If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children with Neurological Impairment.
Oropharyngeal dysphagia (90%), gastroesophageal reflux (50%-75%), delayed gastric emptying (67%), and/or ineffective esophageal peristalsis (61%) are associated with undernutrition. Moreover, nearly all NPDC have 1 or more comorbidity that negatively affects feeding and worsens GI symptoms such as retching and bloating, requiring prompt gastric decompression.
long-term access is represented by jejunal tube introduction through gastrostomy (percutaneous endoscopic gastrojejunostomy [PEGJ]), surgical gastrojejunostomy (SJ), or direct percutaneous endoscopic jejunostomy (DPEJ).
European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children with Neurological Impairment.
Medical position paper: Nutrition support for neurologically impaired children: A clinical report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.
Because PEGJ allows both gastric decompression via PEG and simultaneous jejunal nutrition via PEGJ, it is the preferred method, especially in NPDC who are unfit for surgery. However, PEGJ is associated with technical adverse events that compromise its long-term durability, such as tube clogging or retrograde dislodgement, necessitating repeated hospitalization: the average duration of PEGJ in NPDC is 39 days.
Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the pediatric sedation research consortium.
SJ (open or laparoscopic) is effective in the management of gastric outlet obstruction (GOO) but is limited by its invasiveness and morbidity, mainly related to an unfriendly anatomy. DPEJ is a tubeless option, but its diffusion is limited by high procedural failure rates (20%-30%)
Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the pediatric sedation research consortium.
and difficult management of the concomitant decompressive gastrostomy.
Endoscopic ultrasound-guided gastrojejunostomy with lumen-apposing metal stents (LAMSs) is a novel, minimally invasive technique for the palliation of malignant GOO. An overall clinical success rate of 80% has also been reported for benign GOO (eg, chronic pancreatitis or pyloric stenosis) but does not support the rerouting of a PEJ-tube.
To our knowledge, the use of this technique in NPDC to reroute a jejunal tube has not been reported previously, and the technique could be considered in other clinical scenarios to reduce the risk of PEJ tube dislodgement.
Methods
A 17-year-old boy (weight, 28 kg) with severe neurological impairment and dystonic syndrome resulting from neonatal kernicterus in jejunal feeding was referred to us for repeated PEGJ tube dislodgment. Severe scoliosis and osteopenia, slow gastric emptying, retching, and GERD were associated. In the past 2 years, because of repeated displacement of the gastrojejunal tube, the patient experienced repeated hospitalization, and parenteral nutrition was necessary. On the last endoscopy, a low-profile 16F PEG was placed; however, gastric feeding was not tolerated. SJ and DPEJ were considered as secondary options. Thus, we attempted an EUS-guided LAMS-assisted gastrojejunostomy.
Results
The procedure (Video 1, available online at www.giejournal.org) was performed with fluoroscopy and with the patient under general anesthesia. A linear echoendoscope (Pentax EG38-J10UT, PENTAX Europe GmbH Hamburg, Germany) was used. The target bowel loop was filled with saline solution, indigo carmine, and contrast with a catheter (Figs. 1 and 2). A cautery-tipped 15- × 10-mm LAMS (Hot Axios; Boston Scientific, Marlborough, Mass) was employed to create the gastrojejunostomy under EUS and fluoroscopy guidance (Fig. 3). The correct position of the LAMS was confirmed by fluoroscopy (Fig. 4). The LAMS position in the stomach was 5 cm from the PEG bumper (Fig. 5). Six months later, the LAMS was removed, and the gastrojejunostomy was easily intubated with a standard gastroscope. Both afferent and efferent jejunal loops were explored. The PEJ tube was placed from the stomach into the efferent jejunal loop through the gastrojejunostomy under x-ray guidance (Fig. 6). Three months after rerouting, 55% of caloric intake tolerance by jejunal feeding and a 5-kg improvement in weight were obtained, with a progressive autonomization from parenteral nutrition.
Figure 1X-ray guided filling-catheter placement. Note the severe scoliosis.
Figure 6Percutaneous endoscopic jejunostomy tube placed through the gastrojejunostomy after the removal of lumen-apposing metal stent, 6 months after its placement.
PEGJ rerouting through an EUS-guided, LAMS-assisted gastrojejunostomy may prevent dislodgement of the PEGJ tube and facilitate jejunal feeding in NPDC. Ethical and cost-effectiveness considerations are awaited.
EUS-guided, LAMS-assisted gastrojejunostomy for re-routing a PEGJ tube in neurologically impaired children.
References
Romano C.
van Wynckel M.
Hulst J.
et al.
European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children with Neurological Impairment.
Medical position paper: Nutrition support for neurologically impaired children: A clinical report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.
Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the pediatric sedation research consortium.
00043-1&id=gr1.jpg){kind=link}
00043-1&id=gr2.jpg){kind=link}
00043-1&id=gr3.jpg){kind=link}
00043-1&id=gr4.jpg){kind=link}
00043-1&id=gr5.jpg){kind=link}
00043-1&id=gr6.jpg){kind=link}