Application of nasojejunal nutrition tube after surgery for congenital gastric wall muscle layer defect in neonates
Highlight box
Key findings
• It is feasible to provide enteral nutrition through nasojejunal feeding after surgery for neonatal gastric wall muscle layer defects, which can shorten the time to achieve complete enteral nutrition, shorten hospitalization time, and improve postoperative results.
What is known and what is new?
• Early enteral nutrition can promote recovery after gastrointestinal surgery.
• The application of nasojejunal nutrition tube is widely used in adult gastric surgery.
• Application of nasojejunal tube in neonatal surgery for gastric wall muscle layer defects
What is the implication, and what should change now?
• Postoperative feeding with nasogastric tube can effectively help children recover without increasing complications
Introduction
Congenital muscular layer defect of the gastric wall is an urgent neonatal condition. It usually presents acutely, progresses rapidly, and can be critical. It often develops into disseminated intravascular coagulation and multiple organ failure due to sepsis and infectious shock, with a mortality rate of as high as 38–64% (1). Improvement in prognosis and increased survival rates are closely related to advances in surgical procedures, monitoring and nutritional support. Surgical intervention is the only means to treat congenital gastric wall muscular layer defects. To prevent vomiting and poor anastomosis healing, fasting after gastric surgery is deemed necessary, usually lasting 5–7 days (2). This will lead to increased use of parenteral nutrition and treatment costs, prolonged hospital stays, and may also result in complications such as cholestatic jaundice, sepsis and intestinal developmental delay (3).
In recent years, early enteral nutrition after gastrointestinal-related surgeries has been widely used. Research shows that early enteral feeding after surgery can not only promote the recovery of gastrointestinal motility and reduce intestinal adhesions but also improve the healing of anastomoses and incisions, and lower complications (4). Although the effectiveness of early enteral nutrition after gastric surgery in adults has been proven significant, there are relatively few reports on early enteral nutrition in newborns after gastric muscular layer defect repair. The purpose of this study is to investigate the use of early enteral nutrition with nasojejunal tube after repair of gastric muscular layer defects in neonates to assess its safety and potential benefits. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-153/rc).
Methods
Participants and procedure
A retrospective analysis study was conducted on children diagnosed with neonatal gastric wall muscular layer defect through examination and surgery at our hospital from October 1, 2015, to October 1, 2023. Inclusion criteria: (I) age at onset ≤28 days; (II) intraoperative diagnosis of gastric wall muscular layer defect with or without perforation. The diagnostic criteria were: the edge of the defect was necrotic, and the muscle layer at the edge gradually became thinner until the center was missing. Postoperative pathology confirmed a defect in the gastric wall muscle layer; (III) the surgical method was simple gastric repair; (IV) excluded neonates with other severe malformations or chromosomal abnormalities. Collect basic data such as child’s gender, gestational age at birth, birth weight, age at onset, history of perinatal asphyxia, extent of gastric wall muscular layer defect and infection indicators. All participants were followed up for 3 months after surgery.
This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Fujian Children’s Hospital (No. 2024ETKLRK12001) and informed consent was taken from all the patients’ parents or legal guardians.
Grouping and measures
The children were divided into two groups based on whether a jejunal feeding catheter was placed during the procedure: one group was the nasojejunal tube feeding (NTF) group, where an 8-Fr (diameter 2.67 mm) nasojejunal nutrition tube was placed through the nasal cavity into the proximal jejunum 10 cm before suturing the gastric wall tissue. All children underwent abdominal X-ray examination 24 hours after surgery to confirm the correct position of the nasojejunal nutrition tube. The other group was the total parenteral nutrition (TPN) group, which did not have a nasojejunal nutrition tube placed during the procedure. Both groups of children routinely had an 8-Fr (diameter 2.67 mm) nasogastric tube inserted (Figure 1).
NTF group
Enteral nutrition was started through the nasojejunal tube with a microcontinuous pump 24 hours post-operation, beginning with 5% glucose solution for the first 24 hours. Gradually transition to formula milk when well-tolerated. On the seventh day after surgery and with no bile like drainage fluid in the gastric tube, oral feeding was initiated. Then they gradually transitioned from tube feeding to completely oral feeding, supplementing insufficient calorie intake with parenteral nutrition. Once gastrointestinal intolerance occurred, such as bloating, vomiting, or diarrhea, feeding advancement was discontinued and close monitoring was implemented. Reduce or stop enteral nutrition if necessary, and restore enteral nutrition after symptoms are relieved. A constant temperature heater was used to maintain continuous heating of the feed in the micro infusion pump during enteral nutrition.
