Percutaneous fluoroscopically guided jejunostomy placement.
Richard Howard M,Widlus David M,Malloy Patrick C
The Journal of trauma
PURPOSE:To describe our experience with fluoroscopically guided direct jejunostomy placement in patients with enterocutaneous fistula, or neoplastic or postsurgical changes of the stomach or duodenum that preclude traditional gastrostomy placement. MATERIALS:Nineteen patients underwent percutaneous direct jejunostomy tube placement with fluoroscopic guidance from August 2004 through March 2006. There were 15 men and four women whose ages ranged from 28 to 82 years (mean, 54 years). Seven patients had surgical changes to the stomach that precluded traditional gastrostomy access, one patient had a duodenal tumor, two had unresectable gastric tumors, and nine had small bowel pathology that required distal access. RESULTS:Jejunal access was initially successful in 18 of 19 (95%) procedures. Follow-up ranged from 10 days to 509 days. Two catheters were removed as they were no longer needed. Seven patients' initial tubes were still functioning at the end of their follow-up. One tube was removed secondary to pain and irritation at the insertion site. Three tubes were occluded. One patients' tube was inadvertently pulled out. In two patients, feeding was not tolerated secondary to fistula distal to the jejunostomy. Two patients died with their initial tubes. Primary patency was 285 days (95% CI 162-407). One death occurred 10 days postprocedure for a 30-day mortality of 1 of 19 (5%). CONCLUSIONS:Percutaneous direct jejunostomy placement is a relatively safe and effective means of gaining enteral access in patients who have enterocutaneous fistula or who have either postsurgical or neoplastic changes of the stomach that preclude traditional gastrostomy placement.
10.1097/TA.0b013e31811eaa91
Transnasal route: new approach to endoscopy.
Lee Sun-Young,Kawai Takashi
Gut and liver
Transnasal esophagogastroduodenoscopy (TN-EGD) has recently become one of the frequently used methods of upper gastrointestinal endoscopy in some countries. Changes in blood pressure, heart rate, and oxygen saturation are smaller for TN-EGD than for conventional transoral esophagogastroduodenoscopy, making it a safer procedure. Lower pain and gag reflex enable TN-EGD to be performed without conscious sedation. TN-EGD is applied in various gastrointestinal (GI) procedures such as percutaneous endoscopic gastrostomy, nasoenteric feeding tube placement, endoscopic retrograde cholangiopancreaticography with nasobiliary drainage and lithotripsy, long intestinal tube placement in small-bowel obstruction, esophageal manometry, foreign body removal, botulinum toxin injection for achalasia, esophageal varix evaluation with the aid of endoscopic ultrasonography, and the double-scope technique for endoscopic submucosal dissection. The establishment of standard training programs and nationwide guidelines, the dissemination of educational information, the improvement in endoscopy devices and accessories, and the availability of insurance coverage for the procedure will obviously further widen the adoption of TN-EGD.
10.5009/gnl.2008.2.3.155
Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study.
Hsu Chien-Wei,Sun Shu-Fen,Lin Shoa-Lin,Kang Shiu-Ping,Chu Kuo-An,Lin Chih-Hsun,Huang Hsiu-Hua
Critical care medicine
OBJECTIVE:To determine whether medical intensive care unit (ICU) patients receiving nasoduodenal (ND) feedings achieve optimal nutritional support and better clinical outcomes compared with patients receiving nasogastric (NG) feedings. DESIGN:A prospective, randomized, clinical study. SETTING:Medical ICU of a university-affiliated tertiary medical center. PATIENTS:One hundred twenty-one medical ICU patients required enteral feeding. INTERVENTIONS:Patients were randomized to receive enteral feeding. One group received ND feedings and the other group received NG feedings. All patients followed the same protocol. MEASUREMENTS AND MAIN RESULTS:The primary outcome of optimal nutritional support was assessed by measurement of time to goal tube feed rate and daily calorie and protein intake. Secondary clinical outcomes included number of ICU, hospital and ventilator days, number of the days in the study, blood-glucose levels, incidence of vomiting, diarrhea, gastrointestinal bleeding, tube replaced, tube clogged, fever, bacteremia, and ventilator-associated pneumonia (VAP), and mortality rate. Results showed that the ND group had a higher average daily calorie and protein intake compared with NG group and achieved nutritional goals earlier. In terms of clinical outcomes, patients in the ND group had a lower rate of vomiting and VAP. The other clinical outcomes such as number of ICU days, hospital days, ventilator days, blood-glucose level, tube replaced or clogged, diarrhea, gastrointestinal bleeding, fever, bacteremia, and mortality rate were not significantly different between two groups. CONCLUSIONS:Patients who received ND feedings achieved nutritional goals earlier than those who received NG feeding. ND feeding group also has a lower rate of vomiting and VAP in the medical ICU setting.
10.1097/CCM.0b013e31819ffcda
Laparoscopic proximal Roux-en-Y gastrojejunal diversion in children: preliminary experience from a single center.
Mattioli Girolamo,Buffa Piero,Gandullia Paolo,Schiaffino Maria Cristina,Avanzini Stefano,Rapuzzi Giovanni,Pini Prato Alessio,Guida Edoardo,Costanzo Sara,Rossi Valentina,Basile Angelina,Montobbio Giovanni,DellaRocca Mirta,Mameli Leila,Disma Nicola,Pessagno Alice,Tomà Paolo,Jasonni Vincenzo
Journal of laparoendoscopic & advanced surgical techniques. Part A
BACKGROUND:Neurologically impaired children (NIC) have a high risk of recurrence of gastroesophageal reflux (GER) following fundoplication. A postpyloric feeding tube may be useful when gastric emptying disorders occur; however, dislocation and difficulty in feeding management often require more aggressive procedures. Total esophagogastric dissociation (Bianchi's TEGD) is an alternative to the classic fundoplication procedure, whereas laparoscopic gastric bypass is a frequently performed procedure in morbid obesity, improving gastric outlet. AIM:The aim of this paper is to present a preliminary experience on the laparoscopic Roux-en-Y gastrojejunal bypass, associated with Nissen fundoplication and gastrostomy, to treat and prevent GER in NIC with gastric emptying disorders. MATERIALS AND METHODS:Eight neurologically impaired children underwent surgical treatment because of feeding problems and pulmonary complications. The procedure included: 1) hiatoplasty, 2) Nissen fundoplication, 3) 20-cm Roux-en-Y gastrojejunal anastomosis and jejuno-jejunal anastomosis, and 4) gastrostomy. RESULTS:All cases were fed on postoperative day 3 without any intraoperative complications. One case developed an obstruction of the distal anastomosis due to adhesion and needed reoperation. Outcome was clinically evaluated with serial upper gastrointestinal contrast studies and endoscopies. CONCLUSIONS:Laparoscopic proximal Roux-en-Y gastrojejunal diversion, without gastric resection, is a safe, feasible procedure that improves gastric emptying and reduces the risk of GER recurrence. Yet, long-term results still have to be evaluated.
10.1089/lap.2008.0291
[Utility of single- and double-balloon enteroscopy].
Bordas Josep M,Llach Josep,Mata Alfredo
Gastroenterologia y hepatologia
Single- and double-balloon enteroscopes have similar efficacy. The entire small bowel can be examined through the oral route in 60-90minutes in 25-40% of patients. Using the oral and rectal routes, complete examinations can be performed in 75% of patients The diagnostic indications are mid-gastrointestinal bleeding tumors, Crohn's disease, intestinal obstruction and atypical malabsorption. Therapeutic indications include access to enterostomy, hemostasis, foreign body withdrawal, dilatation and polypectomy in the small bowel. This procedure is also useful to place enteral feeding tubes in patients with an excluded stomach. Hemostatic efficacy is high in patients with elevated transfusional requirements. For polypectomy, this technique has not been demonstrated to have the same efficacy/risk as colonoscopy. Complications include pancreatitis (0.34%) and perforation (0.34-6.4%). The level of evidence for almost all indications is low, since few prospective and homogeneous studies have been performed.
10.1016/j.gastrohep.2008.12.010
[Enteral nutrition in patients with ulcerative and postburn cicatrix strictures of the esophagus and stomach outcome region].
Abakumov M M,Kostiuchenko L N
Eksperimental'naia i klinicheskaia gastroenterologiia = Experimental & clinical gastroenterology
Decompensated cicatrices stricture of upper alimentary canal is a complex disease clinically presenting a high mechanical blocking and leads to expressed abnormality of homeostasis, which requires its pathogenetic correction of urgency evidence. The greatest difficulty is correct protein-energy malnutrition and water-electrolyte metabolism. Prior to the imposition of stoma for feeding should begin immediately with standard parenteral nutrition solutions. In a subsequent it is nessesary to resort more physiologecal tube alimentasion. As with esophageal postambustion stricture electrical activity of the stomach inhibiting and in essentially remains small bowel function, preference should be given to ways of enteral threpsology support. This can be used as a balanced composition in breeding (primary breeding should be 1: 2) and special blends for intraintestinal alimentation (close chyme on line carrying the major components). In the case of postambustion struck of outlet termination stomach department when identified violations of the underlying functions of the digestive canal division, rational come to gentle tactics of enteral alimentation using mixtures, completely similar in composition to himus. At stricture janitor ulcer genesis appropriate tactics is enteral correction, similar to that used in the event of postambustion strictures of the zones when bowel function is largely preserved.
Non-occlusive small bowel necrosis in association with feeding jejunostomy after elective upper gastrointestinal surgery.
Spalding Duncan Rc,Behranwala Kasim A,Straker Peter,Thompson Jeremy N,Williamson Robin Cn
Annals of the Royal College of Surgeons of England
INTRODUCTION:Non-occlusive small bowel necrosis (NOSBN) has been associated with early postoperative enteral feeding. The purpose of this study was to determine the incidence of this complication in an elective upper gastrointestinal (GI) surgical patient population and the influence of both patient selection and type of feeding jejunostomy (FJ) inserted, based on the experience of two surgical units in affiliated hospitals. PATIENTS AND METHODS:The records were reviewed of 524 consecutive patients who underwent elective upper GI operations with insertion of a FJ for benign or malignant disease between 1997 and 2006. One unit routinely inserted needle catheter jejunostomies (NCJ), whilst the other selectively inserted tube jejunostomies (TJ). RESULTS:Six cases of NOSBN were identified over 120 months in 524 patients (1.15%), with no difference in incidence between routine NCJ (n = 5; 1.16%) and selective TJ (n = 1; 1.06%). Median rate of feeding at time of diagnosis was 105 ml/h (range, 75-125 ml/h), and diagnosis was made at a median of 6 days (range, 4-18 days) postoperatively. All patients developed abdominal distension, hypotension and tachycardia in the 24 h before re-exploratory laparotomy. Five patients died and one patient survived. CONCLUSIONS:The understanding of the pathophysiology of NOSBN is still rudimentary; nevertheless, its 1% incidence in the present study does call into question its routine postoperative use especially in those at high risk with an open abdomen, planned repeat laparotomies or marked bowel oedema. Patients should be fully resuscitated before initiating any enteral feeding, and feeding should be interrupted if there is any evidence of feed intolerance.
10.1308/003588409X432347
Comparative evaluation of nasoenteral feeding and jejunostomy feeding in acute corrosive injury: a retrospective analysis.
Kochhar Rakesh,Poornachandra Kuchhangi Sureshchandra,Puri Pankaj,Dutta Usha,Sinha Saroj K,Sethy Pradeepta K,Wig Jai D,Nagi Birinder,Singh Kartar
Gastrointestinal endoscopy
BACKGROUND:Nutritional support in corrosive injury patients is traditionally achieved through total parenteral nutrition (TPN) or jejunostomy feeding (JF). There are no reports of nasoenteral tube feeding in patients with corrosive ingestion. OBJECTIVE:We report our experience with nasoenteral tube feeding (NETF) and compare the outcome of these patients with those undergoing JF. SETTING:Tertiary medical center in North India. DESIGN AND INTERVENTION:The records of 53 and 43 patients with severe acute corrosive injury who underwent NETF and JF, respectively, were reviewed. All had received a 50-kcal/kg, 2-g/kg protein homogenized liquid diet for 8 weeks. A contrast study was performed at 8 weeks, and body weight and serum albumin levels were recorded at hospitalization and at 8 weeks. MAIN OUTCOME MEASUREMENTS:Change in weight and serum albumin at 8 weeks and stricture development rate. RESULTS:Strictures developed in 41 (80.39%) and 36 (83.72%) patients in the NETF and JF groups, respectively. Development of esophageal stricture (P = .71) and gastric stenosis (P = .89) was comparable in the 2 groups. No significant changes in serum albumin and weight were noted at 8 weeks in either group. The complication rate was lower in the NETF group compared with the JF group. Although all of the patients in the NETF group had a patent lumen, 5 in the JF group had total obstruction precluding endoscopic intervention. LIMITATIONS:Retrospective study design. CONCLUSION:NETF is as effective as JF in maintaining nutrition in patients with severe corrosive injury. The stricture development rate is similar, but nasoenteral tube placement provides a lumen for dilatation should a tight stricture develop.
10.1016/j.gie.2009.03.009
A randomized double blind comparison of short-term duodenally administrated whale and seal blubber oils in patients with inflammatory bowel disease and joint pain.
Bjørkkjaer Tormod,Araujo Pedro,Madland Tor Magne,Berstad Arnold,Frøyland Livar
Prostaglandins, leukotrienes, and essential fatty acids
Compared with soy oil, 10 days treatment with seal oil (SO), 10mLx3 daily, self-administrated through a nasoduodenal feeding tube, relieves joint pain in patients with inflammatory bowel disease (IBD). This randomized, controlled, double blind pilot trial compares SO and whale oil (WO) administered similarly by duodenal tube, for 10 days in 18 patients with IBD-related joint pain (n=9 per group). Other long chain n-3 polyunsaturated fatty acids were prohibited 7-days prior to and during study. Significant changes from baseline to study end were observed in both groups: reduced plasma arachidonic acid to eicosapentaenoic acid ratio and prostaglandin E(2) (PGE(2)) levels (tendency in WO group), decreased IBD-related joint pain and IBD-disease activity, and improved quality of life. These changes were not significantly different between SO and WO groups. Inhibition of cyclooxygenase is consistent with amelioration of IBD-related joint pain, but, as active control was used, effects need confirmation.
10.1016/j.plefa.2009.07.005
Percutaneous gastrojejunostomy placement in a heart failure patient with biventricular assist devices.
Page Sonya,Cecere Renzo,Valenti David
JPEN. Journal of parenteral and enteral nutrition
Heart failure patients who require a ventricular assist device often present a nutrition challenge. A 39-year-old woman suffering from an acute ST elevated myocardial infarction and severe cardiogenic shock underwent implant of left and right ventricular assist devices (BiVAD). Neurologic deficits prevented her from safely resuming oral intake, and long-term feeding access was required. The decision was made to insert a percutaneous gastrojejunostomy under fluoroscopic guidance. Patients implanted with ventricular assist devices may require enteral nutrition support. Placement of feeding access other than through the nasoenteric route can be rendered more challenging because of anatomical constraints related to BiVAD positioning; however, whenever enteral nutrition support is required for extended periods, percutaneous or ostomy access offers easier delivery of nutrition. Although technically difficult, successful placement of the enteral feeding tube allowed for continuous 24-hour feeds to optimize nutrition intake. This is the first time that a percutaneous enteral feeding access was obtained for a ventricular assist device patient at the authors' institution, and it has proven valuable in providing long-term nutrition in a safe and efficient manner.
10.1177/0148607109338214
A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients.
White Hayden,Sosnowski Kellie,Tran Khoa,Reeves Annelli,Jones Mark
Critical care (London, England)
INTRODUCTION:To compare outcomes from early post-pyloric to gastric feeding in ventilated, critically ill patients in a medical intensive care unit (ICU). METHODS:Prospective randomized study. Ventilated patients were randomly assigned to receive enteral feed via a nasogastric or a post-pyloric tube. Post-pyloric tubes were inserted by the bedside nurse and placement was confirmed radiographically. RESULTS:A total of 104 patients were enrolled, 54 in the gastric group and 50 in the post-pyloric group. Bedside post-pyloric tube insertion was successful in 80% of patients. Patients who failed post-pyloric insertion were fed via the nasogastric route, but were analysed on an intent-to treat basis. A per protocol analysis was also performed. Baseline characteristics were similar for all except Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was higher in the post-pyloric group. There was no difference in length of stay or ventilator days. The gastric group was quicker to initiate feed 4.3 hours (2.9 - 6.5 hours) as compared to post-pyloric group 6.6 hours (4.5 - 13.0 hours) (P = 0.0002). The time to reach target feeds from admission was also faster in gastric group: 8.7 hours (7.6 - 13.0 hours) compared to 12.3 hours (8.9 - 17.5 hours). The average daily energy and protein deficit were lower in gastric group 73 Kcal (2 - 288 Kcal) and 3.5 g (0 - 15 g) compared to 167 Kcal (70 - 411 Kcal) and 6.5 g (2.8 - 17.3 g) respectively but was only statistically significant for the average energy deficit (P = 0.035). This difference disappeared in the per protocol analysis. Complication rates were similar. CONCLUSIONS:Early post-pyloric feeding offers no advantage over early gastric feeding in terms of overall nutrition received and complications TRIAL REGISTRATION: CLINICAL TRIAL:anzctr.org.au:ACTRN12606000367549.
10.1186/cc8181
Hepatology - Guidelines on Parenteral Nutrition, Chapter 16.
Plauth M,Schuetz T,
German medical science : GMS e-journal
Parenteral nutrition (PN) is indicated in alcoholic steatohepatitis (ASH) and in cirrhotic patients with moderate or severe malnutrition. PN should be started immediately when sufficientl oral or enteral feeding is not possible. ASH and cirrhosis patients who can be sufficiently fed either orally or enterally, but who have to abstain from food over a period of more than 12 hours (including nocturnal fasting) should receive basal glucose infusion (2-3 g/kg/d). Total PN is required if such fasting periods last longer than 72 h. PN in patients with higher-grade hepatic encephalopathy (HE); particularly in HE IV degrees with malfunction of swallowing and cough reflexes, and unprotected airways. Cirrhotic patients or patients after liver transplantation should receive early postoperative PN after surgery if they cannot be sufficiently rally or enterally nourished. No recommendation can be made on donor or organ conditioning by parenteral administration of glutamine and arginine, aiming at minimising ischemia/reperfusion damage. In acute liver failure artificial nutrition should be considered irrespective of the nutritional state and should be commenced when oral nutrition cannot be restarted within 5 to 7 days. Whenever feasible, enteral nutrition should be administered via a nasoduodenal feeding tube.
10.3205/000071
[Enteric nutrition and esophageal impactation: what relationship].
Caldeira Ana,Casanova Paula,Sousa Rui,Martins Paulo,Banhudo António,Pimentel Jorge
Acta medica portuguesa
INTRODUCTION AND OBJECTIVES:In the intensive care unit (ICU), enteral feeding is the method of choice for providing adequate nutrition in intubated patients. The oesophageal impactation (EI) by enteric nutrition (EN) results from solidification of the solution in esophagus lumen with formation of bezoar and although rare, is gradually becoming more common in clinical practice. In recent years some have been diagnosed cases of enteric nutrition impact, in an ICU. The authors seek to better understand their risk factors in order to prevent its occurrence. METHODS:Retrospective study of patients with endoscopic diagnosis of EI, in ICU, over a period of 3 years. RESULTS:There were 1367 patients in the ICU, 1003 did EN and 9 had a EI diagnosis. Mean age - 66 years, 7 males, all of them with invasive ventilation support. Mean ICU stay - 32 days, and EI at 20th day, 12 days after started EN. In all the cases, EN is due to the solidification of the EN solution in esophagus. 7 patients had esophageal reflux risk factors: 4 previously known and 3 identified after EI diagnosis. The endoscopic treatment was successful in 7 patients. CONCLUSION:The EI frequency is low. The ICU average delay (32 days) in this series is twice the total of patients admitted during this period (14,27 days), reflecting the greater severity of the patients studied. Several cases could be implicated in the etiology of that clinical entity. Whenever risk factors are present it should be considered both the endoscopic introduction of nasojejunal tube and specific positioning strategies, to prevent reflux and gastric estasis. Medical and endoscopic treatment solved the majority of related cases that are available in the literature; however, in some specific cases it was necessary to use surgical treatment.
Endoscopic nasojejunal feeding tube placement in patients with severe hepatopancreatobiliary diseases: a retrospective study of 184 patients.
Ji Feng,Zhao Jing-Li,Jin Xi,Jiao Chun-Hua,Hu Yu-Yao,Xu Qin-Wei,Chen Wei-Xing
Hepatobiliary & pancreatic diseases international : HBPD INT
BACKGROUND:Total parenteral nutrition (TPN) has been recognized as the mainstay of nutritional support in patients with severe hepatopancreatobiliary (HPB) diseases for decades. However, recent studies advocate the utilization of endoscopic nasojejunal feeding tube placement (ENFTP), rather than the conventional approach. This study was designed to compare the clinical value of ENFTP and TPN in patients with severe HPB diseases. METHODS:Two groups of patients with severe HPB diseases were analyzed retrospectively. One group of 88 patients received ENFTP, and the other 96 received TPN. Routine blood levels, serum glucose and prealbumin, hepatic and renal function, serum lipid, and calcium were measured at baseline and after 1, 2, and 4 weeks of nutritional support. Also, complication rate, mortality, nutritional support time, mechanical ventilation time, mean length of time in intensive care unit, and duration of hospital stay were analyzed. RESULTS:After 4 weeks of nutritional support, the degree of recovery of red blood cells, prealbumin, and blood glucose was greater in the ENFTP than in the TPN group (P<0.05). Furthermore, the ENFTP group showed a lower incidence of septicemia, multiple organ dysfunction syndrome, peri-pancreatic infection, biliary infection, and nosocomial infection, in addition to shorter nutritional support time and hospital stay (P<0.05). CONCLUSIONS:ENFTP is much more effective than TPN in assisting patients with severe HPB diseases to recover from anemia, low prealbumin level, and high serum glucose, as well as in decreasing the rates of various infections (pulmonary infection excluded), multiple organ dysfunction syndrome rate, nutrition support time, and length of hospital stay. Therefore, ENFTP is safer and more economical for clinical application.
A comparative analysis of safety and efficacy of different methods of tube placement for enteral feeding following major pancreatic resection. A non-randomized study.
Abu-Hilal Mohammad,Hemandas Anil K,McPhail Mark,Jain Gaurav,Panagiotopoulou Ioanna,Scibelli Tina,Johnson Colin D,Pearce Neil W
JOP : Journal of the pancreas
CONTEXT:Postoperative enteral nutrition is thought to reduce complications and speed recovery after pancreatic resection. There is little evidence on the best route for delivery of enteral nutrition. Currently we use percutaneous transperitoneal jejunostomy or percutaneous transperitoneal gastrojejunostomy, or the nasojejunal route to deliver enteral nutrition, according to surgeon preference. OBJECTIVE:To compare morbidity, efficiency, and safety of these three routes for enteral nutrition following pancreaticoduodenectomy. PATIENTS:Data were obtained from a prospectively maintained database, for all patients undergoing pancreatic resection between January 2007 and June 2008. One-hundred pancreatic resected patients underwent enteral nutrition: 93 had Whipple's operations and 7 had total pancreatectomies. INTERVENTION:Enteral nutrition was delivered by agreed protocol, starting within 24 h of operation and increasing over 2-3 days to meet full nutritional requirement. RESULTS:Delivery route of enteral nutrition was: percutaneous transperitoneal jejunostomy in 25 (25%), percutaneous transperitoneal gastrojejunostomy in 32 (32%) and nasojejunal in 43 (43%). The incidence of catheter-related complications was higher in percutaneous techniques: 24% in percutaneous transperitoneal jejunostomy and 34% in percutaneous transperitoneal gastrojejunostomy as compared to nasojejunal technique (12%). Median time to complete establishment of oral intake was 14, 14 and 10 days in percutaneous transperitoneal jejunostomy, percutaneous transperitoneal gastrojejunostomy, and nasojejunal groups, respectively. Nasojejunal tubes were removed at median 11 days (mean 11.5 days) compared to 5-6 weeks for percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy. Commonest catheter-related complication in the percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy was blockage (n=6; 10.5%), followed by pain after removal of feeding tube at 5-6 weeks (n=5; 8.8%), whereas in the nasojejunal group it was blockage (n=3; 7.0%), followed by displacement (n=2; 4.7%). Two patients died postoperatively in this cohort, however, there were no catheter-related mortalities. CONCLUSION:Enteral nutrition following pancreatic resection can be delivered in different ways. Nasojejunal feeding was associated with fewest and less serious complications. On current evidence surgeon preference is a reasonable way to decide enteral nutrition but a randomized controlled trial is needed to address this issue.
Postoperative ileus: it costs more than you expect.
Asgeirsson Theodor,El-Badawi Khaled I,Mahmood Ali,Barletta Jeffrey,Luchtefeld Martin,Senagore Anthony J
Journal of the American College of Surgeons
BACKGROUND:The clinical impact of postoperative ileus (POI) after colectomy is difficult to quantify financially because of administrative coding limitations. Accurate data are important to allow pharmaco-economic analysis of methods aimed at reducing POI. The aim of this study was to assess the financial impact of POI for the 30-day episode of care for colectomy. STUDY DESIGN:We reviewed all colectomy patients at our institution from July 2007 to June 2008. Primary POI was defined as more than three episodes of emesis with return to NPO diet status and/or reinsertion of nasogastric tube; secondary POI was associated with intraabdominal complications. Readmission for gastrointestinal failure was defined as delayed POI (no radiologic or surgical identification of small bowel obstruction). All other complications requiring readmission were grouped together for analysis. Data reviewed included primary admission and readmission costs, reason for readmission, intervention, index and total length of stay, narcotic use, time to ambulation, and time to enteral feeds. RESULTS:One hundred eighty-six colectomies were eligible for analysis, with 45 cases (38 primary and 7 secondary) of POI during the index admission. The total cost was significantly higher for patients with POI ($16,612 versus $8,316; p < 0.05). However, readmission costs were not statistically different for delayed POI and other complications ($3,546 versus $6,705). CONCLUSIONS:POI occurred in 24% (84% primary) of colectomy patients and disproportionately affected cost at the index admission. Interestingly, delayed POI was similar in cost to readmission for other serious adverse surgical complications.
10.1016/j.jamcollsurg.2009.09.028
Percutaneous transesophageal gastrostomy tube placement: an alternative to percutaneous endoscopic gastrostomy in patients with intra-abdominal metastasis.
Singal Ashwani Kumar,Dekovich Alexander A,Tam Alda L,Wallace Michael J
Gastrointestinal endoscopy
BACKGROUND:PEG/jejunostomy (PEG/J) is often placed in patients with metastatic gastric cancer for palliating bowel obstruction or for feeding. However, PEG/J placement may not always be possible for many reasons. OBJECTIVE:We wish to bring attention to the percutaneous transesophageal gastrostomy/jejunostomy (PTEG/J) as a viable alternative to nasogastric decompression in patients who are not candidates for PEG/J. PTEG/J is a largely unknown technique in the United States that designed to gain access to the stomach and proximal small bowel in these patients. We describe the use of PTEG/J in 3 patients with metastatic gastric cancer by using resources and techniques readily available in a well-stocked interventional radiology suite. PATIENTS:In the first case, percutaneous transesophageal gastrostomy (PTEG) was placed for palliation of intractable nausea and vomiting in a 37-year-woman with diffuse gastric cancer and peritoneal carcinomatosis. In the second case, PTEG was extended into the jejunum for feeding a 60-year-old woman with metastatic gastric cancer. In the third case, PTEG extending into the jejunum was placed in a 69-year-old man for palliation of bowel obstruction caused by metastatic gastric cancer and peritoneal carcinomatosis. METHODS:After adequate sedation is administered, a 22 x 4-mm balloon catheter is passed into the esophagus over a guidewire just below the thoracic inlet. The balloon is ruptured with a needle passed through the neck under US guidance. A guidewire is then passed through the needle into the balloon and carried into the stomach or proximal small bowel by advancing the balloon catheter. The track is then dilated over the guidewire and a pigtail 45-cm-long 14F nephrostomy tube then passed into the stomach or into the proximal small bowel over the guidewire. The catheter is secured by suturing to the skin of the neck. RESULTS:PTEG/J was effective in achieving palliation or feeding in our patients. No complications occurred. CONCLUSIONS:PTEG/J is a safe and effective alternative to standard percutaneous gastrostomy/jejunostomy tube placement for decompression of bowel obstruction or feeding in appropriately selected patients.
10.1016/j.gie.2009.10.037
Severe acute pancreatitis: surgical management in a third-level hospital.
Servín-Torres Erick,Velázquez-García José Arturo,Delgadillo-Teyer Germán,Galindo-Mendoza Luis,Bevia-Pérez Francisco,Rivera-Bennet Fausto
Cirugia y cirujanos
BACKGROUND:Severe acute pancreatitis has a reported mortality of 10-30% in specialized hospitals, representing 20% of patients diagnosed with acute pancreatitis. Indications for surgery are infected necrosis, necrosis persistent, fulminant pancreatitis or acute pancreatitis complications such as bleeding or intestinal perforation. METHODS:We studied patients diagnosed with pancreatitis from January 1, 2000 to December 31, 2007. RESULTS:We analyzed records of 82 patients, 63.4% were male and the most common etiology of pancreatitis was biliary in 63.4% of patients. Morbidity was 62.19%; 35.36% had pulmonary complications. In 15.85% of patients there was enterocutaneous fistula and 10.9% had bleeding. Mortality was 20.73%. In our hospital, all patients with severe acute pancreatitis are managed in the intensive care unit. Parenteral nutrition is only indicated in patients intolerant to oral feeding or with inability to place a nasojejunal tube. Use of antibiotics is based on carbapenem, and surgical indications are infected pancreatic necrosis, persistent sterile pancreatic necrosis, fulminant acute pancreatitis and abdominal hypertension, and complications such as intestinal perforation and bleeding. CONCLUSIONS:It is recommended that patients with severe acute pancreatitis are managed by a multidisciplinary team in an intensive care unit. The role of parenteral nutrition and antibiotics should be individualized.
Impact of bolus volume on small intestinal intra-luminal impedance in healthy subjects.
Nguyen Nam Q,Bryant Laura K,Burgstad Carly M,Fraser Robert-J,Sifrim Daniel,Holloway Richard H
World journal of gastroenterology
AIM:To assess the impact of bolus volume on the characteristics of small intestinal (SI) impedance signals. METHODS:Concurrent SI manometry-impedance measurements were performed on 12 healthy volunteers to assess the pattern of proximal jejunal fluid bolus movement over a 14 cm-segment. Each subject was given 34 boluses of normal saline (volume from 1 to 30 mL) via the feeding tube placed immediately above the proximal margin of the studied segment. A bolus-induced impedance event occurred if there was > 12% impedance drop from baseline, over > or = 3 consecutive segments within 10 s of bolus injection. A minor or major impedance event was defined as a duration of impedance drop < 60 s or > or = 60 s, respectively. RESULTS:The minimum volume required for a detectable SI impedance event was 2 mL. A direct linear relationship between the SI bolus volume and the occurrence of impedance events was noted until SI bolus volume reached 10 mL, a volume which always produced an impedance flow event. There was a moderate correlation between the bolus volume and the duration of impedance drop (r = 0.63, P < 0.0001) and the number of propagated channels (r = 0.50, P < 0.0001). High volume boluses were associated with more major impedance events (> or = 10 mL boluses = 63%, 3 mL boluses = 17%, and < 3 mL boluses = 0%, P = 0.02). CONCLUSION:Bolus volume had an impact on the type and length of propagation of SI impedance events and a threshold of 2 mL is required to produce an event.
10.3748/wjg.v16.i17.2151
Continuous versus intermittent delivery of nutrition via nasoenteric feeding tubes in hospitalized canine and feline patients: 91 patients (2002-2007).
Campbell Jennifer A,Jutkowitz L Ari,Santoro Kari A,Hauptman Joe G,Holahan Melissa L,Brown Andrew J
Journal of veterinary emergency and critical care (San Antonio, Tex. : 2001)
OBJECTIVE:To compare continuous to intermittent feeding at delivering prescribed nutrition in hospitalized canine and feline patients. DESIGN:Retrospective clinical study. SETTING:University teaching hospital. ANIMALS:Fifty-four cats and 37 dogs. MEASUREMENTS AND MAIN RESULTS:Twenty-four-hour periods of prescribed and delivered nutrition (kcal) were recorded, and the percentage of prescribed nutrition delivered (PPND) was calculated. If the patient received nasoenteric feeding for >1 day, then the average PPND per day was calculated. Frequency of gastrointestinal complications (vomiting, diarrhea, and regurgitation) was calculated per patient for each group. The PPND was not significantly different between patients fed continuously (99.0%) and patients fed intermittently (92.9%). Vomiting affected 29% of patients (26/91), diarrhea affected 26% of patients (24/91), and regurgitation affected 5% of patients (5/91). There was no significant difference in incidence of gastrointestinal complications between the patients fed continuously and the patients fed intermittently. There was a significantly higher incidence of diarrhea and regurgitation in dogs than in cats. CONCLUSIONS:PPND was not significantly different for continuous versus intermittent feeding via nasoenteric tubes. Frequencies of gastrointestinal complications were not significantly different between patients fed continuously and patients fed intermittently. Enterally fed dogs had a significantly higher frequency of regurgitation and diarrhea than enterally fed cats. Prospective studies are warranted to investigate causes for these potential inter-species differences.
10.1111/j.1476-4431.2010.00523.x
Enteral access by double-balloon enteroscopy: an alternative method of direct percutaneous endoscopic jejunostomy placement.
Despott E J,Gabe S,Tripoli E,Konieczko K,Fraser C
Digestive diseases and sciences
BACKGROUND:Although direct percutaneous endoscopic jejunal feeding tube placement is an increasingly accepted method of providing small-bowel access for long-term enteral nutrition, it is reliant on push enteroscopy and remains a technically challenging procedure with significant failure rates. Double-balloon enteroscopy, with its ability to provide controlled small-bowel intubation may facilitate direct percutaneous endoscopic jejunal tube placement. AIMS AND METHODS:We report a prospective series of ten consecutive cases of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunal placement, accompanied by a step-by-step illustrated overview of the technique. RESULTS:Direct percutaneous endoscopic jejunal tube placement by double-balloon enteroscopy was successful in nine of the ten attempted cases. In the first case, direct percutaneous endoscopic jejunal placement was abandoned due to inadequate transillumination; there were no procedure-related complications in any of our patients. CONCLUSIONS:This first reported prospective case series of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunal placement shows a promisingly high success rate; larger comparative studies are required to clearly establish any advantages over the originally described push enteroscopy method.
10.1007/s10620-010-1306-2
A novel application for single-incision laparoscopic surgery (SILS): SIL jejunostomy feeding tube placement.
Mohiuddin S Sameer,Anderson C Erik
Surgical endoscopy
BACKGROUND:Single-incision laparoscopic surgery (SILS) is rapidly gaining popularity as the practical alternative to natural orifice transluminal endoscopic surgery (NOTES). Although SILS achieves essentially the same goal as NOTES (a nearly invisible scar in the umbilicus), it does not carry the significant potential risks of a transluminal approach. The SILS approach has been most commonly described for cholecystectomy and appendectomy. The authors describe a novel application for this approach in the placement of a feeding jejunostomy tube. The described application for this technique is the first to be reported. METHODS:The authors describe use of the technique for two intensive care unit (ICU) patients requiring long-term postpyloric tube feeds. Access was obtained through the umbilicus with the SILS port. The selected loop of the jejunum was exteriorized through this incision, and the feeding tube was placed. The loop was returned into the abdomen, and the SILS port was replaced in the incision. Under laparoscopic visualization and guidance, the feeding tube was brought externally through a predetermined site in the left midabdomen. RESULTS:Two patients underwent SILS jejunostomy tube placement. The average operating time was 42.5 min. No intraoperative or immediate postoperative complications occurred. Tube feedings were started on postoperative day 1 for both patients, with good bowel function. CONCLUSION:The SILS technique for jejunostomy placement is a promising and feasible alternative to the current methods. It is less invasive than the open approach while providing complete intraabdominal visualization. It is less technically demanding than the direct percutaneous endoscopic jejunostomy (PEJ) approach and avoids the risks and difficulties associated with it. The same benefits of other SILS procedures are evident in this application. The authors believe a series study will further highlight long-term benefits and any potential complications.
10.1007/s00464-010-1168-x
Successful enteral nutrition in the treatment of esophagojejunal fistula after total gastrectomy in gastric cancer patients.
Portanova Michel
World journal of surgical oncology
BACKGROUND:Esophagojejunal fistula is a serious complication after total gastrectomy in gastric cancer patients. This study describes the successful conservative management in 3 gastric cancer patients with esophagojejunal fistula after total gastrectomy using total enteral nutrition. METHODS:Between January 2004 to December 2008, 588 consecutive patients with a proven diagnosis of gastric cancer were taken to the operation room to try a curative treatment. Of these, 173 underwent total gastrectomy, 9 of them had esophagojejunal fistula (5.2%). In three selected patients a trans-anastomotic naso-enteral feeding tube was placed under fluoroscopic vision when the fistula was clinically detected and a complete polymeric enteral formula was used. RESULTS:The complete closing of the esophagojejunal fistula was obtained in day 8, 14 and 25 respectively. CONCLUSION:In some selected cases it is possible to make a successful enteral nutrition using a feeding tube distal to the leak area inserted with the help of fluoroscopic vision. The specialized management of a gastric surgery unit and nutritional therapy unit are highlighted.
10.1186/1477-7819-8-71
The provision of a percutaneously placed enteral tube feeding service.
Westaby David,Young Alison,O'Toole Paul,Smith Geoff,Sanders David S
Gut
There is overwhelming evidence that the maintenance of enteral feeding is beneficial in patients in whom oral access has been diminished or lost. Short-term enteral access is usually achieved via naso-enteral tube placement. For longer term tube feeding there are recognised advantages for enteral feeding tubes placed percutaneously. The provision of a percutaneous enteral tube feeding service should be within the remit of the hospital nutrition support team (NST). This designated team should provide a framework for patient selection, pre-assessment and post-procedural care. Close working relations with community-based services should be established. An accredited therapeutic endoscopist should be a member of the NST and direct the technical aspects of the service. Every endoscopy unit in an acute hospital setting should provide a basic percutaneous endoscopic gastrostomy (PEG) service. This should include provision for fitting a PEG jejunal extension (PEGJ) if required. Specialist units should be identified where a more comprehensive service is provided, including direct jejunal placement (DPEJ), as well as radiological and laparoscopically placed tubes. Good understanding of the indications for percutaneous enteral tube feeding will prevent inappropriate procedures and ensure that the correct feeding route is selected at the appropriate time. Each unit should adopt and become familiar with a limited range of PEG tube equipment. Careful adherence to the important technical details of tube insertion will reduce peri-procedural complications. Post-procedural complications remain relatively common, however, and an awareness of the correct approach to managing them is essential for all clinicians involved in providing a percutaneous enteral tube feeding service. Finally, ethical considerations should always be taken into account when considering long-term enteral feeding, especially for patients with a poor quality of life.
10.1136/gut.2009.204982
Microbiological and immunological effects of enteral feeding on the upper gastrointestinal tract.
Smith Aileen Robertson,Macfarlane Sandra,Furrie Elizabeth,Ahmed Shakil,Bahrami Bahram,Reynolds Nigel,Macfarlane George Tennant
Journal of medical microbiology
Enteral feeding via a percutaneous endoscopic gastrostomy tube is required for nutritional support in patients with dysphagia. Enteral tube feeding bypasses the innate defence mechanisms in the upper gastrointestinal tract. This study examined the surface-associated microbial populations and immune response in the gastric and duodenal mucosae of eight enteral nutrition (EN) patients and ten controls. Real-time PCR and fluorescence in situ hybridization were employed to assess microbiota composition and mucosal pro-inflammatory cytokine expression. The results showed that EN patients had significantly higher levels of bacterial DNA in mucosal biopsies from the stomach and duodenum (P<0.05) than the controls, and that enterobacteria were the predominant colonizing species on mucosal surfaces in these individuals. Expression of the pro-inflammatory cytokines interleukin (IL)-1α, IL-6 and tumour necrosis factor-α was significantly higher in gastric and small intestinal mucosae from patients fed normal diets in comparison with those receiving EN (P<0.05). These results indicate that EN can lead to significant bacterial overgrowth on upper gastrointestinal tract mucosae and a significantly diminished pro-inflammatory cytokine response.
10.1099/jmm.0.026401-0
Creating a culture of clinical excellence in critical care nutrition: the 2008 "Best of the Best" award.
Heyland Daren K,Heyland Richard D,Cahill Naomi E,Dhaliwal Rupinder,Day Andrew G,Jiang Xuran,Morrison Siouxzy,Davies Andrew R
JPEN. Journal of parenteral and enteral nutrition
OBJECTIVE:To develop, validate, and implement a system to reward top performers in critical care nutrition practice and to illuminate characteristics of top-performing intensive care units (ICUs). DESIGN:An international, prospective, observational, cohort study conducted in May 2008. SETTING:179 ICUs from 18 countries. PATIENTS:2956 consecutively enrolled mechanically ventilated adult patients who stayed in the ICU for at least 72 hours. INTERVENTIONS:To qualify for the "Best of the Best" (BOB) award, sites had to have implemented a nutrition protocol and contributed complete data on a minimum of 20 patients. MEASUREMENTS AND MAIN RESULTS:Data on nutrition practices were collected from ICU admission to ICU discharge for a maximum of 12 days. Eligible sites were ranked based on their performance on the following 5 criteria: adequacy of provision of energy, use of enteral nutrition (EN), early initiation of EN, use of promotility drugs and small bowel feeding tubes, and adequate glycemic control. Of the 179 participating ICUs, 81 qualified for the BOB award. Overall, the average nutrition adequacy across sites was 56.2% (site range, 20.3%-90.1%). The top 10 performers were identified and publicly recognized. Regression analysis suggested that the presence of a dietitian in the ICU was associated with a high BOB award ranking, whereas being located in the United States or China, relative to other participating countries, was associated with worst performance. CONCLUSIONS:There is variable performance with respect to critical care nutrition practices across the world.
