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Access for Enteral Nutrition

  • Julia ZimmerEmail author
  • Michael W. L. Gauderer
Living reference work entry
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Abstract

Enterostomies are key interventions in the management of various surgical and nonsurgical pediatric conditions. They are employed for feeding, decompression, or a combination of both.

A large palette of options is now available, the choice of procedure depending on the specific indication, the experience of the management team and the available resources. If the access is primarily for long-term feeding, the optimal kind must be carefully chosen, taking into account the patients’ specific needs, comorbidities, habitus, and caretakers’ experience. Ideally the choice is a team decision. Regular early and long-term follow-up are essential to assure optimal functionality and minimal morbidity.

Keywords

Enteral nutrition Enteral access Nasogastric tube Orogastric tube Gastrostomy Gastrojejunal access Jejunal access Enterostomy Percutaneous endoscopic gastrostomy Laparoscopic-assisted techniques Minimally invasive gastrostomy Minimally invasive jejunostomy 

Introduction

Enteral access is used for short-, intermediate-, or long-term feeding, decompression, or a combination of both. Direct enteral nutrition is indicated when the patient’s food intake does not meet the needs to support adequate growth and development and to treat malnutrition (Abdelhadi et al. 2016; Vermilyea and Goh 2016). The advantages of enteral feeding over parenteral nutrition are well documented, notably the preservation of essential gastrointestinal physiology, and the absence of complications of intravenous access (Vermilyea and Goh 2016; Pang et al. 2017).

In the last three to four decades, remarkable progress has been made in enteral access regarding indications, formulas, and, notably, the advent of minimally invasive access techniques (Baker et al. 2015; Ray et al. 2017). Although gastrostomies and jejunostomies were previously performed in patients with major congenital anomalies of the gastrointestinal tract and abdominal wall, contemporary indications are more likely to be for nonsurgical conditions. Typically, these are children with the inability to swallow secondary to central nervous lesions (Fig. 1), or patients requiring feeding supplementation following trauma or chemotherapy, chronic malnutrition secondary to anorexia and other conditions (Abdelhadi et al. 2016).
Fig. 1

Five-year-old with cystinosis demonstrating feeding on a teaching doll

Naso-, Orogastric or Naso-, Oroenteric Access

Naso- or orogastric or naso- or oroenteric tubes are well suited for short and intermediary use. They are usually employed from a couple of weeks to a few months (Abdelhadi et al. 2016; Ricciuto et al. 2015). In addition to nutrition, these access devices allow the administration of medication or fluids when needed (Fig. 2) (Abdelhadi et al. 2016; Irving et al. 2014). If properly placed, secured, and regularly flushed, naso- or orogastric tubes generally decompress more effectively than gastrostomy tubes (Vermilyea and Goh 2016).
Fig. 2

Premature infant with continuous nasoenteric pump feeding

A plain abdominal X-ray is still the most employed method to verify proper tube position (Vermilyea and Goh 2016). However, there is an understandable hesitation in its use due to radiation exposure (Abdelhadi et al. 2016; Irving et al. 2014). Other accepted methods are visual observation of gastric aspirate or gastric pH testing, although these can be unreliable (Irving et al. 2014). Furthermore, the use of proton pump inhibitors or histamine 2 receptor antagonists may complicate pH testing (Vermilyea and Goh 2016). The use of electromagnetic device and capnography is currently controversial (Abdelhadi et al. 2016; Gilbert and Burns 2012; Powers et al. 2011). Ultrasound has been proposed to verify tube placement in critically ill children, but this technique is limited, because intragastric contents, mostly gas, make interpretation difficult (Abdelhadi et al. 2016; Adams et al. 2014). Because of the possibility of pitfalls, the traditional, simple air insufflation and auscultation is no longer recommended as the sole method for verification of placement (Vermilyea and Goh 2016).

In nonendotracheal intubated children, the main early complication of nasoenteric tube placement is accidental catheter introduction into the trachea. Long-term complications of these tubes include poor securing with damage to the nose or lip, naso-oto-pharyngeal irritation and infection, gastroesophageal reflux and aspiration, and esophageal and gastric mucosal erosion (Abdelhadi et al. 2016; Idowu et al. 2010; Kim et al. 2017; Vermilyea and Goh 2016). Fortunately, contemporary enteric tubes are highly biocompatible, hydrophobic, lubricious, and minimally irritating. For neonates, infants, and small children, feeding tubes of sizes 5 and 8 Fr are well suited. For decompression, they need to be 8 Fr or larger, and not too long. In general, nasoenteric tubes are preferred over nasogastric tubes. However, in certain instances, such as premature infants, orogastric tubes are used (Gauderer 2009).

Gastrostomy

Gastrostomy is the preferred choice for long-term enteral access because it is physiologic, well tolerated, and permit both, continuous and bolus feedings. Oral feedings and physiological activities are not interfered with. Additional advantages include, among others, the option for gastric venting and the administration of nonpalatable diets and medications. Although well tolerated and essential in the management of numerous pediatric conditions, gastrostomies have, nevertheless, a long list of potential early and late complications (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 operations in continuous use. Few procedures have challenged the creativity of surgeons more than this seemingly simple conduit between the gastric mucosa and the surface of the abdominal wall. Figure 3 illustrates the evolution of gastric access since the mid-nineteenth century (Gauderer and Stellato 1986).
Fig. 3

Evolution of gastrostomy in chronological order of development. 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 incision (1846, by Sedillot and Fenger), and (c) through a counterincision (1890, by Ssabanejev). Type 3: formation of a channel from the anterior gastric wall, (d) catheter parallel to stomach (1891), and (e) catheter perpendicular to stomach (1894). Type 4: formation of a tube from the gastric wall, (f) without valve (1901) and (g) with valve (1899). Type 5: (h) formation of a tube from small or large bowel (1906). Type 6: (i) gastrostomy without celiotomy (percutaneous endoscopic) (1980). (j and k) contemporary gastrostomy with two low-profile devices, the original button and a balloon-type device

Indications

Esophageal Abnormalities

With contemporary approaches to esophageal atresia repair, a gastrostomy is no longer routinely employed. It is indicated in cases of esophageal atresia without fistula, difficult repairs, staging procedures, and when the child has associated anomalies that may interfere with feeding. Gastrostomies are also needed in cases of severe esophageal stricture, such as those secondary to ingestion of caustic substances (Gauderer 2011).