TPN group
Gastrointestinal decompression was routinely retained after surgery without placing a nasojejunal feeding tube during the procedure. After 7 days of TPN and with no bile drainage from the gastric tube, oral feeding was initiated, gradually increasing the amount until fully transitioned to oral feeding.
Observation indicators
The observations collected in this study include: time to first oral feeding after surgery, time to fully reach enteral nutrition after surgery, postoperative length of hospital stay, time to first bowel movement after surgery, duration of the surgery, feeding intolerance (abdominal distension, vomiting), and postoperative complications, such as anastomotic leaks, occurrence of neonatal necrotizing enterocolitis (NEC), cholestasis.
Statistical analysis
Data analysis was performed using SPSS 27.0 statistical software. The Shapiro-Wilk method was used for normality testing; normally distributed quantitative data were expressed as means ± standard deviation, and comparisons between the two groups were made using independent samples t-test. Non-normally distributed quantitative data were expressed as median (P25, P75), and comparisons between the two groups were made using the rank-sum test. Categorical data were expressed as cases (percentages), and comparisons between the two groups were made using the χ2 test or Fisher’s exact probability method.
Results
Baseline data
A total of 42 patients were included in this study, with 19 patients in the NTF group (11 males, 8 females, age range, 2–30 days) and 23 patients in the TPN group (9 males, 14 females, age range, 1–16 days). There was no statistically significant difference in baseline data between the two groups (Table 1). All participants were followed up for 3 months after surgery.
Table 1
| Characteristics | NTF (n=19) | TPN (n=23) | P value |
|---|---|---|---|
| Gender | 0.23 | ||
| Female | 8 (42.1) | 14 (60.9) | |
| Male | 11 (57.9) | 9 (39.1) | |
| Gestational age at birth (weeks) | 34.63±3.27 | 35.26±2.78 | 0.50 |
| Birth weight (g) | 2,272.89±717.13 | 2,527.17±319.13 | 0.17 |
| Age at onset (day) | 4.68±2.65 | 3.83±2.12 | 0.25 |
| Perinatal asphyxia | 0.27 | ||
| Yes | 3 (15.8) | 7 (30.4) | |
| No | 16 (84.2) | 16 (69.6) | |
| Scope of gastric defect (cm2) | 12.43±5.77 | 11.98±7.02 | 0.83 |
| WBC (109/L) | 9.13±6.12 | 7.60±3.52 | 0.34 |
| CRP (mg/L) | 29.06±28.35 | 35.07±25.24 | 0.47 |
Data are presented as mean ± standard deviation or n (%). CRP, C-reactive protein; NTF, nasojejunal tube feeding; TPN, total parenteral nutrition; WBC, white blood cell count.
Observation indicators
Time to first oral feeding after surgery
The time to first oral feeding after surgery in the NTF group and TPN group was 7.79±0.98 and 8.48±2.17 days. There was no statistically significant difference between the two groups (P=0.21) (Table 2).
Table 2
| Variables | NTF (n=19) | TPN (n=23) | t | P value |
|---|---|---|---|---|
| First oral feeding (days) | 7.79±0.98 | 8.48±2.17 | −1.278 | 0.21 |
| Reach TEN (days) | 17.21±3.51 | 20.00±4.22 | −2.298 | 0.03 |
| First bowel movement (hours) | 44.63±9.81 | 51.70±10.83 | −2.194 | 0.03 |
| LOS (days) | 20.05±3.95 | 22.96±4.96 | −2.066 | 0.045 |
| Duration of the surgery (hours) | 2.14±0.68 | 1.83±0.56 | 1.592 | 0.12 |
Data are presented as mean ± standard deviation. LOS, length of hospital stay; NTF, nasojejunal tube feeding; TEN, total enteral nutrition; TPN, total parenteral nutrition.
Time to reach total enteral nutrition
The time to reach total enteral nutrition in the NTF group and the TPN group was 17.21±3.51 and 20.00±4.22 days, with the NTF group being significantly lower than the TPN group, and the difference was statistically significant (P=0.03) (Table 2).
Time to first bowel movement after surgery
The time to first bowel movement after surgery in the NTF group and the TPN group were 44.63±9.81 and 51.70±10.83 h, with the NTF group having an earlier defecation time than the TPN group, and the difference was statistically significant (P=0.03) (Table 2).
Postoperative length of hospital stay
The postoperative length of hospital stay in the NTF group and TPN group were 20.05±3.95 and 22.96±4.96 days, with the NTF group having a shorter duration than the TPN group, and the difference is statistically significant (P=0.045) (Table 2).
Duration of the surgery
The duration of the surgery in the NTF group and TPN group were 2.14±0.68 and 1.83±0.56 h with no statistical significance (P=0.12) (Table 2).