10.1177/0148607110361901
[Clinical and laboratory evaluation of the efficiency of parenteral nutrition in destructive forms of acute calculous cholecystitis].
Zhurikhin A V,Kitiashvili I Z,Kutukov V V
Klinicheskaia laboratornaia diagnostika
A clinical and laboratory studies were undertaken to evaluate the efficiency of perioperative parenteral nutrition in destructive forms of acute calculous cholecystitis. Based on the general and biochemical blood analyses and the time course of changes in humoral immunological parameters, the authors concluded that enteral tube nutrition had a positive impact on the postoperative period. A nasojejunal access reducing the risk of acute pancreatitis, which was used during tube feeding, showed benefits.
Duodenal switch with omentopexy and feeding jejunostomy--a safe and effective revisional operation for failed previous weight loss surgery.
Greenbaum David F,Wasser Samuel H,Riley Tina,Juengert Tinamarie,Hubler June,Angel Karen
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery
BACKGROUND:As the number of weight loss operations has increased, the number of patients who have failed to maintain sufficient weight loss has also increased, providing a management challenge to the bariatric surgeon. Conversion to a duodenal switch with omentopexy and feeding jejunostomy was performed for these patients. METHODS:Between September 2006 and January 2010, 41 revisional operations were performed at 1 institution and by 1 operating surgeon. The data were prospectively collected and reviewed for several parameters, including excess weight loss, mortality, and morbidity. These results are reported. RESULTS:A total of 41 patients underwent conversion of their original bariatric operation to a duodenal switch with omentopexy and feeding jejunostomy. The initial operations had been gastric bypass in 32 patients, vertical banded gastroplasty in 5, and laparoscopic adjustable gastric banding in 4. The average excess weight loss was 54% in 31 patients at 6 months, 66% in 22 patients at 1 year, and 75% in 9 patients at 2 years. No patients died. The average hospital stay was 6.4 days. A total of 9 proven or suspected leaks (22%) developed. One was at the enverted staple line of a jejunojejunostomy that was diagnosed and treated the next day with little subsequent morbidity. The others were at the gastrogastrostomy or lateral gastric staple line and all occurred in conversions from gastric bypass. They were all ischemic type leaks and presented 5-11 days after surgery and closed relatively uneventfully with J-tube feedings and antibiotic/antifungal treatment. Other major complications included 1 pulmonary embolism (2%), 1 small bowel obstruction at the site of the feeding jejunostomy (2%), 2 stenoses (4%)-1 at the duodenoenterostomy and 1 in the body of the vertical gastrectomy. This gives a total major complication rate of 30%. A total of 3 patients required reoperation because of a jejunojejunostomy leak, small bowel obstruction, and stenosis at the vertical gastrectomy. No gastrogastrostomy leaks required surgical or radiologic intervention. One required revision for malnutrition, but otherwise the nutrition remained good. CONCLUSION:Revisional surgery to a duodenal switch is a complex operation and carries a high potential for major complications. Nonetheless, it can be accomplished safely with good long-term results. Omentopexy, drainage, and feeding jejunostomy should be considered at surgery to treat the high potential for delayed ischemic leaks.
10.1016/j.soard.2010.10.015
Percutaneous endoscopic gastrojejunostomy for a patient with an intractable small bowel injury after repeat surgeries: a case report.
Hara Masayasu,Takayama Satoru,Takeyama Hiromitsu
Journal of medical case reports
INTRODUCTION:The management of intestinal injury can be challenging, because of the intractable nature of the condition. Surgical treatment for patients with severe adhesions sometimes results in further intestinal injury. We report a conservative management strategy using percutaneous endoscopic gastrojejunostomy for an intractable small bowel surgical injury after repeated surgeries. CASE PRESENTATION:A 78-year-old Japanese woman had undergone several abdominal surgeries including urinary cystectomy for bladder cancer. After this operation, she developed peritonitis as a result of a small bowel perforation thought to be due to an injury sustained during the operation, with signs consistent with systemic inflammatory response syndrome: body temperature 38.5°C, heart rate 92 beats/minute, respiratory rate 23 breaths/minute, white blood cell count 11.7 × 109/L (normal range 4-11 × 109/μL). Two further surgical interventions failed to control the leak, and our patient's clinical condition and nutritional status continued to deteriorate. We then performed percutaneous endoscopic gastrojejunostomy, and continuous suction was applied as an alternative to a third surgical intervention. With this endoscopic intervention, the intestinal leak gradually closed and oral feeding became possible. CONCLUSION:We suggest that the technique of percutaneous endoscopic gastrojejunostomy combined with a somatostatin analog is a feasible alternative to surgical treatment for small bowel leakage, and is less invasive than a nasojejunal tube.
10.1186/1752-1947-5-55
The hydrophobicity and roughness of a nasoenteral tube surface influences the adhesion of a multi-drug resistant strain of Staphylococcus Aureus.
Lima J C,Andrade N J,Soares N F F,Ferreira S O,Fernandes P E,Carvalho C C P,Lopes J P,Martins J F L
Brazilian journal of microbiology : [publication of the Brazilian Society for Microbiology]
IN THIS STUDY, WE EXAMINED THE PHYSIOCHEMICAL PROPERTIES OF NASOENTERAL FEEDING TUBES MADE FROM TWO DIFFERENT TYPES OF POLYMER: silicone materials and polyurethane. The internal surfaces of the nasoenteral feeding tubes were analyzed for their hydrophobicity, roughness, microtopography, rupture-tension and ability to stretch. We also studied the adhesion of an isolated, multi-drug resistant strain of S. aureus to these polymers. The polyurethane nasoenteral tube, which was classified as hydrophilic, was more resistant to rupture-tension and stretching tests than the silicone tube, which was classified as hydrophobic. Additionally, the polyurethane tube had a rougher surface than the silicone tube. Approximately 1.0 log CFU.cm(-2) of S. aureus cells adhered to the tubes and this number was not statistically different between the two types of surfaces (p > 0.05). In future studies, new polymers for nasoenteral feeding tubes should be tested for their ability to support bacterial growth. Bacterial adhesion to these polymers can easily be reduced through modification of the polymer's physicochemical surface characteristics.
10.1590/S1517-838220110002000013
[Risk and prophylaxis acute pancreatitis while enteral tube feeding in patients operated for destructive cholecystitis].
Zhurikhina A V,Kitiashvili I Z,Kutukov V V,Kondrashova Iu V
Voprosy pitaniia
Determined by risk and method of prophylaxis of acute pancreatitis in the postoperative enteral tube feeding in patients with destructive cholecystitis, analyzed levels of a-amylase in blood serum and clinical manifestations of acute pancreatitis in 135 operated patients. It was established that the use of nasoduodenal access is more likely to cause the elevated level of serum amylase (p<0,05) and more incidence of sings of acute pancreatitis in contrast to nasoduodenal tube placement. For the prevention of acute pancreatitis with enteral tube feeding is preferred mode designed using nasoduodenal access.
[The effects of enteral nutrition versus total parenteral nutrition on gut barrier function in severe acute pancreatitis].
Xu Chun-fang,Huang Xiao-xi,Shen Yun-zhi,Wang Xing-peng,Gong Lei,Wang Ya-dong
Zhonghua nei ke za zhi
OBJECTIVE:To evaluate the effect of enteral nutrition (EN) versus total parenteral nutrition (TPN) on gut barrier function in patients with severe acute pancreatitis (SAP). METHODS:Sixty-three patients with SAP enrolled from 4 hospitals were randomly assigned into EN group (29 cases) and TPN group (34 cases). EN group patients were fed via a spiral nasojejunal feeding tube placed routinely by endoscopy or fluoroscopy, and TPN group patients were nourished intravenously with TPN during the same period. The changes of serum endotoxin, diamine oxidase, and urinary excretion of lactulose and mannitol ratio (L/M) were observed. RESULTS:Plasma concentration of endotoxin were markedly decreased in EN group as compared with that in TPN group at the 7(th), 14(th), 21(th) day of entry trial [(39.30 ± 15.82) EU/L vs (73.05 ± 21.16) EU/L, (22.64 ± 14.31) EU/L vs (49.34 ± 24.54) EU/L, (14.81 ± 10.93) EU/L vs (30.08 ± 14.10) EU/L, P < 0.05]. Plasma concentration of diamine oxidase were markedly decreased in EN group as compared with that in TPN group at the 7(th), 14(th) day of entry trial [(9.97 ± 3.84) U/L vs (19.89 ± 9.89) U/L, (5.42 ± 1.84) U/L vs (8.79 ± 4.08) U/L, both P < 0.05]. The urinary L/M decreased significantly in EN group than those in TPN group at the 7(th), 14(th), 21(th) day of entry trial (0.28 ± 0.25 vs 0.65 ± 0.45, 0.21 ± 0.18 vs 0.54 ± 0.41, 0.08 ± 0.04 vs 0.29 ± 0.06, all P < 0.05). CONCLUSION:EN has better effect on improving intestinal barrier function than TPN in treatment of patients with SAP.
Microaspiration in intubated critically ill patients: diagnosis and prevention.
Nseir Saad,Zerimech Farid,Jaillette Emmanuelle,Artru Florent,Balduyck Malika
Infectious disorders drug targets
Microaspiration of contaminated oropharyngeal secretions and gastric contents frequently occurs in intubated critically ill patients, and plays a major role in the pathogenesis of ventilator-associated pneumonia. Risk factors for microaspiration include impossible closure of vocal cords, longitudinal folds in high-volume low-pressure polyvinyl chloride cuffs, and underinflation of tracheal cuff. Zero positive end expiratory pressure, low peak inspiratory pressure, tracheal suctioning, nasogastric tube and enteral nutrition increase the risk for microaspiration. Other patient related factors include supine position, coma, sedation, and hyperglycemia. Technetium 99 labelled enteral feeding is probably the most accurate marker of microaspiration in critically ill patients. However, use of this radioactive marker is restricted to nuclear medicine departments. Blue methylene is a reliable qualitative marker of microaspiration. However, fiberoptic bronchoscopy is required to diagnose microaspiration of blue dye in ICU patients. Quantitative pepsin measurement in tracheal aspirates is accurate in diagnosing microaspiration of gastric contents in critically ill patients. In addition, this marker is easy to use in routine practice. However, pepsin should be detected rapidly after aspiration. In vitro, and clinical studies suggested that semirecumbent position, polyurethane cuffs, positive end expiratory pressure, low-volume low-pressure cuff, and continuous control of cuff pressure were efficient in reducing microaspiration in ICU patients. Other preventive measures such as subglottic aspiration, tapered shape cuff, guayule latex cuff, lateral horizontal patient position, gastrostomy tube, and postpyloric feeding require further investingation.
10.2174/187152611796504827
Nutrition support in intensive care units in England: a snapshot of present practice.
Sharifi Mahtab N,Walton Anna,Chakrabarty Gayatri,Rahman Tony,Neild Penny,Poullis Andrew
The British journal of nutrition
Nutrition support is an important part of care management in critically ill patients, not only to prevent and treat malnutrition but also it has a significant impact on recovery from illness and overall outcome. There is little information available about present nutritional support practice for patients in intensive care units (ICU) in the UK. This survey was designed to evaluate the present nutrition support practice in ICU and high dependency units (HDU) in England. Data were gathered by a 72 h phone survey from 245 ICU and HDU in 196 hospitals in England. A questionnaire was completed over the telephone, including general information, nutrition support and teams involved in the nutrition management in the ICU. Of 1286 total patients in the ICU, 703 (54·6 %) were receiving nasogastric feeding, two (1·5 %) were receiving feeding via a percutaneous endoscopically placed gastrostomy tube and two (1·5 %) were receiving nasojejunal feeding. One hundred and forty-seven (11·4 %) patients were on parenteral feeding during the study period. A nutrition support team was not available in 158 (83·1 %) ICU and there was no dietitian or specialist nutrition nurse to cover ICU in nine (4·7 %) hospitals. In conclusion, the present survey reported an increased trend in usage of enteral feeding in ICU in England, and a reduction in the use of parenteral nutrition compared with previous surveys. However, we are still far from integrating nutrition into care management in the ICU.
10.1017/S0007114511001619
Evaluation of early enteral feeding through nasogastric and nasojejunal tube in severe acute pancreatitis: a noninferiority randomized controlled trial.
Singh Namrata,Sharma Brij,Sharma Manik,Sachdev Vikas,Bhardwaj Payal,Mani Kalaivani,Joshi Yogendra Kumar,Saraya Anoop
Pancreas
OBJECTIVE:This study aimed to determine the noninferiority of early enteral feeding through nasogastric (NG) compared to nasojejunal (NJ) route on infectious complications in patients with severe acute pancreatitis (SAP). METHODS:Patients with SAP were fed via NG (candidate) or NJ (comparative) route. The primary outcome was the occurrence of any infectious complication in blood, pancreatic tissue, bile, or tracheal aspirate. Secondary end points were pain in refeeding, duration of hospital stay, intestinal permeability assessed by lactulose/mannitol excretion, and endotoxemia assessed by endotoxin core antibody types immunoglobulin G and M. RESULTS:Seventy-eight patients were randomized to feeding by either the NG or the NJ route. During the hospital stay, the presence of any infectious complication in the NG and NJ groups was 23.1% and 35.9% (significantly different), respectively. The effect size of the difference of infectious complications was -12.8 (95% confidence interval, -29.6 to 4.0). The upper limit of the 95% confidence interval was 4.0 and was within the 5% limit set for noninferiority. The value of 8.0 for the number needed to treat implies that 8 patients should be treated with NG compared with the NJ group to prevent 1 patient from any of the infectious complications. CONCLUSIONS:Early enteral feeding through NG was not inferior to NJ in patients with SAP. Infectious complications were within the noninferiority limit. Pain in refeeding, intestinal permeability, and endotoxemia were comparable in both groups.
10.1097/MPA.0b013e318221c4a8
Utilization and morbidity associated with placement of a feeding jejunostomy at the time of gastroesophageal resection.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract
BACKGROUND:The purpose of the study was to evaluate the utilization and morbidity associated with feeding jejunostomy tubes (JT) placed at the time of gastroesophageal resection (GER). METHODS:Under institutional review board approval, a prospective database of patients undergoing GER from January 2004 to September 2010 was reviewed. Data analyzed included patient demographics, postoperative complications, JT use, and JT specific complications. Fisher's exact tests explored associations with utilization of a JT following resection. RESULTS:Seventy-three patients (51 men, 22 women, median age of 59) underwent placement of a JT at the time of GER (total gastrectomy = 28, Ivor-Lewis = 28, subtotal gastrectomy = 8, proximal gastrectomy = 6, and transhiatal esophagectomy = 3) of both malignant (97%) and benign (3%) disease processes. Twenty-one JT specific complications (11 minor and 10 major) were identified. Reoperation was required in the management of two complications (small bowel obstructions), while all other complications were easily managed by an interventional radiologist (n = 8), bedside procedure (n = 5), or did not require intervention (n = 6). Eighty-six percent of patients were discharged tolerating a postgastrectomy diet, 10% nothing per orem, and 4% a liquid diet. Inpatient enteral nutrition (EN) was initiated in 68%, but continued on discharge in only 54% secondary to failure to thrive (54%), dysphagia (21%), anastomic leak (15%), chyle leak (3%), esophagostomy (3%), and duodenal stump leak (3%). The mean time to discontinuance of EN and removal of the JT was 44 days (range, 4-203) and 71 days (range, 15-337) respectively. Although only 13% (n = 5) of patients requiring adjuvant therapy were utilizing their JT at the commencement of therapy, 75% (n = 21) required EN during its course. The median time to adjuvant therapy was found to be slightly longer in those who required outpatient EN versus those who did not (61 vs. 90 days, p = 0.08). However, the median time to adjuvant therapy did not differ between those who were and were not receiving EN at the time of adjuvant therapy commencement (80 vs. 92 days, p = 0.2). Age (p = 0.4), number of co-morbidities (p = 0.2), preoperative percent body weight loss (p = 0.9), and clinical stage (p = 0.8) were not significantly associated with outpatient JT use. Patients who suffered a postoperative complication were most likely to require EN (p = 0.002), an association that strengthened as the number of complications increased (p = 0.0008). Although not statistically significant, a trend towards increased outpatient EN was noted in patients who underwent transhiatal esophagectomy and total gastrectomy (p = 0.06). CONCLUSIONS:JT placement carries a considerable morbidity in patients undergoing GER. However, because it is difficult to preoperatively ascertain who will need prolonged EN, the routine placement of a JT is recommended, particularly in those who will likely require adjuvant therapy or are at high risk for postoperative complications. Despite patient desires for early removal of an unused JT, caution should be taken if adjuvant therapy is being considered.
10.1007/s11605-011-1629-0
Current issues on safety of prokinetics in critically ill patients with feed intolerance.
Nguyen Nam Q,Yi Mei Swee Lin Chen
Therapeutic advances in drug safety
Feed intolerance in the setting of critical illness should be treated promptly given its adverse impact on morbidity and mortality. The technical difficulty of postpyloric feeding tube placement and the morbidities associated with parenteral nutrition prevent these approaches being considered as first-line nutrition. Prokinetic agents are currently the mainstay of therapy for feed intolerance in the critically ill. Current information is limited but suggests that erythromycin or metoclopramide (alone or in combination) are effective in the management of feed intolerance in the critically ill and not associated with significant cardiac, haemodynamic or neurological adverse effects. However, diarrhoea is a very common gastrointestinal side effect, and can occur in up to 49% of patients who receive both erythromycin and metoclopramide. Fortunately, the diarrhoea associated with prokinetic treatments has not been linked to Clostridium difficile infection and settles soon after the drugs are ceased. Therefore, prolonged or prophylactic use of prokinetics should be avoided. If diarrhoea occurs, the drugs should be stopped immediately. To minimize avoidable adverse effects the ongoing need for prokinetic drugs in these patient should be reviewed daily.
10.1177/2042098611415567
Suturing intraabdominal organs: when do we cause tissue damage?
Surgical endoscopy
BACKGROUND:It is generally assumed that safety of tissue manipulations during (laparoscopic) surgery is related to the magnitude of force that is exerted on the tissue. To provide trainees with performance feedback about tissue-handling skills, it is essential to define objective criteria for judging the safety of applied forces. To be of clinical relevance, these criteria should relate the applied forces to the risk of tissue damage. This experimental study was conducted to determine which tractive forces during suturing cause tissue damage in different types of porcine tissues. METHODS:Tractive forces were applied on eight different tissue types (fascia, aorta, vena cava, peritoneum, small and large bowel, uterus, and fallopian tube) of 10 different pigs by placing increasingly higher loads on sutures in the tissue. We determined the load at what tissue damage occurred through visual inspection of the tissue. For each tissue sample, three consecutive measurements were performed. RESULTS:The average maximum acceptable force varied between 11.43 N for fascia to 1.25 N for fallopian tube. The difference in allowable force between these two structures is almost tenfold. Small bowel can be handled with a tractive force almost 1.5-fold higher than large bowel. CONCLUSIONS:Each tissue type was found to have its own individual range of acceptable maximum forces before visual tissue damage occurs. With the results presented in this study, it is possible to provide clinically relevant and validated feedback to trainees about their tissue-handling skills.
10.1007/s00464-011-1986-5
Extreme bariatric endoscopy: stenting to reconnect the pouch to the gastrojejunostomy after a Roux-en-Y gastric bypass.
de Moura Eduardo G H,Galvão-Neto Manoel P,Ramos Almino C,de Moura Eduardo T H,Galvão Thales D,de Moura Diogo T H,Ferreira Flávio C
Surgical endoscopy
BACKGROUND:Among the possible complications of bariatric surgery, fistula and partial dehiscence of the gastric suture are well known. Reoperation often is required but results in significant morbidity. Endoscopic treatment of some bariatric complications is feasible and efficient. METHODS:A modified metallic stent was placed between the gastroaesophageal junction and the alimentary jejunal limb, allowing the passage of a nasoenteric feeding tube into the jejunal limb. RESULTS:Endoscopy showed disruption of nearly the entire staple line at the gastric pouch. The modified stent was placed and allowed wound healing. After 31 days, the stent had migrated and was removed endoscopically. Total closure of the fistula was reported 30 days afterward. CONCLUSIONS:Endoscopic treatment of some bariatric surgery complications is feasible and has been reported previously. This report presents a case of a serious leakage treated by placement of a self-expandable metal stent to bridge the fistula.
10.1007/s00464-011-2060-z
Cost-analysis of nutrition support in patients with severe acute pancreatitis.
Mutch Kelly L,Heidal Kimberly B,Gross Kevin H,Bertrand Brenda
International journal of health care quality assurance
PURPOSE:The purpose of this research was to assess the preferred route of nutrition support (enteral versus parenteral) for treatment of severe acute pancreatitis in the acute care setting. Further, in cases when enteral nutrition is the preferred route, is nasal-bridling a lower-morbidity and cost-effective method? DESIGN/METHODOLOGY/APPROACH:A retrospective review of pre-existing data from an 870-bed hospital system. Medical records were reviewed via an online database system (n = 25 patients) with severe acute pancreatitis. Length of stay and cost were analyzed. FINDINGS:More patients received TPN versus the nasal-jejunal (post-pyloric) tube feeds group. No significant relationship was found between total cost and number of co-morbidities or between either of the two treatment groups. However, a medium to large effect size was shown which could indicate a significant relationship in a larger sample size. ORIGINALITY/VALUE:The findings of this research add to the literature already available and will be of interest to those who specialize in this area.
10.1108/09526861111160571
Role of water soluble contrast agents in assigning patients to a non-operative course in adhesive small bowel obstruction.
Wadani Hamid Ai,Al Awad Naif Ibrahim,Hassan Khairi Ahmed,Zakaria Hazem Mohamed, ,Alaqeel Faten O
Oman medical journal
OBJECTIVES:Adhesive small bowel obstruction (SBO) is a common surgical emergency. It is estimated that at least 60% of SBO are due to post-operative adhesions. Water soluble contrast agents (gastrografin) have been used to identify patients who might be treated non-operatively. This study aims to determine the role of gastrografin in adhesive intestinal obstruction patients. METHODS:In this prospective study, 27 patients admitted between 1(st) August 2004 and 1(st) July 2006 with clinical signs suggestive of postoperative adhesive SBO met the inclusion criteria. After intravenous hydration, nasogastric tube insertion and complete suctioning of the gastric fluid, 100 ml of gastrograsfin was given and plain abdominal radiography was taken 6 hours and 24 hours if the contrast is not seen in the colon. Those in whom the contrast reached the colon in 24 hours were considered to have partial SBO and started oral intake. If gastrografin failed to reach the colon in 24 hours and the patient did not improve in the following 24 hours, laparotomy was performed. RESULTS:Conservative treatment was successful in 31 cases (91%) and 3 (9%) required operation. Patients treated conservatively had short hospital stay (mean=4 days) and tolerated oral feeding with no morbidity or mortality. CONCLUSION:Oral gastrografin helps in the management of patients with postoperative adhesive SBO.
10.5001/omj.2011.116
Current considerations of direct percutaneous endoscopic jejunostomy.
Zhu Yanfei,Shi Liping,Tang Hao,Tao Guoqing
Canadian journal of gastroenterology = Journal canadien de gastroenterologie
UNLABELLED:BACKGROUOND: Direct percutaneous endoscopic jejunostomy (DPEJ) is a well-known approach to deliver postpyloric enteral nutritional support to individuals who cannot tolerate gastric feeding. However, it is technically difficult, and some case series have reported significant procedural failure rates. The present article describes current indications, successes and complications of DPEJ placement. METHODS:A MEDLINE database search was performed to identify relevant articles using the key words "direct percutaneous endoscopic jejunostomy", "percutaneous endoscopic gastrostomy", and "percutaneous endoscopic gastrostomy with a jejunal extension tube". Additional articles were identified by a manual search of the references cited in the key articles obtained in the primary search. RESULTS:DPEJ is gradually becoming more common in the treatment of patients who cannot tolerate gastric feeding. Differences in patient selection and technique modifications may contribute to the various success rates reported. Failure is most often due to inadequate transillumination or gastroduodenal obstruction. Currently, there are limited data to evaluate the safety and effectiveness of DPEJ. CONCLUSION:The clinical use of DPEJ is increasing. With appropriate care and expertise, DPEJ may prove to be reliable and safe.
10.1155/2012/319843
Effect of bypassing the proximal gut on gut hormones involved with glycemic control and weight loss.
Pournaras Dimitri J,Aasheim Erlend T,Bueter Marco,Ahmed Ahmed R,Welbourn Richard,Olbers Torsten,le Roux Carel W
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery
BACKGROUND:The reported remission of type 2 diabetes in patients undergoing Roux-en-Y gastric bypass has brought the role of the gut in glucose metabolism into focus. Our objective was to explore the differential effects on glucose homeostasis after oral versus gastrostomy glucose loading in patients with Roux-en-Y gastric bypass at an academic health science center. METHODS:A comparative controlled investigation of oral versus gastrostomy glucose loading in 5 patients who had previously undergone gastric bypass and had a gastrostomy tube placed in the gastric remnant for feeding. A standard glucose load was administered either orally (day 1) or by the gastrostomy tube (day 2). The plasma levels of glucose, insulin, glucagon-like peptide 1 and peptide YY were measured before and after glucose loading. RESULTS:Exclusion of the proximal small bowel from glucose passage induced greater plasma insulin, glucagon-like peptide 1, and peptide YY responses compared with glucose loading by way of the gastrostomy tube (P <.05). CONCLUSIONS:Exclusion of glucose passage through the proximal small bowel results in enhanced insulin and gut hormone responses in patients after gastric bypass. The gut plays a central role in glucose metabolism and represents a target for future antidiabetes therapies.
10.1016/j.soard.2012.01.021
Evaluation of acute radiation effects on mandibular movements of patients with head and neck cancer.
Bragante Karoline C,Nascimento Daniela M,Motta Neiro W
Revista brasileira de fisioterapia (Sao Carlos (Sao Paulo, Brazil))
OBJECTIVES:To evaluate radiotherapy effects (RT) on mandibular movements of patients with head and neck cancer (H&NC) and associate them to the variables: functional capacity, radiation field, disease staging, type of feeding, concomitant chemotherapy and total dose of RT. METHODS:Twenty-six patients with H&NC were followed up at the RT service. Physical examination was performed in 3 follow up time points: before the beginning of RT (T0), between 14th and 17th session of RT (T1) and after the last session of RT (T2). The physical examination consisted of the assessment of the following variables: mouth opening without pain (MO), maximum mouth opening (MMO), right lateral excursion (RLE), left lateral excursion (LLE) and protrusion (PR) of the jaw. The feeding type and the Karnofsky Performance Status Scale (KPS) were evaluated in each follow up time point. Data with regards to the tumor lesion and the RT were collected from the patient's clinical notes. RESULTS:There was a statistical significant reduction in the values of MO (p=0.006), MMO (p=0.001), LLE (p=0.006) and KPS (p=0.001). There was significant a statistical association among the reduction in KPS and decreased measure of MO (r=0.390, p=0.048) and MMO (r=0.435, p=0.026). The mouth and oropharynx radiation fields when combined showed a significant reduction for both the measure of MO (p=0.005) and for MMO (p=0.004). Patients who used nasoenteric tube feeding (NTF) had greater reduction in the measurement of MMO (p=0.031). The remaining variables showed no statistically significant difference. CONCLUSION:Patients with H&NC present reduction of the measures of MO and MMO during the RT, especially if they present reduced functional capacity, have radiation in the mouth and oropharynx fields and used NTF.
10.1590/s1413-35552012005000021
Efficacy and complications of nasojejunal, jejunostomy and parenteral feeding after pancreaticoduodenectomy.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract
BACKGROUND:European nutritional guidelines recommend routine use of enteral feeding after pancreaticoduodenectomy (PD) whereas American guidelines do not. Data on the efficacy and, especially, complications of the various feeding strategies after PD are scarce. METHODS:Retrospective monocenter cohort study in 144 consecutive patients who underwent PD during a period wherein the routine post-PD feeding strategy changed twice. Patients not receiving nutritional support (n=15) were excluded. Complications were graded according to the Clavien-Dindo classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions. Analysis was by intention-to-treat. Primary endpoint was the time to resumption of normal oral intake. RESULTS:129 patients undergoing PD (111 pylorus preserving) were included. 44 patients (34%) received enteral nutrition via nasojejunal tube (NJT), 48 patients (37%) via jejunostomy tube (JT) and 37 patients (29%) received total parenteral nutrition (TPN). Groups were comparable with respect to baseline characteristics, Clavien ≥II complications (P=0.99), in-hospital stay (P=0.83) and mortality (P=0.21). There were no differences in time to resumption of normal oral intake (primary endpoint; NJT/JT/TPN: median 13, 16 and 14 days, P=0.15) and incidence of delayed gastric emptying (P=0.30). Duration of enteral nutrition was shorter in the NJT- compared to the JT- group (median 8 vs. 12 days, P=0.02). Tube related complications occurred mainly in the NJT-group (34% dislodgement). In the JT-group, relaparotomy was performed in three patients (6%) because of JT-leakage or strangulation leading to death in one patient (2%). Wound infections were most common in the TPN group (NJT/JT/TPN: 16%, 6% and 30%, P=0.02). CONCLUSION:None of the analysed feeding strategies was found superior with respect to time to resumption of normal oral intake, morbidity and mortality. Each strategy was associated with specific complications. Nasojejunal tubes dislodged in a third of patients, jejunostomy tubes caused few but potentially life-threatening bowel strangulation and TPN doubled the risk of infections.
10.1007/s11605-012-1887-5
Tube pharyngostomy--a useful alternative for long-term enteric decompression or enteral feeding.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract
The tube pharyngostomy has been all but forgotten in recent years, and rightfully so when a PEG or PEJ is possible. Nevertheless, the tube pharyngostomy should remain in the armamentarium of the GI surgeon for selected patients in whom longer term enteral access is not available by PEG or PEJ for various technical reasons, for those who absolutely refuse a nasoenteric tube, or as terminal palliation in patients with nonoperable but obstructing intra-abdominal neoplasms. Not only is it easy to place (albeit requiring a brief general anesthetic), but these tubes are much more comfortable than the “misery” to the patient of a nasoenteric tube by avoiding the annoying nasal and nasopharyngeal irritation,sinusitis, trouble with speech and coughing, and general discomfort of a longer term, indwelling nasoenteric tube. Moreover, the tube can be hidden under a turtleneck-types weater, thereby avoiding the social discomfort of a tube exiting the nares. The overall lack of experience and ignorance, not only with these tubes but also with their concept, has precluded many surgeons from recognizing their usefulness,albeit in highly selected patients. With these advantages and caveats in mind, the tube pharyngostomy can prove a valuable adjunct in selected patients.
10.1007/s11605-012-1899-1
[The enteral tube feeding and selective intestinal decontamination for the treatment of the acute pancreatitis].
Myl'nikov A G,Shapoval'iants S G,Pan'kov A G,Korolev S V
Khirurgiia
The treatment results of 174 patients with the acute pancreatitis were analyzed. 51 (29.5%) patients were on total parenteral feeding (the 1st group); 93 (53%) patients received the early enteral feeding through the nasoenteral tube (the 2nd group); 30 (17.5%) patients received the enteral feeding together with the selective intestinal decontamination ( the 3rd group). The combination of enteral feeding together with the selective intestinal decontamination proved to have the positive influence and prevent the infectious complications of the acute pancreatits. Therefore, they should be used in the treatment of such patients.
Severity of illness influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness.
Huang Hsiu-Hua,Chang Sue-Joan,Hsu Chien-Wei,Chang Tzu-Ming,Kang Shiu-Ping,Liu Ming-Yi
Journal of the Academy of Nutrition and Dietetics
BACKGROUND:Few trials have studied the influence of illness severity on clinical outcomes of different tube-feeding routes. Whether gastric or postpyloric feeding route is more beneficial to patients receiving enteral nutrition remains controversial. OBJECTIVE:To test whether illness severity influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness. DESIGN:A 2-year prospective, randomized, clinical study was conducted to assess the differences between the nasogastric (NG) and nasoduodenal (ND) tube feedings on clinical outcomes. PARTICIPANTS/SETTING:One hundred one medical adult intensive care unit (ICU) patients requiring enteral nutrition were enrolled in this study. INTERVENTION:Patients were randomly assigned to the NG (n=51) or ND (n=50) feeding route during a 21-day study period. Illness severity was dichotomized as "less severe" and "more severe," with the cutoff set at Acute Physiology and Chronic Health Evaluation II score of 20. MAIN OUTCOME MEASURES:Daily energy and protein intake, feeding complications (eg, gastric retention/vomiting/diarrhea/gastrointestinal bleeding), length of ICU stay, hospital mortality, nitrogen balance, albumin, and prealbumin. STATISTICAL ANALYSES PERFORMED:Two-tailed Student t tests and Mann-Whitney U tests were used to analyze significant differences between variables in the study groups. Multiple regression was used to assess the effects of illness severity and enteral feeding routes on clinical outcomes. RESULTS:Among less severely ill patients, no differences existed between the NG and ND groups in daily energy and protein intake, feeding complications, length of ICU stay, and nitrogen balance. Among more severely ill patients, the NG group experienced lower energy and protein intake, more tube feeding complications, longer ICU stay, and poorer nitrogen balance than the ND group. CONCLUSIONS:To optimize nutritional support and taking medical resources into account, the gastric feeding route is recommended for less severely ill patients and the postpyloric feeding route for more severely ill patients.
10.1016/j.jand.2012.04.013
Improving survival in decompensated cirrhosis.
International journal of hepatology
Mortality in cirrhosis is consequent of decompensation, only treatment being timely liver transplantation. Organ allocation is prioritized for the sickest patients based on Model for End Stage Liver Disease (MELD) score. In order to improve survival in patients with high MELD score it is imperative to preserve them in suitable condition till transplantation. Here we examine means to prolong life in high MELD score patients till a suitable liver is available. We specially emphasize protection of airways by avoidance of sedatives, avoidance of Bilevel Positive Airway Pressure, elective intubation in grade III or higher encephalopathy, maintaining a low threshold for intubation with lesser grades of encephalopathy when undergoing upper endoscopy or colonoscopy as pre transplant evaluation or transferring patient to a transplant center. Consider post-pyloric tube feeding in encephalopathy to maintain muscle mass and minimize risk of aspiration. In non intubated and well controlled encephalopathy, frequent physical mobility by active and passive exercises are recommended. When renal replacement therapy is needed, night-time Continuous Veno-Venous Hemodialysis may be useful in keeping the daytime free for mobility. Sparing and judicious use of steroids needs to be borne in mind in treatment of ARDS and acute hepatitis from alcohol or autoimmune process.
10.1155/2012/318627
The usefulness of a pectoralis major myocutaneous flap in preventing salivary fistulae after salvage total laryngectomy.
Brazilian journal of otorhinolaryngology
UNLABELLED:Salvage laryngectomy in patients treated with organ preservation protocols is associated with high rates of postoperative complications. The use of non-irradiated tissue flaps in pharyngeal reconstruction could reduce the incidence of these complications. OBJECTIVE:This study aims to evaluate the usefulness of the pectoralis major myocutaneous flap in preventing salivary fistulae during the postoperative period of salvage total laryngectomy (TL). MATERIALS AND METHOD:This retrospective study enrolled 31 patients operated between April of 2006 and May of 2011. All patients had advanced cancer at the time of the salvage procedure and had been treated with chemoradiotherapy or radiotherapy alone. Pharyngeal reconstruction was performed using pectoralis major myocutaneous flap in 19 cases (61%); primary wound closure occurred in 12 patients (39%). RESULTS:Salivary fistulae occurred in 16% of the patients who received the flap and in 58% of the patients with primary closure of the pharynx (p < 0.02). No statistically significant differences were noted between the groups with respect to the mean time for fistula formation, reintroduction of an oral diet, or use of a nasoenteric tube for feeding. CONCLUSION:The pectoralis major myocutaneous flap was found to reduce the incidence of salivary fistulae in salvage laryngectomy procedures.
Effect of rotational therapy on aspiration risk of enteral feeds.
Sams Valerie G,Lawson Christy M,Humphrey Ceba L,Brantley Susan L,Schumacher Leah M,Karlstad Michael D,Norwood Jamison E,Jungwirth Julie A,Conley Caroline P,Kurek Stanley,Barlow Patrick B,Daley Brian J
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
BACKGROUND:Enteral nutrition has been demonstrated to reduce ventilator days and the incidence of pneumonia, but the safest route for providing enteral nutrition to mechanically ventilated patients is unclear. Our objective was to determine if there is a difference between the incidences of microaspiration of gastric secretions in patients fed via a nasogastric tube vs a postpyloric tube while undergoing rotational therapy for acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS:Institutional review board approval was obtained for this prospective, randomized study. Patients were randomized to gastric or postpyloric enteral feedings. Daily tracheal secretion samples were collected, and we used an immunoassay to detect pepsin. Using the data for aspiration and tube type, a univariate unadjusted odds ratio was calculated to assess the risk of aspiration between the 2 tube types. An independent samples t test was used to analyze the hypothesis that microaspiration significantly affects lung recovery from ARDS. RESULTS:Of the 20 study patients, 9 (45%) received nasogastric feeds and 11 (55%) received postpyloric feeds. Western blot analysis for the presence of pepsin in each tracheal aspirate revealed microaspiration in 2 nasogastric (22%) and 2 (18%) postpyloric patients. The nasogastric tube provided a protective effect for aspirating with an odds ratio of .778 (95% confidence interval, .09-6.98). An independent samples t test was used and showed no significant change in PaO(2):FiO(2) ratio in the aspirating vs nonaspirating group (P = .552). CONCLUSION:The results of this study indicate that enteral nutrition should not be delayed or stopped to position the tube in patients with ARDS on rotational therapy.
10.1177/0884533612462897
Neonatal short bowel syndrome as a model of intestinal failure: physiological background for enteral feeding.
Goulet O,Olieman J,Ksiazyk J,Spolidoro J,Tibboe D,Köhler H,Yagci R Vural,Falconer J,Grimble G,Beattie R M
Clinical nutrition (Edinburgh, Scotland)
Intestinal failure (IF) is a well identified clinical condition, which is characterised by the reduction of functional gut capacity below the minimum needed for adequate digestion and absorption of nutrients for normal growth in children. Short bowel syndrome (SBS) is the leading cause of IF in neonates, infants and young children usually as a result of extensive intestinal resection during the neonatal period. Simultaneously maintaining optimal nutritional status and achieving intestinal adaptation is a clinical challenge in short bowel patients. Both growth and development of the child as well as gut adaptation should be considered synergistically as primary outcome parameters. Enteral nutrition (EN) can be introduced orally and/or by tube feeding (TF). Several controversies over nutritional treatment of children with SBS related intestinal failure remain. As reported from different centres around the world, most practices are more "experienced based" rather than "evidence based". This is partly due to the small number of patients with this condition. This review (based on a consensus) discusses the physiological principles and nutritional management, including the type of diet and route of delivery. Perspectives in optimizing intestinal adaptation and reducing the consequences of small intestinal bacterial overgrowth are also discussed.
10.1016/j.clnu.2012.09.007
CT fluoroscopy guided percutaneous gastrostomy or jejunostomy without (CT-PG/PJ) or with simultaneous endoscopy (CT-PEG/PEJ) in otherwise untreatable patients.
Spelsberg Fritz W,Hoffmann Ralf-Thorsten,Lang Reinhold A,Winter Hauke,Weidenhagen Rolf,Reiser Maximilian,Jauch Karl-Walter,Trumm Christoph
Surgical endoscopy
PURPOSE:Percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) are substantial for patients with swallowing disorders to maintain enteral nutrition or to decompress palliatively intractable small bowel obstruction. Endoscopic placement can be impossible due to previous (gastric) operation, obesity, hepato-splenomegaly, peritoneal carcinosis, inadequate transillumination, or obstructed passage. Computed tomography (CT)-fluoroscopic guidance with or without endoscopy can enable placement of CT-PG/CT-PJ or CT-PEG/CT-PEJ if endoscopically guided placement fails. In this retrospective study, we will evaluate the feasibility and safety of this method. METHODS:A total of 101 consecutive patients were referred to our department for feeding support (n = 87) or decompression (n = 14). Reasons were: ENT tumor (n = 51), esophageal cancer (n = 19), mediastinal mass (n = 2), neurological disorder (n = 15). Decompression tubes were placed because of cancer (n = 13) or Crohn's disease (n = 1). The following approaches were chosen: CT fluoroscopy and simultaneous gastroscopy (n = 61), inflation of the stomach via nasogastric tube (n = 29), and direct puncture under CT-fluoroscopic guidance (n = 11). RESULTS:CT fluoroscopy-guided gastrostomy was feasible in 89 of 101 patients. No procedure-related mortality was observed. One tube was misplaced into the colon in a patient with a history of gastrectomy. No complication was seen after removal. Minor complications: dislodgement (n = 17), peristomal leakage (n = 7), wound infection (n = 1), superficial skin infection (n = 6), tube obstruction (n = 2). CONCLUSIONS:CT fluoroscopy-guided PG/PJ or PEG/PEJ is feasible and safe and provides adequate feeding support or decompression. It offers the benefits of minimally invasive therapy even in patients with contraindications to established endoscopic methods, combining the advantages of both techniques. Long-term complications-mainly tube-related problems-are easily treated.
