Customized “Right-Sized” Primary Laparoscopic Gastrojejunostomy Tubes for Infants

Abstract

Introduction:

Nutritional support is critical for the growth and development of chronically ill children. Although enteral routes are preferred, gastroesophageal reflux, recurrent aspiration, and dysmotility disorders may limit gastric feeding tolerance. Jejunal delivery mitigates some risks by providing feeds distal to the pylorus, but standard gastrojejunostomy (GJ) tubes are not engineered nor sized for infants. In this 4-minute video, we describe a laparoscopic technique to place a right-sided GJ tube in infants who weigh <10 kg.

Materials and Methods:

A customized GJ tube, size appropriate for infants, can be produced with universally available materials. A standard 14F GJ tube with a 1-cm stem length (Applied Medical Technology, Brecksville, OH) serves as the housing. The jejunal limb is transected with scissors just distal to the retention balloon. An 8F Corpak enteric feeding tube (Medline Industries, Northfield, IL) is cut 18–22 cm from the distal weighted tip. It is then lubricated and threaded tip first into the outer jejunal lumen of the GJ tube until the other (severed) end is seated immediately below the GJ tube valve mechanism. Although this tube within a tube is snug, it is secured with a 3-0 silk transfixation stitch placed just below the level of the retention balloon, incorporating the GJ tube housing and the wall of 6F Corpak without piercing its lumen. A 5-mm trocar is placed obliquely in the left upper quadrant (LUQ), deliberately angled toward the pylorus to permit the GJ tube to track in the transpyloric direction. Transabdominal Prolene sutures secure the gastric wall, and through the 5-mm LUQ incision, a hollow bored needle is passed into the gastric lumen, and a dilator kit is used to sequentially dilate the abdominal and gastric wall to 20F. Next, the 20F dilator is advanced through the pylorus and a 0.89-mm flexible tip polytetrafluorenthylene guidewire (Cook Medical, Bloomington, IN) is passed into the fourth portion of the duodenum. Over this wire, the customized GJ tube is inserted and advanced distally until the tip resides in the transverse portion of the duodenum. The retention balloon is inflated, transabdominal sutures are tied loosely, and an on-table contrast study is performed to confirm placement and patency of the 8F tube.

Conclusion:

This novel approach to primary placement of a “right-sized” GJ tube in an infant is a potential long-term solution that circumvents the risk of obstruction and bowel perforation associated with the standard 14F GJ tube in infants.

Authors have nothing to disclose.

Runtime of video: 3 mins 53 secs