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

How Gastrostomy Tube Placement Influences Gastroesophageal Reflux

A recent prospective observational study (M Aumar et al. J Pediatr 2018; 197: 116-20) examined the effect of percutaneous gastrostomy (PEG) tube placement on gastroesophageal reflux disease (GERD) over a 13 year period. This study included 326 patients, 56% who had neurologic impairment and had a median follow-up of 3.5 years (and in some cases follow-up to 15 years). GERD was defined as gastroesophageal reflux causing troublesome symptoms and/or complications. Routine pH studies or impedance were not performed.

Key findings:

  • GERD was present in 242 of 326 patients at baseline (74%).  GERD appeared in 11% of patients after PEG and was aggravated in 25% with preexisting GERD.
  • Factors associated with worsening GERD were neurologic impairment and preexisting GERD.
  • 53 patients (16%) required anti-reflux surgery with 22 (6%) in the year following PEG. The only factor identified with the need for surgery was neurologic impairment.
  • At last followup, PEG remained in place in 133 children (41%), and had been removed in 99 (30%).  94 children (29%) were deceased, including 2 from an early procedure-related complication.  In those who were deceased, the vast majority occurred related to evolution or complication of their underlying disease.

The authors note that studies have shown that PEG increases GERD, but “the majority of these studies were of low methodologic quality.”

My take: Routine antireflux surgery at the time of PEG placement is NOT needed in the majority of patients, even in those with baseline GERD.  Less than 20% of patients with GERD required antireflux surgery.

Related blog posts:

Surgery for Reflux Works Best in Those Who Need it the Least

In a recent retrospective study (JT Krill et al. Clin Gastroenterol Hepatol 2017; 15: 675-81), the authors reinforce the notion that surgery works best for reflux patients whose symptoms respond best to medical therapy.

Background: In this study, 196 patients with normal anatomy were identified, though 81 had inadequate follow-up at 1 year.  This left 115 patients (median age ~52).  This study examined patients with typical reflux symptoms (regurgitation, heartburn) (n=79 of 115, 68.7%) and extraesophageal symptoms, like cough, hoarseness, and throat clearing (n=36 of 115, 31.3%).  It is noted that 2/3rds of those with extraesophageal symptoms had coexisting typical GERD symptoms.  Most patients had a Nissen fundoplication but some underwent a Toupet fundoplication.

Key findings:

  • 91.5% of those with typical reflux symptoms (who  had responded to medical therapy) were in remission at 1 year; in comparison, only 33.3% (P <.01) of those with extraesophageal symptoms along with poor response to acid suppression therapy exhibited remission following fundoplication.
  • “The severity of acid reflux on pH monitoring and larger hiatal hernia size were associated with a more favorable outcome at 12 months.”  All patients had either abnormal pH monitoring or endoscopic esophagitis prior to surgery.  Only those with severe reflux had increased likelihood of response to surgery.

Limitations: retrospective study, 81 of 196 patients were excluded due to lack of followup

My take: This study is consistent with other studies in suggesting that reflux surgery is less effective in those who do not respond to medical therapies and who have atypical symptoms.

Related blog post:

From Pitts Street Bridge, Mt Pleasant

Parent Perspective, Pediatric Nutritionist and Traci Nagy

A recent post on The Pediatric Nutritionist blog (Kipp Ellsworth) provides a wealth of useful information for clinicians taking care of children with enteral tubes: Understanding the Parent Perspective: Communicating with Parents and Caregivers about Tube Feeding

The presentation was given by Traci Nagy who founded the FeedingTubeAwareness website, which I have been a big fan for several years.  I probably recommend this website at least once everyday at work.  Of course, I am not the only one familiar with this website which is why it has had more than 200,000 hits last year.

This post includes a 37 slide lecture and links to previous publications.  The “open letter number one” is particularly useful and is reviewed in the slide presentation.  The “open letter number two” also has some useful points, though many would disagree on the utility of testing gastric emptying before fundoplication.