10.1007/s00464-012-2574-z
Application of stent placement or nasojejunal feeding tube placement in patients with malignant gastric outlet obstruction: a retrospective series of 38 cases.
Lin Chin-Lung,Perng Chin-Lin,Chao Yee,Li Chung-Pin,Hou Ming-Chih,Tseng Hsiuo-Shan,Lin Han-Chieh,Lee Kuei-Chuan
Journal of the Chinese Medical Association : JCMA
BACKGROUND:Malignant gastric outlet obstruction (MGOO), a late complication of advanced carcinoma of the stomach, duodenum, periampulla or pancreas, causes significant malnutrition and morbidity. The current treatment for MGOO is palliative in nature, with the goal of maintaining the best quality of life possible during the terminal phase of the illness. METHODS:A total of 38 patients with MGOO were enrolled in our institute from January 2007 to December 2011; 18 patients received nasojejunal (NJ) feeding tube placement, and 20 patients received duodenal stent placement. Food intake, measured by the gastric outlet obstruction scoring system (GOOSS), survival, complications, recurrent obstructive symptoms, and reintervention were evaluated in both groups. RESULTS:No significant differences were noted with regard to patient characteristics, survival rate (NJ group: 140 days vs. stent group: 186 days, p = 0.617), and complication rate. Recurrent obstructions developed more frequently in patients treated with NJ feeding tube placement than in those treated with duodenal stent placement [12 (66.7%) vs. 5 (25%), p = 0.014]. The duration for patency was shorter in the NJ group than in the stent group (median: 40 days vs. 130 days, p = 0.009). The GOOSS score was significantly better in the stent group than in the NJ group. CONCLUSION:NJ tube placement and duodenal stent placement are both effective and safe treatments for patients with MGOO. Both groups had similar complication rates and survival rates. While NJ tube placement is associated with lower costs, stent placement has a longer duration of patency, superior oral intake, and a lower reintervention rate. We suggest that stent placement should be considered first in patients who are able to afford the related costs.
10.1016/j.jcma.2012.08.013
Early nasogastric tube feeding versus nil per os in mild to moderate acute pancreatitis: a randomized controlled trial.
Petrov Maxim S,McIlroy Kerry,Grayson Lorraine,Phillips Anthony R J,Windsor John A
Clinical nutrition (Edinburgh, Scotland)
BACKGROUND & AIMS:Nasojejunal tube feeding is a standard of care in patients with predicted severe acute pancreatitis (AP) and several recent trials suggested that nasogastric tube feeding (NGT) is as safe and efficient as nasojejunal tube feeding in these patients. The aim was to investigate whether NGT presents any benefit to patients with mild to moderate AP. METHODS:The study design was a randomized controlled trial. The patients in the intervention group received NGT within 24 h of hospital admission. The patients in the control group were on nil per os (NPO). The severity of acute pancreatitis was determined according to the new international multidisciplinary classification. RESULTS:There were 17 patients randomly allocated to the NGT group and 18 to the NPO group. The visual analogue pain score decreased to a significantly greater extent in the NGT group (from median 9 (range 7-9) at baseline to 1 (0-3) at 72 h after randomization) compared with the NPO group (from 7 (5-9) to 3 (1-4) (p = 0.036). The number of patients not requiring opiates at 48 h after randomization was significantly different (p = 0.024) between NGT (9/17) and NPO (3/18). Oral food intolerance was observed in 1/17 patient in the NGT group and 9/18 patients in the NPO group (p = 0.004). The overall hospital stay in the NGT group was 9 (5-12) days as compared with 8.5 (6-13) days in the NPO group (p = 0.91). CONCLUSIONS:NGT commenced within 24 h of hospital admission is well tolerated in patients with mild to moderate acute pancreatitis. Further, when compared with NPO, it significantly reduces the intensity and duration of abdominal pain, need for opiates, and risk of oral food intolerance, but not overall hospital stay.
10.1016/j.clnu.2012.12.011
Transpyloric versus gastric tube feeding for preterm infants.
Watson Julie,McGuire William
The Cochrane database of systematic reviews
BACKGROUND:Enteral feeding tubes for preterm infants may be placed in the stomach (gastric tube feeding) or in the upper small bowel (transpyloric tube feeding). There are potential advantages and disadvantages to both routes. OBJECTIVES:To determine the effect of feeding via the transpyloric route versus feeding via the gastric route on feeding tolerance, growth and development, and adverse consequences (death, gastro-intestinal disturbance including necrotising enterocolitis, aspiration pneumonia, chronic lung disease, pyloric stenosis) in preterm infants. SEARCH METHODS:We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 3), MEDLINE, EMBASE, and CINAHL (to June 2012), conference proceedings, and previous reviews. SELECTION CRITERIA:Randomised or quasi-randomised controlled trials comparing transpyloric with gastric tube feeding in preterm infants. DATA COLLECTION AND ANALYSIS:We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors. We synthesised data using a fixed-effect model and reported typical risk ratio (RR), risk difference (RD), and mean difference (MD). MAIN RESULTS:We found nine eligible trials in which a total of 359 preterm infants participated. All of the trials contained methodological weaknesses with lack of allocation concealment, absence of blinding of caregivers or assessors, and incomplete follow-up being the major potential sources of bias. The included trials did not detect any statistically significant effects on feeding tolerance or in-hospital growth rates. Meta-analyses found that infants allocated to receive transpyloric feeding had a higher risk of gastro-intestinal disturbance (typical RR 1.48 (95% confidence interval (CI) 1.05 to 2.09); typical RD 0.09 (95% CI 0.02 to 0.17); number needed to treat for an additional harmful outcome (NNTH) 10 (95% CI 6 to 50); six studies, 245 infants) and all-case mortality (typical RR 2.46 (95% CI 1.36 to 4.46); typical RD 0.16 (95% CI 0.07 to 0.26); NNTH 6 (95% CI 4 to 14); six studies, 217 infants). However, the trial that contributed most weight to these findings was likely to have been affected by selective allocation of the less mature and sicker infants to transpyloric feeding. We did not find any statistically significant differences in the incidence of other adverse events, including necrotising enterocolitis, intestinal perforation, and aspiration pneumonia. AUTHORS' CONCLUSIONS:The available data do not provide evidence of any beneficial effect of transpyloric feeding for preterm infants. Some evidence of harm exists, including a higher risk of gastrointestinal disturbance and mortality, but these findings should be interpreted and applied cautiously because of methodological weaknesses in the included trials.
10.1002/14651858.CD003487.pub3
A novel ballooned-tip percutaneous endoscopic gastrojejunostomy tube: a pilot study.
Kim Katherine J,Victor David,Stein Ellen,Valeshabad Ali Kord,Saxena Payal,Singh Vikesh K,Lennon Anne Marie,Clarke John O,Khashab Mouen A
Gastrointestinal endoscopy
BACKGROUND:The tip of currently available percutaneous endoscopic gastrojejunostomy (PEGJ) tubes frequently migrates back into the stomach. OBJECTIVE:To study the safety of a novel, ballooned-tip, PEGJ tube and assess the risk of retrograde migration into the stomach within 3 weeks of placement. DESIGN:Prospective clinical study (NCT01551095). SETTING:Tertiary-care center. PATIENTS:Seven patients who required post-pyloric feeding were included. INTERVENTION:Placement of PEGJ feeding tubes. MAIN OUTCOME MEASUREMENTS:Position of the PEGJ, abdominal radiograph findings, adverse events. RESULTS:Seven patients underwent placement of self-propelled PEGJ tubes during the study period. Technical success was achieved in all patients (100%). All procedures were rated as technically simple, and jejunostomy tubes were placed in <5 minutes during all procedures. Abdominal radiographs showed that the jejunostomy tubes were in the jejunum in all 7 patients at both 1 and 3 weeks after tube placement. LIMITATIONS:Small number of patients and short follow-up. CONCLUSION:Ballooned-tip PEGJ feeding tubes were safe and easy to place. The presence of the balloon prevented migration into the stomach. Ballooned-tip PEGJ tubes have the potential to eliminate the need for hospital readmission and repeat endoscopies for retrograde tube migration, and this may result in large systemic cost savings.
10.1016/j.gie.2013.03.005
Poor compliance with ACG guidelines for nutrition and antibiotics in the management of acute pancreatitis: a North American survey of gastrointestinal specialists and primary care physicians.
Sun Edward,Tharakan Mathew,Kapoor Sumit,Chakravarty Rajarshi,Salhab Aladin,Buscaglia Jonathan M,Nagula Satish
JOP : Journal of the pancreas
CONTEXT:Despite recent updates in the treatment of acute pancreatitis emphasizing enteral nutrition over parenteral nutrition as well as minimizing antibiotic usage, mortality rates from acute pancreatitis have not improved. Data has been limited regarding physician compliance to these guidelines in the United States. METHODS:A 20 question survey regarding practice patterns in the management of acute pancreatitis was distributed to physicians at multiple internal medicine and gastroenterology conferences in North America between 2009 and 2010. Responses were analyzed using the chi-square test and multivariate logistic regression. RESULTS:Out of 406 available respondents, 43.3% of physicians utilize total parenteral nutrition/peripheral parenteral nutrition (TPN/PPN) and 36.5% utilize nasojejunal (NJ) feedings. The preferred route of nutrition was significantly related to practice type (P<0.001): academic physicians were more likely to use NJ tube feeding than private practice physicians (52.1% vs. 19.9%) while private practitioners were more likely to utilize TPN/PPN than academic physicians (70.2% vs. 20.5%). Gastroenterologists and primary care physicians were equally non-compliant as both groups favored parenteral nutrition. Multivariate logistic regression demonstrated that practice type (P<0.001) was the only independent predictor of route of nutrition. Most survey respondents appropriately do not routinely utilize antibiotics for acute pancreatitis, but when antibiotics are initiated, they are for inappropriate indications such as fever and infection prophylaxis. CONCLUSIONS:Many North American physicians are noncompliant with current ACG practice guidelines for the use of artificial nutrition in the management of acute pancreatitis, with overuse of TPN/PPN and underutilization of jejunal feedings. Antibiotics are initiated in acute pancreatitis for inappropriate indications, although there are conflicting recommendations for antibiotics in severe acute pancreatitis. Improved compliance with guidelines is needed to improve patient outcomes.
10.6092/1590-8577/871
[Nutrition and liver failure].
Plauth M
Medizinische Klinik, Intensivmedizin und Notfallmedizin
In the critically ill liver patient, nutrition support is not very different from that given for other illnesses. In hyperacute liver failure, nutrition support is of less importance than in the other subtypes of acute liver failure that take a more protracted course. Nasoenteral tube feeding using a polymeric standard formula should be the first-line approach, while parenteral nutrition giving glucose, fat, amino acids, vitamins, and trace elements is initiated when enteral nutrition is insufficient or impracticable. In chronic liver disease, notably cirrhosis, there is frequently protein malnutrition indicating a poor prognosis and requiring immediate initiation of nutrition support. Enteral nutrition ensuring an adequate provision of energy and protein should be preferred. Particular care should be taken to avoid refeeding syndrome and to treat vitamin and trace element deficiency.
10.1007/s00063-012-0200-4
Perioperative outcomes in radical cystectomy: how to reduce morbidity?
Richards Kyle A,Steinberg Gary D
Current opinion in urology
PURPOSE OF REVIEW:To define the incidence of perioperative morbidity following contemporary radical cystectomy and identify preoperative, intraoperative, and postoperative strategies to reduce complications. RECENT FINDINGS:When complications are methodically and systematically recorded, 64% of patients will sustain a complication within 90 days of radical cystectomy. Various preoperative, postoperative, and intraoperative strategies have been identified to reduce morbidity. Prior to surgery, patients should have reversible medical conditions treated, mechanical bowel preparation can be omitted if using small bowel for reconstruction, venous thromboembolism and antimicrobial infection prophylaxis should be initiated, nutrition should be optimized, and patient education should be provided. During surgery, complications can be attenuated by utilizing meticulous surgical technique, minimizing blood loss, fluid management can be guided by transesophageal cardiovascular Doppler, and lower extremity repositioning should be performed as soon as feasible. After surgery, early mobilization, incentive spirometry, early nasogastric tube removal, alvimopan usage, and judicious jejunostomy tube feeding, or total parenteral nutrition usage may reduce morbidity. SUMMARY:Morbidity is common following radical cystectomy, but careful attention to preoperative, intraoperative, and postoperative details can help reduce this risk.
10.1097/MOU.0b013e32836392bb
Gastrostomy tube use after transoral robotic surgery for oropharyngeal cancer.
Al-Khudari Samer,Bendix Scott,Lindholm Jamie,Simmerman Erin,Hall Francis,Ghanem Tamer
ISRN otolaryngology
Objective. To evaluate factors that influence gastrostomy tube (g-tube) use after transoral robotic surgery (TORS) for oropharyngeal (OP) cancer. Study Design/Methods. Retrospective review of TORS patients with OP cancer. G-tube presence was recorded before and after surgery at followup. Kaplan-Meier and Cox hazards model evaluated effects of early (T1 and T2) and advanced (T3, T4) disease, adjuvant therapy, and free flap reconstruction on g-tube use. Results. Sixteen patients had tonsillar cancer and 13 tongue base cancer. Of 22 patients who underwent TORS as primary therapy, 17 had T1 T2 stage and five T3 T4 stage. Seven underwent salvage therapy (four T1 T2 and three T3 T4). Nine underwent robotic-assisted inset free flap reconstruction. Seventeen received adjuvant therapy. Four groups were compared: primary early disease (PED) T1 and T2 tumors, primary early disease with adjunctive therapy (PEDAT), primary advanced disease (PAD) T3 and T4 tumors, and salvage therapy. Within the first year of treatment, 0% PED, 44% PEDAT, 40% PAD, and 57% salvage patients required a g-tube. Fourteen patients had a temporary nasoenteric tube (48.3%) postoperatively, and 10 required a g-tube (34.5%) within the first year. Four of 22 (18.2%) with TORS as primary treatment were g-tube dependent at one year and had received adjuvant therapy. Conclusion. PED can be managed without a g-tube after TORS. Similar feeding tube rates were found for PEDAT and PAD patients. Salvage patients have a high rate of g-tube need after TORS.
10.1155/2013/190364
Comparative analysis of the efficacy and complications of nasojejunal and jejunostomy on patients undergoing pancreaticoduodenectomy.
Zhu Xinhua,Wu Yafu,Qiu Yudong,Jiang Chunping,Ding Yitao
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:The efficacy and feeding-related complications of a nasojejunal feeding tube and jejunostomy after pancreaticoduodenectomy (PD) was investigated with a randomized, controlled clinical trial at the Affiliated Drum Tower Hospital. METHODS:Sixty-eight patients who underwent PD in the Department of Hepatobiliary Surgery were randomly divided into 2 groups: 34 patients received enteral feeding via a nasojejunal tube (NJT group) and 34 patients received enteral feeding via a jejunostomy tube (JT group). The assessment of clinical outcome was based on postoperative investigation of complications. The second part of the assessment included tube related complications and an index on catheter efficiency. RESULTS:There were 15 cases with infectious complications in the JT group and 13 cases in the NJT group, and there was no significant difference in the rate of infectious complications between the 2 groups. The rate of intestinal obstruction and delayed gastric emptying was significantly decreased in the NJT group (P < .05). Catheter-related complications were more common in the JT group as compared with the NJT group (35.3% vs 20.6%, P < .05). The time for removal of the feeding tube and nasogastric tube was significantly decreased in the NJT group. The postoperative hospital stay in the NJT group was significantly decreased (P < .05), and there was no hospital mortality in this study. CONCLUSION:Nasojejunal feeding is safer than jejunostomy, and it is associated with only minor complications. Nasojejunal feeding can significantly decrease the incidence of delayed gastric emptying and shorten the postoperative hospital stay.
10.1177/0148607113500694
Association of preoperative symptoms of gastric outlet obstruction with delayed gastric emptying after pancreatoduodenectomy.
Atema Jasper J,Eshuis Wietse J,Busch Olivier R C,van Gulik Thomas M,Gouma Dirk J
Surgery
BACKGROUND:Delayed gastric emptying (DGE) is among the most common complications after pancreatoduodenectomy (PD) and might demand postoperative nutritional support. The aim of this study was to investigate the association between preoperative symptoms of gastric outlet obstruction and DGE after PD in an attempt to identify patients in whom placement of a feeding tube at time of operation might be beneficial. METHODS:We analyzed a consecutive series of 401 patients undergoing PD from a prospective database. Preoperative symptoms of nausea, vomiting, loss of appetite, weight loss, postprandial complaints, and dysphagia were retrospectively determined. Primary outcome was clinically relevant DGE according to the International Study Group of Pancreatic Surgery classification and the necessity of postoperative insertion of a nasojejunal feeding tube. RESULTS:The incidence of clinically relevant DGE was 33.2% (133/401 patients). A nasojejunal feeding tube was inserted in 119 patients (29.7%). Patients having ≥2 symptoms of gastric outlet obstruction except weight loss (50 patients; 12.5%), were at a greater risk of developing both DGE (21.1% vs 8.2%; P < .001) and the need for insertion of a feeding tube (21.8% vs 8.5%; P < .001). In multivariable logistic regression analysis, the presence of ≥2 symptoms of gastric outlet obstruction other than weight loss remained a significant predictor of DGE (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.7-5.8) and the need for insertion of a nasojejunal feeding tube (OR, 3.1; 95% CI, 1.7-5.7). CONCLUSION:The preoperative presence of ≥2 symptoms of gastric outlet obstruction is a significant predictor of postoperative DGE after PD. By applying this risk factor, patients in whom placement of a feeding tube during surgery should be considered can be identified.
10.1016/j.surg.2013.04.006
Comparison of primary jejunostomy tubes versus gastrojejunostomy tubes for percutaneous enteral nutrition.
Kim Charles Y,Engstrom Bjorn I,Horvath Jeffrey J,Lungren Matthew P,Suhocki Paul V,Smith Tony P
Journal of vascular and interventional radiology : JVIR
PURPOSE:To evaluate technical success and long-term outcomes of percutaneous primary jejunostomy tubes for postpyloric enteral feeding compared with percutaneous gastrojejunostomy (GJ) tubes. MATERIALS AND METHODS:Over a 25-month interval, 41 consecutive patients (26 male; mean age, 55.9 y) underwent attempted fluoroscopy-guided direct percutaneous jejunostomy tube insertion. Insertions at previous jejunostomy tube sites were excluded. The comparison group consisted of all primary GJ tube insertions performed over a 12-month interval concomitant with the jejunostomy tube interval (N = 169; 105 male; mean age, 59.4 y). Procedural, radiologic, and clinical data were retrospectively reviewed. Intervention rates were expressed as events per 100 catheter-days. RESULTS:The technical success rate for percutaneous jejunostomy tube insertion was 96%, versus 93% for GJ tubes (P = .47). Mean fluoroscopy times were similar for jejunostomy and GJ tubes (9.8 vs 10.0 min, respectively; P value not significant). Jejunostomy tubes exhibited a lower rate of catheter dysfunction than GJ tubes, with catheter exchange rates of 0.24 versus 0.93, respectively, per 100 catheter-days (P = .045). GJ tube tip retraction into the stomach occurred in 9.5% of cases, at a rate of 0.21 per 100 catheter-days. Intervention rates related to leakage were 0.19 and 0.03 for jejunostomy and GJ tubes, respectively (P < .01). Jejunostomy and GJ tubes exhibited similar rates of catheter exchange for occlusion and replacement as a result of inadvertent removal. No major complications were encountered in either group. CONCLUSIONS:Percutaneous insertion of primary jejunostomy tubes demonstrated technical success and complication rates similar to those of GJ tubes. Jejunostomy tubes exhibited a lower dysfunction rate but a higher leakage rate compared with GJ tubes.
10.1016/j.jvir.2013.08.012
Variation in feeding practices following the Norwood procedure.
Lambert Linda M,Pike Nancy A,Medoff-Cooper Barbara,Zak Victor,Pemberton Victoria L,Young-Borkowski Lisa,Clabby Martha L,Nelson Kathryn N,Ohye Richard G,Trainor Bethany,Uzark Karen,Rudd Nancy,Bannister Louise,Korsin Rosalind,Cooper David S,Pizarro Christian,Zyblewski Sinai C,Bartle Bronwyn H,Williams Richard V,
The Journal of pediatrics
OBJECTIVES:To assess variation in feeding practice at hospital discharge after the Norwood procedure, factors associated with tube feeding, and associations among site, feeding mode, and growth before stage II. STUDY DESIGN:From May 2005 to July 2008, 555 subjects from 15 centers were enrolled in the Pediatric Heart Network Single Ventricle Reconstruction Trial; 432 survivors with feeding data at hospital discharge after the Norwood procedure were analyzed. RESULTS:Demographic and clinical variables were compared among 4 feeding modes: oral only (n = 140), oral/tube (n = 195), nasogastric tube (N-tube) only (n = 40), and gastrostomy tube (G-tube) only (n = 57). There was significant variation in feeding mode among sites (oral only 0%-81% and G-tube only 0%-56%, P < .01). After adjusting for site, multivariable modeling showed G-tube feeding at discharge was associated with longer hospitalization, and N-tube feeding was associated with greater number of discharge medications (R(2) = 0.65, P < .01). After adjusting for site, mean pre-stage II weight-for-age z-score was significantly higher in the oral-only group (-1.4) vs the N-tube-only (-2.2) and G-tube-only (-2.1) groups (P = .04 and .02, respectively). CONCLUSIONS:Feeding mode at hospital discharge after the Norwood procedure varied among sites. Prolonged hospitalization and greater number of medications at the time of discharge were associated with tube feeding. Infants exclusively fed orally had a higher weight-for-age z score pre-stage II than those fed exclusively by tube. Exploring strategies to prevent morbidities and promote oral feeding in this highest risk population is warranted.
10.1016/j.jpeds.2013.09.042
Gastric electrical stimulation for treatment of clinically severe gastroparesis.
Jayanthi Naga Venkatesh G,Dexter Simon P L,Sarela Abeezar I,
Journal of minimal access surgery
BACKGROUND:Severe, drug-resistant gastroparesis is a debilitating condition. Several, but not all, patients can get significant relief from nausea and vomiting by gastric electrical stimulation (GES). A trial of temporary, endoscopically delivered GES may be of predictive value to select patients for laparoscopic-implantation of a permanent GES device. MATERIALS AND METHODS:We conducted a clinical audit of consecutive gastroparesis patients, who had been selected for GES, from May 2008 to January 2012. Delayed gastric emptying was diagnosed by scintigraphy of ≥50% global improvement in symptom-severity and well-being was a good response. RESULTS:There were 71 patients (51 women, 72%) with a median age of 42 years (range: 14-69). The aetiology of gastroparesis was idiopathic (43 patients, 61%), diabetes (15, 21%), or post-surgical (anti-reflux surgery, 6 patients; Roux-en-Y gastric bypass, 3; subtotal gastrectomy, 1; cardiomyotomy, 1; other gastric surgery, 2) (18%). At presentation, oral nutrition was supplemented by naso-jejunal tube feeding in 7 patients, surgical jejunostomy in 8, or parenterally in 1 (total 16 patients; 22%). Previous intervention included endoscopic injection of botulinum toxin (botox) into the pylorus in 16 patients (22%), pyloroplasty in 2, distal gastrectomy in 1, and gastrojejunostomy in 1. It was decided to directly proceed with permanent GES in 4 patients. Of the remaining, 51 patients have currently completed a trial of temporary stimulation and 39 (77%) had a good response and were selected for permanent GES, which has been completed in 35 patients. Outcome data are currently available for 31 patients (idiopathic, 21 patients; diabetes, 3; post-surgical, 7) with a median follow-up period of 10 months (1-28); 22 patients (71%) had a good response to permanent GES, these included 14 (68%) with idiopathic, 5 (71%) with post-surgical, and remaining 3 with diabetic gastroparesis. CONCLUSIONS:Overall, 71% of well-selected patients with intractable gastroparesis had good response to permanent GES at follow-up of up to 2 years.
10.4103/0972-9941.118833
Early oral feeding after pancreatoduodenectomy enhances recovery without increasing morbidity.
Gerritsen Arja,Wennink Roos A W,Besselink Marc G H,van Santvoort Hjalmar C,Tseng Dorine S J,Steenhagen Elles,Borel Rinkes Inne H M,Molenaar I Quintus
HPB : the official journal of the International Hepato Pancreato Biliary Association
OBJECTIVE:The aim of this study was to evaluate whether a change in the routine feeding strategy applied after pancreatoduodenectomy (PD) from nasojejunal tube (NJT) feeding to early oral feeding improved clinical outcomes. METHODS:An observational cohort study was performed in 102 consecutive patients undergoing PD. In period 1 (n = 51, historical controls), the routine postoperative feeding strategy was NJT feeding. This was changed to a protocol of early oral feeding with on-demand NJT feeding in period 2 (n = 51, consecutive prospective cohort). The primary outcome was time to resumption of adequate oral intake. RESULTS:The baseline characteristics of study subjects in both periods were comparable. In period 1, 98% (n = 50) of patients received NJT feeding, whereas in period 2, 53% (n = 27) of patients did so [for delayed gastric empting (DGE) (n = 20) or preoperative malnutrition (n = 7)]. The time to resumption of adequate oral intake significantly decreased from 12 days in period 1 to 9 days in period 2 (P = 0.015), and the length of hospital stay shortened from 18 days in period 1 to 13 days in period 2 (P = 0.015). Overall, there were no differences in the incidences of complications of Clavien-Dindo Grade III or higher, DGE, pancreatic fistula, postoperative haemorrhage and mortality between the two periods. CONCLUSIONS:The introduction of an early oral feeding strategy after PD reduced the time to resumption of adequate oral intake and length of hospital stay without negatively impacting postoperative morbidity.
10.1111/hpb.12197
Conservative treatment of early postoperative small bowel obstruction with obliterative peritonitis.
Gong Jian-Feng,Zhu Wei-Ming,Yu Wen-Kui,Li Ning,Li Jie-Shou
World journal of gastroenterology
AIM:To investigate the effect of somatostatin and dexamethasone on early postoperative small bowel obstruction with obliterative peritonitis (EPSBO-OP). METHODS:This prospective randomized study included 70 patients diagnosed with EPSBO-OP from June 2002 to January 2009. Patients were randomized into two groups: a control group received total parenteral nutrition and nasogastric (NG) tube feeding; and an intervention group received, in addition, somatostatin and dexamethasone treatment. The primary endpoints were time to resolution of bowel obstruction and length of hospital stay, and the secondary endpoints were daily NG output and NG feeding duration, treatment-related complications, postoperative obstruction relapse, and patient satisfaction. RESULTS:Thirty-six patients were allocated to the intervention group and 34 to the control group. No patient needed to undergo surgery. Patients in the intervention group had an earlier resolution of bowel obstruction (22.4 ± 9.1 vs 29.9 ± 10.1 d, P = 0.002). Lower daily NG output (583 ± 208 vs 922 ± 399 mL/d, P < 0.001), shorter duration of NG tube use (16.7 ± 8.8 vs 27.7 ± 9.9 d, P < 0.001), and shorter length of hospital stay (25.8 vs 34.9 d, P = 0.001) were observed in the intervention group. The rate of treatment-related complications (P = 0.770) and relapse of obstruction (P = 0.357) were comparable between the two groups. There were no significant differences in postoperative satisfaction at 1, 2 and 3 years between the two groups. CONCLUSION:Somatostatin and dexamethasone for EPSBO-OP promote resolution of obstruction and shorten hospital stay, and are safe for symptom control without increasing obstruction relapse.
10.3748/wjg.v19.i46.8722
Risk factors for acute pancreatitis in patients with severe motor and intellectual disabilities.
Tamasaki Akiko,Nishimura Yoko,Kondo Noriko,Shirai Kentaro,Maegaki Yoshihiro,Ohno Kousaku
Pediatrics international : official journal of the Japan Pediatric Society
BACKGROUND:Acute pancreatitis in patients with severe motor and intellectual disability (SMID) is a rare but life-threatening condition. Possible causes of acute pancreatitis in these patients including valproic acid therapy, hypothermia and nasoduodenal tube feeding, have not yet been investigated in detail. The aim of this study was therefore to investigate the risk factors for acute pancreatitis in patients with SMID. METHODS:Five SMID patients with acute pancreatitis and 15 SMID patients without acute pancreatitis were reviewed. Age; serum total cholesterol, triglyceride, total protein, and albumin; height; bodyweight; body surface area; body mass index; daily calorie intake; daily calorie intake per unit of body mass surface area; daily calorie intake per kilogram bodyweight; and valproic acid usage were examined. RESULTS:A statistically significant difference was observed in serum albumin level between the two groups (P = 0.026). CONCLUSION:The mechanism of acute pancreatitis in these patients was considered as pancreatic morphological change, acinar damage, and elevated serum trypsinogen level caused by malnutrition. It is likely that acute pancreatitis in patients with SMID occurs due to the same mechanism as in anorexia nervosa and malnourished patients. To prevent acute pancreatitis in these patients, it is important to maintain adequate nutritional status.
10.1111/ped.12231
Mesenteric ischemia secondary to toxic epidermal necrolysis: case report and review of the literature.
Pradka Sarah P,Smith Jesse R,Garrett Melissa T,Fidler Philip E
Journal of burn care & research : official publication of the American Burn Association
A 28-year-old otherwise healthy man was admitted to the burn center for treatment of toxic epidermal necrolysis (TEN) involving 90% of the TBSA and oropharynx. On hospital day 8, his cutaneous lesions were healing well, but he developed respiratory distress, fever, and abdominal distension. Computerized tomography demonstrated distended bowel, pneumatosis intestinalis, and portal venous gas. He underwent emergent celiotomy. Patchy areas of nonperforated necrosis along the jejunum and ileum were present. No mechanical or embolic source of ischemia could be identified. A 120-cm segment of ischemic small bowel was resected and the abdomen was closed temporarily. On planned "second look" the following day, no further disease was encountered and intestinal continuity was restored. Tube feeds were then initiated and the patient's recovery was uneventful thereafter. Although traditionally considered a skin disorder, TEN may be more accurately described as a disorder affecting the junction of an epithelium and its supporting tissue. It is most prominently manifested at the epidermal-dermal junction, but epithelial-submucosal junctions are also affected. The ocular, respiratory, genitourinary, and gastrointestinal manifestations of TEN are variable and incompletely understood. This disease is rooted in immunological dysfunction and the small bowel is rich in immunologically active tissue; Peyer patches and lymph nodes abound. Clinicians should be vigilant for gastrointestinal tract involvement, which is potentially treatable with resection of the ischemic bowel. The authors suspect that, given the critical condition of many TEN patients, bowel symptoms may be incorrectly attributed to global hypoperfusion and sepsis.
10.1097/BCR.0000000000000006
Endoscopic gastrostomy, nasojejunal and oral feeding comparison in aspiration pneumonia patients.
Onur Ozge E,Onur Ender,Guneysel Ozlem,Akoglu Haldun,Denizbasi Arzu,Demir Hasan
Journal of research in medical sciences : the official journal of Isfahan University of Medical Sciences
BACKGROUND:Aspiration pneumonia is a potentially preventable illness requiring attention to small details of patient care. The type, management, and care of feeding should be carried out properly. MATERIALS AND METHODS:This is a prospective clinical study of enteral feeding on patients admitted to hospital with aspiration pneumonia. The known enteral nutritional methods, advantages, and disadvantages were told to the patient or proxy. If they didn't accept Percutaneous endoscopic gastrostomy (PEG), nasojejunal tube (NJT) was advised. If they denied all of the procedures, oral feeding education was given. A total of 94 patients were enrolled to the study, 29 of them accepted PEG, 42 preferred NJT, and 23 preferred oral route. RESULTS:A total of 94 patients with a mean age of 77.84, standard deviation 10.784; 95% confidence interval (CI) 75.63-80.03 were enrolled to the study of which 27 (28.7%) patients had a history of aspiration pneumonia. Oral feeding was prominently preferred for patients nursed by a relative (15; 65.2% of Oral feeding group and 16% of total) or a caregiver (7; 30.4% of Oral feeding group and 7.4% of total) while only 1 (4.3% of Oral feeding group and 1.1% of total) with a health-care worker (P = 0.001). Overall re-aspiration rates at the 6(th) month were 58%, 78%, 91% in EG, NJT, oral groups, respectively. Sixth months' survival rates of the different feeding groups were not significantly divergent from each other. History of aspiration was also found to be a significant contributor of mortality. CONCLUSION:In aspiration pneumonia patients' long-term survival rates of the different feeding groups were not significantly divergent from each other.
[Enteral tube feeding].
Haller Alois
Therapeutische Umschau. Revue therapeutique
Tube feeding is an integral part of medical therapies, and can be easily managed also in the outpatient setting. Tube feeding by the stomach or small intestine with nasogastral or nasojejunal tubes is common in clinical practice. Long-term nutrition is usually provided through a permanent tube, i. e. a percutaneous endoscopic gastrostomy (PEG). Modern portable nutrition pumps are used to cover the patient's nutritional needs. Enteral nutrition is always indicated if patients can not or should not eat or if nutritional requirements cannot be covered within 3 days after an intervention, e. g. after abdominal surgery. Industrially produced tube feedings with defined substrate concentrations are being used; different compositions of nutrients, such as glutamine fish oil etc., are used dependent on the the condition of the patient. Enteral nutrition may be associated with complications of the tube, e. g. dislocation, malposition or obstruction, as well as the feeding itself, e. g.hyperglycaemia, electrolyte disturbances, refeeding syndrome diarrhea or aspiration). However, the benefit of tube feeding usually exceeds the potential harm substantially.
10.1024/0040-5930/a000497
Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome.
Rajan P S,Bansal S,Balaji N S,Rajapandian S,Parthasarathi R,Senthilnathan P,Praveenraj P,Palanivelu C
Surgical endoscopy
BACKGROUND:Leaks following oesophageal surgery are considered to be amongst the most dreaded complications and contributory to postoperative mortality. Controversies still exist regarding the best option for the management of oesophageal leaks due to lack of standardized treatment protocols. This study was designed to analyse the feasibility outcome and complications associated with placement of removable, fully covered, self-expanding metallic stents for oesophageal leaks with concomitant minimally invasive drainage when appropriate. METHODS:The study group included 32 patients from a prospectively maintained database of oesophageal leaks, with the majority being anastomotic leaks after minimally invasive oesophagectomy (n = 28), followed by laparoscopic cardiomyotomy (n = 3) and extended total gastrectomy (n = 1). The procedures took place between March 2007 and April 2013. RESULTS:Most patients had an intrathoracic leak (n = 22), with a mean time to detection of the leak following surgery of 7.50 days (SD = 2.23). Subsequent to endoscopic stenting, enteral feeding via a nasojejunal tube was started on the second day and oral feeding was delayed until the 14th day (n = 31). Six patients underwent thoracoscopic (n = 5) or laparoscopic drainage (n = 1) along with stenting for significant mediastinal and intra-abdominal contamination. The stent migration rate of our study was 8.54%. The overall success in terms of preventing mortality was 96%. CONCLUSION:Endoscopic stenting should be considered a primary option for managing oesophageal leaks. Delayed oral intake may reduce the incidence of stent migration. Larger stents (bariatric or colorectal stents) serve as a useful option in case of migrated stents. Combined minimally invasive procedures can be safely adapted in appropriate clinical circumstances and may contribute to better outcomes.
10.1007/s00464-014-3471-4
[Role of the small intestinal decompression tube and Gastrografin in the treatment of early postoperative inflammatory small bowel obstruction].
Li Wei,Li Zhixia,An Dali,Liu Jing,Zhang Xiaohu
Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery
OBJECTIVE:To evaluate the role of the small intestinal decompression tube (SIDT) and Gastrografin in the treatment of early postoperative inflammatory small bowel obstruction (EPISBO). METHODS:Twelve patients presented EPISBO after abdominal surgery in our department from April 2011 to July 2012. Initially, nasogastric tube decompression and other conventional conservative treatment were administrated. After 14 days, obstruction symptom improvement was not obvious, then the SIDT was used. At the same time, Gastrografin was injected into the small bowel through the SIDT in order to demonstrate the site of obstruction of small bowel and its efficacy. RESULTS:In 11 patients after this management, obstruction symptoms disappeared, bowel function recovered within 3 weeks, and oral feeding occurred gradually. Another patient did not pass flatus after 4 weeks and was reoperated. After postoperative follow-up of 6 months, no case relapsed with intestinal obstruction. CONCLUSION:For severe and long course of early postoperative inflammatory intestinal obstruction, intestinal decompression tube plus Gastrografin is safe and effective, and can avoid unnecessary reoperation.
Minimally invasive management of postoperative esophagojejunal anastomotic leak.
Facy Olivier,Goergen Martine,Poulain Virginie,Heieck Frank,Lens Vincent,Azagra Juan-Santiago
Surgical laparoscopy, endoscopy & percutaneous techniques
PURPOSE:Postoperative esophagojejunal fistula induces morbidity and mortality after total gastrectomy and affects the long-term survival rate. METHODS:Between 2003 and 2011, 38 patients underwent laparoscopic total gastrectomy and 2 developed an esophagojejunal fistula. RESULTS:The diagnosis was established by a computed tomography scan with contrast ingestion. The absence of complete dehiscence and the vitality of the alimentary loop were checked during laparoscopic exploration, associated with effective drainage. During the endoscopy, dehiscence was assessed and a covered stent and nasojejunal tube were inserted for enteral feeding. The leaks healed progressively, oral feeding was resumed and the drains removed within 3 weeks. The stent was removed 6 weeks. Three months later, the patients were able to eat without dysphagia. CONCLUSIONS:Early diagnosis allows successful conservative management. The objectives are effective drainage, covering by an endoscopic stent and renutrition. Management by a multidisciplinary team is essential.
10.1097/SLE.0b013e31828f6cc5
Comparison between liquid and tablet levothyroxine formulations in patients treated through enteral feeding tube.
Pirola I,Daffini L,Gandossi E,Lombardi D,Formenti A,Castellano M,Cappelli C
Journal of endocrinological investigation
BACKGROUND:The majority of clinicians suggest that enteral feedings should be held 1-2 h prior to and after L-T4 administration despite lack of data for continuous enteral nutrition. AIM:The aim of this study was to: (1) compare the thyroid hormonal profile in patients submitted to L-T4 treatment in tablets or liquid formulation with an enteral feeding tube; (2) evaluate the nursing compliance with the two different formulations. SUBJECTS AND METHODS:20 euthyroid patients submitted to total laryngectomy and thyroidectomy consecutively started L-T4 treatment in tablets (Group T) or in liquid formulation (Group L) with enteral feeding tube the day after surgery. Tablets were crushed before administration and enteral feeding was stopped for 30 min before and after L-T4 treatment, whereas liquid formulation was placed into the nasoenteric tube immediately. A questionnaire about the preparation and administration of thyroxine replacement therapy was given to the nurses. RESULTS:No difference of TSH, fT4 and fT3 before and after L-T4 treatment was observed among patients of Group L. A slightly serum TSH increase was observed in Group T, but not reaching statistical significance (2.50 ± 1.18 vs 2.94 ± 1.22 mUI/L), whereas no difference in fT4 and fT3 levels was found. Preparation and administration of liquid L-T4 was considered excellent by 12/13 nurses, whereas tablet formulation was considered poor by 10/13. CONCLUSIONS:Our data showed that liquid L-T4 formulation can be administered directly through feeding tube with no need for an empty stomach, with a significant improvement in therapy preparation and administration by nurses.
10.1007/s40618-014-0082-9
Tips and tricks for deep jejunal enteral access: modifying techniques to maximize success.
Palmer Lena B,McClave Stephen A,Bechtold Matthew L,Nguyen Douglas L,Martindale Robert G,Evans David C
Current gastroenterology reports
Endoscopic insertion of enteral feeding tubes is a major advance in the delivery of nutrition therapy. Since the first report of percutaneous endoscopic gastrostomy (PEG) in 1980 (Gauderer et al. J Pediatr Surg. 15:872-5, 1980), insertion techniques and equipment have been refined and improved. Despite this progress, deep jejunal enteral access remains a difficult procedure, and many endoscopists do not have experience with the techniques of nasojejunal (NJ) placement, percutaneous endoscopic gastrojejunostomy (PEGJ), or direct percutaneous endoscopic jejunostomy (DPEJ) (Shike and Latkany, Gastrointest Endosc Clin N Am. 8:569-80, 1998). The difference between an exasperating experience and a rewarding procedure lies in mastering the "tips and tricks" that make insertion easy. While the basic techniques are described elsewhere (McClave and Chang 2011), we review several universal basic principles to enhance deep jejunal access, which should promote a more efficient and successful procedure.
10.1007/s11894-014-0409-x
Dual-Purpose Gastric Decompression and Enteral Feeding Tubes Rationale and Design of Novel Nasogastric and Nasogastrojejunal Tubes.