Duodenal Obstruction

Duodenal obstruction is usually associated with proximal duodenal dilatation, atony, and gastric dilatation. If prolonged gastric decompression is anticipated, a fine silicone rubber catheter can be placed alongside a gastrostomy catheter, across the anastomosis and into the proximal jejunum during the initial procedure (Gauderer 2011). Although these tubes are sometimes difficult to place and maintain, this simple and time-honored technique can decrease or eliminate the need for parenteral nutrition.

Major Abdominal Wall Defects

Surgical repair of gastroschisis, and occasionally other major abdominal wall defects, is usually followed by a prolonged ileus. Although decompressive gastrostomies are not routinely indicated, they can be helpful in patients with gastroschisis and associated atresia, particularly those requiring long-term continuous feeding (Gauderer 2011).

Short-Gut Syndrome

Infants who have lost over 50% of their small bowel have profound alteration of gastrointestinal physiology. Initial gastric hypersecretion may require prolonged drainage. As the remaining intestine undergoes adaptive changes, continuous enteral feedings become necessary. As this latter process can be fairly lengthy, direct gastric access via gastrostomy is desirable (Gauderer 2011).

Other Surgical Pathologies

In any condition in which a prolonged ileus or partial luminal occlusion (e.g., complicated meconium ileus, small bowel Hirschsprung’s disease) is anticipated or in whom a complex feeding regimen is likely (e.g., those with intestinal lymphangiectasia), a gastrostomy can facilitate management (Gauderer 2011).

“Nonsurgical” Pathologies

This is, by far, the most common indication for placement of a gastrostomy in contemporary practice. It often becomes necessary in the care of patients with failure to thrive, malignancies, trauma, and/or inability to swallow, as well as those needing feeding supplementation, nonpalatable medications, and chronic malabsorption syndromes. Because the neurologically impaired children frequently have foregut dysmotility and gastroesophageal reflux, in addition to swallowing difficulties, anti-reflux procedures are at times added to gastrostomies (Gauderer 2011). However, this topic continues to be the subject of significant controversy, given the morbidity of anti-reflux procedures and the availability of effective medications (Barnhart 2016; Gantasala et al. 2013; Kakade et al. 2015). In general, gastrostomy and gastrojejunostomy procedures in neurologically impaired and chronically ventilator dependent infants and children have as significant risk of postoperative complications, morbidity and mortality (Chatwin et al. 2013; Liu et al. 2013).

Choice of Procedure/Technique

A wide variety of gastrostomy techniques are available. There are three basic types (Gauderer 2006, 2011; Gauderer and Stellato 1986):
  1. (A)

    Formation of a serosa-lined channel from the anterior gastric wall to the skin surface around a catheter. The catheter is placed in the stomach and exits either parallel or vertically to the gastric serosa.

     
  2. (B)

    Formation of a tube or conduit from a full thickness gastric wall flap to the skin surface.

     
  3. (C)

    Percutaneous techniques, in which the introduced catheter holds the gastric and abdominal walls in apposition, with or without the aid of special fasteners.

     
With certain modifications, each of these methods can be performed employing minimally invasive approaches. Table 1 demonstrates the most commonly used gastrostomies and their characteristics.
Table 1

Comparison of the most commonly use d gastrostomies. From Gauderer (2009, p. 371)

 

Serosa-lined channels

Gastric tubes

Percutaneous endoscopic techniques

Percutaneous imaging guided “radiological” techniques

Laparoscopic and laparoscopically assisted techniques

Catheter/stoma device continuously in use

Yes

No

Yes

Yes

Yes

Laparotomy

Yes

Yes

No

No

No

Laparoscopically feasible

Possible

Yes

Yes

N/A

Yes

Need for gastric endoscopy

No

No

Yes

No

No

Need for abdominal relaxation during operation

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 wound dehiscence/hernia

Yes

Yes

No

No

No

Potential for early dislodgement of catheter

Yes

No

Rare

Yes

Small

Potential for gastric separation

Possible

Possible

Yes

Yes

Possible

Potential for infection

Yes

Yes

Yes

Yes

Yes

Potential for gastrocolic fistula

Low

No

Yes

Low

Low

Incidence of external leakage

Moderate

Significant

Low

Low

Low

“Permanent”

No

Yes

No

No

No

Suitable for passage of dilators for esophageal stricture

Yes

No

No

No

Possible

Limited diameter of catheter

No

N/A

No

Yes

No

Interferes with gastric reoperation (e.g., fundoplication)

No

Yes

No

No

No

Suitable for infants

Yes

No

Yes

Yes

Yes

The open “Stamm” technique is the most widely employed gastrostomy with laparotomy and can be used for children of all sizes, either as an isolated intervention, or when employed in conjunction with another intra-abdominal procedure. For the placement of the standard gastrostomy tube or a skin-level device, general anesthesia is preferred because abdominal wall relaxation is required. After the tract is well healed, this stoma is suitable for the passage of dilators or guide wires in children with esophageal strictures. The construction of a gastric wall tube is difficult in young children and is not appropriate for newborns.

