in whom mobility of intestinal loops is lim-ited (Gauderer 2009, 2011).

16 J. Zimmer and M.W.L. Gauderer

Gastrocolic Fistula Although it can occur withany gastrostomy, this complication is more likelywith the percutaneous endoscopic techniques(Gauderer 2011; Gauderer and Stellato 1986).Appropriate gastric insufflation with downwardcolonic displacement, transillumination, and theindentation on the anterior abdominal wall arecrucial parts during PEG procedure. On the otherhand, overinflationmust be avoided because it candistort the local anatomy, including the position ofthe colon. Additionally, air-filled small bowelloops will displace the colon cranially and moveit between the stomach and the abdominal wall(Gauderer 2011).

Complications Related to Care of Stoma

Skin Irritation and Moniliasis Next to granula-tion tissue, these are the most frequent problemsencountered. Usually related to leakage, andcompounded by occlusive dressings, irritation isbest prevented by avoiding any occlusive devices,including nipples, tape, or gauze pads (Gauderer andStellato 1986). The site should be kept open and dryat all times. Ointments and other solutions, exceptfor the treatment of moniliasis, should be avoided.Catheters, if kept long, can be immobilized with asmall external cross-bar (Gauderer 2011).

Tube Plugging Catheters must be flushed withwater after each feeding to prevent blockage. Inneonates, the amount should be small and addedto the fluid intake (Gauderer 2011).

Administration of Improper Feedings Carefuland slow administration of the appropriate nutri-ent prevents metabolic abnormalities as well asdiarrhea and excessive reflux (Gauderer 2011).

Delay and Trauma in the Reintroduction of aDislodged Catheter Accidental dislodgement oflong gastrostomy catheter is quite common. Thecatheter must be replaced before the tract closes,which can be in a few hours unless it is wellmatured and epithelium lined. Careful dilation ofthe tract is usually successful (Gauderer 2011). Ingastrostomy skin-level devices with jejunal

extension a dislodgment of the jejunal tube backinto the stomach may occur, usually requiringradiologic (fluoroscopy) or endoscopic guidedrepositioning.

Improper catheter reintroduction can lead todamage to the pancreas, liver, or spleen, particu-larly if long stylets or other traumatic instrumentsare used to elongate a mushroom-type tip. Gentleinsertion and aiming toward the gastric cardia orfundus is the method least likely to produce injury(Gauderer 2011).

Complications Related to Catheters

Granulation Tissue This is by far the most fre-quent problem associated with gastrostomies. Ifmild, usually a few applications of silver nitrateare curative. However, if this condition isneglected, granulation tissue will predispose toleakage, bleeding, and chronic discharge. Withexcessive growth, excision and cauterizationbecome necessary. Granulation tissue formationwill cease once epithelialization of the tract hasoccurred (Gauderer 2011).

Leakage Severe continuous leakage is uncom-mon if the gastrostomy is properly constructed(Gauderer and Stellato 1986). The usual causefor leakage is the enlargement of the stoma bypivoting motion of the gastrostomy tube, whichis often too large or too stiff (Gauderer andStellato 1986). Catheters brought through the inci-sion or the thinner midline are more prone to thisproblem. Severe widening of the stoma can lead toskin excoriation, dislodgment of the tube, meta-bolic imbalance, and even death (Gauderer 2011;Gauderer and Stellato 1986). Management ofleakage begins with control of granulation tissueand placement of a smaller, softer catheter toavoid pivoting motion (Gauderer 2011). Inextreme cases, reoperation or stoma relocationbecomes necessary.

Internal (Distal) Migration This may occurwith any gastric tube, but is particularly commonwith long, balloon-type catheters (Gauderer 2011;Gauderer and Stellato 1986).