Silk David B A,Quinn David G
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:The importance of early postoperative nutrition in surgical patients and early institution of enteral nutrition in intensive care unit (ICU) patients have recently been highlighted. Unfortunately, institution of enteral feeding in both groups of patients often has to be postponed due to delayed gastric emptying and the need for gastric decompression. The design of current polyvinylchloride (PVC) gastric decompression tubes (Salem Sump [Covidien, Mansfield, MA] in the United States; Ryles [Penine Health Care Ltd, Derby, UK] in the United Kingdom and Europe) make them unsuitable for their subsequent use as either nasogastric enteral feeding tubes or for continued gastric decompression during postpyloric enteral feeding. To overcome these problems, we have designed a range of polyurethane (PU) dual-purpose gastric decompression and enteral feeding tubes that include 2 nasogastric tubes (double lumen to replace Salem Sump; single lumen to replace Ryles). Two novel multilumen nasogastrojejunal tubes (triple lumen for the United States; double lumen for the United Kingdom and Europe) complete the range. By using PU, a given internal diameter (ID) and flow area can be incorporated into a lower outside diameter (OD) compared with that achieved with PVC. The ID and lumen and flow area of an 18Fr (OD 6.7 mm) PVC Salem Sump can be incorporated into a 14Fr (OD 4.7 mm) PU tube. The design of aspiration/infusion ports of current PVC and PU tubes invites occlusion by gastrointestinal mucosa and clogging by mucus and enteral feed. To overcome this, we have designed long, single, widened, smooth, and curved edge ports with no "dead space" to trap mucus or curdled diet. Involving up to 214° of the circumference, these ports have up to 11 times the flow areas of the aspiration ports of current PVC tubes. CONCLUSION:The proposed designs will lead to the development of dual-purpose nasogastric and nasojejunal tubes that will significantly improve the clinical and nutrition care of postoperative and ICU patients.
10.1177/0148607114551966
Early versus on-demand nasoenteric tube feeding in acute pancreatitis.
Bakker Olaf J,van Brunschot Sandra,van Santvoort Hjalmar C,Besselink Marc G,Bollen Thomas L,Boermeester Marja A,Dejong Cornelis H,van Goor Harry,Bosscha Koop,Ahmed Ali Usama,Bouwense Stefan,van Grevenstein Wilhelmina M,Heisterkamp Joos,Houdijk Alexander P,Jansen Jeroen M,Karsten Thom M,Manusama Eric R,Nieuwenhuijs Vincent B,Schaapherder Alexander F,van der Schelling George P,Schwartz Matthijs P,Spanier B W Marcel,Tan Adriaan,Vecht Juda,Weusten Bas L,Witteman Ben J,Akkermans Louis M,Bruno Marco J,Dijkgraaf Marcel G,van Ramshorst Bert,Gooszen Hein G,
The New England journal of medicine
BACKGROUND:Early enteral feeding through a nasoenteric feeding tube is often used in patients with severe acute pancreatitis to prevent gut-derived infections, but evidence to support this strategy is limited. We conducted a multicenter, randomized trial comparing early nasoenteric tube feeding with an oral diet at 72 hours after presentation to the emergency department in patients with acute pancreatitis. METHODS:We enrolled patients with acute pancreatitis who were at high risk for complications on the basis of an Acute Physiology and Chronic Health Evaluation II score of 8 or higher (on a scale of 0 to 71, with higher scores indicating more severe disease), an Imrie or modified Glasgow score of 3 or higher (on a scale of 0 to 8, with higher scores indicating more severe disease), or a serum C-reactive protein level of more than 150 mg per liter. Patients were randomly assigned to nasoenteric tube feeding within 24 hours after randomization (early group) or to an oral diet initiated 72 hours after presentation (on-demand group), with tube feeding provided if the oral diet was not tolerated. The primary end point was a composite of major infection (infected pancreatic necrosis, bacteremia, or pneumonia) or death during 6 months of follow-up. RESULTS:A total of 208 patients were enrolled at 19 Dutch hospitals. The primary end point occurred in 30 of 101 patients (30%) in the early group and in 28 of 104 (27%) in the on-demand group (risk ratio, 1.07; 95% confidence interval, 0.79 to 1.44; P=0.76). There were no significant differences between the early group and the on-demand group in the rate of major infection (25% and 26%, respectively; P=0.87) or death (11% and 7%, respectively; P=0.33). In the on-demand group, 72 patients (69%) tolerated an oral diet and did not require tube feeding. CONCLUSIONS:This trial did not show the superiority of early nasoenteric tube feeding, as compared with an oral diet after 72 hours, in reducing the rate of infection or death in patients with acute pancreatitis at high risk for complications. (Funded by the Netherlands Organization for Health Research and Development and others; PYTHON Current Controlled Trials number, ISRCTN18170985.).
10.1056/NEJMoa1404393
Effects of Bolus and Continuous Nasogastric Feeding on Gastric Emptying, Small Bowel Water Content, Superior Mesenteric Artery Blood Flow, and Plasma Hormone Concentrations in Healthy Adults: A Randomized Crossover Study.
Chowdhury Abeed H,Murray Kathryn,Hoad Caroline L,Costigan Carolyn,Marciani Luca,Macdonald Ian A,Bowling Timothy E,Lobo Dileep N
Annals of surgery
OBJECTIVE:We aimed to demonstrate the effect of continuous or bolus nasogastric feeding on gastric emptying, small bowel water content, and splanchnic blood flow measured by magnetic resonance imaging (MRI) in the context of changes in plasma gastrointestinal hormone secretion. BACKGROUND:Nasogastric/nasoenteral tube feeding is often complicated by diarrhea but the contribution of feeding strategy to the etiology is unclear. METHODS:Twelve healthy adult male participants who underwent nasogastric intubation before a baseline MRI scan, received 400 mL of Resource Energy (Nestle) as a bolus over 5 minutes or continuously over 4 hours via pump in this randomized crossover study. Changes in gastric volume, small bowel water content, and superior mesenteric artery blood flow and velocity were measured over 4 hours using MRI and blood glucose and plasma concentrations of insulin, peptide YY, and ghrelin were assayed every 30 minutes. RESULTS:Bolus nasogastric feeding led to significant elevations in gastric volume (P < 0.0001), superior mesenteric artery blood flow (P < 0.0001), and velocity (P = 0.0011) compared with continuous feeding. Both types of feeding reduced small bowel water content, although there was an increase in small bowel water content with bolus feeding after 90 minutes (P < 0.0068). Similarly, both types of feeding led to a fall in plasma ghrelin concentration although this fall was greater with bolus feeding (P < 0.0001). Bolus feeding also led to an increase in concentrations of insulin (P = 0.0024) and peptide YY (P < 0.0001), not seen with continuous feeding. CONCLUSION:Continuous nasogastric feeding does not increase small bowel water content, thus fluid flux within the small bowel is not a major contributor to the etiology of tube feeding-related diarrhea.
10.1097/SLA.0000000000001110
Hyperemesis gravidarum, nutritional treatment by nasogastric tube feeding: a 10-year retrospective cohort study.
Stokke Guro,Gjelsvik Bente L,Flaatten Katrine T,Birkeland Elisabeth,Flaatten Hans,Trovik Jone
Acta obstetricia et gynecologica Scandinavica
OBJECTIVE:To investigate maternal and fetal outcome in hyperemesis gravidarum comparing enteral tube feeding of the mothers with other fluid/nutrition regimens. DESIGN:Retrospective hospital-based cohort. SETTING:University hospital, Norway. SAMPLE:All 558 women treated for hyperemesis gravidarum 2002-2011; 273 received water/electrolytes intravenously, 177 received nutritional supplements by peripheral line, 107 received enteral feeding by gastroscopically positioned nasojejunal tube and 10 received total parenteral nutrition. METHODS:Different fluid/nutritional groups were compared by chi-squared or non-parametric tests. The influence (odds ratio) of nutritional regimens on having small-for-gestational-age infants was evaluated by binary logistic regression. MAIN OUTCOME MEASURES:Maternal weight gain during hospitalization and pregnancy, birthweight and gestational age at delivery. RESULTS:Women receiving enteral nutrition had significantly greater weight loss on admission (median 5.0 kg) and at start of nutrition (5.5 kg) than the other treatment groups (4.0 kg) (p < 0.001). Enteral nutrition was administered for up to 41 days (median 5 days) during hospitalization, leading to 0.8 kg weight gain (95% CI 0.5-1.0, p = 0.005). The tube-fed women achieved similar weight gain during pregnancy and experienced similar incidence of preterm birth or small-for-gestational age compared with the other treatment groups. Women with <7 kg total weight gain had increased risk of birthweight <2500 g and small-for-gestational-age infants (odds ratio 3.68, 95% CI 1.89-7.18, p < 0.001). The nutritional regimen used was not an independent risk factor. CONCLUSION:Compared with other fluid/nutrition regimens, enteral tube feeding for women affected by severe hyperemesis gravidarum is associated with adequate maternal weight gain and favorable pregnancy outcomes.
10.1111/aogs.12578
The effects of stimulation of the autonomic nervous system via perioperative nutrition on postoperative ileus and anastomotic leakage following colorectal surgery (SANICS II trial): a study protocol for a double-blind randomized controlled trial.
Peters Emmeline G,Smeets Boudewijn J J,Dekkers Marloes,Buise Marc D,de Jonge Wouter J,Slooter Gerrit D,Reilingh Tammo S de Vries,Wegdam Johannes A,Nieuwenhuijzen Grard A P,Rutten Harm J T,de Hingh Ignace H J T,Hiligsmann Mickael,Buurman Wim A,Luyer Misha D P
Trials
BACKGROUND:Postoperative ileus and anastomotic leakage are important complications following colorectal surgery associated with short-term morbidity and mortality. Previous experimental and preclinical studies have shown that a short intervention with enriched enteral nutrition dampens inflammation via stimulation of the autonomic nervous system and thereby reduces postoperative ileus. Furthermore, early administration of enteral nutrition reduced anastomotic leakage. This study will investigate the effect of nutritional stimulation of the autonomic nervous system just before, during and early after colorectal surgery on inflammation, postoperative ileus and anastomotic leakage. METHODS/DESIGN:This multicenter, prospective, double-blind, randomized controlled trial will include 280 patients undergoing colorectal surgery. All patients will receive a selfmigrating nasojejunal tube that will be connected to a specially designed blinded tubing system. Patients will be allocated either to the intervention group, receiving perioperative nutrition, or to the control group, receiving no nutrition. The primary endpoint is postoperative ileus. Secondary endpoints include anastomotic leakage, local and systemic inflammation, (aspiration) pneumonia, surgical complications classified according to Clavien-Dindo, quality of life, gut barrier integrity and time until functional recovery. Furthermore, a cost-effectiveness analysis will be performed. DISCUSSION:Activation of the autonomic nervous system via perioperative enteral feeding is expected to dampen the local and systemic inflammatory response. Consequently, postoperative ileus will be reduced as well as anastomotic leakage. The present study is the first to investigate the effects of enriched nutrition given shortly before, during and after surgery in a clinical setting. TRIAL REGISTRATION:ClinicalTrials.gov: NCT02175979 - date of registration: 25 June 2014. Dutch Trial Registry: NTR4670 - date of registration: 1 August 2014.
10.1186/s13063-014-0532-x
Randomized study to compare nasojejunal with nasogastric nutrition in critically ill patients without prior evidence of altered gastric emptying.
Friedman Gilberto,Flávia Couto Cecilia Lopes,Becker Maicon
Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine
BACKGROUND AND AIMS:Studies comparing jejunal and gastric nutrition show inconsistent results regarding pneumonia. The aim of this study was to evaluate the incidence of pneumonia comparing gastric with jejunal nutrition. Secondarily, we evaluated 28(th) day Intensive Care Unit (ICU) mortality rate and other complications related to enteral feeding. SUBJECTS:Age >18 years; need for enteral nutrition without contraindication for placement of an enteral tube, duration of ICU stay > than 48 h. METHODS:Patients were randomly assigned to receive enteral feed via a gastric or jejunal tube. Jejunal tubes were inserted at bedside and placement was confirmed radiographically. RESULTS:A total of 115 patients were enrolled, with 61 patients into the gastric tube group and 54 patients into the jejunal group tube. Baseline characteristics were similar. There was no difference in pneumonia or ICU mortality rates, ICU length of stay and ventilator days. Complications rates were similar. CONCLUSIONS:We conclude that the enteral nutrition through a jejunal tube does not reduce the rate of pneumonia in comparison to a gastric tube. In addition, we did not observe differences in rates of gastrointestinal complications or ICU mortality. The routine placement of a jejunal tube in critically ill-patients cannot be recommended.
10.4103/0972-5229.151013
Outcomes of laparoscopic feeding jejunostomy tube placement in 299 patients.
Young Monica T,Troung Hung,Gebhart Alana,Shih Anderson,Nguyen Ninh T
Surgical endoscopy
BACKGROUND:Jejunostomy catheters for jejunal feeding are an effective method to improve nutritional status in malnourish patients. However, this procedure is commonly being performed using an open approach, which can be associated with more postoperative pain and prolonged recovery. The objective of this study was to assess the outcomes of patients who underwent placement of feeding jejunostomy using a laparoscopic approach. METHODS:A retrospective review was performed of patients who underwent laparoscopic jejunostomy tube placement between 1998 and 2014. Main outcome measures included indication for catheter placement, rate of conversion rate to open surgery, perioperative and late morbidity and in-hospital mortality. RESULTS:Two hundred and ninety-nine consecutive patients underwent laparoscopic jejunostomy during the study period. The mean age was 64 years, and 81% of patients were male. The mean BMI was 26.2 kg/m(2). The most common indications for catheter placement were resectable esophageal cancer (78%), unresectable esophageal cancer (10%) and gastric cancer (6%). There were no conversions to open surgery. The 30-day complication rate was 4.0% and included catheter dislodgement (1%), intraperitoneal catheter displacement (0.7%), catheter blockage (1%) or breakage (0.3%), site infection requiring catheter removal (0.7%) and abdominal wall hematoma (0.3%). The late complication rate was 8.7% and included jejuno-cutaneous fistula (3.7%), jejunostomy tube dislodgement (3.3%), broken or clogged J-tube (1.3%) and small bowel obstruction (0.3%). The 30-day mortality was 0.3% for a patient with stage IV esophageal cancer who died in the postoperative period secondary to respiratory failure. CONCLUSION:In this large consecutive series of feeding jejunostomy, the laparoscopic approach is feasible and safe and associated with a low rate of small bowel obstruction and no intraabdominal catheter-related infection.
10.1007/s00464-015-4171-4
Quality of life after early enteral feeding versus standard care for proven or suspected advanced epithelial ovarian cancer: Results from a randomised trial.
Baker Jannah,Janda Monika,Graves Nick,Bauer Judy,Banks Merrilyn,Garrett Andrea,Chetty Naven,Crandon Alex J,Land Russell,Nascimento Marcelo,Nicklin James L,Perrin Lewis C,Obermair Andreas
Gynecologic oncology
BACKGROUND:Malnutrition is common in patients with advanced epithelial ovarian cancer (EOC), and is associated with impaired quality of life (QoL), longer hospital stay and higher risk of treatment-related adverse events. This phase III multi-centre randomised clinical trial tested early enteral feeding versus standard care on postoperative QoL. METHODS:From 2009 to 2013, 109 patients requiring surgery for suspected advanced EOC, moderately to severely malnourished were enrolled at five sites across Queensland and randomised to intervention (n=53) or control (n=56) groups. Intervention involved intraoperative nasojejunal tube placement and enteral feeding until adequate oral intake could be maintained. Despite being randomised to intervention, 20 patients did not receive feeds (13 did not receive the feeding tube; 7 had it removed early). Control involved postoperative diet as tolerated. QoL was measured at baseline, 6weeks postoperatively and 30days after the third cycle of chemotherapy. The primary outcome measure was the difference in QoL between the intervention and the control group. Secondary endpoints included treatment-related adverse event occurrence, length of stay, postoperative services use, and nutritional status. RESULTS:Baseline characteristics were comparable between treatment groups. No significant difference in QoL was found between the groups at any time point. There was a trend towards better nutritional status in patients who received the intervention but the differences did not reach statistical significance except for the intention-to-treat analysis at 7days postoperatively (11.8 intervention vs. 13.8 control, p 0.04). CONCLUSION:Early enteral feeding did not significantly improve patients' QoL compared to standard of care but may improve nutritional status.
10.1016/j.ygyno.2015.03.048
Influence of thoracic duct ligation on the lipid metabolism of patients with esophageal carcinoma after esophagectomy.
Liu J P,Zhang Y H,Yang B,Chen Q,Cao L
Genetics and molecular research : GMR
The aim of this study was to determine the influence of thoracic duct ligation on the lipid metabolism of patients with esophageal carcinoma after esophagectomy. A total of 74 patients with esophageal carcinoma who underwent esophagectomy were divided into 2 groups according to whether or not their thoracic duct was ligated. Thirty-nine patients were in the thoracic duct ligation group and the other 35 assigned to the control group. Enteral feeding was through a nasojejunal tube from the 1st day to the 8th day after operation, and liquid diet was provided starting on the 6th day. We compared the plasma concentrations of cholesterol (CHOL), triglycerides (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) at different time points. There were no statistically significant differences between the two groups in CHOL, TG and HDL levels at different times. However, LDL levels in the thoracic duct ligation group were significantly lower at different times compared to the other group (P < 0.05), where they were the lowest at the end of the 1st month and then gradually recovered 3 months later. Thoracic duct ligation can effectively prevent chylomicrons from being transferred to the blood, reducing the generation of LDL. The establishment of collateral circulation was slow after the ligation of the thoracic duct, which had a negative effect on early postoperative nutrition of patients.
10.4238/2015.March.30.11
Electromagnetic guided bedside or endoscopic placement of nasoenteral feeding tubes in surgical patients (CORE trial): study protocol for a randomized controlled trial.
Gerritsen Arja,de Rooij Thijs,Dijkgraaf Marcel G,Busch Olivier R,Bergman Jacques J,Ubbink Dirk T,van Duijvendijk Peter,Erkelens G Willemien,Molenaar I Quintus,Monkelbaan Jan F,Rosman Camiel,Tan Adriaan C,Kruyt Philip M,Bac Dirk Jan,Mathus-Vliegen Elisabeth M,Besselink Marc G
Trials
BACKGROUND:Gastroparesis is common in surgical patients and frequently leads to the need for enteral tube feeding. Nasoenteral feeding tubes are usually placed endoscopically by gastroenterologists, but this procedure is relatively cumbersome for patients and labor-intensive for hospital staff. Electromagnetic (EM) guided bedside placement of nasoenteral feeding tubes by nurses may reduce patient discomfort, workload and costs, but randomized studies are lacking, especially in surgical patients. We hypothesize that EM guided bedside placement of nasoenteral feeding tubes is at least as effective as endoscopic placement in surgical patients, at lower costs. METHODS/DESIGN:The CORE trial is an investigator-initiated, parallel-group, pragmatic, multicenter randomized controlled non-inferiority trial. A total of 154 patients admitted to gastrointestinal surgical wards in five hospitals, requiring nasoenteral feeding, will be randomly allocated to undergo EM guided or endoscopic nasoenteral feeding tube placement. Primary outcome is reinsertion of the feeding tube, defined as the insertion of an endoscope or tube in the nose/mouth and esophagus for (re)placement of the feeding tube (e.g. after failed initial placement or dislodgement or blockage of the tube). Secondary outcomes include patient-reported outcomes, costs and tube (placement) related complications. DISCUSSION:The CORE trial is designed to generate evidence on the effectiveness of EM guided placement of nasoenteral feeding tubes in surgical patients and the impact on costs as compared to endoscopic placement. The trial potentially offers a strong argument for wider implementation of this technique as method of choice for placement of nasoenteral feeding tubes. TRIAL REGISTRATION:Dutch Trial Register: NTR4420 , date registered 5-feb-2014.
10.1186/s13063-015-0633-1
Free Jejunal Flap for Pharyngoesophageal Reconstruction in Head and Neck Cancer Patients: An Evaluation of Donor-Site Complications.
Razdan Shantanu N,Albornoz Claudia R,Matros Evan,Paty Philip B,Cordeiro Peter G
Journal of reconstructive microsurgery
BACKGROUND:Free jejunal transfer for pharyngoesophageal reconstruction has often been criticized for its associated donor-site morbidity. Conversely, the same argument has been invoked to support use of fasciocutaneous flaps, given their low incidence of donor-site complications. The purpose of the current study was to document donor-site complication rate with free jejunal flaps for pharyngoesophageal reconstruction, in the hands of an experienced surgeon. METHODS:A retrospective chart review was performed for consecutive patients who underwent free jejunal transfer between 1992 and 2012 by the senior author (P.G.C.). Demographic data, abdominal complications, surgical characteristics of small bowel anastomoses, and postoperative bowel function were specifically noted. RESULTS:Overall, 92 jejunal flap reconstructions were performed in 90 patients. The mean follow-up time was 29 months. Twelve (13%) patients had prior abdominal surgery. Donor-site complications included ileus (n = 2), wound cellulitis (n = 1), wound dehiscence (n = 1), and small bowel obstruction (n = 1). Mean time to initiation of tube feeds after reconstruction was 5 days. A total of 77 (86.5%) patients were discharged on an oral diet. The perioperative mortality rate of 2% was not associated with any donor-site complication. CONCLUSION:Free jejunal transfer is associated with minimal and acceptable donor-site complication rates. The choice of flap for pharyngoesophageal reconstruction should be determined by the type of defect, potential recipient site complications, and the surgeon's familiarity with the flap. Potential donor-site complications should not be a deterrent for free jejunal flaps given the low rate described in this study.
10.1055/s-0035-1556872
Impact of Nasojejunal Feeding on Outcome of Patients with Walled Off Pancreatic Necrosis (WOPN) Presenting with Pain: a Pilot Study.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract
BACKGROUND:Drainage is usually recommended in symptomatic walled off pancreatic necrosis (WOPN). WOPN presenting with pain may get symptomatic relief if the pancreas is given rest by initiating nasojejunal (NJ) feed. AIM:The aim of this was to prospectively study the efficacy of nasojejunal (NJ) feeding in patients of WOPN presenting with abdominal pain. METHODS:Twenty-one patients (15 M; 35 ± 12 years) with WOPN (size 7-16 cm) presenting with pain underwent NJ tube placement under endoscopic guidance. Following this, pain relief and long-term outcome were studied. RESULTS:Etiology of pancreatitis was alcohol in 12, gall stones in 6, and idiopathic in 3 patients. NJ tube was successfully placed in all patients and 17/21 (81%) patients had symptomatic relief in 1-4 days (mean 2 ± 1 days) following NJ feeding. NJ tube was removed after 7-10 days (mean 7 ± 1 days), and 14 (61%) patients remained pain free and follow-up imaging (1-8 months) revealed complete resolution or decrease in size of WOPN. Three patients had recurrence of pain and were successfully treated with endoscopic drainage. CONCLUSIONS:NJ feeding improves pain in the majority of patients with WOPN and thus obviates or delays drainage. Majority of nonresponders had disconnected pancreatic duct syndrome (DPDS).
10.1007/s11605-015-2843-y
Jejunal Casein Feeding Is Followed by More Rapid Protein Digestion and Amino Acid Absorption When Compared with Gastric Feeding in Healthy Young Men.
The Journal of nutrition
BACKGROUND:Dietary protein is required to attenuate the loss of muscle mass and to support recovery during a period of hospitalization. Jejunal feeding is preferred over gastric feeding in patients who are intolerant of gastric feeding. However, the impact of gastric vs. jejunal feeding on postprandial dietary protein digestion and absorption kinetics in vivo in humans remains largely unexplored. OBJECTIVE:We compared the impact of gastric vs. jejunal feeding on subsequent dietary protein digestion and amino acid (AA) absorption in vivo in healthy young men. METHODS:In a randomized crossover study design, 11 healthy young men (aged 21 ± 2 y) were administered 25 g specifically produced intrinsically l-[1-(13)C]phenylalanine-labeled intact casein via a nasogastric and a nasojejunal tube placed ~30 cm distal to the ligament of Treitz. Protein was provided in a 240-mL solution administered over a 65-min period in both feeding regimens. Blood samples were collected during the 7-h postprandial period to assess the increase in plasma AA concentrations and dietary protein-derived plasma l-[1-(13)C]phenylalanine enrichment. RESULTS:Jejunal feeding compared with gastric feeding resulted in higher peak plasma phenylalanine, leucine, total essential AA (EAA), and total AA concentrations (all P < 0.05). This was attributed to a more rapid release of dietary protein-derived AAs into the circulation, as evidenced by a higher peak plasma l-[1-(13)C]phenylalanine enrichment concentration (2.9 ± 0.2 vs. 2.2 ± 0.2 mole percent excess; P < 0.05). The total postprandial plasma AA incremental area under the curve and time to peak did not differ after jejunal vs. gastric feeding. Plasma insulin concentrations increased to a greater extent after jejunal feeding when compared with gastric feeding (275 ± 38 vs. 178 ± 38 pmol/L; P < 0.05). CONCLUSIONS:Jejunal feeding of intact casein is followed by more rapid protein digestion and AA absorption when compared with gastric feeding in healthy young men. The greater postprandial increase in circulating EAA concentrations may allow a more robust increase in muscle protein synthesis rate after jejunal vs. gastric casein feeding. This trial was registered at trialregister.nl as NTR2801.
10.3945/jn.115.211615
Feeding patients with preoperative symptoms of gastric outlet obstruction after pancreatoduodenectomy: Early oral or routine nasojejunal tube feeding?
Gerritsen Arja,Wennink Roos A W,Busch Olivier R C,Borel Rinkes Inne H M,Kazemier Geert,Gouma Dirk J,Molenaar I Quintus,Besselink Marc G H
Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]
BACKGROUND:Early oral feeding is currently considered the optimal routine feeding strategy after pancreatoduodenectomy (PD). Some have suggested that patients with preoperative symptoms of gastric outlet obstruction (GOO) who undergo PD have such a high risk of developing delayed gastric emptying that these patients should rather receive routine postoperative tube feeding. The aim of this study was to determine whether clinical outcomes after PD in these patients differ between postoperative early oral feeding and routine tube feeding. METHODS:We analyzed a consecutive multicenter cohort of patients with preoperative symptoms of GOO undergoing PD (2010-2013). Patients were categorized into two groups based on the applied postoperative feeding strategy (dependent on their center's routine strategy): early oral feeding or routine nasojejunal tube feeding. RESULTS:Of 497 patients undergoing PD, 83 (17%) suffered from preoperative symptoms of GOO. 49 patients received early oral feeding and 29 patients received routine tube feeding. Time to resumption of adequate oral intake (primary outcome; 14 vs. 12 days, p = 0.61) did not differ between these two feeding strategies. Furthermore, overall complications and length of stay were similar in both groups. Of the patients receiving early oral feeding, 24 (49%) ultimately required postoperative tube feeding. In patients with an uncomplicated postoperative course, early oral feeding was associated with shorter time to adequate oral intake (8 vs. 12 days, p = 0.008) and shorter hospital stay (9 vs. 13 days, p < 0.001). CONCLUSION:Also in patients with preoperative symptoms of GOO, early oral feeding can be considered the routine feeding strategy after PD.
10.1016/j.pan.2015.07.002
Use of gastrografin in the management of worm-induced small bowel obstruction in children.
Hamid Raashid,Bhat Nisar,Baba Aejaz,Mufti Gowhar,Khursheed Sheikh,Wani Sajad A,Ali Imran,Hassan Faheem
Pediatric surgery international
OBJECTIVE:Ascaris-induced small bowel obstruction (SBO) is a common sequel of Ascaris lumbricoides (AL) infestation. Most cases respond to conservative treatment practiced in different centers worldwide. We conceived a prospective randomized trial to compare the conservative treatment with gastrografin administered in addition to the conservative treatment. STUDY DESIGN:This prospective randomized study was conducted between January 2011 and June 2014 at Department of Paediatric and Neonatal Surgery, a tertiary-care hospital. Patients were divided into two groups, one group received conservative treatment and the other received gastrografin in addition to conservative treatment. Forty patients having uncomplicated AL-induced SBO were included in each group. Gastrografin was administered through nasogastric tube and serial clinical and radiological monitoring was performed. The duration of hospital stay, time between admission and first oral feed, passage of worms/flatus were compared in the two groups. Student's t test was used for comparing these variables. RESULTS:Average time for passage of flatus or worms and resolution of abdominal signs and was shorter in gastrografin group as compared to the conservative group. This difference was found to be statistically significant. The average duration of hospital stay in gastrografin group was 25.20 ± 8.01 h whereas it was 61.12 ± 14.64 h in the conservative group (P < 0.001). The difference in the operation rate was statistically insignificant (2 in gastrografin group and 3 in the conservative group).No serious adverse reaction was noted after gastrografin administration. CONCLUSION:Use of gastrografin resulted in faster relief of signs and symptoms of AL-induced SBO, early passage of worms/flatus and return to oral feeds. However, the role of gastrografin role in reducing the likelihood of laparotomy remains inconclusive. Adverse effects of gastrografin can be prevented if it is used in well-hydrated patients.
10.1007/s00383-015-3793-x
Avulsed Nasoenteric Bridle System Magnet as an Intranasal Foreign Body.
Puricelli Michael D,Newberry Christopher Ian,Gov-Ari Eliav
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
Nasoenteric tubes provide short-term nutrition support to patients unable to take an adequate oral diet. Bridling systems may be used to secure tubes to guard against displacement. We present the first case of an avulsed magnet from a bridling system to raise awareness of this potential complication. The primary methods of securing a nasogastric tube are reviewed, and comparative assessment of the 3 main systems is presented. Diagnosis and management of nasal foreign bodies relevant to this case are reviewed and prevention/safety considerations discussed.
10.1177/0884533615611858
The "omega" jejunostomy tube: A preferred alternative for postpyloric feeding access.
Schlager Avraham,Arps Kelly,Siddharthan Ragavan,Rajdev Priya,Heiss Kurt F
Journal of pediatric surgery
AIM:We present our technique for construction of the "Omega Jejunostomy" (OJ), a novel method of postpyloric feeding using a pouched-jejunal loop capable of accommodating a balloon gastrostomy button. We describe potential indications for the procedure and outcomes in a complex patient population. MATERIALS AND METHODS:We retrospectively reviewed records of patients who underwent an OJ at our institution between 2005 and 2014. Primary outcomes include operating time, length of hospital stay, time to feeding goals, and postoperative complications. RESULTS:We identified 12 children (6 males) with multiple comorbidities who underwent OJ procedures. The median age at surgery was 11years (range 3months-23years). Eleven patients had failed previous alternative feeding access or antireflux procedures. All patients eventually reached their feeding goals. Eight were at goal feeds in <10days. Two achieved goal feeds <1month, one <4months, and one within 7months. There was one OJ failure because of fistula formation requiring surgical revision, and one child was treated successfully but died of unrelated causes. Four children eventually transitioned to PO or G-tube feeds, and six were tolerating feeds via OJ at last follow-up (8-74months). CONCLUSIONS:OJ provides a durable alternative to gastrojejunostomy tube for patients who are poor candidates for or have failed Nissen fundoplication. It is technically easier to perform than a gastroesophageal disconnect procedure, has minimal surgical comorbidities, and can provide durable feeding access and achievement of goal feeds in a complex and refractory patient subset.
10.1016/j.jpedsurg.2015.10.073
Development of automated postoperative enteral nutrition: restricting feeding site inflow to match peristaltic outflow.
Moss Gerald
Annals of surgical innovation and research
BACKGROUND:Surgical stress accelerates postoperative metabolism, while simultaneously compromising gut activity. The dysfunction may be worsened by early feeding. These patients are not expected to fully meet their optimum metabolic requirements using current nutritional regimens. For optimum postoperative enteral nutrition, we must automatically match the patients' feeding site inflows to their impaired peristaltic outflows. An essential adjunct is virtually complete exclusion of swallowed air. The small diameter post-pyloric duodenum is an efficient site for both aspiration and feeding. METHOD:A multi-lumen feeding-decompression tube is utilized to feed an "elemental diet" (1 kcal/ml) at the rate of 3000-5000 ml/day immediately postoperatively. Outflow from the feeding site, relative to inflow, is monitored. Excess aspirate is discarded automatically, so that the re-fed inflow exactly matches the peristaltic outflow. The aspirate (digestive secretions, feedings, and swallowed air) is degassed. The aspirate is then directed by one-way valves alternately, every 30 s, into a pair of 30 ml collection chambers for re-feeding. Simultaneously, the previously collected aspirate (less discarded volume, if required) is delivered by gravity into the slightly more distal duodenum. RESULTS:Within 2 h, the return of the entire aspirate volume is tolerated. The patients' increased metabolic demands are met early on the initial day of surgery. They achieve positive protein balance, with documented enhanced healing (experimentally) and immune globulin synthesis (clinically). Breakfast is tolerated the morning following operation, with discharge soon thereafter. X-ray motility and nutrient absorption studies document the more rapid return of clinically normal peristalsis. CONCLUSION:Automatically keeping the proximal duodenum and stomach continuously decompressed, while simultaneously re-feeding tolerated degassed duodenal aspirate, leads to more rapid return of clinically adequate G-I function postoperatively. In addition to maximizing immediately postoperative nourishment, the secretory globulins are salvaged, and spontaneously delivered into the colon, where they provide natural antimicrobial protection.
10.1186/s13022-015-0022-1
Laparoscopic Roux En Y Esophago-Jejunostomy for Chronic Leak/Fistula After Laparoscopic Sleeve Gastrectomy.
Mahmoud Maysoon,Maasher Ahmed,Al Hadad Mohamed,Salim Elnazeer,Nimeri Abdelrahman A
Obesity surgery
BACKGROUND:Leak following laparoscopic sleeve gastrectomy (LSG) is one of the most serious and devastating complications. Endoscopic stents can treat most early LSG leaks, but is not as effective for chronic LSG leaks/fistulae. The surgical options to treat a chronic leak/fistula after LSG are laparoscopic Roux en Y esophago-jejunostomy (LRYEJ) or laparoscopic Roux en Y fistulo-jejunostomy. METHODS:We reviewed our prospective database for all patients with leak after LSG treated with LRYEJ. We have described our algorithm for managing LSG previously. We prefer to optimize the nutritional status of patients with enteral rather than parenteral nutrition and drain all collections prior to LRYEJ. RESULTS:We have treated four patients utilizing our technique of LRYEJ. Initial endoscopic stent placement was attempted in all four patients (two failed to resolve (50 %) and two had distal stenosis at the incisura not amenable to endoscopic stenting). We utilized enteral feeding through either naso-jejunal (NJ) or jejunostomy tube feeding in 3/4 (75 %) of patients, and in one patient with stenosis, we could not introduce a NJ tube endoscopically due to tight stricture. This patient was placed on total parenteral nutrition (TPN) and went on to develop pulmonary embolism. None of the patient developed leak after LRYEJ. The only patient with stenosis (25 %) had antecolic LRYEJ. In contrast, all patients who had retrocolic LRYGB laparoscopically did not develop stenosis. CONCLUSIONS:Laparoscopic Roux en Y esophago-jejunostomy for chronic leak/fistula after is safe and effective. Preoperative enteral nutrition is important.
10.1007/s11695-015-2018-7
Jejunal feeding is followed by a greater rise in plasma cholecystokinin, peptide YY, glucagon-like peptide 1, and glucagon-like peptide 2 concentrations compared with gastric feeding in vivo in humans: a randomized trial.
The American journal of clinical nutrition
BACKGROUND:Jejunal feeding is preferred instead of gastric feeding in patients who are intolerant to gastric feeding or at risk of aspiration. However, the impact of gastric feeding compared with that of jejunal feeding on postprandial circulating plasma glucose and amino acid concentrations and the associated endocrine response in vivo in humans remains largely unexplored. OBJECTIVE:We compared the impact of administering enteral nutrition as either gastric feeding or jejunal feeding on endocrine responses in vivo in humans. DESIGN:In a randomized, crossover study design, 12 healthy young men (mean ± SD age: 21 ± 2 y) received continuous enteral nutrition that contained noncoagulating proteins for 12 h via a nasogastric tube or a nasojejunal tube placed 30-40 cm distal to the ligament of Treitz. Blood samples were collected during the 12-h postprandial period to assess the rise in plasma glucose, amino acid, and gastrointestinal hormone concentrations. RESULTS:No differences were observed in the postprandial rise in circulating plasma amino acid and glucose concentrations between regimens. Jejunal feeding resulted in higher peak plasma insulin concentrations than did gastric feeding (392 ± 53 compared with 326 ± 54 pmol/L, respectively; P < 0.05). The postprandial rise in plasma cholecystokinin, peptide YY (PYY), glucagon-like peptide 1 (GLP-1), and glucagon-like peptide 2 (GLP-2) concentrations was greater after jejunal feeding than after gastric feeding, with higher peak concentrations and a greater postprandial incremental AUC for GLP-1 and cholecystokinin (all P < 0.05). Plasma ghrelin concentrations did not differ between regimens. CONCLUSIONS:Enteral nutrition with gastric or jejunal feeding in healthy young men results in similar postprandial plasma amino acid and glucose concentrations. However, the endocrine response differs substantially, with higher peak plasma cholecystokinin, PYY, GLP-1, and GLP-2 concentrations being attained after jejunal feeding. This effect may result in an improved anabolic response, greater insulin sensitivity, and an improved intestinotropic effect. Nevertheless, it may also lead to delayed gastric emptying. This trial was registered at trialregister.nl as NTR2801.
10.3945/ajcn.115.116251
Beneficial Effects of Early Enteral Nutrition After Major Rectal Surgery: A Possible Role for Conditionally Essential Amino Acids? Results of a Randomized Clinical Trial.
van Barneveld Kevin W Y,Smeets Boudewijn J J,Heesakkers Fanny F B M,Bosmans Joanna W A M,Luyer Misha D,Wasowicz Dareczka,Bakker Jaap A,Roos Arnout N,Rutten Harm J T,Bouvy Nicole D,Boelens Petra G
Critical care medicine
OBJECTIVES:To investigate direct postoperative outcome and plasma amino acid concentrations in a study comparing early enteral nutrition versus early parenteral nutrition after major rectal surgery. Previously, it was shown that a low plasma glutamine concentration represents poor prognosis in ICU patients. DESIGN:A preplanned substudy of a previous prospective, randomized, open-label, single-centre study, comparing early enteral nutrition versus early parenteral nutrition in patients at high risk of postoperative ileus after surgery for locally advanced or locally recurrent rectal cancer. Early enteral nutrition reduced postoperative ileus, anastomotic leakage, and hospital stay. SETTING:Tertiary referral centre for locally advanced and recurrent rectal cancer. PATIENTS:A total of 123 patients with locally advanced or recurrent rectal carcinoma requiring major rectal surgery. INTERVENTIONS:Patients were randomized (ALEA web-based external randomization) preoperatively into two groups: early enteral nutrition (early enteral nutrition, intervention) by nasojejunal tube (n = 61) or early parenteral nutrition (early parenteral nutrition, control) by jugular vein catheter (n = 62). Eight hours after the surgical procedure artificial nutrition was started in hemodynamically stable patients, stimulating oral intake in both groups. Blood samples were collected to measure plasma glutamine, citrulline, and arginine concentrations using a validated ultra performance liquid chromatography-tandem mass spectrometric method. MEASUREMENTS AND MAIN RESULTS:Baseline concentrations were comparable for both groups. Directly after rectal surgery, a decrease in plasma amino acids was observed. Plasma glutamine concentrations were higher in the parenteral group than in the enteral group on postoperative day 1 (p = 0.027) and day 5 (p = 0.008). Arginine concentrations were also significantly increased in the parenteral group at day 1 (p < 0.001) and day 5 (p = 0.001). CONCLUSIONS:Lower plasma glutamine and arginine concentrations were measured in the enteral group, whereas a better clinical outcome was observed. We conclude that plasma amino acids do not provide a causal explanation for the observed beneficial effects of early enteral feeding after major rectal surgery.
10.1097/CCM.0000000000001640
Optimized total thoracoscopic and laparoscopic esophagectomy for esophageal cancer.
Zhou Shao-hui,Song Yong-bin,Liu Li-jun,Cui Hong-shang
World journal of surgical oncology
BACKGROUND:Total thoracoscopic and laparoscopic esophagectomy (TLE) has attracted attention with the advantage of better operative field and minimal wound for the esophageal cancer. However, various severe complications are also reported during the TLE such as cervical anastomotic leakage, chylothorax, and tracheal injury. The aim of this study was to introduce a new optimized TLE procedure for the esophageal cancer and assess its safety and clinical effects. METHODS:We retrospectively collected the clinical data of 30 patients with esophageal cancer who underwent optimized TLE procedures between January 2014 and December 2014. The optimized TLE procedures mainly include as follows: (1) 50 ml of sesame oil-milk mixture (1:1) is injected via gastric tube after endotracheal intubation; (2) patients are intubated with a single lumen endotracheal tube; (3) patients were positioned at 150° in the left prone position rather than lateral decubitus position; and (4) duodenal feeding tube was not placed intraoperatively and however triple lumen nasojejunal feeding tube was placed on the second postoperative day under imaging guidance. Operation time, amount of blood loss, number of dissected nodes, length of hospital stays, and complications were recorded. RESULTS:The mean operation time of the optimized TLE group was 202.13 ± 13.74 min. The mean visible blood loss of the optimized TLE group was 300.00 ± 120.12 ml. The postoperative hospital stays in the optimized TLE group were 16.27 ± 4.51 days. The number of dissected nodes in the optimized TLE group was 13.57 ± 2.76. The postoperative complications for the optimized TLE procedure were seen in one case (3.3%). CONCLUSIONS:The method of optimized TLE is an effective, reliable, and safe procedure for the treatment of esophageal cancer, which provide favorable outcomes in terms of operation time, blood loss, length of hospital stays, the number the dissected nodes, and reduced incidence of postoperative complications compared to previous literatures. Further studies with a large number of samples are warranted.
10.1186/s12957-016-0824-6
Early nasojejunal tube feeding versus nil-by-mouth in acute pancreatitis: A randomized clinical trial.
Stimac D,Poropat G,Hauser G,Licul V,Franjic N,Valkovic Zujic P,Milic S
Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]
BACKGROUND/OBJECTIVES:There is substantial evidence of superiority of enteral nutrition (EN) to parenteral nutrition in acute pancreatitis (AP) treatment, but few studies evaluated its effectiveness compared to no intervention. The objective of our trial was to compare the effects of EN to a nil-by-mouth (NBM) regimen in patients with AP. METHODS:Patients with AP were randomized to receive either EN via a nasojejunal tube initiated within 24 h of admission or no nutritional support. Systemic inflammatory response syndrome (SIRS) was assessed as the primary outcome. Secondary outcomes included mortality, organ failure, local complications, infected pancreatic necrosis, surgical interventions, length of hospital stay, adverse events and inflammatory response intensity. Outcomes were compared using Student's t-test and Mann-Whitney U test as appropriate. RESULTS:214 patients were randomized in total, 107 to each group. SIRS occurrence was similar between groups, with 48 (45%) versus 51 (48%), respectively (RR 0.94; 95% CI 0.71-1.26). No significant reduction of persistent organ failure (RR 0.81; 95% CI 0.52-1.27) and mortality (RR 0.59; 95% CI 0.28-1.23) was present in the EN group. There were no significant differences in other outcomes between the groups. When analyzing the occurrence of SIRS and mortality in subgroup of patients with severe disease no significant differences were noted. CONCLUSION:Our results showed no significant reduction of persistent organ failure and mortality in patients with AP receiving early EN compared to patients treated with no nutritional support (NCT01965873).
10.1016/j.pan.2016.04.003
Septotomy and Balloon Dilation to Treat Chronic Leak After Sleeve Gastrectomy: Technical Principles.
Campos Josemberg Marins,Ferreira Flávio Coelho,Teixeira André F,Lima Jones Silva,Moon Rena C,D'Assunção Marco Aurélio,Neto Manoel Galvão
Obesity surgery
BACKGROUND:Chronic leaks after laparoscopic sleeve gastrectomy (LSG) are often difficult to treat by endoscopy metallic stent. Septotomy has been indicated as an effective procedure, but the technical aspects have not been detailed in previous publications (Campos JM, Siqueira LT, Ferraz AA, et al., J Am Coll Surg 204(4):711, 2007; Baretta G, Campos J, Correia S, et al., Surg Endosc 29(7):1714-20, 2015; Campos JM, Pereira EF, Evangelista LF, et al., Obes Surg 21(10):1520-9, 2011). We herein present a video (6 min) demonstrating the maneuver principles of this technique, showing it as a safe and feasible approach. METHODS:A 32-year-old male, with BMI 43.4 kg/m(2), underwent LSG. On the tenth POD, he presented with a leak and initially was managed with the following approach: laparoscopic exploration, drainage, endoclips, and 20-mm balloon dilation. However, the leak remained for a period of 6 months. On the endoscopy, a septum was identified between the leak site and gastric pouch, so it was decided to "reshape" this area by septotomy. Septotomy procedure: Sequential incisions were performed using argon plasma coagulation (APC) with 2.5 flow and 50 W (WEM, SP, Brazil) over the septum in order to allow communication between the perigastric cavity (leak site) and the gastric lumen. The principles below must be followed: (1) Scope position: the endoscopist's left hand holds the control body of the gastroscope while the right hand holds the insertion tube; the APC catheter has no need to be fixed. This avoids movements and unprogrammed maneuvers. (2) Before cutting, the septum is placed in the six o'clock position on the endoscopic view, by rotating the gastroscope. (3) The septum is sectioned until the bottom of the perigastric cavity (leak site). (4) That section is made towards the staple line. (5) Just after the septotomy, a Savory-Gilliard guidewire (Cook Medical, Indiana, USA) through the scope must be inserted until the duodenum, followed by 30-mm balloon (Rigiflex®, Boston Scientific, MA, USA) insertion. The balloon catheter must be firmly held during gradual inflation (maximum 10 psi) to avoid slippage and laceration. This allows increasing the gastric lumen. (6) Septotomy by electrocautery with a needle knife (Boston Scientific, MA, USA) can be made when an intensive fibrotic septum is present; bleeding is rare in this case. In this case, the endoclip previously used was removed from the septum with forceps to avoid heat transmission. Small staples visualized in the fistula orifice were not completely removed due to technical difficulties and friable tissue. RESULTS:Two sessions were performed in 15 days, resulting in leak closure. The patient was submitted to radiological control 1 week after the second session, which revealed fistula healing, without gastric stenosis. The nasoduodenal feeding tube remained for 7 days, when the patient started oral diet. This patient was followed for 18 months without recurrence. CONCLUSIONS:Septotomy and balloon dilation were initially performed on a difficult-to-treat chronic fistula after gastric bypass and named before as stricturotomy (Campos JM, Siqueira LT, Ferraz AA, et al., J Am Coll Surg 204(4):711, 2007). This procedure allows internal drainage of the fistula and deviates oral intake to the pouch. In addition, achalasia balloon dilation treats strictures and axis deviation of the gastric chamber, promoting reduction of the intragastric pressure. Septotomy and balloon dilation are technically feasible and might be useful in selected cases for closure of chronic leaks after LSG.
10.1007/s11695-016-2256-3
Improving the Outcome of Acute Pancreatitis.
Bruno Marco J,
Digestive diseases (Basel, Switzerland)
Acute pancreatitis (AP) is the most common indication for hospital admission and its incidence is rising. It has a variable prognosis, which is mainly dependent upon the development of persistent organ failure and infected necrotizing pancreatitis. In the past few years, based on large-scale multicenter randomized trials, some novel insights regarding clinical management have emerged. In patients with infected pancreatic necrosis, a step-up approach of percutaneous catheter drainage followed by necrosectomy only when the patient does not improve, reduces new-onset organ failure and prevents the need for necrosectomy in about a third of patients. A randomized pilot study comparing surgical to endoscopic necrosectomy in patients with infected necrotizing pancreatitis showed a striking reduction of the pro-inflammatory response following endoscopic necrosectomy. These promising results have recently been tested in a large multicenter randomized trial whose results are eagerly awaited. Contrary to earlier data from uncontrolled studies, a large multicenter randomized trial comparing early (within 24 h) nasoenteric tube feeding compared with an oral diet after 72 h, did not show that early nasoenteric tube feeding was superior in reducing the rate of infection or death in patients with AP at high risk for complications. Although early ERCP does not have a role in the treatment of predicted mild pancreatitis, except in the case of concomitant cholangitis, it may ameliorate the disease course in patients with predicted severe pancreatitis. Currently, a large-scale randomized study is underway and results are expected in 2017.
10.1159/000445257
Routes of early enteral nutrition following oesophagectomy.
Elshaer M,Gravante G,White J,Livingstone J,Riaz A,Al-Bahrani A
Annals of the Royal College of Surgeons of England
Introduction Oesophagectomy for cancer is a challenging procedure with a five-year overall survival rate of 15-20%. Early enteral nutrition following oesophagectomy is a crucial component of the postoperative recovery and carries a significant impact on the outcome. Different methods of enteral feeding were conducted in our unit. The aim of this study was to examine the efficacy and safety of nasojejunal tube (NJT), jejunostomy tube (JT) and pharyngostomy tube (PT) feeding after oesophagectomy. Methods A retrospective review was carried out of prospectively collected data on patients with oesophageal cancer who underwent an oesophagectomy between 2011 and 2014. The primary outcome was feeding tube related complications such as occlusion, dislocation and leak. The secondary outcomes were length of stay and 30-day morbidity. Results A total of 90 oesophagectomies were included in the study. A NJT was inserted in 41 patients (45.6%), a JT was used in 14 patients (15.5%) and a PT was the route for enteral nutrition in 35 patients (38.9%). In total, five patients (5.5%) developed tube related complications. There were no tube related complications in the NJT group but one JT patient (7.1%) developed tube related cellulitis (p=0.189) and four PT patients (11.4%) developed tube related haemorrhage (p=0.544), tube dislocation (p=0.544) or cellulitis (p=0.189). The median length of stay and 30-day postoperative morbidity were similar between the groups. Conclusions NJT feeding is a less invasive, feasible route for early enteral nutrition following oesophagectomy. A randomised controlled trial is recommended to verify these findings.
10.1308/rcsann.2016.0198
Development and characterization of a technique for percutaneous radiologic gastrojejunostomy tube placement in the dog.
Mack Rebekah M,Staiger Benjamin,Langlois Daniel K,Mehler Stephen J,Lam Nathaniel,Moore Trevor,Brown Andrew,Beal Matthew W
Journal of veterinary emergency and critical care (San Antonio, Tex. : 2001)
OBJECTIVE:To develop and describe a technique for percutaneous radiologic gastrojejunostomy tube placement in the dog. DESIGN:Prospective technique development study. SETTING:University teaching hospital. ANIMALS:Six healthy adult male Beagles. INTERVENTIONS:Following anesthetic induction, fluoroscopic and ultrasound guidance were used to identify an appropriate gastropexy site on the left lateral abdomen. Gastropexy was performed using gastrointestinal suture anchors. An over-the-wire catheter technique using fluoroscopic guidance was used to achieve jejunal access. An 18F/8F, 58 cm, dual-lumen gastrojejunal feeding tube was placed via serial over-the-wire dilation of the body wall using an 18F peel-away introducer kit. Tube location was determined radiographically immediately following placement and on days 2, 4, after emesis on day 4, and at time of gastrojejunal feeding tube removal (day 16-18). MEASUREMENTS AND MAIN RESULTS:Percutaneous radiologic gastrojejunostomy (PRGJ) tube placement was successful in all dogs. Median time to pyloric passage with the guide wire was 23.5 minutes (range, 9-93 minutes). Median total procedure time was 53 minutes (range, 49-113 minutes). Significant tube migration was not observed at any point during the study. One dog developed linear foreign body obstruction secondary to the tube on day 5 that was relieved by release of the jejunal component. Other complications were minor and included mild-to-moderate peristomal inflammation in all dogs and removal of the feeding tube on day 3 by 1 dog. Feedings were well tolerated in all dogs. CONCLUSIONS:PRGJ tube placement in the dog is a safe and minimally invasive technique that allows for jejunal feeding without surgery or endoscopy. The high success rates, acceptable procedural times, and minimal complications are appealing for use in critically ill patients. Although additional evaluations are needed, PRGJ tube placement may be considered for dogs that require postpyloric feeding with or without gastric decompression.
10.1111/vec.12506
Foley Catheters as Temporary Gastrostomy Tubes: Experience of a Nurse-Led Service.
Metussin Adli,Sia Rusanah,Bakar Suriawati,Chong Vui Heng
Gastroenterology nursing : the official journal of the Society of Gastroenterology Nurses and Associates
Percutaneous endoscopic gastrostomy tube is the modality of choice for long-term enteral nutrition. In the event that replacement tubes are not available, urinary catheters can be used to maintain patency of the gastrostomy tract. This study reports our experience in a nurse-led service using Foley catheters as temporary gastrostomy tubes and the associated complications. Patients who had used Foley catheter as gastrostomy tube over a 2-year period (Jan 2011 to December 2012) were studied. Twenty-one patients had used Foley catheters as a temporary gastrostomy tube, and 12 (57.4%) did not experience any complications, including three patients who were still using Foley catheters at a median of 15 months (range 3-18). Two patients preferred the Foley catheter as feeding tubes. Six patients had replacements with formal balloon replacement tubes, and two patients did not require replacement. Complications occurred in nine (42.6%) patients: repeated burst Foley catheter balloon with peristomal leakage (n = 4), lumen blockage (n = 1), and catheter migration resulting in small bowel obstruction (n = 4). All complications were successfully managed with tube replacements. We showed that in a nurse-led service, using a Foley catheter as a temporary feeding gastrostomy tube is safe, but requires monitoring for complications.
10.1097/SGA.0000000000000187
Early Enteral Versus Total Parenteral Nutrition in Patients Undergoing Pancreaticoduodenectomy: A Randomized Multicenter Controlled Trial (Nutri-DPC).
Perinel Julie,Mariette Christophe,Dousset Bertrand,Sielezneff Igor,Gainant Alain,Mabrut Jean-Yves,Bin-Dorel Sylvie,Bechwaty Michel El,Delaunay Dominique,Bernard Lorraine,Sauvanet Alain,Pocard Marc,Buc Emmanuel,Adham Mustapha
Annals of surgery
OBJECTIVES:The aim of this study was to compare nasojejunal early enteral nutrition (NJEEN) with total parenteral nutrition (TPN), after pancreaticoduodenectomy (PD), in terms of postoperative complications. BACKGROUND:Current nutritional guidelines recommend the use of enteral over parenteral nutrition in patients undergoing gastrointestinal surgery. However, the NJEEN remains controversial in patients undergoing PD. METHODS:Multicenter, randomized, controlled trial was conducted between 2011 and 2014. Nine centers in France analyzed 204 patients undergoing PD to NJEEN (n = 103) or TPN (n = 101). Primary outcome was the rate of postoperative complications according to Clavien-Dindo classification. Successful NJEEN was defined as insertion of a nasojejunal feeding tube, delivering at least 50% of nutritional needs on PoD 5, and no TPN for more than consecutive 48 hours. RESULTS:Postoperative complications occurred in 77.5% [95% confidence interval (95% CI) 68.1-85.1] patients in the NJEEN group versus 64.4% (95% CI 54.2-73.6) in TPN group (P = 0.040). NJEEN was associated with higher frequency of postoperative pancreatic fistula (POPF) (48.1% vs 27.7%, P = 0.012) and higher severity (grade B/C 29.4% vs 13.9%; P = 0.007). There was no significant difference in the incidence of post-pancreatectomy hemorrhage, delayed gastric emptying, infectious complications, the grade of postoperative complications, and the length of postoperative stay. A successful NJEEN was achieved in 63% patients. In TPN group, average energy intake was significantly higher (P < 0.001) and patients had an earlier recovery of oral feeding (P = 0.0009). CONCLUSIONS:In patients undergoing PD, NJEEN was associated with an increased overall postoperative complications rate. The frequency and the severity of POPF were also significantly increased after NJEEN. In terms of safety and feasibility, NJEEN should not be recommended.
10.1097/SLA.0000000000001896
Complications of Feeding Jejunostomy Tubes in Patients with Gastroesophageal Cancer.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract
BACKGROUND:Feeding jejunostomy tubes (FJT) in patients undergoing resection of gastroesophageal cancers facilitate perioperative nutrition. Data regarding FJT use and complications are limited. STUDY DESIGN:A single institution review was performed for patients who underwent perioperative FJT placement for gastrectomy or esophagogastrectomy from 2007 to 2015. FJT-related and unrelated complications were evaluated. RESULTS:FJTs were inserted for total/completion gastrectomy (n = 49/117, 41.9 %), proximal gastrectomy (n = 7/117, 6.0 %), or esophagogastrectomy (n = 61/117, 52.1 %). Ninety percent (n = 106/117) of patients used an FJT at some time point. Although the majority of patients (75.2 %) used FJTs after discharge, 8.5 % (n = 10/117) never used the FJT and 10.3 % (n = 12/117) used the FJT only during hospitalization. Overall, 44.4 % (n = 52/117) had FJT-related complications, including dislodgement (n = 22), clogging (n = 13), and leakage (n = 6). The majority of FJT complications were resolved by telephone triage (13.5 %) or bedside/clinic intervention (57.7 %), but 3.4 % required operative intervention for small bowel obstruction (n = 3) and hemorrhage (n = 1). FJT complications were more common with gastrectomy than esophagogastrectomy (53.6 vs. 36.0 %), perhaps related to longer FJT use in gastrectomy patients (71 vs. 38 days). CONCLUSIONS:FJT-related complications are common, occurring more frequently after gastrectomy than esophagogastrectomy. In most patients, complications can be managed by simple measures, rarely requiring operative intervention. Nevertheless, the need for FJTs should be carefully considered to balance nutritional benefits with the risks of insertion and usage.
10.1007/s11605-016-3297-6
Serial Frozen Fecal Microbiota Transplantation in the Treatment of Chronic Intestinal Pseudo-obstruction: A Preliminary Study.
Gu Lili,Ding Chao,Tian Hongliang,Yang Bo,Zhang Xuelei,Hua Yue,Zhu Yifan,Gong Jianfeng,Zhu Weiming,Li Jieshou,Li Ning
Journal of neurogastroenterology and motility
BACKGROUND/AIMS:Chronic intestinal pseudo-obstruction (CIPO) is a serious, life-threatening motility disorder that is often related to bacterial overgrowth. Fecal microbiota transplantation (FMT) results in restoration of the normal intestinal microbial community structure. We investigated the efficacy of FMT in the treatment of CIPO patients. METHODS:Nine patients (age 18-53 years) with CIPO were enrolled in this prospective, open-label study. Patients received FMT for 6 consecutive days through nasojejunal (NJ) tubes and were followed up for 8 weeks after treatment. We evaluated the rate of clinical improvement and remission, feeding tolerance of enteral nutrition, and CT imaging scores of intestinal obstructions. Lactulose hydrogen breath tests were performed before FMT and 8 weeks after FMT to evaluate for the presence small intestinal bacterial overgrowth (SIBO). RESULTS:FMT significantly alleviated bloating symptoms, and symptoms of pain were relieved 2 weeks after FMT. Enteral nutrition administered through a NJ tube after FMT was well-tolerated by 66.7% (6/9) of patients. CT scores of intestinal obstructions were significantly reduced after FMT ( = 0.014). SIBO was eliminated in 71.0% (5/7) of patients. CONCLUSIONS:This pilot study demonstrated the safety of using FMT. FMT may relieve symptoms in selected patients with CIPO. FMT may also improve patient tolerance of enteral nutrition delivered via a NJ tube.
10.5056/jnm16074
A wandering tube.
Dubin Ina,Gelber Moshe,Schattner Ami
CJEM
The predominant causes of acute mechanical small bowel obstruction in geriatric patients are adhesions and hernias, which is not much different than in other adult age groups. Unusual etiologies may be encountered, such as volvulus or gallstone ileus, but a displaced feeding gastrostomy tube is a distinctly rare cause of intestinal obstruction which needs to be considered by emergency physicians as it may be increasingly encountered.
10.1017/cem.2016.393
Double Pigtail Stent Insertion for Healing of Leaks Following Roux-en-Y Gastric Bypass. Our Experience (with Videos).
Donatelli Gianfranco,Dumont Jean-Loup,Dhumane Parag,Dritsas Stavros,Tuszynski Thierry,Vergeau Bertrand Marie,Meduri Bruno
Obesity surgery
BACKGROUND:Roux-en-Y gastric bypass (RYGB) is complicated by a leak in 0-4.3% of cases. Treatment by fully covered stents has been reported to be associated with some life-threatening complications. We report our experience of insertion of double pigtail stents. METHODS:Thirty-three patients (20M, 43 years-20/65), presenting with a leak at an average of 10 days after RYGB (4-35), were treated by double pigtail stent insertion and a nasojejunal feeding tube. Sixty percent of these patients had undergone surgical drainage prior to stenting for control of sepsis. Thirty leaks were located at the top of staple line and three at the gastro-jejunal anastomosis. At a 4-weekly follow-up, ablation or re-stenting was performed depending on status of fistula closure and patients were placed on normal diet. RESULTS:At the first follow-up, 10/33 fistulae healed, one patient presented with clinical failure (3%) and needed surgery, and 22/33were re-stented. Twenty-one out of these 22 developed a secondary sub-clinical gastro-gastric fistula and one, instead, developed complex (gastro-gastric, gastro-colic) fistula. All (22) primary fistulae healed following four more weeks of treatment. Average treatment duration was of 61 days (28-99). Thirty-two patients (97%) at a follow-up of 1-33 months are asymptomatic. CONCLUSIONS:Leaks following RYGB can be successfully and safely managed by double pigtail stents. Upper gastric staple line leaks are responsible for the formation of a secondary sub-clinic gastro-gastric fistula which needs no additional treatment.
10.1007/s11695-016-2465-9
Endoscopically Guided Laparoscopic Gastrojejunostomy Tube Placement for Patients with Distal Esophageal Stents.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract
Patients with distal esophageal pathology such as perforation, trachea-esophageal fistulae, and/ or obstructing gastroesophageal junction tumor present a challenging situation in terms of feeding access where an esophageal stent is placed across the gastroesophageal junction. In order to allow simultaneous gastric decompression and post-pyloric feeds without significant reflux up through the stent, a gastrojejunostomy (GJ) tube is a viable option. We hereby describe a hybrid approach to placing these GJ tubes in this cohort of patients using simultaneous laparoscopy, endoscopy, and fluoroscopy with minimal manipulation of the stent itself. We have employed this technique of placing GJ tubes 2-3 days following placement of the esophageal stent in six consecutive patients. All patients tolerated the procedure well without any complications. Endoscopically guided laparoscopic GJ tubes are ideal for bridging patients, with distal esophageal pathology requiring esophageal stents, to oral intake.
10.1007/s11605-017-3379-0
Morbidity and Mortality after Pancreatoduodenectomy: A Five Year Experience in Bangabandhu Sheikh Mujib Medical University.
Das B C,Khan A S,Elahi N E,Uddin M S,Debnath B C,Khan Z R
Mymensingh medical journal : MMJ
Mortality and morbidity was assessed after adoption of a systematic care for patient with pancreatoduodenectomy starting from patient selection and preparation, operative technique, and postoperative care. In this prospective study seventy patients who underwent pancreatoduodenectomy for periampullary carcinoma with curative intent between January 2010 and December 2014 were carefully analyzed prospectively. Patients were selected those who had ampullary carcinoma, lower bile duct carcinoma and small size carcinoma head of pancreas without local invasion and distant metastasis, and the patient who did not have any major disabling comorbid diseases. All patients were assessed uniformly before surgery and deficiency were corrected up to normal level before operation. Pancreatoduodenectomy and standard lymphadenectomy was performed meticulously with minimum blood loss. The pancreatojejunal reconstruction was performed using duct-to-mucosa method mostly. A nasojejunal feeding tube was placed in most patients for starting postoperative early oral feeding. Broad spectrum antibiotics and the epidural analgesia were mostly prescribed for good control infection and pain. Proper nutrition was maintained in calculative way through central venous line and nasojejunal feeding tube in the early postoperative period. General care, early mobilization and chest physiotherapy were given routinely in each patient. Seventy-seven percent (n=54) patients did not have any postoperative complications and they were discharged from hospital within 12-14 postoperative days. The morbidity occurred in 16 patients (23%) and most common complication was wound infection (18%, n=9). The rest complications were pancreatojejunal anastomotic leakage - 2, hepaticojejunal anastomosis leakage - 1, melaena - 1, intra-abdominal abscess - 1, intra-abdominal hemorrhage - 1, and renal dysfunction - 1. The mortality rate was 5.7% (n=4), causes of death were massive myocardial infarction; 1, failure of reversal from anesthesia; 1, massive intraabdominal bleeding; 1 and CV catheter related severe sepsis; 1. Review of recent published literature revealed that mortality and morbidity our series is better than low volume center and almost similar with high volume center of pancreatoduodenectomy surgery. Our systematic management policy of careful patient selection, planned approach in the form of proper work up, meticulous conduction of the procedure, appropriate postoperative care provides an acceptable morbidity and mortality after pancreatoduodenectomy.
Self-Expanding Metal Stents Improve Swallowing and Maintain Nutrition During Neoadjuvant Therapy for Esophageal Cancer.
Smith Zachary L,Gonzaga Jason E,Haasler George B,Gore Elizabeth M,Dua Kulwinder S
Digestive diseases and sciences
BACKGROUND:Patients with locally advanced esophageal cancer can have significant dysphagia. Nutritional support during neoadjuvant therapy is often delivered via nasoenteric or percutaneous feeding tubes. These approaches do not allow for per-oral feeding. AIMS:Evaluate the safety and efficacy of fully covered self-expanding metal esophageal stents for nutritional support during neoadjuvant therapy. METHODS:This was a pilot, prospective study at a single tertiary center. From March 2012 to May 2013, consecutive patients with esophageal cancer eligible for neoadjuvant therapy were enrolled. Metal stents were placed prior to starting neoadjuvant therapy. Data were collected at baseline and predetermined intervals until an endpoint (surgery or disease progression). Outcomes included dysphagia grade, satisfaction of swallowing score, nutritional status (weight, serum albumin), impact on surgery, and adverse events. RESULTS:Fourteen stents were placed in 12 patients (59.1 ± 9.5 years, 11 men, 1 woman). Dysphagia grade (pre 3.4 ± 0.5 vs post 0.2 ± 0.4, p < 0.0001) and swallowing scores (20.2 ± 5.9 vs 6.3 ± 4.7, p < 0.0001) significantly improved after stent placement. Improvements were sustained throughout neoadjuvant therapy. Body weight and serum albumin levels remained stable. Adverse events included severe chest pain (2), food impaction (1), and delayed stent migration (2). Five patients underwent surgical resection. No significant chemoradiation or operative adverse events occurred due to the presence of a stent. CONCLUSIONS:During neoadjuvant therapy for esophageal cancer, self-expanding metal stents are safe and effective in relieving dysphagia and maintaining nutrition. They allow patients to eat orally, thereby improving patient satisfaction. The presence of an in situ stent did not interfere with surgery.
10.1007/s10620-017-4562-6
Application of small intestine decompression combined with oral feeding in middle and late period of malignant small bowel obstruction.
Li Dechun,Du Hongtao,Shao Guoqing,Guo Yongtuan,Lu Wan,Li Ruihong
Oncology letters
The application value of small intestine decompression combined with oral feeding in the middle and late period of malignant small bowel obstruction was examined. A total of 22 patients with advanced malignant small bowel obstruction were included in the present study. An ileus tube was inserted via the nose under fluoroscopy into the obstructed small intestine of each patient. At the same time, the insertion depth the of the catheter was adjusted. When the catheter was blocked, small bowel selective angiography was performed to determine the location and cause of the obstruction and the extent of the obstruction, and to determine the length of the small intestine in the site of obstruction, and to select the variety and tolerance of enteral nutrition. We observed the decompression tube flow and ease of intestinal obstruction. In total, 20 patients were treated with oral enteral nutrition after abdominal distension, and 22 cases were treated by the nose to observe the drainage and the relief of intestinal obstruction. The distal end of the catheter was placed in a predetermined position. The symptoms of intestinal obstruction were relieved 1-4 days after decompression. The 22 patients with selective angiography of the small intestine showed positive X-ray signs: 18 patients with oral enteral nutrition therapy had improved the nutritional situation 2 weeks later. In 12 cases, where there was anal defecation exhaust, 2 had transient removal of intestinal obstruction catheter. In conclusion, this comprehensive treatment based on small intestine decompression combined with enteral nutrition is expected to become a new therapeutic approach and method for the treatment of patients with advanced tumor small bowel obstruction.
10.3892/ol.2017.6153
High versus low energy administration in the early phase of acute pancreatitis (GOULASH trial): protocol of a multicentre randomised double-blind clinical trial.
Márta Katalin,Szabó Anikó N,Pécsi Dániel,Varjú Péter,Bajor Judit,Gódi Szilárd,Sarlós Patrícia,Mikó Alexandra,Szemes Kata,Papp Mária,Tornai Tamás,Vincze Áron,Márton Zsolt,Vincze Patrícia A,Lankó Erzsébet,Szentesi Andrea,Molnár Tímea,Hágendorn Roland,Faluhelyi Nándor,Battyáni István,Kelemen Dezső,Papp Róbert,Miseta Attila,Verzár Zsófia,Lerch Markus M,Neoptolemos John P,Sahin-Tóth Miklós,Petersen Ole H,Hegyi Péter,
BMJ open
INTRODUCTION:Acute pancreatitis (AP) is an inflammatory disease with no specific treatment. Mitochondrial injury followed by ATP depletion in both acinar and ductal cells is a recently discovered early event in its pathogenesis. Importantly, preclinical research has shown that intracellular ATP delivery restores the physiological function of the cells and protects from cell injury, suggesting that restoration of energy levels in the pancreas is therapeutically beneficial. Despite several high quality experimental observations in this area, no randomised trials have been conducted to date to address the requirements for energy intake in the early phase of AP. METHODS/DESIGN:This is a randomised controlled two-arm double-blind multicentre trial. Patients with AP will be randomly assigned to groups A (30 kcal/kg/day energy administration starting within 24 hours of hospital admission) or B (low energy administration during the first 72 hours of hospital admission). Energy will be delivered by nasoenteric tube feeding with additional intravenous glucose supplementation or total parenteral nutrition if necessary. A combination of multiorgan failure for more than 48 hours and mortality is defined as the primary endpoint, whereas several secondary endpoints such as length of hospitalisation or pain will be determined to elucidate more detailed differences between the groups. The general feasibility, safety and quality checks required for high quality evidence will be adhered to. ETHICS AND DISSEMINATION:The study has been approved by the relevant organisation, the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (55961-2/2016/EKU). This study will provide evidence as to whether early high energy nutritional support is beneficial in the clinical management of AP. The results of this trial will be published in an open access way and disseminated among medical doctors. TRIAL REGISTRATION:The trial has been registered at the ISRCTN (ISRTCN 63827758).
10.1136/bmjopen-2017-015874
Direct percutaneous endoscopic jejunostomy - Should we move on to single- and double-balloon enteroscopy techniques?
Mönkemüller Klaus,Olano Carolina,Rickes Steffen
Revista espanola de enfermedades digestivas : organo oficial de la Sociedad Espanola de Patologia Digestiva
Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful technique to access the jejunum in order to: a) provide enteral nutrition to individuals when the gastric route is absent or contraindicated; and b) to decompress the jejunum in patients with malignant small bowel obstruction. Traditionally, DPEJ is performed using a colonoscope or enteroscope, which is advanced as deep as possible into the jejunum. The insertion technique of the feeding tube is identical to the one used for a gastrostomy tube (Ponsky-Gauderer method).
10.17235/reed.2017.5182/2017
Short-term outcome after cystectomy: comparison of early oral feeding in an enhanced recovery protocol and feeding using Bengmark nasojejunal tube.
Voskuilen C S,van de Putte E E Fransen,der Hulst J Bloos-van,van Werkhoven E,de Blok W M,van Rhijn B W G,Horenblas S,Meijer R P
World journal of urology
PURPOSE:Cystectomy for bladder cancer is associated with a high risk of postoperative complications. Standardized perioperative protocols, such as enhanced recovery after surgery (ERAS) protocols, aim to improve postoperative outcome. Postoperative feeding strategies are an important part of these protocols. In this two-centre study, we compared complications and length of hospital stay (LOS) between an ERAS protocol with early oral nutrition and a protocol with early enteral feeding with a Bengmark nasojejunal tube. METHODS:We retrospectively reviewed 154 consecutive patients who underwent cystectomy for bladder cancer in two hospitals (Hospital A and B) between 2014 and 2016. Hospital A uses an ERAS protocol (n = 45), which encourages early introduction of an oral diet. Hospital B uses a fast-track protocol comprising feeding with a Bengmark nasojejunal tube (Bengmark-protocol, n = 109). LOS and complications according to Clavien classification were compared between protocols. RESULTS:Overall 30-day complication rates in the ERAS and Bengmark protocol were similar (64.4 and 67.0%, respectively; p = 0.463). The rate of postoperative ileus (POI) was significantly lower in the Bengmark protocol (11.9% vs. 34.4% in the ERAS protocol, p = 0.009). This association remained significant after adjustment for other variables (odds ratio 0.32, 95% confidence interval 0.11-0.96; p = 0.042). Median LOS did not differ significantly between protocols (10 days vs. 11 days in the ERAS and Bengmark protocols, respectively; p = 0.861). CONCLUSIONS:Early oral nutrition in Hospital A was well tolerated. However, the Bengmark protocol was superior with respect to occurrence of POI. A prospective study may clarify whether the lower rate of POI was due to the use of early nasojejunal tube feeding or other reasons.
10.1007/s00345-017-2133-2
Home enteral nutrition after minimally invasive esophagectomy can improve quality of life and reduce the risk of malnutrition.
Wu Zixiang,Wu Ming,Wang Qi,Zhan Tianwei,Wang Lian,Pan Saibo,Chen Gang
Asia Pacific journal of clinical nutrition
BACKGROUND AND OBJECTIVES:The potential benefits of home enteral nutrition (HEN) and the effects of HEN on quality of life (QOL) after esophagectomy remain unclear. The aim was to investigate the effect of 3 months HEN on health related QOL and nutritional status of esophageal cancer patients who were preoperatively malnourished. METHODS AND STUDY DESIGN:142 malnourished (PG-SGA stage B or C) patients with esophageal cancer were assigned to receive Ivor Lewis minimally invasive esophagectomy (MIE group) with laparoscopic jejunal feeding tube placement or open esophagectomy (OE group) with nasojejunal feeding tube placement. After discharge, patients in the MIE group received HEN with 500-1000 kcal/d for 3 months, while the OE group patients did not receive HEN, as nasojejunal feeding tubes had been removed. QLQ-C30 and PG-SGA questionnaires were used to evaluate the QOL and the risk of malnutrition. RESULTS:67 patients were enrolled in the MIE group and 75 patients were enrolled in the OE group. Symptoms related to fatigue, nausea, vomiting, pain, and appetite loss were significantly decreased in the patients treated with 3 months HEN. Similarly, patients treated with 3 months HEN had a lower risk of malnutrition than patients did not receive HEN (PG-SGA score, 5.7 vs 7.9, p<0.01). More patients in the MIE group (received 3 months HEN) were able to complete postoperative chemoradiotherapy than patients in the OE group (p<0.01). CONCLUSIONS:MIE and subsequent treatment with 3 months HEN can improve the QOL and reduce the risk of malnutrition in preoperatively malnourished patients.
10.6133/apjcn.032017.22
Gastrojejunoscopy facilitates placement of a percutaneous transgastric jejunostomy in a patient with a pancreaticoduodenectomy and multiple-failed feeding tube placements.
Chick Jeffrey Forris Beecham,Shields James,Gemmete Joseph J,Hage Anthony,Srinivasa Ravi N
Radiology case reports
Enteral access is one of the most common procedures performed in abdominal and interventional radiology. The surgical anatomy of the postoperative stomach may, however, make enteral access challenging. This report describes a patient with a pancreaticoduodenectomy complicated by a gastrojejunostomy leak who underwent 2 unsuccessful transoral endoscopic nasojejunal tube placements and 2 failed percutaneous gastrojejunostomy tube placements. Eventually, a gastrojejunostomy tube was placed utilizing percutaneous techniques with fluoroscopy assistance and gastrojejunoscopy guidance. A combined technique with fluoroscopy and endoscopy, both controlled by interventional radiology, may be useful in patients with complex postsurgical gastrointestinal anatomy who require enteral access.
10.1016/j.radcr.2017.09.004
Reduced incidence of feeding tube dislodgement and missed feeds in burn patients with nasal bridle securement.
Li Alexander Y,Rustad Kristine C,Long Chao,Rivera Emiko,Mendiola Meghan,Schenone Maaike,Karanas Yvonne L
Burns : journal of the International Society for Burn Injuries
INTRODUCTION:Feeding tubes in burn patients are at high risk for becoming dislodged as traditional tape securement does not adhere well to sloughed skin, resulting in nutrition delivery disruption and placing patients at increased risk for iatrogenic injury upon reinsertion. METHODS:Seventy-four patients admitted to our regional burn center requiring nasoenteric nutritional support were prospectively followed. Fourty-one patients received a nasal bridle while thirty-three received traditional tape and elastic dressings. Primary outcomes centered on measuring clinical efficacy of the nasal bridle system. RESULTS:Conventional tape-secured feeding tubes were dislodged more frequently (0.9±0.2 times per 10 feeding days vs. 0.2±0.1 times per 10 feeding days; p=0.005). Nasal bridle secured tubes showed significantly longer functional life on Kaplan Meier analysis (hazard ratio 0.35; p=0.01). Fewer abdominal x-ray studies were performed to confirm tube placement in nasal bridle patients (1.48±0.13 for nasal bridle vs. 2.21±0.21 for conventional tape-secured; p=0.003). Overall, patients with bridle securement had fewer hours of missed enteric feeds (2.51±0.95hours vs. 6.72±2.07hours; p=0.05). Importantly, utilization of a nasal bridle decreased overall estimated costs for enteric feeding management ($1,379.72±120.70 vs. $1,107.66±63.95; p=0.05). CONCLUSIONS:Utilization of a nasal bridle system provides a reliable method for securement of nasoenteric feeding tubes with clinical benefits in the burn patient population.
10.1016/j.burns.2017.05.025
Nasoenteric feeding discharge planning for cancer patients in a Brazilian teaching hospital: a best practice implementation project.
Poveda Vanessa de Brito,Marques da Silva Adriana,Toyama Aline Cordeiro,Andrade da Silva Jomana,Shimoda Gilcéria Tochika,Püschel Vilanice Alves de Araújo
JBI database of systematic reviews and implementation reports
OBJECTIVES:The objective of this project was to improve local practice in nasoenteric feeding discharge planning for cancer patients in a cancer teaching hospital in São Paulo, Brazil. INTRODUCTION:Nasoenteric tubes are commonly used for enteral nutrition in patients with cancer for over seven days during their recovery and this may be continued at home, with clear benefits. RESULTS:Baseline audit results indicated poor compliance (between 0% and 22%) with the current evidence, although good compliance (100%) was observed for three audit criteria. Implementation of the strategies, including changes to achieve higher participation of caregivers, resulted in an improvement of the audited criteria (100% compliance was maintained for three criteria, compliance increased from 22% to 67% for a further three criteria, with 0% compliance for one criterion). CONCLUSIONS:Despite the short time frame of this study, an increase in compliance with best practices proposed by the Joanna Briggs Institute was observed. Implementing a multidisciplinary meeting before patient discharge remains a challenge.
10.11124/JBISRIR-2017-003506
Associations of hyperosmolar medications administered via nasogastric or nasoduodenal tubes and feeding adequacy, food intolerance and gastrointestinal complications amongst critically ill patients: A retrospective study.
Wesselink Evertine,Koekkoek Kristine W A C,Looijen Martijn,van Blokland Dick A,Witkamp Renger F,van Zanten Arthur R H
Clinical nutrition ESPEN
BACKGROUND:Adequate nutrition is essential during critical illness. However, providing adequate nutrition is often hindered by gastro-intestinal complications, including feeding intolerance. It is suggested that hyperosmolar medications could be causally involved in the development of gastro-intestinal complications. The aims of the present study were 1) to determine the osmolality of common enterally administered dissolved medications and 2) to study the associations between nasogastric and nasoduodenal administered hyperosmolar medications and nutritional adequacy as well as food intolerance and gastro-intestinal symptoms. METHODS:This retrospective observational cohort study was performed in a medical-surgical ICU in the Netherlands. Adult critically ill patients receiving enteral nutrition and admitted for a minimum ICU duration of 7 days were eligible. The osmolalities of commonly used enterally administrated medications were measured using an osmometer. Patients were divided in two groups: Use of hyperosmolar medications (>500 mOsm/kg) on at least one day during the first week versus none. The associations between the use of hyperosmolar medications and nutritional adequacy were assessed using multiple logistic regression analysis. The associations between hyperosmolar medication and food intolerance as well as gastrointestinal symptoms were assessed using ordinal logistic regression. RESULTS:In total 443 patients met the inclusion criteria. Of the assessed medications, only three medications were found hyperosmolar. We observed no associations between the use of hyperosmolar medications and nutritional adequacy in the first week of ICU admission (caloric intake β -0.27 95%CI -1.38; 0.83, protein intake β 0.32 95%CI -0.90; 1.53). In addition, no associations were found for enteral feeding intolerance, diarrhea, obstipation, gastric residual volume, nausea and vomiting in ICU patients receiving hyperosmolar medications via a nasogastric tube. A subgroup analysis of patients on duodenal feeding showed that postpyloric administration of hyperosmolar medications was associated with increased risk of diarrhea (OR 138.7 95%CI 2.33; 8245). CONCLUSIONS:Our results suggest that nasogastric administration of hyperosmolar medication via a nasogastric tube does not affect nutritional adequacy, development of enteral feeding intolerance and other gastro-intestinal complications during the first week after ICU admission. During nasoduodenal administration an increased diarrhea incidence may be encountered.
10.1016/j.clnesp.2018.04.001
Delivering a home enteral feeding service to the residents of Trafford.
Ford Alison
British journal of community nursing
The number of patients receiving Home Enteral Tube Feeding (HETF) has increased over a number of years. Some patients may have a short term nasogastric/nasojejunal tube placed to help them achieve their nutritional requirements in the short term. Other patients may need to be fed via a gastrostomy tube, either fully or in combination with oral diet long-term. It is important that all patients on HETF receive regular and continuous support. In light of this, Trafford NHS Trust has established a multi-professional nutrition support clinic.
10.12968/bjcn.2018.23.Sup7.S13
Practice Patterns and Utilization of Tube Feedings in Acute Pancreatitis Patients at a Large US Referral Center.
Machicado Jorge D,Gougol Amir,Paragomi Pedram,OʼKeefe Stephen J,Lee Kenneth,Slivka Adam,Whitcomb David C,Yadav Dhiraj,Papachristou Georgios I
Pancreas
OBJECTIVES:Clinical trials on tube feedings (TFs) have not been sufficiently powered to change practice patterns in acute pancreatitis (AP). We aimed to describe the use, duration, and resource utilization of TF in AP patients at an expert US center. METHODS:Of 423 AP patients prospectively enrolled at the University of Pittsburgh Medical Center from 2004 to 2014, 139 (33%) received TF. Data on TF were assessed in 100 (72%) of 139 patients with complete data available. RESULTS:Patients on TF were more likely to be male, be obese, have alcohol etiology, and have moderately severe (34% vs 19%) or severe AP (62% vs. 3%) (P < 0.05). Tube feedings were started after a median of 5 days (interquartile range, 3-8 days) from admission and were administered for a median of 39 days (interquartile range, 19-58 days). A nasojejunal route (95%) with an oligomeric formula (92%) was the preferred TF strategy. Feeding tube complications led to at least 1 endoscopic tube replacement in 42% of patients and to an unexpected health care visit in 29% of those discharged on TF (16/55 patients). CONCLUSIONS:Tube feedings form an important component in the management of patients with moderately severe and severe AP. Further studies should define the optimal utilization of TF and ways to reduce TF-related complications.