My take: Look at this post -it will help you be a more effective clinician if you take care of kids with enteral tubes.

A few of the slides:

Screen Shot 2016-05-06 at 3.13.34 PM

Screen Shot 2016-05-06 at 3.28.53 PM Screen Shot 2016-05-06 at 3.27.36 PM Screen Shot 2016-05-06 at 3.27.24 PM

Transoral Fundoplication for Refractory Gastroesophageal Reflux

A new endoscopic technique’s efficacy has recently been reported (Gastroenterol 2015; 148: 324-33).  Since this technique is not likely to be broadly applicable to the pediatric population for some time, I will not delve into all of the details.

In essence, a carefully selected group (n=129 from a screened group of 696) of adult patients with persistent regurgitation underwent transoral fundoplication; this eliminated troublesome regurgitation in 67% compared to 45% who were randomized to sham/PPI.  Severe complications were rare.

Here is a picture of the technique:

Transoral Fundoplication

Transoral Fundoplication

Link: Description and a video animation of the procedure

Bottomline: This endoscopic procedure along with the Stretta procedure and the LINX device (using magnets) offer alternatives to surgical fundoplication in carefully-selected patients with refractory gastroesophageal reflux symptoms.

New drugs approved by FDA:

Ceftolozane (Zerbaxa) -combines a cephalosporin with a beta-lactamase inhibitor (tazobactam).  Indications: complicated intra-abdominal infections (in combination with metronidazole), and complicated urinary tract infections. From FDA: FDA approves new antibacterial drug Zerbaxa

Viekira Pak -combination of 3 new drugs: ombitasvir, paritaprevir, and dasabuvir along with  older drug: ritonavir.  Indications: Hepatitis C genotype 1. From FDA: FDA approves Viekira Pak to treat hepatitis C

Related blog posts to fundoplication:

Expert Commentary on GERD Surgery in Infants

In this month’s “GI & Hepatology News,” Dr. Ben Gold and Dr. Jose Garza comment on antireflux surgery in infants (page 12) (related article on page 1 of same issue). Initial reference: JAMA Surg 2013 [doi: 10.1001/jamasurg.2013.2685]. See the following link.  They comment on the lack of workup for many of these infants who undergo this major surgery and the frequent lack of involvement by pediatric gastroenterologists.

PDF: December issue – American Gastroenterological Association

Long-term Outcomes with Pediatric PEG Placement

As noted about a week ago in this blog, gastrostomy tube (gtube) placement in children is much different from gtube placement in adults.

A retrospective study from Boston Children’s followed 138 patients who had PEG tube placed between 1999-2000 (JPGN 2013; 57: 663-67).  The median followup was approximately 5 years.

Results:

  • Median time to elective tube removal was 10.2 years.
  • ~50% of patients continued with gastrostomy tube 10 years after placement.
  • 11% (n=15) had at least 1 major complication related to gastrostomy placement.  Major complication was defined as any unplanned adverse events requiring hospitalization, surgery (eg. fundoplication) or interventional radiology (eg. gastrojejunal tube placement). Most major complications occurred during the first 6-12 months following placement with the most common being cellulitis (n=10).
  • 18% of the cohort died during the 10-year study period because of non-gastrostomy-related issues.  No deaths were attributed to gastrostomy tube placement.

Bottomline: The need for gastrostomy tube placement is associated with frequent comorbidities.  A significant number of patients undergoing gastrostomy tube placement experience major complications.

Also noted:

JPGN 2013; 57: 659-62. This prospective study of 69 patients showed that early reintroduction of feedings after gastrostomy placement, 4 hours postoperatively, was safe and compared favorably to those fed 12 hours postoperatively.  Early feedings were associated with hospital duration, on average, of 6.7 hours. At this center, prophylactic antibiotics were not administered without apparent increase in infections.

JPGN 2013; 57: 668-72. This retrospective study of 77 children with feeding disorders showed that inpatient behavioral interventions are effective in transitioning children from gastrostomy tube feeding to oral feeding.

Related blog entries: