A lot has changed in the field of pediatric gastroenterology since I completed my training 16 years ago. One technology that is used frequently now is the gastrojejunal (GJ) tube for feeding neurologically-impaired children. Previously, GJ tubes were used as a temporary solution. Part of the rational for short-term usage was that these tubes were often difficult to maintain; they could easily become dislodged or clogged.
A recent study documents the more frequent usage of GJ tubes and their indefinite usage to treat complex feeding issues (JPGN 2013; 56: 523-27).
This retrospective chart review encompassed a 10 year period (1999-2009) at a single academic center. In total 33 patients were treated with GJ tubes with 160 placements. The mean age at initial placement was 6 years and the mean weight 19.4 kg. 76% of the patients had cerebral palsy/neurologic disorder, 21% had congenital heart disease, and 9% had chronic lung disease.
Common indications for replacement: dislodgment, obstruction, coiling into stomach, and broken tubing.
Three techniques were used:
- Fluoroscopy with guide wire and subsequent GJ
- Gastroduodenscopy via gastrostomy site to place guidewire for GJ placement
- Tube placement during esophagogastroduodenoscopy
Most procedures (85%) did not require sedation.
- 13 (39%) maintained on GJ throughout study period
- 10 (30%) converted to gastric or oral feeds
- 5 (15%) surgical intervention
- 5 (15%) deceased
- Duration of tube survival: mean 91 days for Mic-Key GJ (low profile) and 177 days for coaxial PEG-PEJ (e.g. 16 French Corflo gastric tube with 6 French jejunal tube)
When reading the study, it is hard to ignore Figure 3 which shows more than 30 placements per year after 2007 whereas the number was about two per year before 2001. In the discussion, the authors do not focus on how this technology has been embraced so widely. It is mostly a discussion on the indications, methods, and complications. Indications included high aspiration risk, intractable vomiting, failed Nissen fundoplication, and gastroparesis. “Our study showed that long-term jejunal feeding via GJ tubes is possible and safe.”
My preference is generally to avoid GJ feedings as a primary intervention for long-term feeding problems. That is, when patients need gastrostomy tube feeds but are prone to vomiting, most often a fundoplication is worthwhile. When a patient has had a fundoplication that is no longer effective, a GJ tube should be considered.
Related blog links: