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J Ped Surg Case Reports 1 (2013) 406e409

Journal of Pediatric Surgery CASE REPORTS

journal homepage: www.jpscasereports.com

Percutaneous transesophageal gastrotubing in a child with severemotor and intellectual disabilitiesq

An effective alternative route of enteral feeding

Satohiko Yanagisawa a,*, Takehito Oshio a,b, Yasuhide Morikawa a

aDepartment of Pediatric Surgery, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi 329-2763, JapanbDepartment of Pediatric Surgery, Shikoku Central Hospital, 2233, Kawanoe, Shikokuchuo, Ehime 799-0193, Japan

a r t i c l e i n f o

Article history:Received 29 August 2013Received in revised form1 November 2013Accepted 1 November 2013

Key words:PTEGChildrenSevere motor and intellectual disabilitiesGastrostomy

q This is an open-access article distributed undeCommons Attribution-NonCommercial-No Derivativemits non-commercial use, distribution, and reproductthe original author and source are credited.* Corresponding author. Tel.: þ81 0287 37 2221; fax

E-mail address: s.yanagisawa@jichi.ac.jp (S. Yanagi

2213-5766/$ e see front matter � 2013 The Authors.http://dx.doi.org/10.1016/j.epsc.2013.11.002

a b s t r a c t

Percutaneous transesophageal gastrotubing (PTEG) was performed in a 12-year-old boy with severemotor and intellectual disabilities (SMID) whose trunk was severely deformed. He was referred to ourpediatric surgical service for tracheostomy and percutaneous endoscopic gastrostomy (PEG) due torespiratory failure and difficulty in oral intake. Considering that the patient could not maintain a supineposition, a standard gastrostomy procedure, either open or endoscopic, could not be performed. More-over, postoperative care for gastrostomy would be challenging. Therefore, PTEG through the stretchedanterior neck was indicated. PTEG involves creating an echo-guided percutaneous esophageal punctureunder fluoroscopy to introduce a feeding tube from the esophagus into the stomach. PTEG has not beenused in pediatric patients yet however, the procedure seems to be an effective alternative route of enteralfeeding in children with SMID who cannot undergo PEG, as demonstrated in the present report.

� 2013 The Authors. Published by Elsevier Inc. All rights reserved.

The use of gastrostomy for enteral feeding and fundoplication topreventgastroesophageal reflux (GER) in childrenwith severemotorand intellectual disabilities (SMID) has been a part of daily practicefor pediatric surgeons. Children with SMID often have severedeformities of the trunk. The more severe the deformity, the moredifficult it is to perform a gastrostomy. In case of dislocation of thestomach into the subcostal space due to elevation of the diaphragm,percutaneous puncture of the stomach is not feasible when per-forming percutaneous endoscopic gastrostomy (PEG). Postoperativeskin care around the gastrostomy site is also difficult. In the presentreport, we describe percutaneous transesophageal gastrotubing(PTEG) as a practicable solution for a child with SMIDwho could notundergo gastrostomy because of a severe deformity of the trunk.

1. Case report

A 12-year-old boy with SMID was referred to our pediatric sur-gical service for tracheostomy and percutaneous endoscopic

r the terms of the CreativeWorks License, which per-

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: þ81 0287 37 5315.sawa).

Published by Elsevier Inc. All right

gastrostomy (PEG) because of respiratory failure and difficulty inoral intake. The patient had spastic tetraplegia and epilepsy due toacute encephalitis at the age of 1 year. At the age of 12 years, hewas diagnosed with an inflammatory bowel disease, mostly sus-pected to be ulcerative colitis, and was treated with elemental dietand sulfasalazine, as was his mother. However, sudden cardiopul-monary arrest occurred during the course of the treatment. Despiterecovery from the cardiopulmonary arrest, he needed mechanicalventilation. His trunk was severely bent backward, with his headreaching his buttocks. Because of the deformity, the lung field andintestinal gas formation could not be estimated by standard radi-ography; an upper gastrointestinal examination could not be per-formed either. Instead, anatomical and organic abnormalities of theesophagus and stomach were estimated based on computedtomographic findings. Because the patient could not maintain asupine position, a standard gastrostomy procedure, either open orendoscopic, could not be performed. Moreover, postoperative carefor the gastrostomy site seems to be difficult in this case. Therefore,PTEG through the stretched anterior neck was indicated.

He was positioned in prone with his chest, neck and head bentover his back under general anesthesia. (Fig. 1a and b) The PTEGprocedure is described in detail in Table 1 and Fig. 2. A PTEG kit witha 15-Fr catheter (Sumitomo Bakelite Co., Ltd, Tokyo, Japan.) wasused. A straight guidewire was introduced through the nasogastrictube, then the nasogastric tube was pulled out and replaced with

s reserved.

Fig. 1. Operative position: (a) Overview of the severe deformity that caused the patientto bend the upper part of his body backward in supine position. (b) Schematic diagramof (a).

S. Yanagisawa et al. / J Ped Surg Case Reports 1 (2013) 406e409 407

rupture-free balloon (RFB) catheter. The RFB catheter was made forPTEG procedure. When we punctured an existing balloon catheter,the balloon ruptured and collapsed quickly. Oishi and colleaguesmade the RFB catheter which can preserve the volume of balloonafter puncture. The RFB was slightly inflated with mixed contrastmedium to check its position at the thoracic esophagus, under

Table 1The PTEG procedure.

1. Preparation of the PTEG device, sterilization, and setting up forfluoroscopy

2. Checking the anatomical location of the esophagus and cervical organs byultrasonography

3. Insertion of the straight guidewire in the esophagus via the nasal cavity4. Insertion of the rupture-free balloon (RFB) in the esophagus through the

straight guidewire5. Dilatation of the RFB and pulling it toward the cervical esophagus under

fluoroscopy6. Full dilatation of the RFB and confirmation of the puncture point by

ultrasonography7. Echo-guided puncturing of the RFB and insertion of the angled guidewire

into the RFB8. Insertion of the RFB catheter toward the stomach to separate the RFB and

angled guidewire9. Confirming the position of the angled guidewire in the thoracic esophagus

and pulling out of the straight guidewire and RFB catheter underfluoroscopy

10. Insertion of the dilator with a peel-away sheath over the angled guidewire11. Pulling out of the angled guidewire and dilator12. Introducing the placement tube in the stomach, peeling off the sheath,

and tube fixation

fluoroscopy. Then, the RFB catheter was inflated in the cervicalesophagus; 6 mL of contrast medium. The position of RFB wasconfirmed by ultrasonography that was placed between the thyroidgland and cervical vessels, just below the skin (Fig. 3). The puncturepoint of the PTEG was planned to be as lateral as possible for thetracheostomy. The RFB was punctured with an 18-G punctureneedle under ultrasonographic guidance. Successful puncture ofRFB was confirmed by pouring the contrast medium through thepuncture needle. The angled guidewire was then inserted 5 cm intothe RFB through the sheath under fluoroscopy. After collapsing theRFB, the RFB catheter was brought into the thoracic esophagus withthe angled guidewire. The RFB catheter was pushed toward thestomach to leave the angled guidewire in the esophagus, then thesheath, the RFB catheter and straight guidewire were removed.The dilator with a peel-away sheath was inserted through theangled guidewire into the esophagus, and the dilator and guidewirewere pulled out. A 15-Fr PTEG tubewas introduced into the stomachthrough the peel-away sheath and secured by stitching at the neck.The procedure took approximately 20 min to complete. Tracheos-tomy was performed with the standard procedure. The distancebetween the tracheostomy and PTEG sites was 4 cm (Fig. 4).

The postoperative course was uneventful. Infusion of elementaldiet started on the first postoperative day. Complications such aswound infection and tube dislocation, and symptoms associatedwith GER were not detected. The PTEG tube was replaced witha button-type PTEG tube 2 months after the procedure. PTEG tube,which was replaced every 2 months of period, has been wellmanaged without obstructions.

2. Discussion

PTEG is a minimal invasive esophagotomy procedure developedby Oishi and his colleagues [1,2]. However, great care has to betaken to avoid the mispuncture of the thyroid gland and cervicalvessels when performing esophageal puncture. The RFB catheterprovides a solution to this problem. As the balloon becomes infla-ted, the left part of the thyroid gland and left carotid artery arepushed aside. A new and safe puncture space is created, and then itallows surgeon to perform puncture safely under ultrasonographyand fluoroscopy, even in the cases whose trunk deformed severely[1,2].

