Is Roux‐en‐Y Feeding Jejunostomy a Safe and Effective Operation in Children? A Systematic Review Exploring Outcomes

Abstract

Objectives: Roux-en-Y jejunostomy (REYJ) may establish feeding in children with foregut dysmotility or severe gastro-esophageal reflux disease (GERD). Nevertheless, concerns have been raised about safety and efficacy. We, therefore, evaluated outcomes of REYJ by systematic review to determine if this was a satisfactory option for achieving enteral autonomy in children with complex nutritional needs. Methods: A PRISMA-adherent systematic review was conducted of studies reporting children undergoing feeding REYJ. Two authors performed processes independently; the senior author resolved disagreements. Embase, CINAHL and Medline were searched (inception-01/21). Additional databases, references, and 'grey' literature were searched. Methodological Index for Non-randomized Studies (MINORS) and a bespoke system assessed methodological quality. Results: Of 362 articles, 10 met eligibility criteria (9 retrospective series; 1 conference proceeding). Unpublished data were also attained. Interobserver agreement for MINORS (kappa ¼ 0.47) and bespoke scoring (kappa ¼ 0.58) were moderate. After consensus, median MINORS score was 37.5% (IQR 6.3%) and bespoke 50% (IQR 20.8%), indicating poor methodological quality. One hundred sixty-four patients were reported (age range: 2 months to 19 years). Time to full feeds and length of stay were inadequately reported but most achieved enteral autonomy. No studies reported patient/caregiver-questionnaires. Seventy-six complications were documented (Clavien-Dindo grading was infeasible). Morbidity included peristomal leakage (N ¼ 26), internal hernia/volvulus (N ¼ 8), and SSI (N ¼ 7). Thirty-eight patients died (2 procedure-attributable) during follow-up (range: 1 month to 15 years). Conclusions: Up to 50% patients experience complications after REYJ (often minor) with 23% patients dying during follow-up, often comorbidityattributable. REYJ can achieve enteral autonomy although parents/ caregivers of children should be counselled accordingly.

A clinical consensus paper on jejunal tube feeding in children

“…Investigations may overlap with those done as part of fundoplication assessment. An upper gastrointestinal contrast study may be considered to exclude mechanical obstruction 1,20 . The indication for upper gastrointestinal endoscopy prior to JT feeding varies depending on individual patient circumstances, and in children with unexplained intolerance to gastric feeding or significant gastrointestinal symptoms, it may be helpful to exclude underlying mucosal inflammation or malabsorptive disorders 1 .…”

“…gastrointestinal contrast study may be considered to exclude mechanical obstruction. 1,20 The indication for upper gastrointestinal endoscopy prior to JT feeding varies depending on individual patient circumstances, and in children with unexplained intolerance to gastric feeding or significant gastrointestinal symptoms, it may be helpful to exclude underlying mucosal inflammation or malabsorptive disorders. 1 A review of results of preoperative evaluation done at the time of GT insertion found that no specific diagnostic test reliably predicted whether patients remained on GT feeding or required conversion to JT feeding.…”

“…10 A recent systematic review assessing safety and efficacy outcomes of Roux-en-Y jejunostomy in children reported complications in about 50%, including small bowel volvulus around the feeding Roux-en-Y limb, jejuno-colic fistula, abdominal wall infection, and stoma leakage. 20 Tube-or equipment related complications are common. 6 The cumulative radiation exposure for patients requiring frequent GJT replacement can be significant and may be underrecognized.…”

Laparoscopic Roux-en-Y feeding jejunostomy as a long-term solution for severe feeding problems in children

“…More publications about open Roux-en-Y jejunostomy are available. Recently, a systematic review comparing these publications was published [ 20 ]. Open surgery is associated with a different type (more severe) and a higher rate of complications compared to the LRFJ, as there is a high (6–40%) incidence of wound infections [ 17 , 23 , 24 ] and volvulus (14–25%) [ 24 – 26 ] compared to respectively 8% and 0% in our patient population.…”

“…As demonstrated by a recent systematic review evaluating the outcomes of Roux-en-Y jejunostomy in the pediatric population, more data regarding the outcomes of LRFJ are lacking in current literature. All but one of the included studies evaluated the outcomes in children undergoing open Roux-en-Y jejunostomy [ 20 ].…”