Joseph A. Picoraro, MD, from the Department of Pediatrics, Columbia University Medical Center, in New York, New York, USA discusses this Original Article, “Gastrojejunal tube placement through an established gastrostomy via an endoscopic transgastric approach in a pediatric population.”

The focus of our study was to analyze the advantages and challenges of an innovative and relatively new technique to place gastrojejunal feeding tubes in pediatric patients by an endoscopic transgastric approach with fluoroscopic confirmation. Gastrojejunal feeding tubes (GJTs) are an essential feeding modality in many pediatric patients but require frequent replacement and maintenance. The risks inherent to placement and replacement depend on the technique. Certain endoscopic methods require sedation and fluoroscopic methods by interventional radiologists rely on a sizeable amount of radiation. An alternate endoscopic method by a transgastric approach that utilizes fluoroscopy primarily to confirm final placement can be performed without sedation and limits radiation exposure. With recent but limited description in children, we felt it important to assess the advantages and challenges of this technique in children at our institution and share our findings with our colleagues at other centers to inform their practice.

A total of 47 GJT placements were performed by this technique, all of which resulted in successful tube placement in the distal duodenum or jejunum. Mean fluoroscopy time was 10 seconds, and, in a subcohort of patients with GJT placements previously performed by IR, the average fluoroscopy time was significantly less by the endoscopic method described in our article. In 6 patients, more than one endoscopic attempt was required due to coiling of the GJT in the stomach. Pyloric obstruction caused by the GJT balloon developed in one patient necessitating replacement with a smaller GJT. Sedation was used in 30% of placements.

Important considerations for this technique include: appropriate gastric stoma size, orientation of gastric stoma and pyloric opening, guidewire displacement, and looping of the GJT in the stomach. All of these can be addressed with proper preparation and experience.

We demonstrate here that this technique minimizes the need for sedation, which is important in children, because sedative and anesthetic agents may impair cognitive development. Furthermore we show that radiation can be limited, which is a crucial consideration in pediatric patients who are at higher risk of the effects of radiation.

Prospective evaluation of larger cohorts in multiple centers is necessary to appropriately determine the optimal method and timing of GJT placement in pediatric patients. These future studies should directly compare endoscopic transgastric GJT placement with other techniques to determine which factors affect technique-related outcomes, including: clinical indication for GJT placement, gastrointestinal anatomy, prior surgery and behavior. Given its advantages, endoscopic transgastric placement of GJTs with fluoroscopic confirmation could become the mainstay method of GJT placement in pediatrics.

We look forward to working with other pediatric centers to prospectively evaluate this technique.

Find the abstract for this article here.

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