PTEG can be indicated for all patients who require gastrostomyas an alternative choice of treatment [3]. In fact, PTEG was per-formed in patients who could not undergo PEG because of variousreasons, such as those with previous gastrectomy, transverse liveror/and colon between the stomach and abdominal wall, massiveascites, severe upward dislocation of the stomach, or a disabilitythat makes endoscopy infeasible. The contraindications of PTEGinclude coagulation disorders and esophageal lesions in danger ofmassive bleeding such as esophageal varices. In particular, PTEG iscontraindicated for patients with right recurrent nerve palsybecause of a possible damage of left recurrent nerve by the punc-ture [2].

The advantages of PTEG include the absence of irritation andpain in the throat due to contact with the nasogastric tube. Post-operative management of PTEG is easier than PEG for patients orcaregivers under home medical care. In addition to its efficacy as aroute for enteral feeding, PTEG was also found to be effective inrelieving symptoms of malignant obstruction in adult patients [3].

In pediatric patients, PTEG is not common. In PubMed, only 1pediatric case of PTEG was reported [4]. In the report, PTEG wasperformed in a 4-year-old boy who could not undergo PEG becauseof surgical complications associated with Crohn’s disease, such asanastomotic failure, multiple peritoneal abscesses, enter-ocutaneous fistula and hepatomegaly.

Fig. 2. Illustrations of the PTEG procedure. Details of the movement of the guidewire and tube. The movement of the guidewires and tubes described in detail. The numbersdescribed in illustration presented the number of PTEG procedure.

Fig. 3. Findings of cervical ultrasonography before and after dilatation of RFB: The esophagus located at left back of trachea. After dilatation of RFB, esophagus dislocated sub-cutaneous position where the operator could puncture easily. Thy: thyroid, Eso: esophagus, Tra: trachea, Ao: internal cervical aorta, RFB: rupture-free balloon.

S. Yanagisawa et al. / J Ped Surg Case Reports 1 (2013) 406e409408

Fig. 4. The location of the PTEG and tracheostomy: the anterior neck after the oper-ation. By vertically shifting the puncture point of the PTEG, tracheostomy and PTEGwas managed without difficulty.

S. Yanagisawa et al. / J Ped Surg Case Reports 1 (2013) 406e409 409

In patients with SMID, 4 cases of PTEG were reported in Japan.All the patients were older than 15 years and indicated for PTEG asthey could not undergo PEG because of severe deformities of thetrunk. Before the procedure, 3 of 4 patients already had symptomsof GER. 2 of whom had worsened symptoms after PTEG. By placingthe feeding tube in the jejunum in place of PTEG tube, symptoms ofGER were relieved. Then they could continue the infusion. Con-cerning association with tracheostomy, 3 of 4 patients underwenttracheostomy before or after PTEG without hindrances to thepostoperative management of the PTEG as in our case.

PTEG was indicated for the present case because a standardgastrostomy procedure, either open or endoscopic, could not beperformed. PTEG was found to be an effective and safe procedure inchildrenwith SMID. The postoperative management did not require

complicated care. Therefore, we recommend PTEG as a therapeuticchoice for children for whom gastrostomy is difficult tomanage andthose who could not undergo PEG.

3. Conclusion

PTEG has not been used in pediatric patients, but the procedureseems to be an effective alternative route of enteral feeding inchildren with SMID who cannot undergo PEG as demonstrated inthe present case.

Consent

Written informed consent was obtained from the patient’s nextof kin for publication of this case report and accompanying images.A copy of written consent is available for review by the Editor-in-Chief of the journal on request.

Conflict of interest statementNone of the authors have any conflict of interest to disclose.

Sources of fundingThere was no source of funding for this publication.

References

[1] Oishi H, Shindo H, Shirotani N, Kameoka S. A nonsurgical technique to create anesophagostomy for difficult case of percutaneous endoscopic gastrostomy. SurgEndosc 2003;17:1224e7.

[2] Oishi H, Shindo H, Shirotani N, Kameoka S. Indications of percutaneous trans-esophageal gastric-tube drainage. Jpn J Surg Ther 2002;86:91e2.

[3] Mackey R, Chand B, Oishi H, Kameoka S, Ponsky JL. Percutaneous trans-esophageal gastrostomy tube for decompression of malignant obstruction:report of the first case and our series in the US. J Am Coll Surg 2005;201:695e700.

[4] Inoue M, Uchida K, Kawamoto A, Okugawa Y, Otake K, Miki C, et al. Percuta-neous transesophageal gastrostomy (PTEG) placement in an infant. J PediatrGastroenterol Nutr 2007;45:363e5.