Access for Enteral Nutrition 17

External Migration Overzealous approxima-tion of external immobilizing devices (bumper)can lead to embedding of the inner cross-bar ofthe PEG catheter, mushroom tip, or balloon in thegastric and abdominal wall, resulting in theso-called buried bumper syndrome (BBS)(Abdelhadi et al. 2016; Cyrany et al. 2016;Gauderer 2009, 2011; Gauderer and Stellato1986). It occurs not in only in PEG patients butalso in patients with low-profile balloon G tubesand nonballoon G tubes (Abdelhadi et al. 2016).The bumper can end up anywhere between thestomach mucosa and the skin surface, which istypical for rigid or semi-rigid internal immobili-zation devices (Cyrany et al. 2016). The usualpresentations are malfunction with limited flow,leakage, lack of to-and-fro motion of the catheter,or the formation of an abscess (Abdelhadi et al.2016). The catheter should be removed andreplaced. This problem can be avoided by givingthe catheter enough “play,” i.e., a little to-and-fromotion (Gauderer 2011). Since the developmentof skin-level devices such as buttons, problemswith BBS decreased markedly.

Perforation of Esophagus and SmallBowel Accidental inflation of a balloon-typecatheter in the esophagus esophagus or smallbowel might lead to wall disruption (Gauderer2011).

Gastrostomy Closure and PersistentGastrocutaneous Fistula

When a stoma is no longer needed, the cathetercan be simply removed. If the gastrostomy hasbeen in place for less than 6–12 months, the tractusually closes spontaneously. If this does notoccur, operative closure under general anesthesiamay become necessary. The stoma tract is dis-sected down to the deepest possible extra-peritoneal level. The tract is then closed inlayers using absorbable sutures (Gauderer 2009,2011).

Jejunostomy

Jejunostomies are not used as frequently asgastrostomies because they are more difficult toplace and maintain, are more complication proneand less physiologic (Abdelhadi et al. 2016;Gauderer 2009).

Depending on their expected length of use,jejunostomies can be divided into short-term(e.g., nasojejunal catheters), medium-term (e.g.,transgastric jejunal tubes), and long-term access(see below) and into indirect and direct jejunalaccess, depending on how the catheters are placed(Gauderer 2009).

For direct jejunal access, a nonballoon buttonin older children and a T-tube in infants arerecommended. The T-tube is then converted to askin-level device with the external port-valve.Balloon catheters should not be used as theymight occlude the lumen. Any of the gastricaccess devices will work in the Roux-en-Y setup(DeCou et al. 1993; Gauderer 2009).

Indications

In the last two decades, there has been anincreased use of jejunostomies in the pediatricage group as many children with complex medicalproblems and unable to use a gastrostomy are inneed for long-term enteral access. Postpyloricfeedings are used to overcome problems relatedto aspiration, gastric emptying, gastroesophagealreflux disease, gastric paresis, microgastria, orgastric outlet obstruction (Vermilyea and Goh2016). Gastrojejunal tubes may eliminate theneed for anti-reflux surgery in patients with gas-troesophageal reflux (Axelrod et al. 2006).

The usual purpose of jejunostomies is feeding,whereas the administration of medication is a lesscommon use. Classic procedures combined gas-tric decompression combined with intra-jejunalfeeding (Fig. 19).

18 J. Zimmer and M.W.L. Gauderer

Choice of Procedure

Several techniques for insertion of jejunal feedingtubes have been suggested, such as fine-needlecatheter jejunostomy, endoscopically orlaparoscopically controlled or percutaneouslyinserted jejunal (Pang et al. 2017) (Fig. 20).

Needle Catheter JejunostomyThese are for short-term use via direct jejunalaccess. This approach can be employed as anadjunct during other intra-abdominal interventions.However, these catheters plug easily, are nearlyimpossible to change, and are associated with sev-eral serious complications (Gauderer 2009).

Catheter Placement Directly intothe JejunumThis approach is for long-term usage. The tradi-tional technique is the formation of a Witzel-typechannel. This method has two disadvantages: ifthe tube becomes dislodged or plugged, it is diffi-cult to change, and in small children the formationof a channel substantially reduces the diameter ofthe lumen (Gauderer 2009).