10.1097/MPA.0000000000001141
Laparoscopic Duodenojejunostomy for the SMA Syndrome.
Zentralblatt fur Chirurgie
OBJECTIVE:The Superior Mesenteric Artery Syndrome (SMAS) was first described by Rokitansky in 1842. Clinical symptoms include postprandial pain, nausea, vomiting and weight loss. Duodenojejunostomy is the treatment of choice for patients with SMAS. We now present a case of a young female with SMAS who successfully underwent laparoscopic duodenojejunostomy. INDICATIONS:The first line treatment for SMAS is medical management, which includes infusion therapy, bowel rest, parenteral nutrition and a nasojejunal feeding tube inserted into the jejunum past the obstruction. If medical therapy fails, surgery is recommended. PROCEDURE:A symptomatic patient with body mass index (BMI) of 19.4 kg/m underwent laparoscopic duodenojejunostomy. The patient tolerated the procedure well. The post-operative period was uneventful and the patient was discharged after three days. On six month follow up, the patient had gained weight and her symptoms were completely resolved. CONCLUSION:SMAS is still a poorly recognised pathology. A high index of suspicion should be given for patients with unclear causes of postprandial nausea, vomiting and abdominal pain, especially in young females. A laparoscopic approach seems to be safe and effective for patients with SMAS.
10.1055/a-0668-1991
Fecal bacteriotherapy in the treatment of Clostridium difficile infection.
Stebel R,Svačinka R,Vojtilová L,Freibergerová M,Husa P
Epidemiologie, mikrobiologie, imunologie : casopis Spolecnosti pro epidemiologii a mikrobiologii Ceske lekarske spolecnosti J.E. Purkyne
AIM:Using a prospective analysis to assess the success of faecal bacteriotherapy (FBT) in antibiotic-associated colitis due to Clostridium difficile. To analyse whether any of the factors according to which the treated patients can be categorized has a statistically significant effect on the therapeutic outcome. MATERIALS AND METHODS:During the 2-year study period (2015-2016), 71 patients received FBT. After treatment, the patients were followed up by means of clinic visits or by phone. If colitis did not recur within eight weeks of follow-up, the treatment was considered successful. RESULTS:The overall success rate was 76%, with statistically insignificant decline in recurrences. Subgroup analysis did not show any statistically significant difference in the success rate between the routes of administration, i.e. through a naso-enteral feeding tube and rectal enema. Likewise, there were no statistically significant differences in the success rate between the types of prior antibiotic therapy or between using fresh and cryo-stored stool suspension. No unexpected adverse event or lethality occurred during the study period. CONCLUSIONS:Faecal bacteriotherapy is a successful and safe therapeutic alternative for recurrent C. difficile infections.
Early Initiation of Post-Pyloric Feeding in Patients with Major Burns: Experience in Taiwan Formosa Water Park Dust Explosion Disaster.
Tseng Yu-Chen,Chen Bao-Chung,Chen Chun-Ting,Chou Yu-Ching,Dai Niann-Tzyy,Chen Peng-Jen,Huang Tien-Yu,Shih Yu-Lueng,Chang Wei-Kuo,Hsieh Tsai-Yuan,Lin Jung-Chun
The Tohoku journal of experimental medicine
Early initiation of enteral nutrition improves clinical outcomes in critical patients with serious burns. Post-pyloric tube feeding is a valuable therapeutic option for severely burned patients with poor gastric emptying. How early post-pyloric feeding can be initiated to provide more benefits to patients has not yet been examined. A fire erupted at a recreational water park in New Taipei City, Taiwan, on June 27, 2015. The results of early initiation versus delayed post-pyloric feeding in severely burned patients in this mass-casualty incident were compared. Door-to-post-pyloric feeding time ≤ 24 h was considered as early post-pyloric feeding (EPF) and that > 24 h was considered as delayed post-pyloric feeding (DPF). Thirteen patients with severe burn injuries (> 40% of the total body surface area) were assigned to undergo either EPF (five patients) or DPF (eight patients). This study is a "fortuitously controlled" study, and the authors were able to formulate and test whether EPF is better than DPF by comparing the two groups. In patients in the EPF, the intake of calories increased rapidly and was maintained throughout the study period. In addition, rapid restoration of plasma magnesium concentrations as well as pronounced recovery of platelet count in the EPF group was observed. In conclusion, our findings indicate that the time from injury to the onset of post-pyloric feeding is crucial, and EPF allows for the administration of calculated caloric needs. Therefore, EPF can be successfully initiated with beneficial outcomes of nutritional reconstruction in severely burned patients.
10.1620/tjem.247.111
Effect of early and delay starting of enteral feeding in post-pancreaticoduodenectomy patients.
Das Bidhan C,Haque Mozammel,Uddin Mohammad Saief,Nur-E-Elahi Md,Khan Zulfiqur Rahman
Annals of hepato-biliary-pancreatic surgery
BACKGROUNDS/AIMS:This study was undertaken to see the effect of early starting of enteral feeding after pancreatoduodenectomy (PD). The results were compared with existing nutritional practice in which enteral feeding started, usually after 7 to 8 postoperative day (PODs) in our institute. METHODS:Thirty patients whome underwent a PD from January 2016 to December 2016 were included in the study. They were divided into two groups, I and II. In group I (n=15), enteral feeding was started from the 2 POD through the nasojejunal feeding tube along with parenteral partial nutrition support. In group II (n=15), no enteral feeding was given up to seventh and eighth PODs, except the perenteral feeding. Post-operatively, serum albumin levels, total lymphocyte count, total bilirubin levels, serum alkaline phosphate levels were measured for two weeks postoperatively in all the patients for assessing nutritional, immunological and cholestasis status. The mortality, morbidity and lengths of post-operative hospital stay were also recorded. RESULTS:Postoperatively, the serum albumin level and lymphocyte count decreased from the pre-operative level on the third POD and it gradually increased from the seventh POD onwards in both groups. However, they remained persistently higher in group I than group II. The total bilirubin and alkaline phosphatase decreased to normal levels within the seventh POD in Group I. However, they remained higher than normal levels on POD 14 in Group II. The morbidity and hospital stay was significantly lower in group I than group II. CONCLUSIONS:Early enteral feeding should be considered after PD. This is because it will improve nutritional, immunological status and cholestasis. Therefore, it reduces morbidity and shortens the hospital stay.
10.14701/ahbps.2019.23.1.56
Risk factors associated with intolerance to enteral nutrition in moderately severe acute pancreatitis: A retrospective study of 568 patients.
Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association
BACKGROUND/AIMS:To assess the frequency of and risk factors for intolerance to enteral nutrition through nasogastric (NG) or nasojejunal (NJ) tube feeding in patients with moderately severe acute pancreatitis. PATIENTS AND METHODS:Patients who underwent enteral nutrition via the nasojejunal tube or nasogastric tube, from January 2012 to December 2017, were enrolled. Demographic and etiological data, admission variables, enteral nutrition related variables, and radiological variables were evaluated using univariate and multivariate analysis. RESULTS:A total of 568 patients were included, with 235 (41.4%) receiving nasojejunal tube feeding and 333 (56.8%) receiving nasogastric tube feeding. Tube-feeding intolerance was observed in 184 patients (32.4%), occurring at a median of 3 days (range, 1-5 days) after the start of enteral nutrition. The variables independently associated with risk of intolerance to tube feeding were hypertriglyceridemia (odds ratio, 8.13;95% CI, 5.21-10.07; P = 0.002), the presence of systemic inflammatory response syndrome (odds ratio, 6.58;95% CI, 3.03-8.34; P = 0.002), acute gastrointestinal injury-III status (odds ratio, 5.51;95% CI, 2.30-7.33; P = 0.02), the time from admission to commencement of enteral nutrition (odds ratio, 7.21;95% CI, 2.16-9.77; P = 0.001), and pancreatic infection (odds ratio, 6.15;95% CI, 4.94-8.75; P = 0.002) Patients with tube-feeding intolerance required prolonged enteral nutrition (P < 0.001) and had longer hospitalizations (P < 0.001). CONCLUSIONS:Tube-feeding intolerance accounts for a considerable proportion in patients with moderately severe acute pancreatitis. The presence of hypertriglyceridemia, systemic inflammatory response syndrome and acute gastrointestinal injury grade III or pancreatic infection and the time from admission to commencing enteral nutrition increase the risk for tube-feeding intolerance.
10.4103/sjg.SJG_550_18
Efficacy of Endoscopic Treatment of Post-Sleeve Gastrectomy Fistulas According to the Radiological Type.
Sportes A,Aireini G,Kamel R,Pratico C,Raynaud J J,Sabate J M,Donatelli G,Benamouzig R
Obesity surgery
BACKGROUND AND AIMS:The originality of this retrospective study relies on the evaluation of the effectiveness of the endoscopic internal drainage (EID) according to the type of fistula. METHODS:The type of fistula was classified initially according to a CT scan with oral opacification: fistula without a communicating abscess (type I), fistula with a communicating abscess (type II), and fistula with an abscessed sub- and sus-diaphragmatic communicating collection (type III). Treatment algorithm consisted of the insertion of a nasojejunal feeding tube (NJFT) for type I fistulas and the placement of a NJFT with EID with or without surgical drainage for types II and III. RESULTS:Forty-nine patients were included. The clinical success rate with fistula healing was 100% in group I, 96% in group II, and 12% for group III (p = 0.001). Mean time for diagnosis of the fistula was significantly higher in type III (p = 0.04). The mean estimated size of the defect was higher in type II, 11.2 mm and III, 10 mm versus type I, 2.8 mm (p = 0.001). The average number of scheduled endoscopic sessions were 2, 2.7, and 5.2 for types I, II, and III, respectively (p = 0.001). The number of unscheduled reinterventions was also significantly higher in type III (p = 0.03). The NJFT was left in place for a significantly longer duration in type III (136 days) compared to types I (3, 13) and II (49) p = 0.001. CONCLUSION:This study shows that proper characterization of the type of fistula before the endoscopic treatment of post-sleeve fistulas improves the efficacy of the endoscopic treatment.
10.1007/s11695-019-03825-4
Therapeutic strategies in gastroparesis: Results of stepwise approach with diet and prokinetics, Gastric Rest, and PEG-J: A retrospective analysis.
Strijbos Denise,Keszthelyi Daniel,Smeets Fabiënne G M,Kruimel Joanna,Gilissen Lennard P L,de Ridder Rogier,Conchillo José M,Masclee Ad A M
Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society
BACKGROUND:Gastroparesis is characterized by abnormal gastric motor function with delayed gastric emptying in the absence of mechanical obstruction. In our tertiary referral center, patients are treated with a stepwise approach, starting with dietary advice and prokinetics, followed by three months of nasoduodenal tube feeding with "gastric rest." When not successful, a percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) for long-term enteral feeding is placed. AIM:To evaluate the effect of this stepwise approach on weight and symptoms. METHODS:Analyses of data of all referred gastroparesis patients between 2008 and 2016. KEY RESULTS:A total of 86 patients (71% female, 20-87 years [mean 55.8 years]) were analyzed of whom 50 (58%) had adequate symptom responses to diet and prokinetics. The remaining 36 (decompensated gastroparesis) were treated with three months gastric rest. Symptom response rate was 47% (17/36). Significant weight gain was seen in all patients, independent of symptom response. In the remaining 19 symptom non-responders, the enteral feeding was continued through PEG-J. Treatment was effective (symptoms) in 37%, with significant weight gain in all. In 84% of patients, the PEG-J is still in use (mean duration 962 days). CONCLUSIONS AND INFERENCES:Following a stepwise treatment approach in gastroparesis, adequate symptom response was reached in 86% of all patients. Weight gain was achieved in all patients, independent of symptom response. Diet and prokinetics were effective with regard to symptoms in 58%, temporary gastric rest in 47%, and PEG-J as third step in 37% of patients.
10.1111/nmo.13588
Routine placement of feeding jejunostomy tube during esophagectomy increases postoperative complications and does not improve postoperative malnutrition.
Koterazawa Yasufumi,Oshikiri Taro,Hasegawa Hiroshi,Yamamoto Masashi,Kanaji Shingo,Yamashita Kimihiro,Matsuda Takeru,Nakamura Tetsu,Suzuki Satoshi,Kakeji Yoshihiro
Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus
Esophagectomy for esophageal cancer is a highly invasive procedure, and a feeding jejunostomy tube (FJT) is routinely placed to ensure adequate enteral nutrition. However, the effect of perioperative short-term FJT placement remains controversial, and the aim of this study was to assess risks and benefits of routine FJT placement during esophagectomy and to determine parameters that can identify patients needing long-term FJT. This retrospective study included 393 patients who had undergone esophagectomy with gastric tube reconstruction via the posterior mediastinal route at the Kobe University Hospital and the Hyogo Cancer Center between April 2010 and December 2017. Propensity score matching was used to identify matched patients (139 per group) in the FJT and no-FJT groups. The incidence of postoperative complications and weight loss (3 months post-procedure) was compared in the matched cohort and significant risk factors predicting the need for long-term FJT placement in the whole cohort were identified. In the matched cohort, while weight loss was not different between the FJT and no-FJT groups (11% vs. 10%), the incidence of small bowel obstruction in the FJT group (11.5%) was significantly higher than that in the no-FJT group (0%). Multivariate analysis revealed that age (≥75 years), preoperative therapy, anastomosis leakage, and pulmonary complications were independent risk factors for long-term FJT placement. Routine placement of an FJT during esophagectomy increases small bowel obstruction and does not result in better nutritional status, suggesting that selective long-term FJT placement in high-risk patients should be considered.
10.1093/dote/doz021
Correction: Electromagnetic-Guided Bedside Placement of Nasoenteral Feeding Tubes by Nurses Is Non-Inferior to Endoscopic Placement by Gastroenterologists: A Multicenter Randomized Controlled Trial.
Gerritsen Arja,de Rooij Thijs,Dijkgraaf Marcel G,Busch Olivier R,Bergman Jacques J,Ubbink Dirk T,van Duijvendijk Peter,Erkelens Willemien G,Klos Mariël,Kruyt Philip M,Bac Dirk Jan,Rosman Camiel,Tan Adriaan C,Molenaar Quintus I,Monkelbaan Jan F,Mathus-Vliegen Elisabeth M,Besselink Marc G,
The American journal of gastroenterology
10.14309/ajg.0000000000000252
The occlusion balloon reduction technique for de novo placement and salvage of malpositioned enteric tubes.
Chick Jeffrey Forris Beecham,Jairath Neil,Bundy Jacob J,Adapa Arjun,Shields James J,Hage Anthony N,Srinivasa Ravi N
Abdominal radiology (New York)
PURPOSE:Nasoenteric, gastrojejunostomy, and jejunostomy tubes are methods of enteral nutrition in patients with functioning gastrointestinal tracts who cannot maintain adequate oral intake. Current placements; however, may be complicated by redundant wire and catheter loops within the stomach preventing operators from optimal feeding tube placement and predisposing patients to feeding tube prolapse. This report describes the occlusion balloon reduction technique for salvage of malpositioned tubes and placement of new enteric tubes in the setting of redundant loops. MATERIALS AND METHODS:Five patients underwent the occlusion balloon reduction technique for jejunostomy (n = 3), gastrojejunostomy (n = 1), or nasojejunal tube placement (n = 1). All patients (n = 5) had redundant wires coiled within the stomach. In all patients (n = 5), a 9-French × 32 mm × 120 cm Coda balloon was inserted over the wire and passed into the small bowel. The balloon was inflated after which reduction of redundancy in the upper gastrointestinal tract was performed. Feeding tubes were then placed with tips in the distal jejunum. Technical success of the occlusion balloon reduction technique, successful placement of enteric tube, complications, and follow-up were recorded. RESULTS:The occlusion balloon reduction was technically successful in all patients (n = 5). Feeding tube placement was successful in all patients (n = 5). No minor or major complication occurred. Mean follow-up was 56 days. CONCLUSION:The occlusion balloon reduction technique provides a method for reduction of redundant wire and catheter loops within the stomach during enteric tube placement or repositioning.
10.1007/s00261-019-02029-9
Meta-analysis of effect of routine enteral nutrition on postoperative outcomes after pancreatoduodenectomy.
Tanaka M,Heckler M,Mihaljevic A L,Probst P,Klaiber U,Heger U,Hackert T
The British journal of surgery
BACKGROUND:The optimal nutritional treatment after pancreatoduodenectomy is still unclear. The aim of this meta-analysis was to investigate the impact of routine enteral nutrition following pancreatoduodenectomy on postoperative outcomes. METHODS:RCTs comparing enteral nutrition (regular oral intake with routine tube feeding) with non-enteral nutrition (regular oral intake with or without parenteral nutrition) after pancreatoduodenectomy were sought systematically in the MEDLINE, Cochrane Library and Web of Science databases. Postoperative data were extracted. Random-effects meta-analyses were performed to compare postoperative outcomes in the two arms, and pooled odds ratios (ORs) or mean differences (MDs) were calculated with 95 per cent confidence intervals. In subgroup analyses, the routes of nutrition were assessed. Percutaneous tube feeding and nasojejunal tube feeding were each compared with parenteral nutrition. RESULTS:Eight RCTs with a total of 955 patients were included. Enteral nutrition was associated with a lower incidence of infectious complications (OR 0·66, 95 per cent c.i. 0·43 to 0·99; P = 0·046) and a shorter length of hospital stay (MD -2·89 (95 per cent c.i. -4·99 to -0·80) days; P < 0·001) than non-enteral nutrition. Percutaneous tube feeding had a lower incidence of infectious complications (OR 0·47, 0·25 to 0·87; P = 0·017) and a shorter hospital stay (MD -1·56 (-2·13 to -0·98) days; P < 0·001) than parenteral nutrition (3 RCTs), whereas nasojejunal tube feeding was not associated with better postoperative outcomes (2 RCTs). CONCLUSION:As a supplement to regular oral diet, routine enteral nutrition, especially via a percutaneous enteral tube, may improve postoperative outcomes after pancreatoduodenectomy.
10.1002/bjs.11217
Nutritional Support in Postcardiotomy Shock Extracorporeal Membrane Oxygenation Patients: A Prospective, Observational Study.
Hunt Megan F,Pierre Alejandro Suarez-,Zhou Xun,Lui Cecillia,Lo Brian D,Brown Patricia M,Whitman Glenn J,Choi Chun W
The Journal of surgical research
BACKGROUND:Despite the 6000 patients treated with extracorporeal membrane oxygenation (ECMO) annually, there is a paucity of data regarding the nutritional management of these patients. MATERIALS AND METHODS:We performed a prospective, observational study of nutrition in postcardiotomy shock patients at our institution. Over a 3.5-year study period, we identified 50 ECMO patients and 225 non-ECMO patients. We identified type, amount, duration, and disruption of nutritional delivery by cohort. The primary outcome was percent of caloric goal met, and secondary outcome was gastrointestinal complications. RESULTS:ECMO patients met less of their caloric (29% versus 40%, P = 0.017) and protein goals (34% versus 55%, P < 0.001) compared with non-ECMO patients. Tube feeds were administered more slowly (26 versus 37 mL/h, P < 0.001) and held for longer (8.3 versus 4.5 h/d, P < 0.001) in ECMO patients because of procedures (60%) and high-dose pressors (20% versus 7%, P < 0.001). Multivariate analysis demonstrated that ECMO decreased caloric intake by 14%, with no detected increased risk of gastrointestinal complications. CONCLUSIONS:-ECMO patients received significantly less nutrition support compared with a non-ECMO population. Tube feed hold deficits could potentially be avoided by utilizing postpyloric tubes to feed through procedures, by eliminating holds for vasopressors/inotropes in hemodynamically stable patients, or by establishing volume-based feeding protocols. Further clinical studies are needed to establish efficacy of these interventions and to understand the impact of nutrition on outcomes in ECMO patients.
10.1016/j.jss.2019.06.054
Causes of nasoenteral tube obstruction in tertiary hospital patients.
Borges José L A,De Souza Ivens A O,Costa Michele C V,Ruotolo Fabiana,Barbosa Livia M G,De Castro Isac,Ribeiro Paulo C
European journal of clinical nutrition
BACKGROUND/OBJECTIVES:Obstruction of the nasoenteral tube is one of the complications of enteral nutrition therapy, and its causes and frequency of occurrence are not well understood. To evaluate the causes of enteral nutrition feeding tube obstruction. To study the time elapsed between the beginning of the nutrition therapy and the obstruction of the tube. SUBJECTS/METHODS:This was a retrospective cohort study of 1170 patients aged 18 years or older who were hospitalized at Sírio-Libanês Hospital between January 2015 and October 2017, and who were undergoing enteral nutrition therapy delivered using an infusion pump through a nasogastric or nasoenteral tube. The study population included 683 (58%) men and 487 (42%) women. The median age was 79 years. Of these, 1084 patients received enteral nutrition and medication through the feeding tube, and 86 received medication alone. Variables investigated as causes of feeding tube obstruction were the administration of medication through the tube, type of diet, and use of symbiotics. RESULTS:Obstruction rates were 4% for up to 40 days of observation and 8% for the total observation time. The time for obstruction of 10% of the tubes in patients receiving rivaroxaban, linagliptin, metformin, and nystatin was 16, 19, 20, and 28 days, respectively. CONCLUSIONS:The main cause of nasoenteral tube obstruction (odds ratio) was the combination of metformin (2.0), nystatin (3.1), linagliptin (4.3), rivaroxaban (2.4), and a high-protein diet (1.9). Overall, proper tube care and strict compliance with tubal drug delivery guidelines can result in low tube obstruction rates.
10.1038/s41430-019-0475-0
Volume-Based Protocol Improves Delivery of Enteral Nutrition in Critically Ill Trauma Patients.
Sachdev Gaurav,Backes Kehaulani,Thomas Bradley Winston,Sing Ronald Fong,Huynh Toan
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:Critically ill patients on enteral nutrition (EN) often do not receive goal nutrition support. Factors impeding delivery of EN include interruption for procedures, tube dislodgement, and high gastric residuals. A volume-based feeding protocol (VP) is designed to adjust the infusion rate to compensate for interruptions. We hypothesize that implementation of a VP would increase delivery of EN over the conventional hourly rate method (CM). METHODS:This study compared patients on CM to those on VP. The primary outcome measured was percentage of goal EN delivered during the entire intensive care unit (ICU) stay. Inclusion criteria for the study consisted of patients aged >18 years, traumatic mechanism of injury and admission to the ICU >72 hours, hemodynamic stability to receive EN per the trauma ICU standard of practice, and EN via nasogastric or post-pyloric feeding tube. RESULTS:We evaluated 227 patients over a 20-month period. Seventy-nine patients in the VP group were compared with the control group of 148 patients. Patients on VP received a significantly higher percentage of goal EN than those on CM (73.3% vs 65%, P = .0002). There was no difference in the incidence of diarrhea (CM 4.16% vs VP 5.19%; P = .29) or tube dislodgment (CM 2.04% vs VP 1.61%; P = .51). CONCLUSION:Implementation of a VP significantly increased delivery of EN by 8.3% over that given by the CM in critically ill trauma patients with no difference in feeding-related complications.
10.1002/jpen.1711
[Effect of post-pyloric feeding by spiral nasoenteric tubes on ventilator-associated pneumonia in neurocritical care patients: a retrospective analysis of three clinical randomized controlled trials].
Ouyang Xin,He Zhimei,Hu Bei,Chen Chunbo
Zhonghua wei zhong bing ji jiu yi xue
OBJECTIVE:To explore the effect of post-pyloric feeding by spiral nasoenteric tubes on ventilator-associated pneumonia (VAP) in neurocritical care patients. METHODS:A retrospective study was performed to analyze the clinical data of 175 neurocritical care adult patients with mechanical ventilation (MV) more than 48 hours, who were enrolled in three randomized controlled trials (RCT) conducted by Guangdong Provincial People's Hospital for post-pyloric tube placement between April 2012 to March 2019. The following patient clinical data were collected when patients were enrolled: gender, age, neurologic diagnosis, comorbidities, medication, endotracheal reintubation, bronchoscope treatment, the distal site of nasoenteric tubes, and acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score, Glasgow coma scale (GCS) score, and acute gastrointestinal injury (AGI) grade assessed. Patients were divided into VAP group and non-VAP group according to the occurrence of VAP, and the differences of each index between the two groups were compared. Then the influencing factors of P < 0.1 were included in multivariate Logistic regression analysis to identify the potential risk factors affecting the incidence of VAP. Furthermore, patients were divided into gastric feeding group and post-pyloric feeding group according to the distal site of nasoenteric tubes, and subgroup analysis was performed to evaluate the variety of VAP in patients with different tube sites and status. RESULTS:(1) Forty-two patients occurred VAP in 175 MV patients, and the incidence of VAP was 24.0%. (2) Univariate analysis showed the P value of post-pyloric feeding, APACHE II score, GCS score and bronchoscope treatment were less than 0.1, and post-pyloric feeding and GCS score in VAP group were significantly lower than those in non-VAP group [post-pyloric feeding: 19.0% (8/42) vs. 36.8% (49/133), GCS: 5 (3, 7) vs. 6 (4, 9), both P < 0.05]. Multivariate Logistic regression analysis indicated that post-pyloric feeding was independent protective factor [odds ratio (OR) = 0.360, 95% confidence internal (95%CI) = 0.151-0.857, P = 0.021] and bronchoscope treatment was the independent risk factor (OR = 2.210, 95%CI = 1.051-4.647, P = 0.036) for VAP. (3) The incidence of VAP was 28.8% (34/118), 0% (0/4), 8.3% (1/12), 26.7% (4/15), 22.2% (2/9) and 5.9% (1/17) respectively when tube tip in stomach, D1, D2, D3, D4 and jejunum confirmed by abdominal radiography. Post-pyloric feeding in each proportion seemed to present lower VAP rate compared with gastric feeding, however, no significant difference was found (all P > 0.05). (4) The incidence of VAP in post-pyloric feeding group was significantly lower than that in gastric feeding group [14.0% (8/57) vs. 28.8% (34/118), OR = 0.403, 95%CI = 0.173-0.941, P = 0.032]. Lower VAP rate appeared on patients with SOFA < 12 (OR = 0.392, 95%CI = 0.154-0.995, P = 0.044) and AGI grade ≥ II (OR = 0.086, 95%CI = 0.011-0.705, P = 0.006) fed by post-pyloric route according to the result of subgroup analysis stratified by age, gender, APACHE II score, SOFA score and AGI grade. CONCLUSIONS:Post-pyloric feeding would decrease the incidence of VAP in neurocritical care patients on MV.
10.3760/cma.j.issn.2095-4352.2019.08.011
The Clinical Importance of 21-Day Combined Parenteral and Enteral Nutrition in Active Inflammatory Bowel Disease Patients.
Nutrients
The aim of the study was to show the clinical magnitude of short-term feeding: enteral nutrition (EN) combined with parenteral nutrition (PN) in active Crohn's disease and ulcerative colitis patients. Among 122 eligible inflammatory bowel disease (IBD) patients, 65 met the inclusion criteria. Combined EN and PN was administered for 21 days, wherein over the first 3-5 days of treatment, trophic enteral nutrition (300 kcal/day) was used with an energy increase of up to 1500 kcal. An EN was administered using a nasogastric tube or, in case of intolerance, using a naso-jejunal tube. For PN, the "All in One" system was used according to individually prepared admixtures (ESPEN Guidelines). In addition to routine blood measurement (i.e., ALAT, ASPAT, GGTP, creatinine, lipid profile), the following parameters were assessed: adiponectin, leptin, (hs)TNF-α, hsIL-6 and hsIL-10, TSH, NT-proBNP, serum vitamin B12 concentration, and tHcy. The results showed a considerable improvement in all clinically significant parameters ( < 0.05), showing the benefits and importance of short-term well-balanced EN combined with PN for nutritional and clinical status in IBD patients with active disease. The daily work at hospitals with active IBD patients demonstrates the potential of continued administration of home-based nutrition by patients.
10.3390/nu11092246
Observation of inadvertent tube loss in ICU: effect of nasal bridles.
British journal of nursing (Mark Allen Publishing)
BACKGROUND:safe placement and securement of feeding tubes are essential to establishing early enteral nutrition. Nasogastric or nasojejunal feeding tubes are often inadvertently removed, and using a nasal bridle can reduce the number of tube replacements required. AIM:to review current nasal bridle practices on one intensive care unit. Over a 3-month period, nasal bridle use was recorded to measure unintentional tube loss and tube duration (the time a tube remained in situ). METHOD:an observational service evaluation. FINDINGS:109 patients were recruited; 205 tubes were passed and 77 bridles were inserted, with 42% (=46) of the bridles placed on day 1. Tubes secured with tape were more likely to be dislodged than tubes secured with a bridle, P=0.0001. Duration of tubes remaining in situ was significantly longer in patients who had a bridle fitted on day 1, P=0.0001 compared with tubes secured with tape. CONCLUSION:securing a tube with a nasal bridle from day 1 is independently associated with reduced tube loss, increased duration of tube use, and likelihood that the tube would reach redundancy when it was no longer required.
10.12968/bjon.2019.28.18.1170
Impact of Using a Novel Gastric Feeding Tube Adaptor on Patient's Comfort and Air Leaks During Non-invasive Mechanical Ventilation.
Quintero Oscar Ivan,Sanchez Alvaro Ignacio,Chavarro Paola Andrea,Casas Isabel Cristina,Ospina Tascón Gustavo Adolfo
Archivos de bronconeumologia
INTRODUCTION:The presence of oral or naso-enteral probes during non-invasive mechanical ventilation (NIMV) increases the risk of leakage and patient discomfort. The objective of this study was to evaluate the effectiveness of a novel tube adapter for NIMV (TA-NIMV) in relation to leakage and comfort level. METHODS:A non-randomized quasi-experimental design was performed in an adult intensive care unit of a highly complex hospital, in which patients were their own controls. We included adult patients who required NIV with oronasal mask and who simultaneously had oral or naso-enteric tubes. The interventions were as follows: every participant received two therapies, one with the TA-NIMV and one conventional therapy of NIMV (CT-NIMV). Comfort could be evaluated in 99 patients with a Glasgow Coma Scale of 15. The outcomes of interest was the average percentage of air leak and patient comfort during each intervention. RESULTS:196 patients were included in the study during a 16-month period. The mean air leak percentage was 9.2% [standard deviation (SD), 7.7] during TA-NIMV and 32.5% (SD, 12.5) during CT-NIMV (p<0.001). 84.9% reported being comfortable or very comfortable during TA-VMNI. 66.7% Uncomfortable or Very uncomfortable during CT-NIMV (p<0.001). CONCLUSION:Higher comfort levels and lower air leakage volume percentages were achieved using the TA-NIMV than those achieved by CT-NIMV.
10.1016/j.arbres.2019.10.002
A Simple Bed-side Method of Enteral Feeding through Distal Mucous Fistula in Patients with Short Bowel Syndrome to overcome Parenteral Dependency: The Jategaonkar Technique.
Jategaonkar Priyadarshan Anand,Yadav Sudeep Pradeep
Journal of the College of Physicians and Surgeons--Pakistan : JCPSP
Today, massive proximal small bowel resection with diverting stoma formation is a relatively common occurrence, especially in an emergency setting. However, the resultant short bowel syndrome remains difficult to manage on various nutritional fronts and commencing total parenteral nutrition, along with plethora of its associated complications, becomes almost obligatory for these unfortunate patients. In this context, the authors describe an innovative, yet, handy method of enteral feeding through distal mucous fistula using two commonly available tubes in the ward, with the aim to maximise the usage of the available gut and to outwit the ensuing need of parenteral supplementation, and name it the Jategaonkar technique. Backed with successful experience of 18 cases, it is especially useful in low-income countries and can be mastered readily even by junior doctors, paramedic staff, and stoma therapists or by patient's kin, alike. Such a procedure is yet to be reported in the available literature.
10.29271/jcpsp.2019.12.1212
Roux-en-Y Feeding Jejunostomy - The Preferred Surgical Option for Enteral Nutrition in Patients with Leaks or Fistula after Gastric Sleeve.
Copaescu Catalin,Smeu Bogdan,Habibi Mani
Chirurgia (Bucharest, Romania : 1990)
Leaks are rare complications of laparoscopic sleeve gastrectomy (LSG) but, they may cause significant and prolonged morbidity. Enteral nutrition is mandatory for the gastric leak or fistula therapy's success and the naso-jejunal tube (NJT) as well the loop feeding jejunostomy (LFJ) have some limitations and morbidities. We propose an alternative, the laparoscopic Roux-en-Y feeding jejunostomy (LRYFJ) to support the mid- and long-term nutritional need of the patients complicated with gastric leaks or fistulas. Aim: to investigate the laparoscopic Roux-en-Y feeding jejunostomy (LRFJ) and to evaluate the surgical technique, its efficiency and outcomes. The surgical steps of LRFJ are described in detail and the technical challenges are commented. The IRB approval was obtained for performing the LRYFJ in patients with gastric leaks or fistulas after LSG and to run the present study. All the patients who received LRYFJ in our center since 2015 were included into a prospective study. The patient's medical characteristics, as well the procedure's technical challenges and outcomes are analyzed. Six patients (4 females, 2 males; age 37.1 +- 11.5 years) who previously underwent LSG, were referred to our unit after the initial drainage for gastric leak in other institution and, LRYFJ was performed in all. Mean operative time was 127.5 +- 61.2 minutes. Mean duration of jejunal nutrition was 183.83 +- 128.2 days. No related mortality was encountered. Laparoscopic fistulo-jejunostomy was the definitive fistula treatment in five of the patients (83.3 %) while in one patient (16.6 %) the leak was spontaneously healed. Conclusion: Adequate nutritional support is mandatory for the gastric sleeve leak treatment. LRYFJ has many advantages over naso-jejunal tube and loop type feeding jejunostomy particularly in treatments of prolonged sleeve leaks or fistulas. Our experience demonstrates that LRYFJ can be implemented safely with the technique we described.
10.21614/chirurgia.114.6.798
Quality improvement programme reduces errors in oral medication preparation and administration through feeding tubes.
BMJ open quality
BACKGROUND:Patients with nasogastric/nasoenteric tube (NGT/NET) are at increased risk of adverse outcomes due to errors occurring during oral medication preparation and administration. AIM:To implement a quality improvement programme to reduce the proportion of errors in oral medication preparation and administration through NGT/NET in adult patients. METHODS:An observational study was carried out, comparing outcome measures before and after implementation of the integrated quality programme to improve oral medication preparation and administration through NGT/NET. A collaborative approach based on Plan-Do-Study-Act (PDSA) cycle was used and feedback was given during multidisciplinary meetings. INTERVENTIONS:Good practice guidance for oral medication preparation and administration through NGT/NET was developed and implemented at the hospital sites; nurses were given formal training to use the good practice guidance; a printed list of oral medications that should never be crushed was provided to all members of the multidisciplinary team, and a printed table containing therapeutic alternatives for drugs that should never be crushed was provided to prescribers at the prescribing room. RESULTS:Improvement was observed in the following measures: crushing enteric-coated tablets and mixing drugs during medication preparation (from 54.9% in phase I to 26.2% in phase II; p 0.0010) and triturating pharmaceutical form of modified action or dragee (from 32.8 in phase I to 19.7 in phase II; p 0.0010). Worsening was observed though in the following measures: crush compressed to a fine and homogeneous powder (from 7.4%% in phase I to 95% phase II; p 0.0010) and feeding tube obstruction (from 41.8% in phase I to 52.5% phase II; p 0.0950). CONCLUSION:Our results highlight how a collaborative quality improvement approach based on PDSA cycles can meet the challenge of reducing the proportion of errors in oral medication preparation and administration through NGT/NET in adult patients. Some changes may lead to unintended consequences though. Thus, continuous monitoring for these consequences will help caregivers to prevent poor patient outcomes.
10.1136/bmjoq-2019-000882
Soluble Dietary Fiber Reduces Feeding Intolerance in Severe Acute Pancreatitis: A Randomized Study.
Chen Ting,Ma Yuanyuan,Xu Lei,Sun Cheng,Xu Hongxia,Zhu Jingci
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:Feeding intolerance of enteral nutrition (EN) frequently occurs in patients with severe acute pancreatitis (SAP) because of intestinal motility disorders. Soluble dietary fiber (SDF) modulates the intestinal motility. The present study examined whether SDF can improve intestinal motility and permeability, and thereby reduce feeding intolerance, in patients with SAP. METHODS:This study was a single-blind, randomized, controlled, single-center trial. Forty-nine patients with SAP were included. The control and SDF groups received the same EN solution via a nasojejunal tube. The SDF group additionally received 20-g/d polydextrose. The primary outcome was the time to reach the energy goal. Follow-up was continued for 28 days after admission or until discharge from the hospital. RESULTS:Among 49 randomized patients, 46 patients (n = 22, control group; n = 24, SDF group) were included in the intent-to-treat analysis. The time to reach the energy goal was 7.00 (6.00, 8.25) days and 5.00 (4.25, 6.00) days in the control and SDF groups, respectively (P < 0.001). The rates of feeding intolerance were significantly reduced in the SDF group (59.09% vs 25.00%, P < .05). SDF was associated with decreases in the incidence of abdominal distension (72.73% vs 29.17%, P < .01), diarrhea (40.91% vs 8.33%, P < .05), and constipation (72.73% vs 12.50%, P < .001). The time to first flatus and first defecation were significantly shorter in the SDF group (P < .001). The intestinal mucosal barrier function and levels of gastrointestinal hormone were improved by SDF, as evidenced by significantly reduced blood levels of diamine oxidase, D-lactic acid, endotoxin, and vasoactive intestinal peptide (P < .05). CONCLUSIONS:SDF shortens the time to reach the energy goal during EN and improves intestinal permeability and motility disorders, thus reducing the incidence of feeding intolerance in SAP patients.
10.1002/jpen.1816
Acute Kidney Injury Caused by Superior Mesenteric Artery Syndrome.
Case reports in nephrology
BACKGROUND:Superior mesenteric artery (SMA) syndrome is a rare cause of upper gastrointestinal obstruction leading to acute kidney injury (AKI). METHODS:We report a case of 23-year-old army personnel who presented with persistent vomiting leading to severe hypokalaemia, metabolic alkalosis, and acute kidney injury resulting in cardiorespiratory arrest. RESULTS:After successful resuscitation, he was supported with haemodialysis and aggressive electrolytes correction. He was repeatedly not able to tolerate nasogastric (NG) tube feeding and computerised tomography of abdomen was performed, and the diagnosis of SMA syndrome was made. Gastroscopy examination revealed duodenal ulcer at D1, pinhole D1-D2 junction, but there was no evidence of intraluminal mass or lesions leading to upper gastrointestinal obstruction. A nasojejunal tube was inserted to bypass the narrow segment of the duodenum, and he was put on nutritional support. He was subsequently weaned off dialysis support as his renal function gradually improved and later on normalised. He remains symptoms free, and he gained five kilograms in four months after discharge. CONCLUSIONS:SMA syndrome is a rare cause of upper gastrointestinal obstruction but should be considered as a differential diagnosis in a patient who presented with recurrent vomiting and AKI with metabolic alkalosis.
10.1155/2020/8364176
An Ivor Lewis Esophagectomy Designed to Minimize Anastomotic Complications and Optimize Conduit Function.
Ramchandani Neal K,Kesler Kenneth A,Rogers Jonathon D,Valsangkar Nakul,Stokes Samatha M,Jalal Shadia I
Journal of visualized experiments : JoVE
We describe a novel esophagogastric anastomotic technique ("side-to-side: staple line-on-staple line", STS) for intrathoracic anastomoses designed to create a large diameter anastomosis while simultaneously maintaining conduit blood supply. This technique aims to minimize the incidence of anastomotic leaks and strictures, which is a frequent source of morbidity and occasional mortality after esophagectomy. We analyze the results of this STS technique on 368 patients and compared outcomes to 112 patients who underwent esophagogastric anastomoses using an end-to-end stapler (EEA) over an 8-year time interval at our institution. The STS technique involves aligning the remaining intrathoracic esophagus over the tip of the lesser curve staple line of a stomach tube, created as a replacement conduit for the esophagus. A linear stapling device cuts through and restaples the conduit staple line to the lateral wall of the esophagus in a side-to-side fashion. The open common lumen is then closed in two layers of sutures. There was a total of 12 (3.8%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis. Two of eight patients (25%) had anastomotic leaks after esophagectomy for end-stage achalasia as compared to a 2.8% leak rate (10/336) after esophagectomy for other conditions. Eighteen (5.2%) patients required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of patients undergoing STS anastomoses following hospital discharge. In contrast, patients undergoing EEA anastomoses demonstrated anastomotic leak and stricture rates of 16.1% and 14.3% respectively (p<0.01). Time analysis of postoperative contrast studies following the STS technique typically demonstrated a straight/uniform diameter conduit with essentially complete contrast emptying into the small bowel within 3 minutes in 88.4% of patients. The incidence of esophagogastric anastomotic leaks and strictures were extremely low using this novel anastomotic technique. Additionally we believe that based on time and qualitative analyses of postoperative contrast studies, this technique appears to optimize postoperative upper gastrointestinal tract function; however, further comparative studies are needed.