Postoperative feeding intolerance
In the NTF group, 3 patients developed abdominal distension and 5 patients developed vomiting. In the TPN group, 11 patients developed abdominal distension and 7 patients developed vomiting. The development of abdominal distension in the TPN group was significantly higher than that in the NTF group (P=0.03) (Table 3).
Table 3
| Characteristics | NTF (n=19) | TPN (n=23) | χ2 | P value |
|---|---|---|---|---|
| Abdominal distension | 4.805 | 0.03 | ||
| Yes | 3 (15.8) | 11 (47.8) | ||
| No | 16 (84.2) | 12 (52.2) | ||
| Vomiting | 0.086 | 0.77 | ||
| Yes | 5 (26.3) | 7 (30.4) | ||
| No | 14 (73.7) | 16 (69.6) | ||
| Anastomotic leak | 0.019 | 0.89 | ||
| Yes | 1 (5.3) | 1 (4.3) | ||
| No | 18 (94.7) | 22 (95.7) | ||
| Cholestasis | 0.532 | 0.47 | ||
| Yes | 1 (5.3) | 4 (17.4) | ||
| No | 18 (94.7) | 19 (82.6) | ||
| NEC | 0.030 | 0.86 | ||
| Yes | 2 (10.5) | 1 (4.3) | ||
| No | 17 (89.5) | 22 (95.7) | ||
| Death | 0.185 | 0.67 | ||
| Yes | 1 (5.3) | 2 (8.7) | ||
| No | 18 (94.7) | 21 (91.3) | ||
Data are presented as n (%). NEC, neonatal necrotizing enterocolitis; NTF, nasojejunal tube feeding; TPN, total parenteral nutrition.
Postoperative complications
In the NTF group, 1 patient experienced an anastomotic leak, 1 patient had cholestasis, 2 patients developed NEC, and 1 patient died from severe infection. In the TPN group, 1 patient had an anastomotic leak, 4 patients had cholestasis, 1 patient developed NEC, 1 patient died from severe infection, and 1 patient died after the family abandoned treatment. These differences are not statistically significant (Table 3).
Discussion
Congenital gastric wall muscular layer defect is a common cause of gastric perforation in newborns and is a rare but highly fatal neonatal acute abdomen syndrome (5). Surgery is the only life-saving method, but early feeding after gastric anastomosis often leads to anastomotic leakage, which typically extends the duration of intravenous nutritional intervention. This may result in intestinal mucosal atrophy, increased apoptosis of intestinal epithelial cells, and impaired mucosal barrier function, even leading to cholestatic jaundice, sepsis, and metabolic diseases (6). Although the overall mortality rate from gastrointestinal perforation caused by gastric wall muscular layer defects in newborns has been decreasing (7,8), postoperative management and nutritional support remain one of the main challenges for clinicians. This is not only to prevent the occurrence of complications associated with intravenous nutrition, but also to hope that early enteral nutrition will aid in the recovery of the anastomosis. The safety and efficacy of early enteral feeding after intestinal anastomosis in children have been validated (9,10). Additionally, early enteral nutrition can help accelerate recovery in adult patients following gastric partial resection, however, there are fewer reports on nutritional support post-gastric anastomosis in newborns. In this study, the NTF group used an enteral feeding tube placed in the jejunum during surgery to provide early enteral nutritional support and assess its impact on newborns after surgery for gastric wall muscular layer defects.
The study shows that the time to first postoperative bowel movement and the time to achieve full enteral nutrition in the NTF group of children are significantly shorter than in the control group, which may be attributed to the early implementation of enteral nutrition via nasojejunal tube. Research indicates that enteral nutrition can stimulate the secretion of intestinal digestive fluids, promote intestinal recovery and peristalsis, and reduce postoperative complications such as intestinal obstruction and infection (11). Following gastric repair in children with congenital muscular layer defects of the stomach, there is minimal interference with the distal small intestine and good functionality, providing a basis for the early enteral nutrition by placing the jejunal feeding tube in the proximal jejunum during surgery. During the procedure, the physician accurately passed the nasojejunal feeding tube through the pylorus to the proximal jejunum upon anastomosing the gastric wall, avoiding anastomotic injury caused by blind insertion postoperatively, which is a simple, convenient, and non-invasive method (12). Early enteral nutrition via the jejunal feeding tube postoperatively nourishes the intestinal mucosa of the distal bowel, promotes mucosal healing, and enhances peristalsis, accelerating the recovery of intestinal function. Given that postoperative fasting is required to reduce gastric tension and the incidence of anastomotic leaks, both groups of patients fasted for at least 7 days, which may account for the similar timing of initial oral feeding postoperatively. However, the NTF group had a faster increase in feeding volume, allowing them to reach full enteral nutrition more quickly. Additionally, prior to oral feeding, the nasogastric tube must ensure no bile-stained drainage, indicating that the retained jejunal feeding tube does not obstruct the passage of gastrointestinal contents, which has also been confirmed in a previous study (13).
Regarding the length of hospital stay post-surgery, the NTF group had a shorter duration compared to the TPN group. Although there were no significant differences between the two groups in terms of gestational age and birth weight, early initiation of enteral nutrition and reduced dependence on intravenous nutrition might be beneficial in shortening postoperative hospital stay, which is consistent with findings from other studies related to gastrointestinal surgeries (14,15). However, a study suggested that early enteral nutrition after gastrointestinal surgery in newborns may not reduce the length of hospitalization (16). The complexity of gastrointestinal malformations in newborns, alongside severe infections and shock during the perioperative period, means that even if gastrointestinal function is restored, a period of anti-infection treatment is still required, which could explain why the differences were not significant (17). Due to the small sample size of this study and its retrospective nature, bias is likely, necessitating a larger prospective study for verification.
Anastomotic leaks are early and serious complications after gastric anastomosis, which not only can increase the patient’s hospital costs and duration but may also raise mortality rates (18,19). In this study, both groups experienced anastomotic leaks postoperatively, with no statistically significant difference. Both groups were successfully treated with active conservative management and prolonged fasting without requiring further surgery. The difference lies in that the NTF group continued to receive nasogastric enteral nutritional support, while the TPN group required TPN, increasing medical expenses. In this study, 2 cases of biliary stasis occurred in the NTF group postoperatively and 4 cases in the TPN group; there was no statistically significant difference between the two groups. However, previous research reported that the risk of biliary stasis increases several times 7–10 days after receiving parenteral nutrition, and is related to liver enzyme levels in the blood (20). Nevertheless, we did not observe a difference in the incidence of biliary stasis, which may be attributed to standardized guidelines for parenteral nutrition support and continuous improvements in parenteral nutrition formulations (21,22).
Abdominal distension and recurrent vomiting are the most common side effects of nasogastric tube enteral nutrition (23). In a report by Peng et al. (16), it was stated that among neonates in the early feeding group after surgery, the incidence of vomiting was 30.0% and that of abdominal distension was 35.9%. In this study, the incidences of abdominal distension in the two groups were 3 and 11 (15.8% vs. 47.8%, P=0.03). Early enteral nutrition promotes peristalsis in the distal small intestine, protects the intestinal mucosa, and regulates gastrointestinal hormones, thereby coordinating gastrointestinal motility and reducing the occurrence of abdominal distension (24). At the same time, we used a nasogastric tube warmer to maintain the nutritional solution, reducing intestinal intolerance. Furthermore, a randomized controlled trial showed that feeding preterm infants at higher temperatures (32–34 ℃) can also reduce the occurrence of apnea (25), but more clinical research is needed to confirm the correlation between nasogastric feeding temperature and tolerance, as well as to determine the most suitable temperature. Due to the reduced stomach volume after gastrectomy and loss of the muscular layer, recurrent vomiting may still occur even when transitioning from jejunal tube feeding to oral feeding. In addition, some are premature infants or low birth weight. All of these will lead to prolonged use of the nasojejunal tube. We use a micro infusion pump to inject at a rate of 0.5 mL/kg per hour, and if there is no reflux vomiting, increase by 0.5 mL/kg per day. When gradually transitioning to oral feeding, reduce the amount of single feeding and increase the frequency. In the absence of feeding intolerance, we do not recommend routinely suctioning gastric residuals before the next feeding, which is supported by systematic reviews and meta-analyses concluding that avoiding routine suctioning before feeding is associated with achieving complete enteral nutrition earlier and shorter hospital stays (26). Additionally, when children receiving enteral nutrition present with abdominal distension, vomiting, or bloody stools, the possibility of NEC should be considered. In patients with gastric perforation, intra-abdominal infection is severe, gastrointestinal ischemia increases the likelihood of NEC occurrence, and actively controlling perioperative infections while reasonably assessing the timing of enteral nutrition is key to prevention and treatment.
Conclusions
In summary, postoperative enteral nutrition through nasojejunal tube for children with congenital gastric wall muscular layer deficiency is safe and feasible. It can shorten the time to full enteral nutrition and hospital stay, reducing feeding intolerance, and it does not increase additional risks or complications. However, due to the rarity of gastric wall muscular layer deficiencies with perforation in neonates and the small number of cases, further accumulation of cases is needed to expand research.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-153/rc
Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-153/dss
Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-153/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-153/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Fujian Children’s Hospital (No. 2024ETKLRK12001) and informed consent was taken from all the patients’ parents or legal guardians.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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