The first gastrostomy without laparotomy was the percutaneous endoscopic gastrostomy (PEG), initially developed for high-risk pediatric patients (Gauderer et al. 1980). Eventually, it became known as the “pull” technique. The procedure has been employed in children of all ages, including neonates, usually for the purpose of long-term enteral 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 wall relaxation, general endotracheal anesthesia is employed in this age group so that the airway is protected from compression during endoscopy. The procedure is very short and there is no postoperative ileus, no potential for bleeding or wound disruption and only minimal interference with subsequent interventions on the stomach, such as a fundoplication (Gauderer 2009). The main disadvantage of this and other pure endoscopic techniques is that the virtual space between the stomach and the abdominal wall cannot be visualized. This shortcoming can be overcome by the addition of laparoscopic control (Croaker and Najmaldin 1997; Stringel et al. 1995). Although in the typical PEG a long tube is initially employed, a primary insertion of a skin-level device is also possible (Ferguson et al. 1993; Novotny et al. 2009).

Several other methods of gastrostomy without laparotomy have been introduced (Gauderer 2009). The percutaneous endoscopic “push” technique is performed with the aid of needle-deployed gastric anchors or “T” fasteners, followed by the Seldinger method of guide wire introduction. Progressive tract dilatations and insertion of a long tube or skin-level gastrostomy device follow (Robertson et al. 1996). A similar approach is used by interventional radiologists and found to be suitable for even very small stomachs (Cahill et al. 2001; Aziz et al. 2004).

In the last two decades, other minimally invasive approaches, such as laparoscopically aided techniques have been introduced. These are essentially expansions of the above methods, significantly increasing the choices of gastric access techniques available to surgeons managing infants (Humphrey and Najmaldin 1997; Rothenberg et al. 1999).

Recent comparative studies regarding efficacy, outcome, and complications of the different techniques have been published, favoring laparoscopic procedures (Akay et al. 2010; Baker et al. 2015; Franken et al. 2015; Landisch et al. 2016; Liu et al. 2013; Merli et al. 2016; Petrosyan et al. 2016). However, in the adult population, the original PEG remains, by far, the procedure of choice. For infants with an abnormal epigastric anatomy, in whom the above techniques are difficult or impossible to perform, a hybrid procedure employing a mini-laparotomy and the PEG principle was developed (Gauderer 2008).

Open Technique

The child is placed on the table with a small roll behind the back. A nasogastric tube is inserted for decompression and to help identify the stomach. A small transverse incision is made over the left upper rectus abdominis muscle (Fig. 4). This incision should be neither too high, because it would bring the catheter too close to the costal margin, nor too low, avoiding the colon and the small bowel. A short vertical incision is an alternative. However, this approach is less desirable because the linea alba is the thinnest area of the abdominal wall. Fascial layers are incised transversely and the rectus muscle retracted or transected. When identification of the stomach is not immediate, downward traction of the flimsy greater omentum readily allows visualization of the transverse colon and stomach (Gauderer 2011).
Fig. 4

Gastrostomy incision and catheter exit site. An alternative is a short vertical midline incision. From Gauderer (2011, pp. 458–9)

The site of the gastrotomy placement on the anterior gastric wall is critical in infants. A position midway between the pylorus and the esophagus is chosen. The site should be neither too high, because this would interfere with a fundoplication, should one be needed in the future, nor too low, because stomas at the level of the antrum are prone to leakage and pyloric obstruction by the catheter. The surgeon must not place the catheter too close to the greater curvature, to avoid the so-called gastric pacemaker and to minimize the potential for gastrocolic fistula (Gauderer and Stellato 1986).

The anterior gastric wall is lifted with two guy sutures (4-0 silk) at the site of the stoma, ensuring that the posterior wall is not included. A concentric purse-string suture (4-0 synthetic, absorbable material) is placed (Fig. 5). The gastrotomy, at the center of the purse-string, is made sharply through the serosa and muscular wall of the stomach (Gauderer 2011).
Fig. 5

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

A small hemostat is introduced to confirm access into the gastric lumen. We prefer a mushroom-type catheter (de Pezzer), sizes 12–14 Fr. gauge, for neonates. The mushroom head of the catheter is stretched with a short stylet to allow atraumatic introduction into the stomach (Fig. 5). The purse-string is tied to invert the seromuscular gastric wall around the tube (Fig. 5). Other suitable catheters are the Malecot or the “T tube,” but both have the disadvantage of becoming more easily dislodged. However, a short “T tube” is useful if the stomach is very small. Long balloon-type catheters, which may rupture, also have a greater propensity for distal migration into the small bowel. Skin-level devices (buttons or balloon-type) may be inserted during the operation, instead of the traditional long tubes (Gauderer et al. 1984, Gauderer 2006). The exit site for the catheter should be through the mid-portion of the rectus muscle about 1–2 cm above or below the laparotomy incision (Figs. 6 and 7). Although some surgeons bring the catheter out by way of the primary abdominal incision, wound complications that may occur in this setting tend to be more complex (Gauderer and Stellato 1986). Once the exit site is chosen, the anterior gastric wall is secured to the posterior aspect of the anterior abdominal wall with four equidistant sutures or, as illustrated, with a continuous suture of double-ended 4-0 synthetic monofilament thread (Wilson and Oliva-Hemker 2001) (Fig. 7). The catheter position is tested by injecting and aspirating saline. Gentle traction on the catheter assures that its intragastric position is maintained (Gauderer 2011).
Fig. 6

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

Fig. 7

The continuous monofilament suture placement is continued anteriorly and then tied, providing a 360° fixation of the stomach to the anterior abdominal wall with a watertight seal. From Gauderer (2011, pp. 458–9)

The posterior rectus sheath is closed with a running suture of 4-0 absorbable, synthetic material. The anterior rectus sheath is approximated with interrupted sutures of the same material. The subcutaneous layer is closed with a couple of 5-0 or 6-0 synthetic, absorbable sutures. The skin can be approximated with either interrupted or continuous 5-0 or 6-0 subcuticular sutures. Adhesive strips cover the incision. The catheter is firmly secured with two sutures of 3-0 or 4-0 synthetic monofilament thread. These sutures are removed after 1 week and a small cross-bar is placed loosely to prevent distal catheter migration. Occlusive dressings are not used after the first couple of postoperative days. Conversion of a long tube to a “button” can be performed after a firm adherence between gastric and abdominal wall is established (Gauderer 2011).

Percutaneous Endoscopic Gastrostomy

The PEG technique (“Pull”-PEG), as initially described (Gauderer et al. 1980), is applicable in children of all sizes. The procedure must, however, be done with great precision and endoscopic skill. PEG incorporates these basic elements (Gauderer 2011):
  • Gastroscopic insufflation brings the stomach into apposition to the anterior abdominal wall (Fig. 8).

  • With the stomach apposed to the abdominal wall, a cannula is introduced percutaneously into the gastric lumen under direct endoscopic guidance (Fig. 8).

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

  • A PEG catheter with a tapered end is attached to the oral end of the guide wire and pulled in a retrograde fashion until it assumes its final position, keeping the stomach firmly, but not too tightly, apposed to the abdominal wall (Fig. 10).

Fig. 8

Percutaneous endoscopic gastrostomy (PEG). Insufflation of air through the endoscope to approximate the stomach to the abdominal wall and displace the colon caudally. Digital pressure is applied to the proposed gastrostomy site, which usually corresponds to the area where transillumination is brightest. Transillumination and clear visualization of an anterior gastric wall indentation are key points. Drawn of long-lasting local anesthetic into a syringe and injection of the proposed PEG. The needle is advanced further, and continuous aspiration pressure is applied to the plunger. Air aspiration should only occur when the tip of the needle enters the gastric lumen. From Gauderer (2011, pp. 460–1)

Fig. 9

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

Fig. 10

The needle is removed and the guide wire inserted. The polypectomy snare (alternatively alligator or biopsy forceps) grasps the guide and exit it through the mouth. From Gauderer (2011, pp. 460–1)

Although there are multiple variations of the original PEG technique (Croaker and Najmaldin 1997; Ferguson et al. 1993; Gauderer et al. 1980; Gauderer and Stellato 1986; Novotny et al. 2009; Robertson et al. 1996; Stringel et al. 1995) and several types of catheters, one must be cautious, because most of these are not suitable for use in infants. We employ a 16 Fr. Gauge (or smaller) commercially available silicone rubber pediatric PEG catheter. Larger, stiffer catheters, or those with a stiff, noncollapsible inner retainer, can easily tear the infant’s esophagus (Gauderer 2011).

A single dose of an i.v. broad-spectrum antibiotic is administered at the outset. The child remains in the supine position throughout the procedure. The abdomen is cleansed and sterilely draped. Gastroscopy is performed with the smallest pediatric gastroscope available. The scope is inserted and advanced slowly into the stomach, at which point the light is seen through the left upper quadrant abdominal wall. With the gastroscope in place, insufflation distends the stomach, apposes it against the anterior abdominal wall, and displaces the colon downward. When the room lights are dimmed, the gastric contour is clearly visible, particularly in small children.

The preferred gastrostomy site is over the mid-portion of the left rectus muscle. Digital pressure is exerted at this site, and this is seen by the endoscopist as a “polypoid lesion” or “mound” on the anterior gastric wall (gastric transillumination and endoscopically visualized digital indentation of the stomach are the most important factors in safe PEG placement). The endoscopist then places an endoscopic polypectomy snare around this invagination of the anterior gastric wall. Digital pressure is released and a 0.5–0.7 cm skin incision is made. A hemostat with slightly opened prongs is placed in the incision, recreating and maintaining the intragastric “mound” (Fig. 9). Through this incision and through the prongs of the hemostat, a 16-gauge, smoothly tapered, i.v. cannula and needle are thrust through abdominal and gastric walls under endoscopic visualization. This should be performed quickly to avoid displacing the stomach from the abdominal wall. The snare, if properly positioned initially, will be around the advancing cannula. If not, it can be maneuvered to encircle the cannula. A long, monofilament synthetic suture or a plastic-covered steel guide wire is then advanced through the cannula and grasped by the snare (Fig. 10). If there is difficulty with the snare, a biopsy or alligator-type forceps may be used. As the gastroscope and snare are withdrawn, the suture is brought out of the patient’s mouth (Fig. 10). The previously selected PEG catheter is then connected to the suture outside the patient’s mouth and both suture and catheter are coated with a water-soluble lubricant. Traction on the abdominal portion of the suture or guide wire pulls the catheter in a retrograde fashion, through the mouth, esophagus, and stomach, and across the abdominal wall (Fig. 11). The gastroscope is reintroduced to verify the catheter position under direct vision. While re-endoscopy might theoretically be unnecessary, we believe it adds safety to the procedure (Gauderer 2011).
Fig. 11

The appropriate sized PEG catheter is attached to the oral end of the guide wire and pulled in a retrograde manner through the infant’s esophagus and stomach, and then across the gastric and abdominal walls. The inset shows the position of the catheter at the end of the procedure. From Gauderer (2011, pp. 460–1)

Traction on the catheter is continued until the inner catheter retainer or “dome” loosely touches the gastric mucosa (Fig. 11). Markings on the commercially available catheters, or markings added to tubes without marks, are helpful in indicating the final position of the tube. The external cross-bar is then placed (Fig. 10). Excessive pressure by the external cross-bar on the abdominal wall will produce pressure necrosis and eventual catheter extrusion, and should be avoided. The tapered catheter end is cut off and a connector attached. Tape is used for temporary catheter immobilization. The catheter may be converted to a skin-level device by using the external port valve at any time. To replace the PEG catheter with a “button” or balloon-type skin-level device, we find it is prudent to wait until firm adhesions between the stomach and abdominal wall are established. This may take 1–3 months or longer (Gauderer 2011).

