Predicting the Need for Gastrojejunostomy Tube Placement Instead of Gastrostomy Tube Placement

A recent study (ME McSweeney et al. JPGN 2018; 66: 887-92) determined that preoperative characteristics were unable to determine which patients who had gastrostomy tube (GT) placement would ultimately need conversion to gastrojejunostomy (GJ) placement.

This retrospective study matched 79 GJ patients with 79 GT patients.

Key points: 

  • These patients had similar rates of successful preoperative nasogastric feeding trials (GT 84.5% vs GJ 83.1%), and similar rates of abnormal swallow studies (53.8% and 62.2% respectively).
  • In the entire cohort, 11 patients had fundoplication (all GJ patients)
  • GT patients were more likely to have tube permanently removed: 20.5% vs 2.5% for GJ patients. Many (45.6%) of the GJ converted patients went back to GT feeds
  • Overall, from an initial cohort of 902 patients, 8.8% “required conversion” to GJ feeds
  • GJ-converted patients had a trend towards fewer hospitalizations.

While not a result in the study, the issue of GJ compared with fundoplication is briefly discussed.  The authors in their discussion of preoperative workup state that

“the complications of fundoplication are more significant and the risks are higher than GJ placement”

In my view, this is one of the most consequential parts of their discussion.  While the authors have extensive experience, I think the issue regarding GJ tube placement and fundoplication is more murky.  GJ tubes can be difficult to maintain and I have not seen long-term well-controlled studies comparing outcomes between GJ placement and fundoplication.

Other pointers in the discussion:

  • Fundoplication has “minimal impact/no impact” to reduce respiratory-related admissions, mainly because the main mechanism is aspiration rather than reflux
  • For isolated oropharyngeal dysphagia, one could argue that “an enteral tube is not indicated anymore” based on published data

My take: This is an important retrospective study that illustrates how difficult it is to know preoperatively which patients need GJ placement (or fundoplication) compared to GT placement alone.  In our institution, we are reluctant to place GT placement if a patient has not demonstrated tolerance of nasogastric feeds.

Related blog posts:

Amelia Island

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