Relief of Repeated Intussusception After Repositioning of Postpyloric Feeding Tube

More than one million children with medical complexity (CMC) live in the United States,1 of which at least 80% require surgical feeding tubes at some point in their lifetime.2 Although most of these are gastrostomy tubes (GT),3 certain CMC experience challenges with aspiration or pathologic reflux not amenable to fundoplication. The European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) expert group recommends the gastrojejunostomy tube (GJT) as the route of choice for providing nutrition in children with failure of intragastric feeds and advises the tip of GJT placed beyond the ligament of Treitz to prevent retrograde dislodgement of the tube into the stomach.4GJTs are not without risk and pose known minor and major complications.5 Specifically, GJTs can cause repeated episodes of intussusception leading to pain, hospitalization, prolonged bowel rest, and potential need for bowel resection if missed.6 A solution to consider in this context used enteral feeding tubes that terminate in the duodenum (gastroduodenal or GDT), which renders intussusception improbable given the fixation of the Ligament of Treitz to the retroperitoneum.7 GDTs are used infrequently given theoretical risks, including the retrograde flow of feeds from the duodenum to the stomach which may lead to aspiration as well as risk of bowel perforation.8 Notably, GJT also carries a risk of aspiration4 and bowel perforation.9–12 Given the potential lower risk of intussusception, equivalent or higher risk of aspiration, and equivalent or lower risk of bowel perforation compared with GJTs, GDTs may be a viable option in CMC who experience repeated intussusception around their GJT.We present a case series of 3 patients who experienced repeated intussusception around their GJT that subsequently remitted after their feeding tubes were repositioned into the duodenum, without ensuing bowel perforation.A 14-kg 2-year-old with multiple chronic conditions including severe neurological impairment, enteral feeding tube dependence, and chronic respiratory insufficiency experienced severe feeding intolerance and recurrent aspiration. The patient's low-profile GT was converted to a 45-cm, low-profile Applied Medical Technology (AMT) GJT. Four days later, the patient had abdominal pain and emesis. Ultrasonography demonstrated intussusception around the tip of the GJT, and it was replaced with a temporary GT. Three days later, a 30-cm, low-profile GJT was reinserted. Within 24 hours, the patient developed abdominal pain and emesis; ultrasonography again demonstrated intussusception around the tip of GJT, and it was again replaced with a temporary GT. After a brief period of feeding via the nasojejunal tube (NJT), a low-profile GDT was inserted, accomplished by truncating the tube length to 16 cm to terminate in the distal duodenum. The patient tolerated duodenal feeds without further episodes of intussusception and was discharged home. At the time of writing, now more than 2 years after GDT placement, the patient has remained on duodenal feeds without recurrence of intussusception, feeding intolerance, or aspiration pneumonia.A 12-kg 2-year-old child with multiple chronic conditions including neurologic impairment and enteral feeding tube dependence experienced severe gastric feeding intolerance in infancy, for which postpyloric feeds were first administered via NJT and eventually, a low-profile AMT GJT was placed. The patient subsequently experienced 2 separate episodes, 5 months apart, of severe abdominal pain and irritability. Ultrasonography revealed intussusception around the tip of the GJT during both episodes. After recovering from the second episode of intussusception, the patient had a low-profile GDT placed with the tube length truncated to 16.5 cm to terminate in the distal duodenum. At the time of writing, now more than 2 years after GDT placement, this patient has also remained on duodenal feeds without recurrence of intussusception, feeding intolerance, or aspiration pneumonia.A 16-kg 9-year-old child with leukodystrophy, severe gastroesophageal reflux disease (GERD) status post fundoplication, enteral feeding tube dependence, and a history of recurrent aspiration pneumonia experienced severe feeding intolerance and chronic aspiration. The patient's GT was converted to a 30-cm, low-profile AMT GJT. Two days later, the patient developed emesis and abdominal pain; ultrasonography demonstrated intussusception along the course of the GJT, and it was replaced with a temporary GT. Two days later, a 45-cm, low-profile GJT was reinserted. Nine days later, the patient was readmitted with a sudden onset of bilious emesis and tachycardia. Ultrasonography demonstrated intussusception at the tip of the GJT, and it was again replaced with a temporary GT. Seven days later, a 22-cm AMT low-profile micro-GDT ("micro" indicating a narrower, more flexible tube compared with the standard jejunal tube) was inserted. Six months later the tube required replacement with the same size and caliber tube because the distal end had coiled in the stomach. One week later, the patient had an episode of presumed aspiration pneumonia (clinical diagnosis without radiographic evidence) that required 24 hours of hospitalization for intravenous antibiotics. After aspiration pneumonia, parents were offered to switch back to GJT; however, they elected to continue with the GDT as they perceived the recurrent symptomatic intussusception to be more distressing to the patient than the episode