Prospective evaluation of a new through-the-scope nasoduodenal enteral feeding tube

Postpyloric Feeding Access in Infants and Children: A State of the Art Review

Achieving postpyloric feeding access is a clinical challenge faced by the pediatric gastroenterologist in everyday practice. Currently, there is limited literature published on the topic. This article provides a practical summary of the literature on the different methods utilized to achieve postpyloric feeding access including bedside, fluoroscopic, endoscopic and surgical options. Indications and complications of these methods are discussed as well as a general approach to infants and children that require intestinal feeding.

Therapeutic Efficacy of Nasoenteric Tube Feeding in Children Needing Enteral Nutrition

Background: There is limited information on therapeutic benefits and tube-related complications of pediatric nasoenteric (NE) tube feeding. We viewed, from different clinical aspects, NE tube feeding in children who are under intolerable conditions. Methods: A 10-years retrospective study enrolled 77 pediatric patients who underwent an endoscopic-guided placement of the NE tube for enteral nutrition. The evaluated data, including growth parameters, feeding volume, parenteral nutrition (PN) dependence, and nutritional markers [serum hemoglobin (Hb) and albumin] before and after NE tube feeding were compared. Tube-related complications and major adverse events were also recorded. Results: A total of 77 patients (including 50 males) underwent 176 endoscopic-guided placements of the NE tube with an average duration of 133.7 (6.0-1,847.3) days. The gastroesophageal reflux disease-related symptoms (vomiting, desaturations, and aspiration pneumonia) improved in 71.4% of patients. Feeding volume increased significantly after intervention, especially in patients with delayed gastric emptying, from 144.8 ± 28.5 to 1,103.1 ± 524.7 ml/days (p < 0.001). Weaning from PN was successfully achieved in 84.3% of patients with an average of 9.33 ± 7.30 days. About 16 patients (20.8%) were subsequently highly compatible with oral feeding after NE tube placement for an average of 24.7 ± 14.1 days. Patients either without neurologic dysfunction or with no ventilator-dependent status had a higher chance of shifting to oral feeding. Weight-for-age z-scores increased by 0.15 ± 1.33 after NE tube intervention. One NE tube-related adverse event, which caused bowel perforation at 6 days post-insertion, was recorded. No direct tube-related mortality was observed. Conclusions: Endoscopic-guided NE tube placement is a relatively safe, non-invasive procedure for pediatric patients who require enteral nutrition. Feeding via NE tube showed beneficial effects such as improvement in symptoms, PN weaning, and maintenance of body growth without major tube-related complications.

Application of bronchoscope for the placement of nasoenteric feeding tube in patients with esophagectomy: a novel technique

BACKGROUND

Currently the available techniques for the placement of nasoenteric feeding tube (NET), utilizing transnasal gastroscope are fast and tolerable, which is known as the most popular method. However, lots of hospitals don't have this endoscopic system. Bronchoscope, which is the basic respiratory endoscope, not only has the advantages of transnasal endoscopy, but also is popular in common hospitals. We used oxygen instillation as air supply plant of the bronchoscope, which broke its application limitation in digestive tract. The aim of this study is to evaluate the feasibility and availability of the method of placing NET with the bronchoscope in patients with esophagectomy.

METHODS

From January 2013 to January 2016, a total of 48 patients with esophagectomy who underwent NET placement with the bronchoscope were included in our study. Information concerning age, gender, as well as background disease of the patients was collected. The success rate, procedure duration, and complications were recorded for each patient.

RESULTS

The technique success rate reached 100%, procedure time ranged from 150 to 750 s, with an average time of 257 s. All patients tolerated well under local anesthesia, no complication of epistaxis or perforation occurred.

CONCLUSIONS

The new technique of placing NET with the bronchoscope is fast, safe, effective, and well tolerated for patients with esophagectomy.

Gastroenteric tube feeding: techniques, problems and solutions

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.

Endoscopic clip-assisted feeding tube placement reduces repeat endoscopy rate: results from a randomized controlled trial

OBJECTIVES

To determine whether endoscopic clip-assisted nasoenteral feeding tube placement is more effective than standard feeding tube placement with transnasal endoscopy.

METHODS

Between August 2009 and February 2011, 143 patients referred for endoscopic nasoenteral feeding tube placement were randomized between clip-assisted and standard nasoenteral tube placement. Endoscopies were performed in the endoscopy unit and intensive care unit in a tertiary referral center in the Netherlands. For the clip-assisted procedure, the feeding tube was introduced with a suture fixed to the tip, picked up in the stomach with an endoclip and attached (as distal as possible) to the duodenal wall. In the standard group, a guide wire was placed in the duodenum using a transnasal endoscope, followed by blind insertion of a feeding tube over the guide wire. Primary end point was a repeat endoscopy for incorrect tube placement or spontaneous retrograde tube migration. Secondary end points were incorrect tube placement, spontaneous migration of feeding tube, directs medical costs, and procedure-related (serious) adverse event (SAE).