10.3791/59255
Chyme Reinfusion in Intestinal Failure Related to Temporary Double Enterostomies and Enteroatmospheric Fistulas.
Picot Denis,Layec Sabrina,Seynhaeve Eloi,Dussaulx Laurence,Trivin Florence,Carsin-Mahe Marie
Nutrients
Some temporary double enterostomies (DES) or entero-atmospheric fistulas (EAF) have high output and are responsible for Type 2 intestinal failure. Intravenous supplementations (IVS) for parenteral nutrition and hydration compensate for intestinal losses. Chyme reinfusion (CR) artificially restores continuity pending surgical closure. CR treats intestinal failure and is recommended by European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN) when possible. The objective of this study was to show changes in nutritional status, intestinal function, liver tests, IVS needs during CR, and the feasibility of continuing it at home. A retrospective study of 306 admitted patients treated with CR from 2000 to 2018 was conducted. CR was permanent such that a peristaltic pump sucked the upstream chyme and reinfused it immediately in a tube inserted into the downstream intestine. Weight, plasma albumin, daily volumes of intestinal and fecal losses, intestinal nitrogen, and lipid absorption coefficients, plasma citrulline, liver tests, and calculated indices were compared before and during CR in patients who had both measurements. The patients included 185 males and 121 females and were 63 ± 15 years old. There were 37 (12%), 269 (88%) patients with EAF and DES, respectively. The proximal small bowel length from the duodeno-jejunal angle was 108 ± 67 cm ( = 232), and the length of distal small intestine was 117 ± 72 cm ( = 253). The median CR start was 5 d (quartile 25-75%, 2-10) after admission and continued for 64 d (45-95), including 81 patients at home for 47 d (28-74). Oral feeding was exclusive 171(56%), with enteral supplement 122 (42%), or with IVS 23 (7%). Before CR, 211 (69%) patients had IVS for nutrition (77%) or for hydration (23%). IVS were stopped in 188 (89%) 2 d (0-7) after the beginning of CR and continued in 23 (11%) with lower volumes. Nutritional status improved with respect to weight gain (+3.5 ± 8.4%) and albumin (+5.4 ± 5.8 g/L). Intestinal failure was cured in the majority of cases as evidenced by the decrease in intestinal losses by 2096 ± 959 mL/d, the increase in absorption of nitrogen 32 ± 20%, of lipids 43 ± 30%, and the improvement of citrulline 13.1 ± 8.1 µmol/L. The citrulline increase was correlated with the length of the distal intestine. The number of patients with at least one liver test >2N decreased from 84-40%. In cases of Type 2 intestinal failure related to DES or FAE with an accessible and functional distal small bowel segment, CR restored intestinal functions, reduced the need of IVS by 89% and helped improve nutritional status and liver tests. There were no vital complications or infectious diarrhea described to date. CR can become the first-line treatment for intestinal failure related to double enterostomy and high output fistulas.
10.3390/nu12051376
Comparison of Feeding Efficiency and Hospital Mortality between Small Bowel and Nasogastric Tube Feeding in Critically Ill Patients at High Nutritional Risk.
Nutrients
Nasogastric tube enteral nutrition (NGEN) should be initiated within 48 h for patients at high nutritional risk. However, whether small bowel enteral nutrition (SBEN) should be routinely used instead of NGEN to improve hospital mortality remains unclear. We retrospectively analyzed 113 critically ill patients with modified Nutrition Risk in Critically Ill (mNUTRIC) score ≥ 5 and feeding volume < 750 mL/day in the first week of their stay in the intensive care unit (ICU). Age, sex, mNUTRIC score, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score were matched in the SBEN ( = 48) and NGEN ( = 65) groups. Through a univariate analysis, factors associated with hospital mortality were SBEN group (hazard ratio (HR), 0.56; 95% confidence interval (CI), 0.31-1.00), Simplified Organ Failure Assessment (SOFA) score on day 7 (HR, 1.12; 95% CI, 1.03-1.22), and energy intake achievement rate < 65% (HR, 2.53; 95% CI, 1.25-5.11). A multivariate analysis indicated that energy intake achievement rate < 65% on the third follow-up day (HR, 2.29; 95% CI, 1.12-4.69) was the only factor independently associated with mortality. We suggest initiation of SBEN on the seventh ICU day before parenteral nutrition initiation for critically ill patients at high nutrition risk.
10.3390/nu12072009
Complications of feeding jejunostomy placement: a single-institution experience.
Okida Luis Felipe,Salimi Tara,Ferri Francisco,Henrique Juliana,Lo Menzo Emanuele,Szomstein Samuel,Rosenthal Raul J
Surgical endoscopy
BACKGROUND:Feeding jejunostomy is an alternative route of enteral nutrition in patients undergoing major gastrointestinal operations when a feeding gastrostomy is not suitable. METHODS:A single institution review of patients who underwent open or laparoscopic jejunostomy tube (JT) placement between 2009 and 2019 was performed. Data collected included demographics, preoperative serum albumin, surgery indication, concomitancy of procedure, size of JT tube and time to its removal. JT complications were analyzed in the early postoperative period (< 30 days) and in a long-term follow-up (> 30 days). The Chi-square test was used to compare rates of complications according to tube size. RESULTS:Seventy-three patients underwent JT placement, and gastroesophageal cancer (n = 48, 65.7%) was the most common indication. The JT was most frequently placed concomitantly (n = 56, 76.7%) to the primary operation and through a laparoscopic approach (n = 66, 90.4%). A total of 14 patients (19.1%) had early complications and 15 had late complications (20.5%). The reasons for early complications were clogged JT (n = 8, 10.9%), JT dislodgement (n = 3, 4.1%), leakage (n = 2, 2.7%), small bowel obstruction adjacent to the site of the jejunostomy tube (n = 2, 2.7%), JT site infection (n = 1, 1.3%), and intraperitoneal JT displacement (n = 1, 1.3%). The reasons for late complications were clogged JT (n = 6, 8.2%), JT dislodgement (n = 6, 8.2%), JT site infection (n = 3, 4.1%), and JT leakage (n = 1, 1.3%). There was no procedure-related mortality in this series. However, 12 patients (16.4%) died due to their baseline disease. The mean time to tube removal was 83.4 ± 93.6 days. The most frequently used JT size was 14 French (n = 39, 53.4%) but in nine patients the tube size was not reported. No statistical significance (p = 0.75) was found when comparing the two most commonly used sizes to rates of complications. CONCLUSION:The rate of JT complications in our study is comparable to other published reports in literature. As an alternative route for nutritional status optimization, the procedure appears to be safe despite the number of complications.
10.1007/s00464-020-07787-y
The Optimal Feeding Enterostomy Creation During Esophagectomy to Reduce the Long-Term Risk of Small Bowel Obstruction.
Otake Reiko,Okamura Akihiko,Kanamori Jun,Takahashi Keita,Ushida Yuta,Imamura Yu,Mine Shinji,Watanabe Masayuki
World journal of surgery
BACKGROUND:Although feeding jejunostomy (FJ) is commonly created during esophagectomy for postoperative enteral nutrition, it can be a cause of postoperative small bowel obstruction (SBO). We introduced a technique of feeding enterostomy using the round ligament of the liver (FERL) to reduce SBO. In this study, we aimed to clarify the efficacy of FERL in reducing the postoperative SBO compared with FJ. METHODS:We assessed 400 consecutive patients who underwent esophagectomy with gastric tube reconstruction between 2011 and 2016, before and after the introduction of FERL (FJ, n = 200; FERL, n = 200). The cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy were compared between the FJ and the FERL groups. RESULTS:Thoracoscopic and laparoscopic surgery was more frequent in the FERL group than in the FJ group (p < 0.001). The cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy in the FERL group were significantly less frequent than those in the FJ group (p < 0.001 and p = 0.006, respectively). When stratifying by the abdominal surgical approach, the cumulative incidences of postoperative SBO and SBO associated with feeding enterostomy in a laparoscopic approach were less frequent in the FERL group than those in the FJ group (both p < 0.001). CONCLUSIONS:The FERL technique can reduce the incidences of postoperative SBO and SBO associated with feeding enterostomy in patients undergoing esophagectomy.
10.1007/s00268-020-05701-0
Feeding jejunostomy in upper gastrointestinal resections: a UK-wide survey.
Ireland P,Jaunoo S
Annals of the Royal College of Surgeons of England
INTRODUCTION:The usage of a feeding jejunostomy has been a well-established practice in maintaining nutrition in patients undergoing resections for upper gastrointestinal cancer. As surgical technique has evolved, together with the adoption of enhanced recovery after surgery pathways, the routine insertion of feeding jejunostomy tubes appears to be changing. MATERIALS AND METHODS:A survey was constructed using Google Forms. The link was distributed to consultant upper gastrointestinal surgeons via the Association of Upper Gastrointestinal Surgeons' membership database. Results were collated and analysed using Microsoft Excel. RESULTS:A total of 55 responses were received from 28 units across the UK; 27 respondents (49.1%) no longer routinely use feeding jejunostomy in upper gastrointestinal resections, oesophagectomy or gastrectomy. The most common primary feeding modality used by these respondents was oral diet 17 (65.4%), with total parenteral nutrition (19.2%) and nasojejunal (11.5%) routes also being used. Respondents who used feeding jejunostomies inserted them primarily for oesophagectomy ( = 27; 96.4%), with fewer surgeons using them in extended total gastrectomy ( = 12; 42.9%) and total gastrectomy ( = 11; 39.3%). Of the total, 20 surgeons (71.4%) would insert the jejunostomy using an open approach, with 19 (67.9%) employing a Witzel tunnel. Eleven respondents (39.3%) would continue feeding via the jejunostomy after discharge. Some 24 responders thought that feeding jejunostomies did not facilitate the enhanced recovery after surgery pathway (strongly and slightly disagree), whereas 17 considered that they did (strongly and slightly agree); 13 responders did not have strong views either way. CONCLUSIONS:There is a split in current practice regarding the usage of feeding jejunostomies. There is also a division of opinion on the role of feeding jejunostomy in enhanced recovery after surgery.
10.1308/rcsann.2020.0153
Nutrition and Gastrointestinal Dysmotility in Critically Ill Burn Patients: A Retrospective Observational Study.
Sierp Emma Louise,Kurmis Rochelle,Lange Kylie,Yandell Rosalie,Chapman Marianne,Greenwood John,Chapple Lee-Anne S
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:Gastrointestinal (GI) dysmotility impedes nutrient delivery in critically ill patients with major burns. We aimed to quantify the incidence, timing, and factors associated with GI dysmotility and subsequent nutrition delivery. METHODS:A 10-year retrospective observational study included mechanically ventilated, adult, critically ill patients with ≥15% total body surface area (TBSA) burns receiving nutrition support. Patients with a single gastric residual volume ≥250 mL were categorized as having GI dysmotility. Daily medical and nutrition data were extracted for ≤14 days in the intensive care unit (ICU). Data are mean (SD) or median (interquartile range). Factors associated with GI dysmotility and the effect on nutrition and clinical outcomes were assessed. RESULTS:Fifty-nine patients were eligible; 51% (n = 30) with GI dysmotility and 49% (n = 29) without. Baseline characteristics (dysmotility vs no dysmotility) were age (48 [33-60] vs 34 [26-46] years); Acute Physiology and Chronic Health Evaluation II score (16 [12-17] vs 13 [10-16]); sex ([men] 80% vs 86%); and TBSA (49% [35%-59%] vs 38% [26%-55%]). Older age was associated with increased probability of dysmotility (P = .049). GI dysmotility occurred 32 (19-63) hours after ICU admission but was not associated with reduced nutrient delivery. Postpyloric tube insertions were attempted in 83% (n = 25) of patients, with 72% (n = 18) being successful. Postpyloric feeding achieved higher nutrition adequacy than gastric feeding (energy: 82% [95% CI, 70-94] vs 68% [95% CI, 63-74], P = .036; protein: 75% [95% CI, 65-86] vs 61% [95% CI, 56-65], P = .009). CONCLUSION:GI dysmotility occurs early in critically ill burn patients, and postpyloric feeding improves nutrition delivery.
10.1002/jpen.1979
Nonocclusive mesenteric ischemia associated with postoperative jejunal tube feeding: Indicators for clinical management.
Albrecht Hendrik Christian,Trawa Mateusz,Gretschel Stephan
The Journal of international medical research
Postoperative nutrition via a jejunal tube after major abdominal surgery is usually well tolerated. However, some patients develop nonocclusive mesenteric ischemia (NOMI). This morbid complication has a grave prognosis with a mortality rate of 41% to 100%. Early symptoms are nonspecific, and no treatment guideline is available. We reviewed cases of NOMI at our institution and cases described in the literature to identify factors that impact the clinical course. Among five patients, three had no necrosis and one had segmental necrosis and perforation. These patients recovered with limited resection and decompression of the bowel and abdominal compartment. In one patient with extended bowel necrosis at the time of re-laparotomy, NOMI progressed and the patient died of multiple organ failure. The extent of small bowel necrosis at the time of re-laparotomy is a relevant prognostic factor. Therefore, early diagnosis and treatment of NOMI can improve the prognosis. Clinical symptoms of abdominal distension, cramps and high reflux plus paraclinical signs of leukocytosis, hypotension and computed tomography findings of a distended small bowel with pneumatosis intestinalis and portal venous gas can help to establish the diagnosis. We herein introduce an algorithm for the diagnosis and management of NOMI associated with jejunal tube feeding.
10.1177/0300060520929128
Factors associated with insufficient nasogastric tube visibility on X-ray: a retrospective analysis.
European radiology
OBJECTIVES:Chest X-ray imaging is frequently used for verifying the position of a blindly inserted nasogastric tube. A high-quality X-ray increases the likelihood of conclusive visibility of tube tip positioning, thus avoiding risks due to a misplaced tube (e.g., pulmonary intubation, pneumothorax, small bowel insertion). Therefore, this study aims to determine patient-related and environmental factors affecting the visibility of nasogastric tubes on X-ray in adults. METHODS:A retrospective descriptive analysis of routinely collected clinical data was performed on all included patients (N = 215) from a prospective randomized trial in a general hospital. A chest X-ray was taken of each patient needing a nasogastric feeding tube, after which visibility and positioning of the tube on X-ray was independently evaluated by 3 radiologists. RESULTS:In 14.9% (n = 32) of all patients, image quality was insufficient, so no conclusive visibility of nasogastric tube positioning could be found. A patient-related predictor regression model (sex, age, body mass index) explained 21% of variance for an insufficient visibility of the nasogastric tube (Nagelkerke R = 0.21). An environmental factor regression model demonstrates a guidewire being inside the tube or not during X-ray as a predictor for a conclusive visibility on X-ray. CONCLUSIONS:High body mass index, male sex, and the absence of a guidewire inside the nasogastric tube at the time of chest X-ray are associated with a risk of insufficient visibility of the tube on X-ray. Patient profiles can be defined in which supplementary attention is needed when obtaining chest X-rays whose purpose is to confirm nasogastric tube positioning. KEY POINTS:• The quality of chest X-rays to confirm the positioning of nasogastric tubes in adults can be improved considerably. • There are several factors influencing the confirmation of nasogastric tube positioning on X-ray. • Defining patient profiles at risk for an insufficient visibility of the tube on X-ray will indirectly contribute to an improvement of the chest X-ray quality.
10.1007/s00330-020-07302-w
Equal efficacy of gastric and jejunal tube feeding in liver cirrhosis and/or alcoholic hepatitis: a randomised controlled study.
Bager Palle,Olesen Lene,Baltzer Rikke L,Borre Mette,Aagaard Niels K
British journal of nursing (Mark Allen Publishing)
BACKGROUND AND AIM:Malnutrition and muscle mass loss are complications in liver cirrhosis and alcoholic hepatitis (AH). Hospitalised patients who do not meet nutritional requirements are recommended to be fed enterally or parenterally, but no guidelines recommend a specific type of tube. This study aimed to compare the efficacy of jejunal versus gastric feeding. METHOD:40 inpatients with liver cirrhosis and/or AH, a nutritional risk score more than 2 and a reduced daily energy intake were included. Half were randomised to nasogastric (NG) and half to nasojejunal (NJ) tube feeding. All received Peptamen AF as a supplement to oral intake. Participants were followed up until discharge or death. FINDINGS:The study evaluated the data for 33 patients for 7 days after tube insertion. Mean daily energy intake for 7 days was 6509 kJ (NG) vs 6605kJ (NJ) (=0.90). Tubes accidently removed by patients: once (=16); twice (=9); three times (=6), with no differences between NG and NJ. CONCLUSION:There were no significant differences in total nutritional intake between early NG feeding and early NJ feeding 7 days after tube insertion. The number of tube replacements was similar in both groups. Choice of tubes for patients with severe liver disease will depend on individual patient characteristics and needs and local facilities.
10.12968/bjon.2020.29.20.1148
Percutaneous Endoscopic Jejunostomy Tube Placement for Treatment of Severe Hyperemesis Gravidarum in Pregnancy.
Kruchko David,Shah Natasha,Broy Charles,Silas Dean
Journal of investigative medicine high impact case reports
Hyperemesis gravidarum is a common disease. Most patients are effectively treated with conservative measures, but gastric feeding and, rarely, post-pyloric feeding can be necessary. A 27-year-old woman, G3P2002, with a history of refractory hyperemesis in previous pregnancies, required placement of a nasojejunal tube but was removed due to an oropharyngeal ulcer. Endoscopic placement of a percutaneous endoscopic transgastric-jejunostomy (PEG-J) tube caused resolution of her symptoms. Twelve days after placement, the distal tube became dislodged and was endoscopically replaced with hemoclip anchoring in the jejunum. PEG-J tube placement is a safe and effective option for nutritional support in refractory hyperemesis gravidarum.
10.1177/2324709620975954
Primary gastrojejunostomy tube placement using laparoscopy with endoscopic assistance: A novel technique.
Gerall Claire,Mencin Ali-Andre,DeFazio Jennifer,Griggs Cornelia,Kabagambe Sandra,Duron Vincent
Journal of pediatric surgery
BACKGROUND:Gastrojejunostomy (GJ) tubes are commonly used to provide postpyloric enteral nutrition in pediatric patients who cannot tolerate gastric feeds. Most techniques depend on a preexisting gastrostomy tube (GT) site to convert to a gastrojejunostomy. Several minimally invasive techniques have been described; however, their risk profile varies widely. DESCRIPTION OF THE OPERATIVE TECHNIQUE:We present a technique for primary laparoscopic GJ tube placement that minimizes the risk of hollow viscus injury and the use of fluoroscopy through endoscopic assistance. RESULTS:Eleven GJ tubes were placed using this technique in patients ranging from 5 months to 17 years of age and weighing 6.3 to 46.0 kg. Endoscopy through the gastrostomy site allowed direct visualization of wire and tube placement. There were no intraoperative or postoperative complications within 30 days of operation. Use of fluoroscopy was limited with minimal total radiation exposure. CONCLUSION:The described technique of laparoscopic primary gastrojejunostomy tube placement with endoscopic assistance was associated with a low complication rate and minimal use of fluoroscopy. LEVEL OF EVIDENCE:IV.
10.1016/j.jpedsurg.2020.10.012
Gastrointestinal Tract: A Neglected Guardian Angel?
Kothekar Amol T,Kulkarni Atul P
Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine
Role of the gastrointestinal (GI) system is not limited to the digestion of food and absorption of water and nutrients. Gastrointestinal mucosa forms a barrier preventing translocation of microbes into the blood. Upper GI tract performs important function of swallowing and prevention of aspiration, failure of which mandates enteral tube feeding. Rate of gastric emptying depends on gastric volume and contents and delayed emptying is observed both in solid and in fatty food. Cricoid pressure during intubation is an important intervention for prevention of aspiration in critically ill patients who are considered as full stomach. To utilize mucosal barrier function optimally, hemodynamically stable patients should preferably receive enteral nutrition even if they are on small doses of vasopressors. Post-pyloric feeds may reduce risk of aspiration and hence are recommended for patients who are deemed to have high risk for aspiration. Bowel sounds have poor reproducibility, sensitivity, specificity, accuracy, and interobserver agreement, and absent bowel sounds should not be considered as a contraindication to enteral feeding. Kothekar AT, Kulkarni AP. Gastrointestinal Tract: A Neglected Guardian Angel? Indian J Crit Care Med 2020;24(Suppl 4):S146-S151.
10.5005/jp-journals-10071-23616
Post-Operative Superior Mesenteric Artery Syndrome Following Retroperitoneal Sarcoma Resection.
Wong Liam H,Sutton Thomas L,Spurrier Ryan G,Zigman Andrew F,Mayo Skye C
Clinics and practice
Superior mesenteric artery (SMA) syndrome is an uncommon phenomenon caused by the compression of the third portion of the duodenum between the aorta and the SMA. Here, we present a previously healthy 15-year-old male who presented with early satiety and 20 kg weight loss. Computed tomography (CT) demonstrated a massive retroperitoneal liposarcoma displacing the entire small intestine into the right upper quadrant. Following resection of the large mass, the patient was intolerant of oral intake despite evidence of bowel function. Abdominal CT revealed a narrowing of the duodenum at the location of the SMA. A nasojejunal feeding tube was placed past this area, and enteral nutrition was initiated before slowly resuming oral intake. Post-operative SMA syndrome is an uncommon complication but should be considered in patients intolerant of oral intake following resection of large abdominal tumors associated with extensive retroperitoneal fat loss, even in the absence of concomitant major visceral resection.
10.3390/clinpract11010002
Postprandial rise of essential amino acids is impaired during critical illness and unrelated to small-intestinal function.
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:Postprandial rise of plasma essential amino acids (EAAs) determines the anabolic effect of dietary protein. Disturbed gastrointestinal function could impair the anabolic response in critically ill patients. Aim was to investigate the postprandial EAA response in critically ill patients and its relation to small-intestinal function. METHODS:Twenty-one mechanically ventilated patients and 9 healthy controls received a bolus containing 100 ml of a formula feed (Ensure) and 2 g of 3-O-Methyl-d-glucose (3-OMG) via postpyloric feeding tube. Fasting and postprandial plasma concentrations of EAAs, 3-OMG, total bile salts, and the gut-released hormone fibroblast growth factor 19 (FGF19) were measured over a 4-hour period. Changes over time and between groups were assessed with linear mixed-effects analysis. Early (0-60 minutes) and total postprandial responses are summarized as the incremental area under the curve (iAUC). RESULTS:At baseline, fasting EAA levels were similar in both groups: 1181 (1055-1276) vs 1150 (1065-1334) μmol·L-1, P = .87. The early postprandial rise in EAA was not apparent in critically ill patients compared with healthy controls (iAUC , -4858 [-6859 to 2886] vs 5406 [3099-16,853] µmol·L ·60 minutes; P = .039). Impaired EAA response did not correlate with impaired 3-OMG response (Spearman ρ 0.32, P = .09). There was a limited increase in total bile salts but no relevant FGF19 response in either group. CONCLUSION:Postprandial rise of EAA is blunted in critically ill patients and unrelated to glucose absorption measured with 3-OMG. Future studies should aim to delineate governing mechanisms of macronutrient malabsorption.
10.1002/jpen.2103
Primary contributors to gastrostomy tube placement in infants with Congenital Diaphragmatic Hernia.
Fleming Hannah,Dempsey Allison G,Palmer Claire,Dempsey Jack,Friedman Sandra,Galan Henry L,Gien Jason
Journal of pediatric surgery
OBJECTIVE:To identify factors associated with gastrostomy tube (GT) placement in infants with congenital diaphragmatic hernia (CDH). METHODS:Retrospective cohort study of 114 surviving infants with CDH at a single tertiary care neonatal intensive care unit from 2010-2019. Prenatal, perinatal and postnatal characteristics were compared between patients who were discharged home with and without a GT. Prenatal imaging was available for 50.9% of the cohort. Logistic regression was used to assess the association between GT placement and pertinent clinical factors. ROC curves were generated, and Youden's J statistic was used to determine optimal predictive cutoffs for continuous variables. Elastic net regularized regression was used to identify variables associated with GT placement in multivariable analysis. RESULTS:GT was placed in 43.9% of surviving infants with CDH. Prenatal variables predictive of GT placement were percent predicted lung volume (PPLV) <21%, total lung volume (TLV) <30 ml, lung-head ratio (LHR) <1.2 or observed to expected LHR (O/E LHR) <55%. Infants who required a GT were diagnosed earlier prenatally (23.6 ± 3.4 vs. 26.4 ± 5.6 weeks). Patients whose stomach was above the diaphragm on prenatal ultrasound (up) had a higher odds of GT placement compared to those with stomachs below the diaphragm (down) position by a factor of 2.9 (95% CI: 1.25, 7.1); p = 0.0154. Postnatally, infants with GT had lower Apgar scores at 1 and 5 min, longer lengths of stay and higher proportion of flap closures. Infants with a type C or D defect and extracorporeal membrane oxygenation (ECMO) were associated with increased odds of needing a GT. Postnatal association included being NPO for >12 days, need for transpyloric (TP) feeds for >10 days, >14 days to transition to a 30 min bolus feed, presence of gastro-esophageal reflux (GER), chronic lung disease and pulmonary hypertension. In multivariable analysis, duration of NPO, time to TP feeds, transition to 30 min bolus feeds remained significantly associated with GT placement after adjusting for severity of pulmonary hypertension (PH), GER diagnosis and sildenafil treatment. CONCLUSION:Identification of risk factors associated with need for long-term feeding access may improve timing of GT placement and prevent prolonged hospitalization related to feeding issues. LEVEL OF EVIDENCE RATING:Level II (Retrospective Study).
10.1016/j.jpedsurg.2021.02.015
[Effect of electroacupuncture at Zusanli (ST36) and Zhongwan (CV12) on intestinal nutritional feeding intolerance in patients with severe acute pancreatitis].
Ma Liu-Yi,Liu Qian-Qian,Wu Lei,Gao Min,Yin Ze-Yu
Zhen ci yan jiu = Acupuncture research
OBJECTIVE:To observe the effect of electroacupuncture (EA) of Zusanli(ST36) and Zhongwan (CV12) on intestinal nutritional feeding intolerance in patients with severe acute pancreatitis (SAP). METHODS:A total of 68 SAP patients (hospitalized from January of 2018 to December of 2019 in Cangzhou Hospital of Integrated Medicine) were randomly divided into control and EA groups (=34 cases in each group). All patients of the two groups received the same early enteral nutrition treatment through nasojejunal tube. EA (5-15 Hz, 1-5 mA) was applied to bilateral ST36 and CV12 for 20 min, twice a day for 7 days. The incidence of feeding intolerance (abdominal distension, vomiting, diarrhea, constipation, gastrointestinal bleeding), time to reach energy target, intraperitoneal pressure and the number of borborygmus in 1 min were recorded. The contents of plasma high sensitivity -C reactive protein (hs-CRP), IL-6 and endotoxin were measured using Latex immunoturbidimetric method, chemiluminescence and Tachypiens Amebocyte Lysate Azo substrate color development method, respectively, and the contents of urinary lactulose and mannitol detected using high-performance liquid chromatography. The total protein and albumin levels in the blood were measured for assessing the patients' nutrition status, and acute physiology and chronic health evaluation scoring system (APACHE-Ⅱ) score was determined for assessing the severity of disease. RESULTS:Compared with the control group, the incidence of abdominal distension, vomiting and constipation, intolerance rate to feeding, time to reach the energy target, intraperitoneal pressure on day 7, inflammatory indexes, hs-CRP, IL-6, endotoxin, urine L/M on day 4 and 7, and the APACHE Ⅱ score on day 7 were significantly lower (<0.01), and the number of borborygmus in 1 min on day 4 and 7 after the treatment was significantly higher in the EA group (<0.01). In comparison with pretreatment, the abdominal pressure and plasma endotoxin level on day 4 and 7, hs-CRP, IL-6 and L/M ratio on day 1, 4 and 7, as well as APACHE Ⅱ score on day 7 after the treatment were significantly decreased in the two groups (<0.01), and the number of borborygmus on day 4 and 7, and the total protein and albumin on day 7 significantly increased in both the control and EA groups (<0.01). CONCLUSION:EA of ST36 and CV12 can shorten the time to reach the energy target, reduce inflammatory response, improve the intestinal mucosal barrier function, and thus reduce the incidence of feeding intolerance in SAP patients.
10.13702/j.1000-0607.200463
Endoscopic Approaches to Gastroparesis.
Liu Kevin,Enke Thomas,Aadam Aziz
Gastroenterology & hepatology
Gastroparesis is a complex syndrome with multiple underlying etiologies and pathophysiologies that can cause significant morbidity for patients. Currently, there are limited effective and durable medical and surgical treatments for patients with gastroparesis. As such, there has been recent innovation and development in minimally invasive endoscopic treatments for gastroparesis. Endoscopic therapies that have been investigated for gastroparesis include enteral feeding tube placement, intrapyloric botulinum toxin injection, transpyloric stenting, gastric peroral endoscopic myotomy, and gastric electrical stimulation. This article aims to assess the effectiveness of current endoscopic therapies, as well as discuss future directions for endoscopic therapies, in the management of gastroparesis.
Jejunoileal Atresia: A National Cohort Study.
Schmedding Andrea,Hutter Martin,Gfroerer Stefan,Rolle Udo
Frontiers in pediatrics
Jejunoileal atresia (JIA) is a rare disease. We aimed to determine the overall incidence of this malformation and associated malformations in a national cohort. Furthermore, we compared the treatment results of this cohort with the current literature. Data from the major health insurance company, which covers ~30% of the German population, were analyzed. All patients with ICD-10-Code Q41.1-9 (atresia of jejunum, ileum, other parts and not designated parts of the small bowel) who underwent any surgical procedure for small bowel were analyzed in a 10-year period between 2007 and 2016. A total of 435 patients were included in the study. The incidence was 2.1 per 10,000 live births. The male:female ratio was 1:2. Sixty-four percent were premature, 21% had associated cardiac anomalies, 16% had abdominal wall defects, 7% had urogenital malformations, and 7% had cystic fibrosis. Sixty percent of all patients with jejunoileal atresia, 57% of patients with accompanying abdominal wall defects and 72% of patients with associated cystic fibrosis required ostomy as the initial procedure. In 25% of all patients, only one intestinal operation was coded. In 39% of patients, two operations were coded. Twelve percent of all patients required feeding gastrostomy or jejunostomy. Sixteen percent of all patients presented with liver-related complications, i.e., cholestasis or liver insufficiency. Six patients underwent an intestinal lengthening procedure (2 Bianchi, 4 STEP). In five patients, initial lengthening was performed within 1 year after the first intestinal operation. Mortality until 1 year after initial surgery was 5%. Of those who died, 88% were premature, 34% had cardiac anomalies and 16% had abdominal wall defects. None had cystic fibrosis. Patients with ostomy significantly more often needed operative central venous line or operative feeding tube. Short bowel was coded significantly more often in these patients. Patients with JIA present with low mortality. The rate of ostomies is higher than in literature. To give clinical recommendations for the initial surgical approach, further clinical research is needed.
10.3389/fped.2021.665022
A European survey on the practice of nutritional interventions in head-neck cancer patients undergoing curative treatment with radio(chemo)therapy.
Bozzetti Federico,Gurizzan Cristina,Lal Simon,Van Gossum Andre',Wanten Geert,Golusinski Wojciech,Hosal Sefik,Bossi Paolo
European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery
PURPOSE:As the practice of nutritional support in patients with head and neck cancer (HNC) during curative radio(chemo)therapy is quite heterogeneous, we carried out a survey among European specialists. METHODS:A 19-item questionnaire was drawn up and disseminated via the web by European scientific societies involved in HNC and nutrition. RESULTS:Among 220 responses, the first choice was always for the enteral route; naso-enteral tube feeding was preferred to gastrostomy in the short term, while the opposite for period longer than 1 month. Indications were not solely related to the patient's nutritional status, but also to the potential burden of the therapy. CONCLUSION:European HNC specialists contextualize the use of the nutritional support in a comprehensive plan of therapy. There is still uncertainty relating to the role of naso-enteral feeding versus gastrostomy feeding in patients requiring < 1 month nutritional support, an issue that should be further investigated.
10.1007/s00405-021-06920-4
Effect of a Novel, Energy-Dense, Low-Volume Nutritional Food in the Treatment of Superior Mesenteric Artery Syndrome.
Akashi Tetsuro,Hashimoto Risa,Funakoshi Akihiro
Cureus
Superior mesenteric artery syndrome (SMAS) is an intermittent or persistent passage obstruction that occurs in the third portion of the duodenum between the aorta and the superior mesenteric artery. After symptoms stabilize, the nutritional intake is started by ingesting a small amount. Recently, an energy-dense, low-volume nutritional food, Terumeal uplead (Terumo Corporation, Tokyo, Japan) with an energy density of 4.0 kcal/mL, was launched. We report a case of a postoperative SMAS patient who was successfully treated using Terumeal uplead through gastrostomy. An 83-year-old man who developed adhesive intestinal obstruction underwent right hemicolectomy, lysis of adhesion, and partial small bowel resection. Gastric distension persisted after surgery; thus, gastrostomy was performed for decompression and enteral nutrition on the 21st postoperative day, and enteral feeding was started on the 23rd postoperative day. However, fluoroscopy showed obstruction in the third portion of the duodenum, which was considered to be SMAS. To reduce the administration volume, enteral nutrition was replaced with Terumeal uplead from the 28th postoperative day (intermittent administration thrice a day, 300 mL, 1,200 kcal per day). From the 34th postoperative day, the gastrostomy tube was clamped for two hours after administration, and no drainage was observed. Oral intake was resumed from the 36th postoperative day, and it was used in combination with enteral nutrition. Three months later, the patient was discharged home and continued oral ingestion with occasional decompression from the gastrostomy tube. Thus, Terumeal uplead may be useful during the conservative treatment of SMAS by initiation with small amounts.
10.7759/cureus.15243
Digestion-Specific Acupuncture Effect on Feeding Intolerance in Critically Ill Post-Operative Oral and Hypopharyngeal Cancer Patients: A Single-Blind Randomized Control Trial.
Ben-Arie Eyal,Wei Tzu-Hsuan,Chen Hung-Chi,Huang Tsung-Chun,Ho Wen-Chao,Chang Chiu-Ming,Kao Pei-Yu,Lee Yu-Chen
Nutrients
Malnourishment is prevalent in patients suffering from head and neck cancer. The postoperative period is crucial in terms of nutritional support, especially after composite resection and reconstruction surgery. These patients present with a number of risk factors that aggravate feeding intolerance, including postoperative status, prolonged immobility, decreased head elevation, mechanical ventilation, and applied sedative agents. Routine management protocols for feeding intolerance include prokinetic drug use and post-pyloric tube insertion, which could be both limited and accompanied by detrimental adverse events. This single-blind clinical trial aimed to investigate the effects of acupuncture in postoperative feeding intolerance in critically ill oral and hypopharyngeal cancer patients. Twenty-eight patients were randomized into two groups: Intervention group and Control group. Interventions were administered daily over three consecutive postoperative days. The primary outcome revealed that the intervention group reached 70% and 80% of target energy expenditure (EE) significantly earlier than the control group (4.00 ± 1.22 versus 6.69 ± 3.50 days, = 0.012), accompanied by higher total calorie intake within the first postoperative week (10263.62 ± 1086.11 kcals versus 8384.69 ± 2120.05 kcals, = 0.004). Furthermore, the intervention group also needed less of the prokinetic drug (Metoclopramide, 20.77 ± 48.73 mg versus 68.46 ± 66.56 mg, = 0.010). In conclusion, digestion-specific acupuncture facilitated reduced postoperative feeding intolerance in oral and hypopharyngeal cancer patients.
10.3390/nu13062110
Incomplete small bowel obstruction in a patient with ankylosing spondylitis.
Chiang Hsueh-Chien,Chen Chiung-Yu,Chuang Chiao-Hsiung,Hsu Hung-Lung
Radiology case reports
Small bowel obstruction is a blockage in the small intestine, which is usually caused by adhesion scar tissue, hernia, medication, or malignancy. The symptoms of small bowel obstruction include nausea and vomiting of bile, abdominal distention and obstipation. We present a case of a 61-year-old man with ankylosing spondylitis and scoliosis, who suffered from incomplete small bowel obstruction due to unusual direction of duodenum and externally compressed by liver, gallbladder and pancreas. We gave conservative treatment and inserted a nasojejunal tube for enteral feeding, and the duodenum broke free from the grip of liver, gallbladder and pancreas to its normal anatomical direction. Besides common etiology of small bowel obstruction, unusual body shape and smaller abdominal cavity may cause obstruction due to external compression of neighbor organs. Conservative treatments include gastrointestinal decompression, correction of electrolytes abnormality and nutrition support, while surgical intervention is suggested for the patient without improvement on conservative management.
10.1016/j.radcr.2021.05.075
Gene expression analysis in NSAID-induced rat small intestinal disease model with the intervention of berberine by the liquid chip technology.
Chao Guanqun,Wang Qianqian,Ye Fangxu,Zhang Shuo
Genes and environment : the official journal of the Japanese Environmental Mutagen Society
OBJECTIVE:Investigate the effect and mechanism of berberine on the small intestinal mucosa of non-steroidal anti-inflammatory drugs (NSAIDs) related small intestinal injury. MATERIALS AND METHODS:Twenty-four SD rats were randomly divided into control group, model group and intervention group. The model group and intervention group were treated with diclofenac (7.5 mg/kg·d, 2/d), a total of 4 days tube feeding, and the intervention group was treated with 50 mg/kg·d intragastric administration of berberine after 2 days. The control group was treated with 7.5 mg/kg·d, 2/d 0.9% saline tube feeding. Then we screened differential expression of colonic mucosal gene by the liquid chip technology. RESULTS:Compared with the control group, macroscopic and histology score of the model group increased significantly (P < 0.05), HTR4, HTR1a, F2RL3, CALCA, NPY, CRHR2, IL1b, P2RX3, TPH1, HMOX1, TRPV1, VIP, F2RL1, SLC6A4, TFF2, AQP8 content were significantly increased (P < 0.05), NOS1 content decreased significantly (P < 0.05); Compared with the model group, macroscopic and histology score of the intervention group improved significantly (P < 0.05), and HTR4, F2RL3, NPY, CRHR2, IL1b, VIP, AQP8 content were significantly lower (P < 0.05), NOS1 content increased significantly (P < 0.05). CONCLUSION:Berberine has a protective effect on NSAID-associated small intestinal injury, the mechanism may be that berberine decreases the expression of intestinal mucosa HTR4, F2RL3, NPY, CRHR2, IL1b, VIP, AQP8, and increases the expression of NOS1, that to reduce intestinal permeability and protect intestinal mucosal barrier.
10.1186/s41021-021-00205-2
Risk factors for pneumonia in hospitalized older people with femoral fractures: Results from a Brazilian prospective cohort.
Heart & lung : the journal of critical care
BACKGROUND:Pneumonia is a common complication in older people who are hospitalized to treat different fractures, which increases morbimortality in this population. OBJECTIVES:Estimating the pneumonia incidence density in older people hospitalized to treat femoral fractures and identifying risk factors for this infection. METHODS:Prospective cohort study whose data were collected from a population of older people who were being treated for femoral fractures at a hospital in the central region of Brazil between September 2016 and February 2017. The pneumonia diagnosis was based on radiography and clinical tests. Incidence density was estimated according to gender, age, Charlson comorbidity index, polypharmacy, chronic pulmonary disease, admission to the intensive care unit, surgical treatment, and nasoenteral tube feeding. Magnitude of the associations was estimated by multiple Poisson regression. RESULTS:Among the 200 patients, the pneumonia incidence density was 13.04/1,000 person-days. For men and older people 80 years old or older, the pneumonia incidence density was 15.6/1,000 person-days and 18.3/1,000 person-days, respectively. After adjusting for age, gender, chronic pulmonary disease, and admission to the intensive care unit, use of nasoenteral tubes remained associated with occurrence of pneumonia in older people, and the risk of developing the infection was eight times higher in the population who received nasoenteral feeding than that calculated for the population that did not use the devices (p ≤ 0.001). CONCLUSION:Using nasoenteral tubes during hospital stays increased the risk of developing pneumonia in hospitalized older people, which reinforces the need for continuous care monitoring regarding use of tubes to prevent complications.
10.1016/j.hrtlng.2022.03.009
Outcomes of Continuous Enteral Vancomycin Infusion in Intensive Care Unit Patients: A Novel Treatment Modality for Severe Clostridium Difficile Colitis.
Cureus
Background and objective Severe infection (CDI)-related colitis is associated with high morbidity and mortality. Current guidelines recommend oral vancomycin plus intravenous metronidazole as the first-line treatment and early total colectomy in case of medication failure. In critically ill patients at high surgical risk and with multiple comorbidities, loop ileostomy creation and enteral vancomycin infusion have been employed albeit with limited success. We hypothesized that continuous enteral vancomycin (CEV) infusion via a postpyloric feeding tube would provide a less invasive, efficacious, and safer route to treat high surgical risk patients. Methods All adult (>18 years) non-pregnant patients admitted to the ICU for severe CDI from October 2012 to October 2016 and received CEV after the failure of conventional therapy were included. Vancomycin was prepared as a 1-2-mg/ml enteral solution and run continuously through a feeding pump at 42 ml/hour via a post-pyloric feeding tube. The primary efficacy endpoint was clinical improvement defined as (a) decrease in stool output, (b) decreased vasopressor requirement, or (c) improved leukocytosis, and the secondary endpoint was treatment failure defined as the need for total colectomy or death due to severe CDI. Results Our cohort comprised 11 patients in total. The median age of the participants was 64 years, and there were more females (67%) than males (36%). Clinical improvement was seen in seven patients (63%); treatment failure documented as the need for total colectomy was observed in two patients (18%), and death attributable to CDI occurred in three patients (27%). Conclusion CEV resulted in clinical improvement in most patients with severe CDI who were at high surgical risk. Sustained intestinal vancomycin delivery may increase luminal concentration and bactericidal effect. The use of a feeding tube and pump provides an effective and less invasive route of vancomycin delivery in critically ill patients.