Catheter Placement in a PartiallyExcluded LoopAnother example for long-term use of jejunalaccess. The main appeals of the Roux-en-Y feed-ing jejunostomy are the decreased likelihood ofleakage and the possibility of safe catheterchange. However, this approach is more complexand increases the possibility of early and latebowel-related complications (DeCou et al. 1993;Gauderer 2009; Williams et al. 2007).

Devices

Gastrojejunal (GJ) buttons have the same designas gastrostomy buttons but have additionally along distal jejunal tube component (Fig. 21)(Vermilyea and Goh 2016). They are low profile/skin-level, have a one-way valve to prevent leak-age when not in use, and are kept in place by aretention balloon (Abdelhadi et al. 2016;Vermilyea and Goh 2016). The gastric part ofthe GJ tube comes in different French diametersto match the patient’s gastrostomy stoma length.The jejunal length is determined by the patient’ssize. The smallest GJ button presently available isa 14 F button (Vermilyea and Goh 2016). Thegastric access is usually used for administrationof medications while the jejunal extension is usedfor enteral nutrition (Abdelhadi et al. 2016).

Postoperative Care and Complications

The postoperative care is similar to that after agastrostomy. However, feeding should be startedat a much slower rate to reduce the risk for ileusand diarrhea. Feedings should be administeredcontinuously by a pump. Following a period ofadaptation, the regimen can be modified to allowfor “windowing.” Some patients may tolerate alimited amount of bolus feeds (Gauderer 2009).Gastrojejunal tubes require frequent exchanges,usually every 3 months (Vermilyea and Goh 2016).

Overall, jejunostomies have significantly morecomplications than gastrostomies. Intestinal vol-vulus around the stoma, internal hernia, adhesivebowel obstruction, and dumping syndrome

Fig. 19 “Classic” combination of gastric decompressionand intra-jejunal feeding. From Gauderer (2011, p. 456)

Access for Enteral Nutrition 19

associated diarrhea have been reported to be spe-cifically jejunostomy-related complications(Abdelhadi et al. 2016; Farrelly and Stitelman2016; Gauderer 2009). Persistent reflux, tube dis-lodgement and intestinal perforation have beenassociated to a morbidity after gastrojejunal tubeplacement (Campwala et al. 2015; Demehri et al.2016; Farrelly and Stitelman 2016). Agastrojejunal button which is too big may causepyloric obstruction in smaller children (Vermilyeaand Goh 2016).

Conclusion and Future Directions

Although both gastrostomy and jejunostomy arebasic surgical procedures, one must carefully con-sider their advantages and disadvantages inrespect of the patient’s comorbidities as theymean major intervention in the children’s life. Aproblematic stoma can complicate the manage-ment of even a simple, temporary condition.

All children with gastrostomies andjejunostomies must be carefully followed to pre-vent long-term catheter-related complications.These children benefit from a team approach,including pediatrician, pediatric surgeon, pediat-ric gastroenterologist, primary nurse, and nutri-tionist. It is also paramount that the parents orcaregivers be an integral part of the decision-making process at the different stages ofmanagement.

An important goal in children with feedingstomas is that, whenever possible, every effortshould be made to institute or resume oralfeedings.

Fig. 20 Options of jejunal access for select-feeding anddecompressing-feeding. (a) Tunneled catheter. (b) Needlecatheter. (c) T-tube. (d) Button. (e) Proximal decomp-ression and distal feeding across an anastomosis.

(f) Temporary decompression feeding using catheterswhen primary anastomosis is unsafe and intestinal exteri-orization is not possible. (g) Roux-en-Y feedingjejunostomy. From Gauderer (2006)

Fig. 21 Patient with gastrostomy skin-level device andjejunostomy button

20 J. Zimmer and M.W.L. Gauderer

Cross-References

▶Anatomy of the Infant and Child▶Esophageal Atresia▶ Fluids and Electrolyte Balance in Infants andChildren

▶Metabolism of Infants and Children▶Necrotizing Enterocolitis▶Nutrition in Infants and Children▶ Principles of Minimally Invasive Surgery inChildren

▶ Specific Risks of the Preterm Infant▶ Surgical Problems of Children with PhysicalDisabilities

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