The PEG catheter can be used immediately after insertion, but some centers wait for 24 h or even longer before staring enteral feedings. However, recent studies showed that early feedings (within 3–6 h) are not associated with a higher complication rate (Corkins et al. 2010; Jensen et al. 2017).

Minimally Invasive Gastrostomies

The application of laparoscopy to pediatric patients expanded the number of options and increased the safety of gastrostomy placement. In addition to the “open” gastrostomy and the conventional PEG, the insertion of a gastrostomy device can be performed either as entirely with laparoscopic assistance (LAP), or laparoscopic control can be employed to assist with the PEG approach (LA-PEG) (Baker et al. 2013, 2015; Georgeson 1998; Livingston et al. 2015; Patel et al. 2014; Stringel et al. 1995; Turial et al. 2009; Vasseur and Reinberg 2015). Various studies have demonstrated that laparoscopic control significantly lower the risk of major complications in children (Baker et al. 2015; Merli et al. 2016; Petrosyan et al. 2016). Although radiologically assisted/guided gastrostomies belong to this group, they will not be described here (Baker et al. 2015; Merli et al. 2016; Petrosyan et al. 2016).

Laparoscopically Assisted Gastrostomies

Direct intra-abdominal visualization by a laparoscope adds safety to the minimally invasive procedures and allows for multiple variations for constructing a gastrostomy (Croaker and Najmaldin 1997; Ferguson et al. 1993; Georgeson 1993; Novotny et al. 2009; Robertson et al. 1996; Stringel et al. 1995). Several approaches have been described. In addition to the videoscopically controlled PEG, the two most common methods are adaptations of the Stamm technique and modifications of the “push” PEG (Livingston et al. 2015; Vasseur and Reinberg 2015). The authors’ preference is for the latter because, in order to place a purse-string suture through the exposed segment of the anterior gastric wall, the trocar site must be sufficiently enlarged. This may predispose the site to leakage. To temporarily anchor the stomach to the abdominal wall, different approaches may be employed, notably T-fasteners and U-stitches. The most suitable site for the gastrostomy is selected in the left upper quadrant and marked. A nasogastric tube is inserted. Pneumoperitoneum is established in the child’s size-appropriate manner, a trocar is placed at the umbilicus and the laparoscope is introduced. A needle is pushed through the previously marked abdominal wall site and the appropriate relation between the anterior gastric wall and the stoma site established. A small skin incision is made and a 5 mm trocar inserted. A grasper is introduced and the gastrostomy site on the anterior gastric wall is lifted toward the parietal peritoneum (Fig. 12). A U-stitch is passed through the abdominal wall, through the anterior gastric wall, and back out through the abdominal wall. A second U-stitch is passed parallel to the first one, 1–2 cm apart (Figs. 1214). The sutures are lifted, maintaining the stomach in contact with the abdominal wall (Fig. 14). The grasper and the trocar are removed. The stomach is insufflated with air through the nasogastric tube and a needle is inserted through the trocar site into the gastric lumen, between the two U-stitches. A Seldinger-type guide wire is passed through the needle into the stomach (Fig. 13). The tract is dilated over the guide wire to the size required to insert either a Foley-type catheter or a balloon-type skin-level device. These are placed over the same guide wire. Stiffening of the catheter shaft with a thin metallic dilator is helpful. The previously placed U-stitches are tied over the wings of the “button” (Figs. 15 and 16). If a long tube is placed, a pair of bolsters is employed. Care must be taken to avoid excessive tension.
Fig. 12

Laparoscopically assisted gastrostomy. After the establishment of pneumoperitoneum, a trocar is inserted at the gastrostomy site, a grasper is introduced, and the appropriate portion of the anterior gastric wall is lifted. Placement of two sutures in the depicted manner. From Gauderer (2011, p. 462)

Fig. 13

Insufflation of the stomach with air through the nasogastric tube. Insertion of a needle through the trocar site into the gastric lumen, between the two U-stitches. A Seldinger-type guide wire is passed through the needle into the stomach. The tract is dilated over the guide wire to the size required to insert either a Foley-type catheter or a balloon-type skin-level device or another low-profile access device. These are placed over the same guide wire. From Gauderer (2011, p. 462)

Fig. 14

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

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

Numerous variations for constructing a laparoscopically controlled or aided gastrostomy have been introduced. These include one or two trocar techniques or micro-invasive strategies (Akay et al. 2010; Baker et al. 2013; Kawahara et al. 2006; Patel et al. 2014; Turial et al. 2009): Large double U-stitch techniques have been modified, e.g., replacement of U-stitches with a continuous double U-stitch suture (Backman et al. 2010), subcutaneous placement of absorbable stay-sutures (Antonoff et al. 2009), or laparoscopically placed sutures to secure the stomach to the abdominal wall (Villalona et al. 2011).

Laparoscopic-Assisted Percutaneous Endoscopic Approach

For optimal visualization of the structures, laparoscopy has been added to the conventional PEG in various techniques (Hassan and Pimpalwar 2011; Idowu et al. 2010; Livingston et al. 2015; Nixdorff et al. 2010; Smitherman and Pimpalwar 2009).

The gastroscope is placed within the stomach and a laparoscopic port is introduced through the umbilicus. Pneumoperitoneum is achieved depending on the patient’s age. A camera is introduced into the peritoneal cavity, the ideal gastrostomy site is chosen, and a skin incision is made for the abdominal wall exit site. Under direct visualization by both gastroscope and laparoscope, T-Fasteners are placed from the gastrostomy site on the abdominal wall into the insufflated stomach. A needle is placed between the sutures from the abdominal incision into the stomach. A guide wire is then introduced. Under direct visualization an appropriate size dilator–peel away sheath is passed over this guide wire into the stomach. Guide wire and dilators are removed. An appropriate size balloon-type button is introduced through the peel away sheath. The latter is removed and the balloon is inflated with saline (usually 3–5 ml). The anchoring sutures are lifted outside and tied subcutaneously. Inspection with both gastroscope and laparoscope ensures a proper gastrostomy device placement (Livingston et al. 2015; Hassan and Pimpalwar 2011).