10.7759/cureus.22872
Effects of Preoperative Oral Nutritional Supplements on Improving Postoperative Early Enteral Feeding Intolerance and Short-Term Prognosis for Gastric Cancer: A Prospective, Single-Center, Single-Blind, Randomized Controlled Trial.
Nutrients
BACKGROUND:Early enteral nutrition (EN) after abdominal surgery can improve the prognosis of patients. However, the high feeding intolerance (FI) rate is the primary factor impeding postoperative EN. METHODS:Sixty-seven patients who underwent radical subtotal or total gastrectomy for gastric cancer (GC) were randomly allocated to the preoperative oral nutritional supplement group (ONS group) or dietary advice alone (DA group). Both groups were fed via nasojejunal tubes (NJs) from the first day after surgery to the fifth day. The primary endpoint is the FI rate. RESULTS:Of the patients, 66 completed the trial (31 in the ONS group, 35 in the DA group). The FI rate in the ONS group was lower than that in the DA group (25.8% vs. 31.4%, = 0.249). The postoperative five-day 50% energy compliance rate in the ONS group was higher than that in the DA group (54.8% vs. 48.6%, = 0.465). The main gastrointestinal intolerance symptoms were distension (ONS vs. DA: 45.2% vs. 62.9, = 0.150) and abdominal pain (ONS vs. DA: 29.0% vs. 45.7%, = 0.226). Postoperative nausea/vomiting rate and heartburn/reflux rate were similar between the two groups. We noted no difference in perioperative serum indices, short-term prognosis or postoperative complication rates between the two groups. CONCLUSIONS:The study shows that short-term preoperative ONS cannot significantly improve FI and the energy compliance rate in the early stage after radical gastrectomy.
10.3390/nu14071472
Over-The-Scope Clip for the Immediate Management of Stapfer Type-1 Duodenal Perforation during Endoscopic Retrograde Cholangiopancreatography.
Case reports in gastroenterology
Iatrogenic Stapfer type-1 duodenal perforations during endoscopic retrograde cholangiopancreatography (ERCP) typically necessitate surgical management and carry significant morbidity and mortality risk. Here, we present a case of a large duodenal perforation during ERCP managed endoscopically with an over-the-scope clip (OTSC) and describe the subsequent post-procedural management. An 80-year-old woman presented to the emergency department with acute cholangitis. Abdominal ultrasound scan revealed a dilated biliary tree with echogenic material in the common hepatic and intrahepatic ducts. The patient proceeded to ERCP, where filling defects consistent with stones were found in the proximal main bile duct on cholangiogram. Stone retrieval was complicated by a large iatrogenic perforation of the infero-lateral duodenal wall, distal to the major ampulla (Stapfer type-1). Following unsuccessful attempts to close the defect using through-the-scope clips, a decision was made to attempt closure endoscopically using an OTSC. The duodenoscope was exchanged for a forward-viewing gastroscope mounted with the OTSC. The perforation defect was fully suctioned into the cap and the clip was successfully deployed. Subsequent on-table fluoroscopy with contrast injection did not demonstrate any extra-luminal contrast leak. The patient developed a post-procedure infra-duodenal collection, however, made a complete recovery with bowel rest, negative pressure regulation at the site of the OTSC using a dual-lumen nasogastric/nasojejunal feeding tube and intravenous piperacillin-tazobactam. Thus, OTSCs potentially offer a safe and effective endoscopic treatment modality for the immediate management of ERCP-related Stapfer type-1 duodenal perforations.
10.1159/000523894
Ventilator-associated pneumonia prevention in the Intensive care unit using Postpyloric tube feeding in China (VIP study): study protocol for a randomized controlled trial.
Trials
BACKGROUND:Ventilator-associated pneumonia is a challenge in critical care and is associated with high mortality and morbidity. Although some consensuses on preventing ventilator-associated pneumonia are reached, it is still somewhat controversial. Meta-analysis has shown that postpyloric tube feeding may reduce the incidences of ventilator-associated pneumonia, which still desires high-quality evidence. This trial aims to evaluate the efficacy and safety profiles of postpyloric tube feeding versus gastric tube feeding. METHODS/DESIGN:In this multicenter, open-label, randomized controlled trial, we will recruit 924 subjects expected to receive mechanical ventilation for no less than 48 h. Subjects on mechanical ventilation will be randomized (1:1) to receive postpyloric or gastric tube feeding and routine preventive measures simultaneously. The primary outcome is the proportion of patients with at least one ventilator-associated pneumonia episode. Adverse events and serious adverse events will be observed closely. DISCUSSION:The VIP study is a large-sample-sized, multicenter, open-label, randomized, parallel-group, controlled trial of postpyloric tube feeding in China and is well-designed based on previous studies. The results of this trial may help to provide evidence-based recommendations for the prevention of ventilator-associated pneumonia. TRIAL REGISTRATION:Chictr.org.cn ChiCTR2100051593 . Registered on 28 September 2021.
10.1186/s13063-022-06407-5
Percutaneous endoscopic gastrostomy and jejunostomy: Indications and techniques.
World journal of gastrointestinal endoscopy
Nutritional support is essential in patients who have a limited capability to maintain their body weight. Therefore, oral feeding is the main approach for such patients. When physiological nutrition is not possible, positioning of a nasogastric, nasojejunal tube, or other percutaneous devices may be feasible alternatives. Creating a percutaneous endoscopic gastrostomy (PEG) is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk. Many diseases require nutritional support by PEG, with neurological, oncological, and catabolic diseases being the most common. PEG can be performed endoscopically by various techniques, radiologically or surgically, with different outcomes and related adverse events (AEs). Moreover, some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent. These conditions highlight many ethical problems that become difficult to manage as treatment progresses. The aim of this manuscript is to review all current endoscopic techniques for percutaneous access, their indications, postprocedural follow-up, and AEs.
10.4253/wjge.v14.i5.250
Comparison of nutritional effectiveness and complication rate between early nasojejunal and nasogastric tube feeding in patients with an intracerebral hemorrhage.
Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia
BACKGROUND:This study aimed to compare nutritional effectiveness and complication rate between early nasojejunal and nasogastric tube feeding in patients with an intracerebral hemorrhage. METHODS:This was a retrospective study. Eighty patients with an intracerebral hemorrhage were divided into a nasojejunal and a nasogastric tube feeding group. Feeding tubes were placed within 6 h after admission, and enteral feeding began within 2 h after tube placement. The nutritional status and complication rate of the 2 groups were compared before and 2 and 4 weeks after beginning feeding. RESULTS:Serum prealbumin, serum albumin, and hemoglobin levels were significantly higher in the nasojejunal tube feeding group than in the nasogastric tube feeding group at 2 and 4 weeks after beginning feeding (all, p < 0.05). The incidence of gastric retention, pulmonary aspiration, and pneumonia were lower in the early nasojejunal tube feeding group than in the early nasogastric tube feeding group (all, p < 0.05). There was no significant difference in the incidence of diarrhea between the 2 groups. CONCLUSION:Compared with early nasogastric feeding, early nasojejunal feeding provides better nutritional effectiveness and a lower incidence of gastric retention, pulmonary aspiration, and pneumonia in patients with an intracerebral hemorrhage.
10.1016/j.jocn.2022.07.004
Association of enteral feeding with microaspiration in critically ill adults.
Applied nursing research : ANR
AIM:This study explored relationships between enteral feeding and tracheal pepsin A. BACKGROUND:Mechanically ventilated (MV) patients receiving enteral feeding are at risk for microaspiration. Tracheal pepsin A, an enzyme specific to gastric cells, was a proxy for microaspiration of gastric secretions. METHODS:Secondary analysis of RCT data from critically ill, MV adults was conducted. Microaspiration prevention included elevated head of bed, endotracheal tube cuff pressure management, and regular oral care. Tracheal secretions for pepsin A were collected every 12 h. Microaspiration was defined as pepsin A ≥ 6.25 ng/mL. Positive pepsin A in >30 % of individual tracheal samples was defined as abundant microaspiration (frequent aspirator). Chi-squared, Fisher's Exact test, and generalized linear model (GLM) were used. RESULTS:Tracheal pepsin A was present in 111/283 (39 %) mechanically ventilated patients and 48 (17 %) had abundant microaspiration. Enteral feeding was associated with tracheal pepsin A, which occurred within 24 h of enteral feeding. Of the patients who aspirated, the majority received some enteral feeding 96/111 (86 %), compared to only 15/111 (14 %) who received no feeding. A greater number of positive pepsin A events occurred with post-pyloric feeding tube location (55.6 %) vs. gastric (48.6 %), although significant only at the event-level. Frequent aspirators (abundant pepsin A) had higher pepsin A levels compared to infrequent aspirators. CONCLUSIONS:Our findings confirmed the stomach as the microaspiration source. Contrary to other studies, distal feeding tube location did not mitigate microaspiration. Timing for first positive pepsin A should be studied for possible association with enteral feeding intolerance.
10.1016/j.apnr.2022.151611
Feeding jejunostomy following esophagectomy may increase the occurrence of postoperative small bowel obstruction.
Medicine
This study aimed to clarify the characteristics and treatment of bowel obstruction associated with feeding jejunostomy in patients who underwent esophagectomy for esophageal cancer. In this single-center retrospective study, 363 patients underwent esophagectomy with mediastinal lymph node dissection for esophageal cancer at the Wakayama Medical University Hospital between January 2014 and June 2021. All patients who underwent esophagectomy routinely underwent feeding jejunostomy or gastrostomy. Feeding jejunostomy was used in the cases of gastric tube reconstruction through the posterior mediastinal route or colon reconstruction, while feeding gastrostomy was used in cases of retrosternal route gastric tube reconstruction. Nasogastric feeding tubes and round ligament technique were not used. Postoperative small bowel obstruction occurred in 19 of 197 cases of posterior mediastinal route reconstruction (9.6%), but in no cases of retrosternal route reconstruction because of the feeding gastrostomy (P < .0001). Of the 19 patients who had bowel obstruction after feeding jejunostomy, 10 patients underwent reoperation (53%) and the remaining 9 patients had conservative treatment (47%). The cumulative incidence of bowel obstruction after feeding jejunostomy was 6.7% at 1 year and 8.7% at 2 years. Feeding jejunostomy following esophagectomy is a risk factor for small bowel obstruction. We recommend feeding gastrostomy inserted from the antrum to the jejunum in the cases of gastric tube reconstruction through the retrosternal route or nasogastric feeding tube in the cases of reconstruction through the posterior mediastinal route.
10.1097/MD.0000000000030746
Safety of Percutaneous Endoscopic Gastrostomy Placement in Patients With SARS-CoV-2 Infection.
Gastroenterology research
Background:Coronavirus disease 2019 (COVID-19) can lead to ventilator-dependent chronic respiratory failure and a need for tube feeding. Percutaneous endoscopic gastrostomy (PEG) placement provides more sustainable longer-term enteral access with fewer side effects compared to the long-term nasogastric tube placement. Bleeding is a recognized complication of PEG placement, and many COVID-19 patients are on antiplatelets/anticoagulants, yet minimal data exist on the safety of PEG tube placement in this context. Methods:A retrospective chart review identified patients who underwent PEG placement between January 2020 and January 2021 at a single institution. Success was defined as PEG placement and use to provide enteral nutrition with no complications requiring removal within 4 weeks. Results:Thirty-six patients with and 104 age- and sex-matched patients without COVID-19 infection were included. More COVID-19 patients were obese, on anticoagulants, had low serum albumin levels and had a tracheostomy in place. Of those patients, 8.3% with COVID-19 developed PEG-related complications compared to 16.3% without (P = 0.28). PEG success rates in patients with and without COVID-19 were similar at 97.2% and 92.3%, respectively (P = 0.44). Conclusion:PEG tube placement is comparatively safe in COVID-19 patients who need long-term enteral access.
10.14740/gr1533
Feeding gastrostomy and duodenostomy using the round ligament of the liver versus conventional feeding jejunostomy after esophagectomy: a meta-analysis.
Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus
Esophageal cancer patients require enteral nutritional support after esophagectomy. Conventional feeding enterostomy to the jejunum (FJ) is occasionally associated with small bowel obstruction because the jejunum is fixed to the abdominal wall. Feeding through an enteral feeding tube inserted through the reconstructed gastric tube (FG) or the duodenum (FD) using the round ligament of the liver have been suggested as alternatives. This meta-analysis aimed to compare short-term outcomes between FG/FD and FJ. Studies published prior to May 2022 that compared FG or FD with FJ in cancer patients who underwent esophagectomy were identified via electronic literature search. Meta-analysis was performed using the Mantel-Haenszel random-effects model to calculate Odds Ratios (ORs) with 95% confidence intervals (CIs). Five studies met inclusion criteria to yield a total of 1687 patients. Compared with the FJ group, the odds of small bowel obstruction (OR 0.09; 95% CI, 0.02-0.33), catheter site infection (OR 0.18; 95% CI, 0.06-0.51) and anastomotic leakage (OR 0.53; 95% CI, 0.32-0.89) were lower for the FG/FD group. Odds of pneumonia, recurrent laryngeal nerve palsy, chylothorax and hospital mortality did not significantly differ between the groups. The length of hospital stay was shorter for the FG/FD group (median difference, -10.83; 95% CI, -18.55 to -3.11). FG and FD using the round ligament of the liver were associated with lower odds of small bowel obstruction, catheter site infection and anastomotic leakage than FJ in esophageal cancer patients who underwent esophagectomy.
10.1093/dote/doac105
Predicting the metabolizable energy and metabolizability of gross energy of conventional feedstuffs for Muscovy duck using in vitro digestion method.
Journal of animal science
In total, two experiments were conducted to evaluate the effectiveness of an in vitro digestion method for predicting the metabolizable energy (ME) and metabolizability of gross energy (ME/GE) values using in vitro digestible energy (IVDE) and the digestibility of gross energy (IVDE/GE) content, respectively, of conventional feedstuffs for Muscovy ducks. In experiment 1, the apparent metabolizable energy (AME), true metabolizable energy (TME), AME/GE, and TME/GE of eight-grain feedstuff samples (two corn samples, three sorghum samples, and three barley samples) and eight protein feedstuff samples (two soybean meal samples, three cottonseed meal samples, and three rapeseed meal samples) were determined by the tube-feeding method with six different ducks for each sample. In experiment 2, a computer-controlled simulated digestion system (CCSDS) contain simulated digestive fluid was used to determine the enzymatic hydrolysis energy value of feedstuffs, which was defined as IVDE in our study. The simulated gastric fluid containing pepsin and simulated small intestinal fluid containing amylase, trypsin, and chymotrypsin for the in vitro gastric and intestinal digestion, respectively. The IVDE and in vitro digestibility of GE (IVDE/GE) of 16 feedstuff samples were determined using the CCSDS with five replicates per sample. The results showed that the IVDE and IVDE/GE were positively correlated with ME and ME/GE of feedstuffs, respectively. The coefficient of determination of eight regression models in predicting ME (grain feedstuffs: AME = 1.050 × IVDE- 0.9293, TME = 1.032 × IVDE + 0.6478; protein feedstuffs: AME = 1.331 × IVDE- 6.685, TME = 1.269 × IVDE-3.490) and ME/GE (grain feedstuffs: AME/GE = 1.069 × IVDE/GE- 6.516, TME/GE = 1.068 × IVDE/GE + 0.7764; protein feedstuffs: AME/GE = 1.093 × IVDE/GE -19.21, TME/GE = 1.196 × IVDE/GE - 13.25) of feedstuffs for Muscovy ducks ranged from 0.8610 to 0.9921. The accuracy of the regression model was acceptable as the difference between measured and predicted ME and ME/GE values was less than 0.45 MJ/kg (100 kcal/kg) and 2.62% for 14 of the 16 feed samples, respectively. In conclusion, the in vitro digestion method can be used to predict the ME and ME/GE of conventional feedstuffs for Muscovy ducks with acceptable accuracy.
10.1093/jas/skad018
A comparative, randomised MRI study of the physiological and appetitive responses to gelling (alginate) and non-gelling nasogastric tube feeds in healthy men.
The British journal of nutrition
Inclusion in nasogastric tube feeds (NGTF) of acid-sensitive, seaweed-derived alginate, expected to form a reversible gel in the stomach, may create a more normal intragastric state and modified gastrointestinal responses. This may ameliorate NGTF-associated risk of diarrhoea, upper gastrointestinal symptoms and appetite suppression. In a randomised, crossover, comparison study, undertaken in twelve healthy males, an alginate-containing feed (F + ALG) or one that was alginate-free (F-ALG) (300 ml) was given over 1 h with a 7-14-d washout period between treatments. Baseline and for 4-h post-feed initiation, MRI measurements were made to establish small bowel water content (SBWC), gastric contents volume (GCV) and appearance, and superior mesenteric artery blood flux. Blood glucose and gut peptides were measured. Subjective appetite and upper gastrointestinal symptoms scores were obtained. pasta consumption 3-h post-feeding was measured. F + ALG exhibited a gastric appearance consistent with gelling surrounded by a freely mobile water halo. Significant main effects of feed were seen for SBWC ( = 0·03) and peptide YY (PYY) ( = 0·004) which were attributed to generally higher values for SBWC with F + ALG (max difference between adjusted means 72 ml at 210 min) and generally lower values for PYY with F + ALG. GCV showed a faster reduction with F + ALG, less between-participant variation and a feed-by-time interaction ( = 0·04). Feed-by-time interactions were also seen with glucagon-like-peptide 1 (GLP-1) ( = 0·02) and glucose-dependent insulinotropic polypeptide (GIP) ( = 0·002), both showing a blunted response with F + ALG. Apparent intragastric gelling with F + ALG and subsequent differences in gastrointestinal and endocrine responses have been demonstrated between an alginate-containing and alginate-free feed.
10.1017/S0007114523000302
Postoperative nutrition in the setting of enhanced recovery programmes.
European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology
Patients undergoing major surgery for gastrointestinal cancer are at high risk of developing or worsening malnutrition and sarcopenia. In malnourished patients, preoperative nutritional support may not be sufficient and so postoperative support is advised. This narrative review addresses several aspects of postoperative nutritional care in the setting of enhanced recovery programmes. Early oral feeding, therapeutic diet, oral nutritional supplements, immunonutrition, and probiotics are discussed. When postoperative intake is insufficient, nutritional support favouring the enteral route is recommended. Whether this approach should use a nasojejunal tube or jejunostomy is still a matter of debate. In the setting of enhanced recovery programmes with early discharge, nutritional follow-up and care should be continued beyond the short time in hospital. In enhanced recovery programmes, the main specific aspects of nutrition are patient education, early oral intake, and post-discharge care. The other aspects do not differ from conventional care.
10.1016/j.ejso.2023.03.006
Laparoscopic Management of Disseminated Peritoneal Leiomyomatosis.
Journal of minimally invasive gynecology
STUDY OBJECTIVE:To show laparoscopic management of disseminated peritoneal leiomyomatosis (DPL). DESIGN:Stepwise demonstration of the technique with narrated video footage. SETTING:DPL is characterized by dissemination and proliferation of peritoneal and subperitoneal lesions primarily originating from smooth muscle cells [1]. Generally considered benign, cases of malignant transformation to leiomyosarcoma have been reported [2,3]. Iatrogenic DPL occurs because of unconfined morcellation resulting in small fragments of myoma that may implant on any organ and start deriving blood supply from it or may be pulled into port site while withdrawing laparoscopic cannulas [4]. It is estimated that the overall incidence of DPL after laparoscopic uncontained morcellation was 0.12% to 0.95% [5]. Mainstay of treatment is surgical resection of myomas and regular follow-up with imaging. A 28-year-old unmarried girl presented with complain of lump abdomen increasing in size for 1 year. She also complained of a 15 kg weight loss in the last 1 year; 4 years ago, patient had undergone laparoscopic myomectomy with unconfined morcellation for a 10 × 8 cm cervical myoma. Presently her menses were regular with a 28-day cycle and 3 to 4 days' average flow. Magnetic resonance imaging showed multiple nodular lesions of varying sizes in relation to small bowel, colon, uterus, and anterior abdominal wall suggestive of DPL. Bilateral ovaries were normal. Tumor markers were as follows: CA 125 23.2 (<35) U/mL Carcinoembryonic antigen 1.67 (<8) ng/mL CA 19-9 47 (<37) U/mL Lactate dehydrogenase 809 (180-360) IU/L Alpha-fetoprotein 2.03 (<10) ng/mL Beta human chorionic gonadotropin 1.2(<2) mIU/mL Tru-cut biopsy was done elsewhere to rule out peritoneal carcinomatosis in view of raised CA 19-9 and lactate dehydrogenase, history of weight loss, and imaging showing multiple abdominal masses. Histopathological examination showed leiomyomatosis and immunohistochemistry for smooth muscle actin, desmin, and vimentin were positive. INTERVENTIONS:On laparoscopy the abdominal cavity was found studded with multiple leiomyomas of varying sizes deriving blood supply from ilium, transverse, descending and sigmoid colon, rectum, left tube, left ovary, pouch of Douglas, bilateral uterosacrals, uterovesical fold, and anterior abdominal wall. Large blood vessels were seen traversing between the descending and sigmoid colon and the myomas. Principles of surgery were as follows: 1. Complete removal of myomas 2. Cauterization of blood vessels feeding the parasitic myomas to minimize blood loss 3. Disscetion abutting the myoma to prevent injury to adjacent viscera. A total of 26 myomas were removed. All the myomas were retrieved by morcellation in a bag. Histopathology confirmed the diagnosis of diffuse peritoneal leiomyomatosis. Follow-up ultrasound at 6 months showed no recurrence of leiomyomatosis. CONCLUSION:Proper mapping of lesions and surgery for complete removal of all masses is the mainstay of treatment. Contained morcellation in bag should be the norm to prevent iatrogenic DPL. Regular follow-up with imaging is required to rule out recurrence.
10.1016/j.jmig.2023.03.006
Laparoscopic Witzel feeding jejunostomy: a procedure overlooked!
Journal of minimally invasive surgery
Purpose:Feeding jejunostomy (FJ) is a critical procedure to establish a source of enteral nutrition for upper gastrointestinal disorders. Minimally invasive surgery has the inherent benefit of better patient outcomes, less postoperative pain, and early discharge. This study aims to describe our total laparoscopic technique of Witzel FJ and to compare its outcome with its open counterpart. Methods:A retrospective database analysis was performed in patients who underwent laparoscopic (n = 20) and open (n = 21) FJ as a stand-alone procedure from July 2018 to July 2022. A readily available nasogastric tube (Ryles tube) and routine laparoscopic instruments were used to perform laparoscopic FJ. Perioperative data and postoperative outcomes were analyzed. Results:Baseline preoperative variables were comparable in both groups. The median operative duration in the laparoscopic FJ group was 180 minutes vs. 60 minutes in the open FJ group ( = 0.01). Postoperative length of hospital stay was 3 days vs. 4 days in the laparoscopic and open FJ groups, respectively ( = 0.08). Four patients in the open FJ group suffered from an immediate postoperative complication (none in the laparoscopic FJ group). After a median follow-up of 10 months, fewer patients in the laparoscopic FJ group had complications such as tube clogging, tube dislodgement, surgical-site infection, and small bowel obstruction. Conclusion:Laparoscopic FJ with the Witzel technique is a safe and feasible procedure with a comparable outcome to the open technique. Patient selection is vital to overcome the initial learning curve.
10.7602/jmis.2023.26.1.28
Effect of blenderized tube feeds on gastric emptying: A retrospective cohort study.
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:Blenderized tube feeds (blends) are associated with lower hospital admissions and reduced gastroesophageal symptoms, but their high viscosity may theoretically prolong gastric emptying. Our objective was to compare differences in gastric emptying with blends vs with formula. METHODS:We retrospectively identified individuals 6 months to 20 years with enteral tubes who underwent 1-h liquid gastric emptying scintigraphy from 1998 to 2020 at Boston Children's Hospital. Examinations were excluded if a postpyloric tube was present, tracer was administered orally or with diet differing from habitual, habitual diet was indeterminable, imaging was terminated early, or >50% of input counts emptied during bolus administration. Emptying was classified as delayed if gastric residual at 1 h was ≥60% of ingested dose. RESULTS:Eighteen examinations (15 individuals) were performed with blends and 35 examinations (32 individuals) with formula. Although percentage of residual at 1 h was significantly higher in patients receiving blends compared with formula (54 ± 17 vs 40 ± 25, P = 0.04), the number of patients with delayed gastric emptying did not differ (39% vs 29%, respectively, P = 0.54). Type of diet, feed volume or concurrent medications did not predict delayed gastric emptying. Children with blends received higher bolus volumes (106 ± 55 vs 66 ± 59 ml; P = 0.02), and this significantly predicted percentage of residual (β = 0.14; P = 0.01). CONCLUSION:The proportion of patients with delayed gastric emptying was similar in children receiving blends and formula. Although the mean percentage of gastric residual was higher with blends, this may be explained by higher bolus volumes administered. This preliminary work suggests that blends compare favorably to formula.
10.1002/jpen.2513
Aspiration pneumonia in enteral feeding: A review on risks and prevention.
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
Enteral feeding plays a critical role in the management of hospitalized patients, especially in intensive care units. In addition to delivering important nutrients, it also maintains the integrity of the gut and microbiota. Enteral feeding is also associated with complications and adverse events, some are related to access placement, metabolic and electrolytes disturbances, and aspiration pneumonia. In tube-fed patients, aspiration pneumonia has a prevalence ranging from 4% to 95% with a mortality rate of 17%-62%. Our review has not showed any significant difference in the incidence of aspiration pneumonia between gastric and postpyloric feeding and, given the ease of gastric access, we therefore suggest using gastric feeding as an initial strategy for the delivery of nutrition unless postpyloric access is otherwise indicated for other clinical reasons.
10.1002/ncp.11020
Preoptimisation in patients with acute obstructive colon cancer (PREOCC) - a prospective registration study protocol.
BMC gastroenterology
BACKGROUND:Postoperative mortality and morbidity rates are high in patients with obstructing colon cancer (OCC). Different treatment options have been evaluated over the years, mainly for left sided OCC. Optimising the preoperative health condition in elective colorectal cancer (CRC) treatment shows promising results. The aim of this study is to determine whether preoptimisation is feasible in patients with OCC, with a special interest/focus on right-sided OCC, and if, ultimately, optimisation reduces mortality and morbidity (stoma rates, major and minor complications) rates in OCC. METHODS:This is a prospective registration study including all patients presenting with OCC in our hospital. Patients with OCC, treated with curative intent, will be screened for eligibility to receive preoptimisation before surgery. The preoptimisation protocol includes; decompression of the small bowel with a NG-tube for right sided obstruction and SEMS or decompressing ileostomy or colostomy, proximal to the site of obstruction, for left sided colonic obstructions. For the additional work-up, additional nutrition by means of parenteral feeding (for patients who are dependent on a NG tube) or oral/enteral nutrition (in case the obstruction is relieved) is provided. Physiotherapy with attention to both cardio and muscle training prior surgical resection is provided. The primary endpoint is complication-free survival (CFS) at the 90 day period after hospitalisation. Secondary outcomes include pre- and postoperative complications, patient- and tumour characteristics, surgical procedures, total in hospital stay, creation of decompressing and/or permanent ileo- or colostomy and long-term (oncological) outcomes. DISCUSSION:Preoptimisation is expected to improve the preoperative health condition of patients and thereby reduce postoperative complications. TRIAL REGISTRATION:Trial Registry: NL8266 date of registration: 06-jan-2020. STUDY STATUS:Open for inclusion.
10.1186/s12876-023-02799-z
Nutrition therapy during noninvasive ventilation: oral or enteral?
Current opinion in critical care
PURPOSE OF REVIEW:Critical care nutrition guidelines primarily focus on patients receiving invasive mechanical ventilation, yet noninvasive ventilation (NIV) is an increasingly common intervention. The optimal route of nutrition delivery in patients receiving NIV has not been established. This review aims to describe the implications of NIV on the route of feeding prescribed. RECENT FINDINGS:Five small, mostly observational, studies have quantified energy or protein intake in patients receiving NIV in critical care, which demonstrate intake to be poor. No study has assessed the impact of feeding route on outcomes. The predominant route of feeding observed is oral intake, yet nutrition intake via this route is lower than that from enteral or parenteral nutrition. Barriers to oral intake include fasting for intubation, the inability to remove NIV apparatus to eat, breathlessness, fatigue and poor appetite, while barriers to enteral nutrition include the impact of the naso-enteric tube on the mask seal and potential aspiration. SUMMARY:Until evidence to support the optimal route of feeding is developed, patient safety should be the key driver of route selection, followed by the ability to achieve nutrition targets, perhaps utilizing a combination of routes to overcome barriers to nutrition delivery.
10.1097/MCC.0000000000001053
Risk factors of aspiration occurrence with different feeding patterns in elderly intensive care unit patients: a cross-sectional study.
Journal of thoracic disease
Background:Elderly intensive care unit (ICU) patients represent a high-risk group of aspiration. Different feeding patterns will lead to different incidences of aspiration. However, there are few studies on the risk factors of aspiration in elderly ICU patients under different feeding patterns. The aim of this study was to analyze the effects of different eating styles on the occurrence of overt and silent aspiration in elderly ICU patients and to compare the independent risk factors, in order to provide a basis for targeted aspiration prevention. Methods:We retrospectively analyzed the incidence of aspiration in elderly patients admitted to the ICU from April 2019 to April 2022, a total of 348 cases. The patients were divided into the oral feeding group, gastric tube feeding group, and post-pyloric feeding group according to their feeding method. Multi-factor logistic regression was used to analyze the independent risk factors for overt and silent aspiration caused by the different eating patterns of patients. Results:Among the 348 elderly ICU patients included, the overall incidence of aspiration was 72%, with a 22% rate of overt aspiration and a 49% rate of silent aspiration. The overt aspiration rates were 16%, 30%, and 21% in the oral, the gastric tube and the post-pyloric feeding group, respectively; while the silent aspiration rates were 52%, 55%, and 40% in the three groups, respectively. Multiple logistic regression analysis showed that the independent risk factors for both overt and silent aspiration were history of aspiration [odds ratio (OR) =0.075, P=0.004; OR =0.205, P=0.042] and gastrointestinal tumor (OR =0.100, P=0.028; OR =0.063, P=0.003) in the oral feeding group. In the gastric tube feeding group, the independent risk factor for both overt and silent aspiration was the history of aspiration (OR =4.038, P=0.040; OR =4.658, P=0.012). In the post-pyloric feeding group, the independent risk factors for both overt and silent aspiration were mechanical ventilation (OR =0.211, P=0.019; OR =0.336, P=0.037) and intra-abdominal hypertension (OR =0.225, P=0.020; OR =0.329, P=0.032). Conclusions:There were significant differences in the influencing factors and characteristics of aspiration among the elderly patients in the ICU with different feeding patterns. Personalized precautions should be implemented early, so as to reduce the possibility of aspiration.
10.21037/jtd-23-430
Impact of a quality improvement programme on the preparation and administration of medications via a nasoenteral feeding tube: 2014-2019 intervention study.
BMJ open quality
AIMS:Evaluate the impact of a quality improvement programme on the reduction of feeding tube obstruction frequencies, analyse the predictive variables of this safety incident, and estimate the economic costs related to the quality improvement programme during the period from 2014 to 2019. METHODS:Plan-Do-Study-Act cycles were performed to test the changes in drug preparation and administration processes via a nasoenteral feeding tube and to evaluate the outcome, process and balance measures. Statistical control charts were elaborated, and the bottom-up direct costing methodology was used to estimate the costs of the improvement programme. The impact of the programme on the monitoring measures was evaluated using logistic regression analysis. INTERVENTIONS:The following changes were tested in the hospital participating in the study: acquisition of the Easy Crush equipment for tablet crushing, use of appropriate packaging to crush hard tablets, standardise procedures for scheduling administration times and/or substitution of the pharmaceutical form, educational activities for the nursing team and elaboration and availability of infographics for the nursing team, patients and/or family/caregivers. RESULTS:There was a significant improvement in the frequency of tube obstructions, from 41.1% in 2014 to 57.9% in 2015-2017 and 9.6% in 2018-2019 (p=0.0010). After the execution of the improvement programme, it was estimated that the cost of dose preparation was reduced from R$1067.50 in 2014 to R$719.80 in 2015-2017 and R$433.10 in 2015-2019. CONCLUSION:By re-establishing the processes of drug preparation and administration via a nasoenteral feeding tube, through the acquisition of appropriate equipment for crushing hard tablets, together with educational activities for the nursing team, we could observe a reduction in tube obstructions and the cost of processes.
10.1136/bmjoq-2022-002183
Nutrition practices in critically ill adults receiving noninvasive ventilation: A quantitative survey of Australian and New Zealand intensive care clinicians.
Australian critical care : official journal of the Confederation of Australian Critical Care Nurses
BACKGROUND:Noninvasive ventilation (NIV) is frequently used in the intensive care unit (ICU), yet there is a paucity of evidence to guide nutrition management during this therapy. Understanding clinicians' views on nutrition practices during NIV will inform research to address this knowledge gap. OBJECTIVE:The objective of this study was to describe Australian and New Zealand clinicians' views and perceptions of nutrition management during NIV in critically ill adults. METHODS:A cross-sectional quantitative online survey of Australian and New Zealand medical and nursing staff with ≥12 months ICU experience was disseminated through professional organisations via purposive snowball sampling from 29 August to 9 October 2022. Data collection included demographics, current practices, and views and perceptions of nutrition during NIV. Surveys <50% complete were excluded. Data are represented in number (%). RESULTS:A total of 152 surveys were analysed; 71 (47%) nursing, 69 (45%) medical, and 12 (8%) not specified. There was limited consensus on nutrition management during NIV; however, most clinicians (n = 108, 79%) reported that nutrition during NIV was 'important or very important'. Oral intake was perceived to be the most common route (n = 83, 55%), and 29 (21%) respondents viewed this as the safest. Most respondents (n = 106, 78%) reported that ≤50% of energy targets were met, with gastric enteral nutrition considered most likely to meet targets (n = 55, 40%). Reported nutrition barriers were aspiration risk (n = 87, 64%), fasting for intubation (n = 84, 62%), and nutrition perceived as a lower priority (n = 73, 54%). Reported facilitators were evidence-based guidelines (n = 77, 57%) and an NIV interface compatible with enteral nutrition tube (n = 77, 57%). CONCLUSION:ICU medical and nursing staff reported nutrition during NIV to be important; however, there was a lack of consensus on the route of feeding considered to be the safest and most likely to achieve nutrition targets. Interventions to minimise aspiration and fasting, including an interface with nasoenteric tube compatibility, should be explored.
10.1016/j.aucc.2023.08.001
Early oral feeding versus nasojejunal early enteral nutrition in patients following pancreaticoduodenectomy: a propensity score-weighted analysis of 428 consecutive patients.
International journal of surgery (London, England)
BACKGROUND:Notwithstanding that significant medical progress has been achieved in recent years, the optimal nutritional support method following pancreaticoduodenectomy (PD) remains uncertain. This study compared the safety and feasibility of early oral feeding (EOF) with nasojejunal early enteral nutrition (NJEEN) after PD. METHODS:A retrospective cohort study was conducted on 428 consecutive patients who underwent PD between August 2018 and December 2020. During the first study phase, the routine postoperative feeding strategy was NJEEN, later replaced by EOF during the second study phase. The primary outcome was the incidence of delayed gastric emptying (DGE) following PD. Propensity score weighting was used to control for confounding factors. RESULTS:Four hundred forty patients underwent PD during the overall study period, with 438 patients aged 18 years and older. Ten patients experienced accidental tube dislodgement or migration and were excluded from the study based on the exclusion criteria. Finally, 211 patients and 217 patients underwent EOF and NJEEN, respectively. After propensity score weighting, it was observed that patients who underwent postoperative EOF experienced a significantly lower DGE (B/C) rate compared to those who underwent postoperative NJEEN [7.38% (31/424) vs. 14.97% (62/413), P =0.0005]. Subgroup analyses according to the presence of soft pancreatic texture yielded consistent results. The EOF group exhibited lower DGE grade, DGE (B/C) rate [5.90% (11/194) vs. 22.07% (43/193), P <0.0001], postoperative gastrointestinal endoscopic intervention rate, and Clavien-Dindo Grade III or higher rate. CONCLUSIONS:EOF is superior to NJEEN in reducing the incidence of grade B/C DGE after PD. The EOF procedure is safe and feasible and should be recommended as the optimal postoperative feeding method following PD.
10.1097/JS9.0000000000000786
Prediction of prokinetic agents in critically ill patients with feeding intolerance: a prospective observational clinical study.
Frontiers in nutrition
Background:Prokinetic agents are currently considered the first-line therapy to improve gastric emptying when feeding intolerance occurred in critically ill adults. In this study, we developed a technique to assess the feasibility of predicting prokinetic agent efficacy in critically ill patients. Methods:The first images of each patient were obtained after EFI had occurred but before the first dose of prokinetic agents was administered and additional images were obtained every morning until the seventh day. The gastric antrum echodensity was recorded based on grayscale values (50th percentile, ED50; 85th percentile, ED85; mean, ED) and daily energy and protein intake was collected as the judgment for effective and ineffective group. A receiver operating characteristic curve was analyzed to distinguish the thresholds between the two groups and thus determine the ability of the gastric antrum echodensity to predict the efficacy of prokinetic agents. Results:In total, 83 patients were analyzed. Patients in the ineffective group had a higher ED (58.13 ± 14.48 vs. 49.88 ± 13.78, < 0.001, difference 95% CI: 5.68, 10.82), ED (74.81 ± 16.41 vs. 65.70 ± 16.05, < 0.001, difference 95% CI:6.16, 12.05), and ED (60.18 ± 14.31 vs. 51.76 ± 14.08, < 0.001, difference 95% CI: 5.85, 11.00) than those in the effective group. Patients in the effective group more easily reached the target energy 16.21 ± 7.98 kcal/kg vs. 9.17 ± 6.43 kcal/kg ( < 0.001), 0.72 ± 0.38 g/kg vs. 0.42 ± 0.31 g/kg ( < 0.001) than in the ineffective group intake by day. Conclusion:The gastric antrum echodensity might serve as a tool for judging the efficacy of prokinetic agents, helping clinicians to decide whether to use prokinetic agents or place a post-pyloric tube when feeding intolerance occurs in critically ill patients.http://www.chictr.org.cn/addproject2.aspx, ChiCTR2200058373. Registered 7 April 2022.
10.3389/fnut.2023.1244517
Gastrointestinal Conditions: Pancreatitis.
FP essentials
Acute pancreatitis is among the most common gastrointestinal disorders requiring hospitalization. The main causes are gallstones and alcohol use. Patients typically present with upper abdominal pain radiating to the back, worse with eating, plus nausea and vomiting. Diagnosis requires meeting two of three criteria: upper abdominal pain, an elevated serum lipase or amylase level greater than 3 times the normal limit, and imaging findings consistent with pancreatitis. After pancreatitis is diagnosed, the Atlanta classification and identification of the systemic inflammatory response syndrome can identify patients at high risk of complications. Management includes fluid resuscitation and hydration maintenance, pain control that may require opioids, and early feeding. Feeding recommendations have changed and "nothing by mouth" is no longer recommended. Rather, oral feeding should be initiated, as tolerated, within the first 24 hours. If it is not tolerated, enteral feeding via nasogastric or nasojejunal tubes should be initiated. Antibiotics are indicated only with radiologically confirmed infection or systemic infection symptoms. Surgical or endoscopic interventions are needed for biliary pancreatitis or obstructive pancreatitis with cholangitis. One in five patients will have recurrent episodes of pancreatitis; alcohol and smoking are major risk factors. Some develop chronic pancreatitis, associated with chronic pain plus pancreatic dysfunction, including endocrine failure (insulin insufficiency) and/or exocrine failure that requires long-term vitamin supplementation.
Treatment escalation for people with anorexia nervosa: setting, therapies and nutritional interventions.
Current opinion in psychiatry
PURPOSE OF REVIEW:Adult patients with severe anorexia nervosa often receive the same unsuccessful treatment without changes regarding the setting, the therapies, or nutritional interventions. RECENT FINDINGS:Settings where people with anorexia nervosa are treated include their general practitioner, an independent psychiatric practice, a community mental health team (CMHT), a specialized eating disorder outpatient service, eating disorder early intervention services, a highly intensive eating disorder outpatient or home treatment programme, eating disorder daycare, an inpatient eating disorder service, a general hospital or a general psychiatric hospital, or residential treatment. At a specialized eating disorder service, patients should be offered evidence-based psychotherapy for anorexia nervosa, dietary advice and physical health monitoring as a first step. Additionally, they may be allocated to a specific treatment pathway, family interventions and creative therapies. As a second step, clinicians may consider integrating interventions targeting psychiatric or physical comorbidities, medication for anorexia nervosa or noninvasive neurostimulation. After several years of futile treatment, deep brain stimulation (DBS) should be considered to prevent a chronic course of anorexia nervosa. Nutritional interventions can be escalated from nutritional counselling to nasogastric tube feeding. Patients who rely on nasogastric tube feeding might benefit from percutaneous endoscopic gastrostomy (PEG). Patients who vomit despite a nasogastric tube, might need nasojejunal tube feeding. SUMMARY:Treatment for people with anorexia nervosa should be regularly reviewed and, if necessary, escalated to avoid a chronic and longstanding disease course.
10.1097/YCO.0000000000000964