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Pediatric laparoscopic‐assisted direct percutaneous jejunostomy

Mike Thomson, Jonathan Goring, Richard Lindley, and Sean Marven

Introduction

Artificial enteric nutritional support is vital in the management of patients who are unable to maintain oral nutrition such as those with upper GI motility disorders, gastroesophageal reflux disease (GERD), faltering growth (FG), recurrent pneumonia, and oral feeding difficulties. Enteral nutrition via a percutaneous gastrostomy (PEG) tube may not be indicated because of severe GERD and/or delayed gastric emptying and/or antro‐pyloric dysmotility.

In some of these circumstances and mainly in the neurologically impaired child, postpyloric feeding can be crucial, thereby avoiding the need for parenteral nutrition. For delivery of long‐term postpyloric feeding, a direct jejunostomy tube provides more stable and secure jejunal access compared with a percutaneous gastrostomy with jejunal extension (PEGJ), with fewer reported complications of blockage/displacement and consequently a decrease in the need for radiological/endoscopic replacement/intervention. Naso‐jejunal tubes often migrate and/or are inadvertently pulled out. PEGJ tubes regularly require replacement with necessary X‐ray exposure – which can be lessened by the endo‐clip maneuver attached to their tip as previously described.

Direct jejunostomy has been attempted before by using, variously, a Roux‐en‐Y loop or a direct surgical jejunostomy. Both have been associated with significant complications and have generally fallen out of favor.

A new approach has recently been advanced which involves a similar technique to PEG but involves the laparoscopist and endoscopist working in tandem.

Photo depicts a laparoscopic view of endoscopic light source seen through the small bowel wall. — **Figure 35.1** Laparoscopic view of endoscopic light source seen through the small bowel wall (note that the brightness of the laparoscope is reduced at this point to facilitate identification).

Photo depicts a Johan instrument is used to occlude the jejunum distal to the endoscope to facilitate distension and reduce passage of distal gas. — **Figure 35.2** A Johan instrument is used to occlude the jejunum distal to the endoscope to facilitate distension and reduce passage of distal gas.

Photo depicts a simultaneous laparoscopic and endoscopic view of trocar inserted into the small bowel. — **Figure 35.3** Simultaneous laparoscopic and endoscopic view of trocar inserted into the small bowel.

Photo depicts an endoscopic view of wire grasped by biopsy forceps. — **Figure 35.4** Endoscopic view of wire grasped by biopsy forceps.

Photo depicts PEJ placed – endoscopic (a) and laparoscopic (b) views showing PEG bumper against jejunal mucosa and loop of jejunum brought up to anterior abdominal wall. — **Figure 35.5** PEJ placed – endoscopic (a) and laparoscopic (b) views showing PEG bumper against jejunal mucosa and loop of jejunum brought up to anterior abdominal wall.

The endoscope is inserted (often either a dual‐channel therapeutic gastroscope or a variable stiffness pediatric colonoscope is preferred as they allow deep jejunal penetration). Once the surgeon has identified the DJ flexure then the laparoscopic lights can be dimmed – this allows for visualization of the light at the tip of the endoscope (Figure 35.1) A soft clamp (laparoscopic Johan instrument) has already been applied distal to this area (Figure 35.2) which prevents distal small bowel distension and resultant obscuring of the view from the laparoscopic angle. A trocar is inserted through the anterior abdominal wall and the endoscope can immobilize the small bowel loop in question (Figure 35.3). As with the PEG technique, a wire is passed through the trocar and grasped by the biopsy forceps (Figure 35.4). Then as for a standard PEG technique, the PEJ is attached outside the patient’s mouth then pulled through to anchor the small bowel to the anterior abdominal wall (Figure 35.5). As for a standard PEG, after three months or so the PEJ can be changed by endoscopy for a low‐profile balloon jejunostomy.

Conclusion

This is an ideal example of the surgical–endoscopy interface and is a significant advance on previous iterations which were mainly surgical alone. Further experience will refine this technique.