As a variation, besides the umbilical port two transabdominally incisions can be made for laparoscopic working instruments and only three sutures may be placed around a proposed gastrostomy site (Smitherman and Pimpalwar 2009).

Although multiple variations exist and undoubtedly others will be described, the principles are essentially the same: safe approximation of the stomach to the abdominal wall, protection of adjacent organs, and comfortable, tension-free gastrostomy device placement.

Choice of Access Device

There are several types of commonly used gastrostomy tubes. The “traditional” long catheters are characterized by the mode of retention (semi-rigid intragastric portion and inflatable intragastric balloon). The skin-level devices or “buttons” are modifications in which the intragastric retention mechanism is similar to those of the long tubes (Gauderer et al. 1984, Gauderer 2009). A comparison of the devices is shown in Table 2. Of the conventional, long tubes, the Foley or balloon catheters are the easiest to insert, but have the disadvantage of balloon deflation leading to dislodgement (Gauderer 2009). Additionally, these catheters are prone to distal migration with possible intestinal obstruction. The de Pezzer and PEG-type catheters are less prone to dislodgement but are a little harder to insert. The Malecot-type catheters, with its relatively soft winged tip, are easier to insert but also more prone to dislodgement (Gauderer 2009).
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 or external migration

Moderate (with special adaptor)

Moderate

Very Low (except balloon 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 moderately difficult

Easy

Easy to moderately difficult

Long-term (particularly ambulatory patients)

Adequate

Adequate

Best suited

Overall complication rates

Significant

Significant

Low

All types of catheters can be used for long-term care, but skin-level devices are best suited for this purpose (Fig. 17). The three most commonly employed skin-level devices are shown in Fig. 18. The original button has the lowest external profile and tends to last considerably longer than the other devices. However, because the mushroom head is difficult to collapse completely, its insertion can be more painful. Although accidental connector dislodgement, after long-term use, could occur with early models, this is not a problem with newer devices (Gauderer 2009). A combination PEG catheter-button for primary insertion is commercially available. However, judging the appropriate button length prior to insertion may be difficult and once the button is deployed, it cannot be changed (Gauderer 2009).
Fig. 17

Child with gastrostomy button

Fig. 18

The three main gastrostomy device groups. From Gauderer (2009, p. 374)

Contemporary balloon-type skin-level devices have the advantages of greater ease in the changing process and a feeding adapter that is more securely connected. Disadvantages include a shorter life span because of balloon deflation and a slightly taller external profile. Additionally, the balloon occupies more intragastric volume and in some earlier models the protruding tip produced erosions on the posterior gastric wall (Gauderer 2009).

The third type is a device with a changeable external port-valve. The greatest advantage of this concept is that an originally placed long gastrostomy tube can be converted to a skin-level device by simply cutting the tube to the desired length above the skin and placing the valve in the shaft. The tract is not disturbed, thus eliminating the possibility of gastric separation. The conversion can be done either immediately after the gastrostomy catheter insertion or any time thereafter. The main disadvantage in the present model is late valve failure. However, if this occurs, the external port-valve is changed, again without removal of the initially placed catheter (Gauderer et al. 1998). Because the valve can be applied at any level on the shaft of the tube, this skin-level device becomes specific for each patient. An additional advantage is that inventory is markedly simplified as the need for multiple catheter lengths is eliminated (Gauderer 2009).

The diameter of the long tubes and the skin-level devices depends on the size of the child and the purpose of the gastrostomy. For infants and small children, 12–16 F tubes are appropriate. For older children, sizes 18–20 F are well suited (Gauderer 2009).

Complications and Management

Although frequently considered a “simple” procedure, a gastrostomy has a considerable potential for early and late morbidity, particularly among neonates (Farrelly and Stitelman 2016; Gauderer 2011). Most of the common problems can be prevented with meticulous attention during placement and subsequent follow-up (Beres et al. 2009). The use of skin-level devices such as the original gastrostomy button (Gauderer et al. 1984; Gauderer and Stellato 1986), the balloon-type versions, or the externally placed port-valve has dramatically decreased the most common problems associated with older, long tubes. Many techniques, whether “open,” endoscopic, or laparoscopically aided, now permit the initial placement of one of these well-tolerated skin-level devices (Gauderer et al. 1998; Gauderer 2011).

Complications Related to Operative Technique

Separation of Stomach from Abdominal Wall

This most frequently occurs after early gastrostomy tube reinsertion, before a firm adhesion between gastric and abdominal walls has occurred, but can also occur at any time thereafter. During the attempt to replace a dislodged catheter, the stomach is pushed away from the abdominal wall; that displacement leads to a partial or complete separation of the stoma. If not recognized soon, severe peritonitis and death may result (Friedman et al. 2004; Gauderer 2011; Gauderer and Stellato 1986). To avoid this problem, the stomach must be firmly anchored to the anterior abdominal wall and the catheter well secured to the skin, particularly with the open techniques. In the event of early removal or dislodgement of the tube, the tract can be gently probed and a thin Foley catheter inserted. This must be followed by injection of a radio-opaque contrast material under fluoroscopy to assure an intragastric position of the tube and absence of intraperitoneal leakage. If there is any question about the position of the catheter, prompt exploration is necessary (Gauderer 2009).

Wound Separation, Dehiscence, and Ventral Hernia

They are usually the result of technical problems after open procedures and carry high morbidity and mortality rates (Gauderer 2009; Gauderer and Stellato 1986). Leakage from an enlarged incision can be life threatening (Gauderer 2009). Such mishaps can be minimized by the use of appropriate, small incisions and by bringing the tube out through a counter-incision.

