Doctors Feed a Child Through His Duodenum in a World-First Endoscopic Feat

When a 12-year-old boy arrived at Guangzhou Red Cross Hospital of Jinan University, his body was failing on nearly every front. Years earlier, he had swallowed a caustic alkali agent that devastated his esophagus, and a series of reconstructive operations had left him with an anatomy that barely resembled a normal upper digestive tract. His stomach had been pulled up into his chest, his throat had been surgically joined directly to that intrathoracic stomach through a pharyngogastric anastomosis, and he was living with a permanent tracheostomy tube. Severe malnutrition had hollowed out his reserves, pneumonia driven by multidrug-resistant organisms was raging in his lungs, and he had slipped into type I respiratory failure. The clinical team faced a deceptively simple question with no easy answer: how do you feed a child whose digestive plumbing has been rebuilt beyond recognition?

The standard answer to long-term feeding problems is a percutaneous endoscopic gastrostomy, or PEG, a procedure in which an endoscope positioned inside the stomach guides the placement of a feeding tube through the abdominal wall. But PEG depends on a fundamental set of anatomical assumptions: that the stomach sits in the abdomen, that it lies close enough to the abdominal wall to be safely punctured, and that transillumination and finger indentation can confirm the path. In this boy, none of those assumptions held. His stomach had been mobilized into the thoracic cavity during reconstruction, placing it far from any safe percutaneous access route in the abdomen. A nasogastric tube, the temporary fallback, was both poorly tolerated and inadequate for the sustained nutritional rehabilitation he desperately needed.

That is where direct percutaneous endoscopic duodenostomy, abbreviated D-PED, enters the story. Instead of anchoring a feeding tube in the stomach, D-PED targets the duodenum, the first segment of small intestine immediately downstream of the stomach. The technique borrows logic from PEG but redirects it: an endoscope advanced into the duodenum allows the operator to identify a suitable puncture site, and a feeding tube is then passed through the abdominal wall directly into the bowel. Feeding delivered into the duodenum bypasses the stomach entirely, which in this patient was not merely an inconvenience but a structural impossibility for conventional access. The procedure had been described in adults, but according to the reporting team, no comparable pediatric case had ever been published.

Before any needle was lifted, the hospital convened a multidisciplinary team assessment, bringing together gastroenterologists, surgeons, anesthesiologists, nutrition specialists, and respiratory clinicians. This step was not bureaucratic ritual. The boy’s type I respiratory failure meant his oxygenation depended on careful ventilatory management, his tracheostomy complicated airway access for any endoscopic procedure, and his malnutrition meant his tissues healed poorly and his infection risk was extreme. The multidisciplinary team mapped out contingency plans for every foreseeable failure mode, from bleeding at the puncture site to dislodgement of the tube, a level of preparation that would soon prove essential.

The first attempt used the introducer technique, the variant of percutaneous endoscopic placement in which a needle is pushed through the abdominal wall into the bowel lumen under endoscopic vision, followed by a guidewire and then the tube itself. In this patient the attempt failed. Bleeding developed at the puncture site, and the tube became dislodged, forcing the team to abandon the placement. In many settings, such a failure might have ended the conversation and consigned the child to prolonged parenteral nutrition delivered intravenously, with all the infectious and metabolic hazards that entails. Instead, the team returned to the multidisciplinary framework, reassessed the anatomy and the mechanics of the failed attempt, and redesigned the strategy.

The second attempt employed the pull technique, the alternative percutaneous approach in which a guidewire passed into the bowel is grasped endoscopically and pulled back out through the mouth, allowing the feeding tube to be drawn down the esophageal route and out through the abdominal wall in one continuous path. Critically, the team selected a feeding tube fitted with an internal retention plate, a bumper-like structure that holds the tube against the inner bowel wall and prevents it from migrating outward or being dislodged by movement. That modification directly addressed the mechanism of the first failure. With this configuration, the D-PED was successfully completed, establishing a stable conduit from the outside world directly into the boy’s duodenum.

The technical distinction between the two techniques is worth unpacking, because it illustrates why individualized procedural strategy matters so much in altered anatomy. The introducer technique is faster and avoids pulling a tube through the mouth and pharynx, which matters in patients with compromised airways or strictures. But it requires a bowel segment that is mobile and apposed to the abdominal wall, and it relies on the retention device staying put. The pull technique, by contrast, uses traction to draw the bowel wall firmly against the abdominal wall, promoting adhesion and sealing around the tract, and an internal retention plate adds a mechanical lock against dislodgement. In a child whose reconstructed upper gastrointestinal tract offered no conventional targets, the traction-based approach with reinforced retention proved to be the configuration his anatomy could tolerate.

What followed the successful placement is the part of the story with the broadest implications. During follow-up, the boy showed marked improvement in his nutritional status, with the enteral feeding route finally delivering the calories and protein his ravaged body needed. His respiratory function improved as well, a reminder that nutrition and pulmonary recovery are deeply intertwined in critically ill children; malnourished patients cannot mount effective immune responses or sustain the respiratory musculature needed to clear multidrug-resistant pneumonia. His quality of life improved alongside his physiology, and the feeding tube provided the reliable, long-term access that nasogastric tubes and intravenous lines had failed to offer.

The authors of the report, Minjie Zhu, Guolin Dai, and colleagues writing in BMC Pediatrics, are careful about the limits of a single case. They emphasize that D-PED may be a feasible and safe option for high-risk pediatric patients when it is supported by multidisciplinary collaboration, comprehensive contingency planning, and an individualized procedural strategy, and they explicitly call for further experience and longer follow-up before the safety and durability of the approach can be established. A case report cannot demonstrate complication rates, and duodenostomy carries its own theoretical risks, including leakage, peritonitis, and tube dysfunction, that only accumulated experience can quantify. Written informed consent for publication was obtained from the patient’s mother, and the authors declare no competing interests.

Even with those caveats, the case expands the map of what is possible in pediatric nutritional support. Children who survive caustic ingestions, congenital anomalies, or tumor resections are increasingly left with reconstructed anatomy that defeats standard feeding solutions, and clinicians have historically had few options beyond intravenous nutrition. This report suggests that the endoscope, guided by a team willing to plan for failure and adapt mid-course, can find a path even into a duodenum that no one had ever punctured before. For the field of pediatric gastroenterology, the message is less about one technique than about a method: treat altered anatomy not as a dead end but as an engineering problem, solved case by case with the full toolkit of endoscopic access techniques.

Subject of Research: Direct percutaneous endoscopic duodenostomy for enteral nutrition in a pediatric patient with complex upper gastrointestinal reconstruction

Article Title: Direct percutaneous endoscopic duodenostomy in a pediatric patient with complex upper gastrointestinal reconstruction: a case report

Article References: Zhu, M., Dai, G., Liu, X., Ye, G., Jiang, S., & Shu, J. (2026). Direct percutaneous endoscopic duodenostomy in a pediatric patient with complex upper gastrointestinal reconstruction: a case report. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07675-9

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07675-9

Keywords: duodenostomy, percutaneous endoscopic duodenostomy, pediatric surgery, enteral nutrition, pharyngogastric anastomosis, caustic esophageal injury, malnutrition, respiratory failure, endoscopy, case report, multidisciplinary team, BMC Pediatrics