of pneumonia. At the time of writing, more than 18 months after reinstituting GDT feeding, the patient has remained on these feeds without recurrence of intussusception or further episodes of pneumonia.We present 3 patients with gastric feeding intolerance, who each developed 2 episodes of intussusception around their low-profile AMT GJT (no distal pigtail) and subsequently had tubes repositioned to terminate in the duodenum. After GDT placement, no further episodes of intussusception occurred, allowing the continuation of postpyloric enteral feeds. Complications in 1 patient included coiling of the tube into the stomach requiring replacement (the most common complication associated with GJT tubes)13 and 1 episode of pneumonia (in a patient who had a history of recurrent aspiration pneumonia despite fundoplication). No cases of bowel perforation were observed in these 3 patients at the time of this report.GJTs are a recommended option for patients with severe reflux and neurologic impairment when they do not tolerate gastric feeds.5 Options for enteral feeding become limited for a subset of these patients who experience repeated symptomatic intussusception around their GJT. As with the patients in this series, the risks of all options should be discussed in shared decision-making with the family (See Table 1). These options include: (1) reattempt GJT, which periodically works, but intussusception may continue to recur in certain patients despite placement in different locations in the jejunum6; (2) return to gastric feeding: some patients may tolerate a retrial of gastric feeds without complications of aspiration or feed intolerance, avoiding further intervention14; (3) placement of a surgical jejunostomy tube (JT): JTs are associated with fewer tube-related, mechanical complications than GJT,15–16 but carry potential complications associated with creating a second transabdominal tract including wound healing, adhesive bowel obstruction, and volvulus13; (4) surgical fundoplication with GT: a longer-term solution in carefully selected children with medical refractory GERD13 but with known failures and complications, especially in patients with neurologic impairment17,18; and (5) prolonged bowel rest using parenteral nutrition before re-attempting enteral feeds.We suggest GDTs also be considered while stratifying preferred options with families. Although not typically used, they may be a suitable option in the subset of patients who continue to be intolerant of gastric feeds and experience repeated symptomatic intussusception around their GJT, especially before considering more invasive options.We acknowledge the limitations of this small retrospective case series at a single institution and recognize that duodenal placement also carries potential complications. The tubing may coil back into the stomach, requiring hospital visits for replacement.5 There is also a theoretical risk that because of proximity, feeds delivered into the duodenum may have a retrograde flow to the stomach more readily than GJT, contributing to increased feed intolerance and aspiration. Finally, as there are limited options in lengths of GJTs, finding the correct jejunal length tube that terminates in the duodenum may require manual trimming of the jejunal arm of the tube or be unobtainable for certain patients.Intestinal perforation has been identified as a rare but serious potential risk for GDT.7 Massoumi and colleagues proposed the theory that radial pressure along the greater curvature flexion point of bowel transition may contribute to perforation and advocated for tubes being placed past the ligament of Treitz.8 However, perforation of the jejunum associated with GJTs has also been described in several cases.8–12 Importantly, in the referenced studies, all 15 patients who developed bowel perforation with GJT terminating either in duodenum or jejunum were younger than 24 months (13 patients <12 months) and weighed less than 11kg (14 patients <8kg). Smaller patients with a narrower diameter and thinner small-bowel wall19 may be at increased risk for the tip of the jejunal tube to cause pressure necrosis11 and eventual perforation at or distal to the ligament of Treitz, regardless of the placement location of the tube. In our case series, all 3 patients were aged over 24 months and over 10 kg in weight at the time of GDT placement and none had evidence of bowel perforation.In patients requiring postpyloric feeds who experience repeated intussusception around their GJT, no perfect solution exists. Depending on the patient's age, size, and medical history, shared decision-making with the family is necessary to determine preferences for quality of life. We propose that the GDT be considered a viable option for patients older than 12 months and under 10kg who are intolerant of gastric feeds and experience repeated symptomatic intussusception with their GJTs, especially before contemplating more invasive options such as fundoplication or surgical jejunostomy. Our next steps include describing the risk of intussusception and those at risk for repeated intussusception around their GJT to help clinicians and families better understand this potential complication.We wish to acknowledge the Division of General Pediatrics and the Complex Care Research team, specifically Dr Chris Feudtner, Dr Morgon Congdon, and Dr Pam Mazzeo for their support of this paper. Institutional review board: the CHOP IRB determined that the proposal does not meet the criteria for human subject research and, therefore, ongoing IRB oversight is not required.