Hemorrhage

Major bleeding is usually related to inadequate hemostasis at the time of catheter insertion (Gauderer 2009). Gentle traction on the catheter can control the bleeding, but (Friedman et al. 2004) reoperation may become necessary.

Infection

This complication can occur with any type of gastrostomy (Beres et al. 2009; Friedman et al. 2004; Gauderer and Stellato 1986; Goldin et al. 2016). Although usually limited to the skin and subcutaneous tissue, it can lead to full-thickness abdominal wall loss. Infections can usually be avoided through the use of prophylactic antibiotic administration and a skin incision only slightly larger than the diameter of the tube (Gauderer 2011).

Injury to the Posterior Stomach Wall and Other Organs

The posterior gastric wall can be damaged or perforated not only during the initial procedure but also later during catheter change (Gauderer and Stellato 1986). Once the tube is introduced, air or saline should be injected to test the tube’s position and function. During open procedures, damage to the liver and spleen can occur through the improper use of retractors or other instruments (Gauderer 2011). The distended colon may be mistaken for the stomach, particularly in patients with intra-abdominal adhesions in whom mobility of intestinal loops is limited (Gauderer 2009, 2011).

Gastrocolic Fistula

Although it can occur with any gastrostomy, this complication is more likely with the percutaneous endoscopic techniques (Gauderer 2011; Gauderer and Stellato 1986). Appropriate gastric insufflation with downward colonic displacement, transillumination, and the indentation on the anterior abdominal wall are crucial parts during PEG procedure. On the other hand, overinflation must be avoided because it can distort the local anatomy, including the position of the colon. Additionally, air-filled small bowel loops will displace the colon cranially and move it between the stomach and the abdominal wall (Gauderer 2011).

Complications Related to Care of Stoma

Skin Irritation and Moniliasis

Next to granulation tissue, these are the most frequent problems encountered. Usually related to leakage, and compounded by occlusive dressings, irritation is best prevented by avoiding any occlusive devices, including nipples, tape, or gauze pads (Gauderer and Stellato 1986). The site should be kept open and dry at all times. Ointments and other solutions, except for the treatment of moniliasis, should be avoided. Catheters, if kept long, can be immobilized with a small external cross-bar (Gauderer 2011).

Tube Plugging

Catheters must be flushed with water after each feeding to prevent blockage. In neonates, the amount should be small and added to the fluid intake (Gauderer 2011).

Administration of Improper Feedings

Careful and slow administration of the appropriate nutrient prevents metabolic abnormalities as well as diarrhea and excessive reflux (Gauderer 2011).

Delay and Trauma in the Reintroduction of a Dislodged Catheter

Accidental dislodgement of long gastrostomy catheter is quite common. The catheter must be replaced before the tract closes, which can be in a few hours unless it is well matured and epithelium lined. Careful dilation of the tract is usually successful (Gauderer 2011). In gastrostomy skin-level devices with jejunal extension a dislodgment of the jejunal tube back into the stomach may occur, usually requiring radiologic (fluoroscopy) or endoscopic guided repositioning.

Improper catheter reintroduction can lead to damage to the pancreas, liver, or spleen, particularly if long stylets or other traumatic instruments are used to elongate a mushroom-type tip. Gentle insertion and aiming toward the gastric cardia or fundus is the method least likely to produce injury (Gauderer 2011).

Complications Related to Catheters

Granulation Tissue

This is by far the most frequent problem associated with gastrostomies. If mild, usually a few applications of silver nitrate are curative. However, if this condition is neglected, granulation tissue will predispose to leakage, bleeding, and chronic discharge. With excessive growth, excision and cauterization become necessary. Granulation tissue formation will cease once epithelialization of the tract has occurred (Gauderer 2011).

Leakage

Severe continuous leakage is uncommon if the gastrostomy is properly constructed (Gauderer and Stellato 1986). The usual cause for leakage is the enlargement of the stoma by pivoting motion of the gastrostomy tube, which is often too large or too stiff (Gauderer and Stellato 1986). Catheters brought through the incision or the thinner midline are more prone to this problem. Severe widening of the stoma can lead to skin excoriation, dislodgment of the tube, metabolic imbalance, and even death (Gauderer 2011; Gauderer and Stellato 1986). Management of leakage begins with control of granulation tissue and placement of a smaller, softer catheter to avoid pivoting motion (Gauderer 2011). In extreme cases, reoperation or stoma relocation becomes necessary.

Internal (Distal) Migration

This may occur with any gastric tube, but is particularly common with long, balloon-type catheters (Gauderer 2011; Gauderer and Stellato 1986).

External Migration

Overzealous approximation of external immobilizing devices (bumper) can lead to embedding of the inner cross-bar of the PEG catheter, mushroom tip, or balloon in the gastric and abdominal wall, resulting in the so-called buried bumper syndrome (BBS) (Abdelhadi et al. 2016; Cyrany et al. 2016; Gauderer 2009, 2011; Gauderer and Stellato 1986). It occurs not in only in PEG patients but also in patients with low-profile balloon G tubes and nonballoon G tubes (Abdelhadi et al. 2016). The bumper can end up anywhere between the stomach mucosa and the skin surface, which is typical for rigid or semi-rigid internal immobilization devices (Cyrany et al. 2016). The usual presentations 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 and replaced. This problem can be avoided by giving the catheter enough “play,” i.e., a little to-and-fro motion (Gauderer 2011). Since the development of skin-level devices such as buttons, problems with BBS decreased markedly.

Perforation of Esophagus and Small Bowel

Accidental inflation of a balloon-type catheter in the esophagus esophagus or small bowel might lead to wall disruption (Gauderer 2011).

Gastrostomy Closure and Persistent Gastrocutaneous Fistula

When a stoma is no longer needed, the catheter can be simply removed. If the gastrostomy has been in place for less than 6–12 months, the tract usually closes spontaneously. If this does not occur, operative closure under general anesthesia may become necessary. The stoma tract is dissected down to the deepest possible extraperitoneal level. The tract is then closed in layers using absorbable sutures (Gauderer 2009, 2011).

Jejunostomy

Jejunostomies are not used as frequently as gastrostomies because they are more difficult to place and maintain, are more complication prone and 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 jejunal access, depending on how the catheters are placed (Gauderer 2009).

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

Indications

In the last two decades, there has been an increased use of jejunostomies in the pediatric age group as many children with complex medical problems and unable to use a gastrostomy are in need for long-term enteral access. Postpyloric feedings are used to overcome problems related to aspiration, gastric emptying, gastroesophageal reflux disease, gastric paresis, microgastria, or gastric outlet obstruction (Vermilyea and Goh 2016). Gastrojejunal tubes may eliminate the need for anti-reflux surgery in patients with gastroesophageal reflux (Axelrod et al. 2006).

The usual purpose of jejunostomies is feeding, whereas the administration of medication is a less common use. Classic procedures combined gastric decompression combined with intra-jejunal feeding (Fig. 19).
Fig. 19

“Classic” combination of gastric decompression and intra-jejunal feeding. From Gauderer (2011, p. 456)

Choice of Procedure

Several techniques for insertion of jejunal feeding tubes have been suggested, such as fine-needle catheter jejunostomy, endoscopically or laparoscopically controlled or percutaneously inserted jejunal (Pang et al. 2017) (Fig. 20).
Fig. 20

Options of jejunal access for select-feeding and decompressing-feeding. (a) Tunneled catheter. (b) Needle catheter. (c) T-tube. (d) Button. (e) Proximal decompression and distal feeding across an anastomosis. (f) Temporary decompression feeding using catheters when primary anastomosis is unsafe and intestinal exteriorization is not possible. (g) Roux-en-Y feeding jejunostomy. From Gauderer (2006)

Needle Catheter Jejunostomy

These are for short-term use via direct jejunal access . This approach can be employed as an adjunct during other intra-abdominal interventions. However, these catheters plug easily, are nearly impossible to change, and are associated with several serious complications (Gauderer 2009).

Catheter Placement Directly into the Jejunum

This approach is for long-term usage. The traditional technique is the formation of a Witzel-type channel. This method has two disadvantages: if the tube becomes dislodged or plugged, it is difficult to change, and in small children the formation of a channel substantially reduces the diameter of the lumen (Gauderer 2009).

Catheter Placement in a Partially Excluded Loop

Another example for long-term use of jejunal access. The main appeals of the Roux-en-Y feeding jejunostomy are the decreased likelihood of leakage and the possibility of safe catheter change. However, this approach is more complex and increases the possibility of early and late bowel-related complications (DeCou et al. 1993; Gauderer 2009; Williams et al. 2007).

Devices

Gastrojejunal (GJ) buttons have the same design as gastrostomy buttons but have additionally a long distal jejunal tube component (Fig. 21) (Vermilyea and Goh 2016). They are low profile/skin-level, have a one-way valve to prevent leakage when not in use, and are kept in place by a retention balloon (Abdelhadi et al. 2016; Vermilyea and Goh 2016). The gastric part of the GJ tube comes in different French diameters to match the patient’s gastrostomy stoma length. The jejunal length is determined by the patient’s size. The smallest GJ button presently available is a 14 F button (Vermilyea and Goh 2016). The gastric access is usually used for administration of medications while the jejunal extension is used for enteral nutrition (Abdelhadi et al. 2016).
Fig. 21

Patient with gastrostomy skin-level device and jejunostomy button

Postoperative Care and Complications

The postoperative care is similar to that after a gastrostomy. However, feeding should be started at a much slower rate to reduce the risk for ileus and diarrhea. Feedings should be administered continuously by a pump. Following a period of adaptation, the regimen can be modified to allow for “windowing.” Some patients may tolerate a limited amount of bolus feeds (Gauderer 2009). Gastrojejunal tubes require frequent exchanges, usually every 3 months (Vermilyea and Goh 2016).

Overall, jejunostomies have significantly more complications than gastrostomies. Intestinal volvulus around the stoma, internal hernia, adhesive bowel obstruction, and dumping syndrome associated diarrhea have been reported to be specifically jejunostomy-related complications (Abdelhadi et al. 2016; Farrelly and Stitelman 2016; Gauderer 2009). Persistent reflux, tube dislodgement and intestinal perforation have been associated to a morbidity after gastrojejunal tube placement (Campwala et al. 2015; Demehri et al. 2016; Farrelly and Stitelman 2016). A gastrojejunal button which is too big may cause pyloric obstruction in smaller children (Vermilyea and Goh 2016).

Conclusion and Future Directions

Although both gastrostomy and jejunostomy are basic surgical procedures, one must carefully consider their advantages and disadvantages in respect of the patient’s comorbidities as they mean major intervention in the children’s life. A problematic stoma can complicate the management of even a simple, temporary condition.

All children with gastrostomies and jejunostomies must be carefully followed to prevent long-term catheter-related complications. These children benefit from a team approach, including pediatrician, pediatric surgeon, pediatric gastroenterologist, primary nurse, and nutritionist. It is also paramount that the parents or caregivers be an integral part of the decision-making process at the different stages of management.

An important goal in children with feeding stomas is that, whenever possible, every effort should be made to institute or resume oral feedings.

Cross-References

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Copyright information

© Springer-Verlag GmbH Germany 2018

Authors and Affiliations

  1. 1.Department of Paediatric SurgeryHannover Medical SchoolHannoverGermany
  2. 2.University of South Carolina School of Medicine GreenvilleGreenvilleUSA

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