Duodenal perforation: A complication of neonatal nasojejunal feeding

Gastrojejunostomy tubes (GJTs) have been associated with intestinal perforation in children < 6 months or < 6 kg. This study evaluated the impact of an institutional practice change recommending a new soft tip GJT for children < 10 kg.

We performed a single-center review of GJT placements among children < 10 kg before (1/1/2010–12/31/2013) and after (7/1/2014–12/31/2016) the practice change. Intestinal perforation, nasojejunal tube (NJT) for > 30 days, and GJT replacement were assessed.

Sixty GJTs were placed in 35 children (54% male; 17.2 ± 9.0 months old) after compared to 147 GJTs in 77 children (44% male, p = 0.32; 14.1 ± 11.8 months, p = 0.08) before the practice change. Use of soft tip GJT was adhered to in 19 placements (32%). There were no intestinal perforations after the practice change (before: 6 (4.1%); p = 0.11). NJT remained > 30 days in 15 patients (65%) after the practice change (before: 13 (35%); p = 0.02). Replacement was required for 53% with soft tip GJT and 18% with standard GJT (p = 0.006).

A reduction in intestinal perforation with an institutional practice change may be explained by fewer GJT placements in high-risk children and longer length of NJT placement. Future protocols may consider age and size restrictions rather than alternative tube types.

Treatment study.

Level III.

The purpose of this study was to define morbidity from gastrojejunostomy tube (GJT) placement in children.

A retrospective single-center 5-year review of GJT placement in children was performed. Age, weight, prior surgery, indication, type of GJT, and complications (GJT replacement, wound complications, and perforation) were recorded. Logistic regression for morbidity was performed.

142 children underwent 394 GJT placements at a median age of 2.7 years (range 5 weeks–18 years). The most common indications were failure to thrive (62%) and reflux (25%). Among the 296 GJT replacements, the most common reason was tube dislodgement (30%). Risk factors for replacement, which occurred at a median interval of 12 weeks (range 2 days–2.4 years), were peristomal complaint (OR = 5.4, p = 0.02) and prior GJT replacement (OR = 1.8, p = 0.03). In all, 7 (5%) jejunal perforations occurred at a median of 3 days (range 0–21 days) from GJT placement. Patients with perforation had a median weight of 4.6 kg (range 3–11.2 kg) and age of 3.9 months (range 8 weeks–2.1 years). Lower weight (p < 0.01) and younger age (p = 0.02) predicted perforation, with those weighing less than 6 kg (OR = 51.9, p < 0.001) or younger than 6 months (OR = 28.6, p < 0.01) at highest risk.

GJT placement has a significant risk of recurrent dislodgement and the highest risk of perforation in children weighing less than 6 kg or younger than 6 months. Alternate feeding options should be strongly considered in this vulnerable population.

We describe the case of a 2-mo-old infant who weighed 3.5 kg, had alveolar interstitial pneumopathy on mechanical ventilation, and developed a duodenal perforation due to a 6-Fr polyurethane transpyloric tube.

Abdominal ultrasound showed the tube to be within the intestinal lumen. Due to this diagnostic error, nutrition was administered through the tube and the patient developed severe peritonitis. Laparotomy showed a perforation due to the transpyloric tube at the level of the union of the second and third portions of the duodenum. The perforation was sutured but the patient developed new intestinal perforations with severe progressive intestinal damage, leading to multiorgan failure and death.

If there is a clinical suspicion of intestinal perforation secondary to insertion of a transpyloric tube, the position of the tube must be confirmed by radiographic and echographic techniques. In case of doubt, the tube should be withdrawn and endoscopic or contrast radiographic evaluation must be performed.

Intraabdominal foregut perforations in children are rare. We conducted a retrospective review with the aim of defining their etiologies, treatment, outcomes, and prognosis.

Abdominal foregut perforations treated during a 10-year period were reviewed. Perforations secondary to blunt or penetrating trauma and inadvertent perforations sustained, recognized, and repaired during surgical procedures, were excluded.

Fourteen perforations were identified, including 1 esophageal, 8 gastric, and 5 duodenal perforations. Seven perforations (50%) occurred in the neonatal period. Of the 7 neonates, 3 (43%) were premature. Nine patients (64%) had significant comorbidities. Six (43%) perforations were spontaneous, 5 (36%) were iatrogenic, and 3 (21%) were direct complications of underlying conditions. Primary repair of the perforation was completed in 11 patients (79%), and staged repair in 1 patient. Significant morbidities related to the perforation occurred in 36% of patients. Twelve patients (86%) survived to discharge. The 10 long-term survivors are on full oral feeds.

Pediatric abdominal foregut perforations have diverse etiologies. Half occur in neonates, evenly divided between term and premature babies. Major comorbidities are common. One third are iatrogenic and potentially preventable. Primary repair should be performed when feasible. Patients who survive the initial complications have excellent long-term outcomes.

Nutritional requirements of extremely premature infants are greater than those of other premature and full-term neonates. Nutrition support for these infants should be initiated early in the neonatal period combined with the use of parenteral nutrition and minimal enteral feedings. Intermittent gastric gavage is the preferred method to provide enteral feeding until sucking and swallowing mechanisms are mature. Fortified preterm human milk is the first choice of feeding, and the best substitute is premature infant formulas. Multivitamin supplementation may be necessary, depending on the daily intake of infant formula. Iron supplementation can be initiated as early as two weeks of age.