Endoscopic ultrasound-guided gastrojejunostomy with lumen-apposing metal stent in a boy with neurological impairment requiring jejunal feeding.

Video 1EUS-guided, LAMS-assisted gastrojejunostomy for re-routing a PEGJ tube in neurologically impaired children.

Background and aims

Significant undernutrition is reported in 13% to 52% of children with neurodevelopmental disabilities (NPDC)., Oropharyngeal dysphagia (90%), gastroesophageal reflux (50%-75%), delayed gastric emptying (67%), and/or ineffective esophageal peristalsis (61%) are associated with undernutrition. Moreover, nearly all NPDC have 1 or more comorbidity that negatively affects feeding and worsens GI symptoms such as retching and bloating, requiring prompt gastric decompression.3, 4, 5

When jejunal feeding is recommended,, long-term access is represented by jejunal tube introduction through gastrostomy (percutaneous endoscopic gastrojejunostomy [PEGJ]), surgical gastrojejunostomy (SJ), or direct percutaneous endoscopic jejunostomy (DPEJ).1, 2, 3, 4, 5, 6, 7, 8 Because PEGJ allows both gastric decompression via PEG and simultaneous jejunal nutrition via PEGJ, it is the preferred method, especially in NPDC who are unfit for surgery. However, PEGJ is associated with technical adverse events that compromise its long-term durability, such as tube clogging or retrograde dislodgement, necessitating repeated hospitalization: the average duration of PEGJ in NPDC is 39 days., Furthermore, the frequent replacement of a jejunal tube is not free from risk: major adverse events are reported in 5% to 12% of cases.9, 10, 11

SJ (open or laparoscopic) is effective in the management of gastric outlet obstruction (GOO) but is limited by its invasiveness and morbidity, mainly related to an unfriendly anatomy. DPEJ is a tubeless option, but its diffusion is limited by high procedural failure rates (20%-30%)10, 11, 12 and difficult management of the concomitant decompressive gastrostomy.

Endoscopic ultrasound-guided gastrojejunostomy with lumen-apposing metal stents (LAMSs) is a novel, minimally invasive technique for the palliation of malignant GOO. An overall clinical success rate of 80% has also been reported for benign GOO (eg, chronic pancreatitis or pyloric stenosis) but does not support the rerouting of a PEJ-tube.12, 13, 14, 15, 16 To our knowledge, the use of this technique in NPDC to reroute a jejunal tube has not been reported previously, and the technique could be considered in other clinical scenarios to reduce the risk of PEJ tube dislodgement.

Methods

A 17-year-old boy (weight, 28 kg) with severe neurological impairment and dystonic syndrome resulting from neonatal kernicterus in jejunal feeding was referred to us for repeated PEGJ tube dislodgment. Severe scoliosis and osteopenia, slow gastric emptying, retching, and GERD were associated. In the past 2 years, because of repeated displacement of the gastrojejunal tube, the patient experienced repeated hospitalization, and parenteral nutrition was necessary. On the last endoscopy, a low-profile 16F PEG was placed; however, gastric feeding was not tolerated. SJ and DPEJ were considered as secondary options. Thus, we attempted an EUS-guided LAMS-assisted gastrojejunostomy.

Results

The procedure (Video 1, available online at www.giejournal.org) was performed with fluoroscopy and with the patient under general anesthesia. A linear echoendoscope (Pentax EG38-J10UT, PENTAX Europe GmbH Hamburg, Germany) was used. The target bowel loop was filled with saline solution, indigo carmine, and contrast with a catheter (Figs. 1 and 2). A cautery-tipped 15- × 10-mm LAMS (Hot Axios; Boston Scientific, Marlborough, Mass) was employed to create the gastrojejunostomy under EUS and fluoroscopy guidance (Fig. 3). The correct position of the LAMS was confirmed by fluoroscopy (Fig. 4). The LAMS position in the stomach was 5 cm from the PEG bumper (Fig. 5). Six months later, the LAMS was removed, and the gastrojejunostomy was easily intubated with a standard gastroscope. Both afferent and efferent jejunal loops were explored. The PEJ tube was placed from the stomach into the efferent jejunal loop through the gastrojejunostomy under x-ray guidance (Fig. 6). Three months after rerouting, 55% of caloric intake tolerance by jejunal feeding and a 5-kg improvement in weight were obtained, with a progressive autonomization from parenteral nutrition.

Figure 1

X-ray guided filling-catheter placement. Note the severe scoliosis.

Figure 2

Target bowel loop filling with saline solution, indigo carmine, and hydrosoluble contrast.

Figure 3

Lumen-apposing metal stent distal flange is opened and the lumen-apposing metal stent is retracted under EUS and x-ray guidance.

Figure 4

Gastrojejunostomy is completed. Contrast medium passes through the lumen-apposing metal stent.

Figure 5

Distal flange of the lumen-apposing metal stent is placed into the stomach.

Figure 6

Percutaneous endoscopic jejunostomy tube placed through the gastrojejunostomy after the removal of lumen-apposing metal stent, 6 months after its placement.

Conclusions

PEGJ rerouting through an EUS-guided, LAMS-assisted gastrojejunostomy may prevent dislodgement of the PEGJ tube and facilitate jejunal feeding in NPDC. Ethical and cost-effectiveness considerations are awaited.

Disclosure

All authors disclosed no financial relationships.