RESULTS

Of the 143 patients included, 71 were randomly assigned to clip-assisted tube placement, and 72 to standard tube placement. Four (5.6%) repeat endoscopies were performed in the clip-assisted group vs. 19 (26.4%) in the standard group (relative risk reduction (RRR) 0.79; 95% confidence interval (CI) 0.40-0.92). The number needed to clip to avoid one repeat endoscopy was 4.8 (95% CI 3.1-11.3). Repeat endoscopies were mostly performed for incorrectly placed tubes, 3 (4.2%) in the clip-assisted group vs. 16 (22.2%, RRR 0.81; 95% CI 0.38-0.94) in the standard group. Spontaneous retrograde tube migration occurred in one (1.4%) clip-assisted placement and three (4.2%) standard tubes. Median costs were higher for clip-assisted tube placement (€519 vs. €423, P<0.01). Four (5.6%) SAEs occurred after clip-assisted feeding tube placement vs. one (1.4%) after standard feeding tube placement (P=0.21).

CONCLUSIONS

Clip-assisted endoscopic nasoenteral feeding tube placement results in fewer repeat endoscopies than standard endoscopic nasoenteral tube placement, due to a higher success rate of initial placement. When tubes are adequately placed, retrograde tube migration rarely occurs.

Nasoenteral feeding tube placement by nurses using an electromagnetic guidance system (with video)

BACKGROUND

The early institution of feeding in patients who need postpyloric feeding tubes is often hampered by a limited availability of endoscopists experienced in safe tube positioning.

OBJECTIVE

To test the feasibility of having nurses place postpyloric feeding tubes by using a universal path finding system device.

DESIGN

Prospective study.

SETTING

Academic hospital.

PATIENTS

The success rate and learning curve of a senior nurse placing postpyloric feeding tubes in 50 patients was studied, followed by a study in 160 patients on the success rates and learning curves of 4 inexperienced nurses instructed by the senior nurse. Finally, the success rate of postpyloric feeding tube placement by the senior nurse in 50 critically ill patients was investigated.

INTERVENTION

Postpyloric feeding tube positioning by nurses using an electromagnetic universal path-finding system device enabling them to follow the path of the tip of the feeding tube on a monitor screen.

MAIN OUTCOME MEASUREMENTS

Success was defined by postpyloric positioning of the feeding tube. The ultimate aim was to reach at least the duodenojejunal flexure.

RESULTS

In the first part, the senior nurse was successful in 72% of cases. There was a clear learning curve. In the second part, the 4 newly instructed nurses had a success rate of 89.4% without an evident learning curve. In the third part, successful feeding tube positioning was achieved in 78% of critically ill patients. Of the 217 successfully positioned tubes, 74% reached at least the duodenojejunal flexure. In half of the unsuccessful cases, an explanation for the failure was found at endoscopy. No complications were seen.

LIMITATIONS

The generalization to less-specialized hospitals should be investigated.

CONCLUSION

Postpyloric positioning of feeding tubes by nurses at the bedside without endoscopy is feasible and safe. Nurses may take over some of the tasks of doctors in a time of high endoscopic needs.

Nasal bridling decreases feeding tube dislodgment and may increase caloric intake in the surgical intensive care unit: a randomized, controlled trial

OBJECTIVE

To determine whether nasal bridling is a low-morbidity practice that decreases feeding tube dislodgment and results in improved caloric intake.

DESIGN

Randomized, controlled trial.

SETTING

Private, tertiary-care referral center.

PATIENTS

A total of 80 surgical intensive care unit patients requiring nasojejunal feeding.

INTERVENTION

Nasal bridling of feeding tubes.

MEASUREMENTS AND MAIN RESULTS

Between January 1, 2008 and July 31, 2008, 80 patients were randomized to have their nasojejunal feeding tubes secured with either a nasal bridle or an adhesive device. Baseline characteristics examined included age, sex, concurrent nasogastric tube presence, primary diagnosis, Acute Physiology and Chronic Health Evaluation III score, need for mechanical ventilation, need for emergent surgery, Riker Sedation Score, and Glascow Coma Scale. Patients were monitored daily for prevalence and cause of feeding tube removal, percentage of goal calories received, nasal ulceration, and sinusitis. Serum albumin and prealbumin levels were collected weekly. All patients were examined, using an intention-to-treat design. Except for a higher prevalence of emergent surgery in the bridled patients, the bridled and unbridled groups had no difference in baseline characteristics. Bridled tubes were less likely to be unintentionally dislodged than unbridled tubes (18% vs. 63%, p < .0001) resulting in bridled patients receiving a higher percentage of goal calories (median 78% [interquartile range, 65%-86%] vs. 62% [interquartile range, 47%-80%], p = .016) than unbridled patients. There were five cases of mild epistaxis upon bridle insertion and four cases of superficial nasal ulceration associated with the bridle. No bridled patients were diagnosed with sinusitis during the study period. Serum albumin and prealbumin levels did not differ between the groups.

CONCLUSIONS

Bridling of nasoenteric feeding tubes in critically ill patients is a low-morbidity practice that reduces the rate of unintentional tube dislodgment and may result in improved caloric intake.

Endoscopic placement of a novel feeding tube

BACKGROUND

Complications of blind feeding tube (FT) placement include pneumothorax, pneumonia, empyema, and death. A safe and effective method of FT placement is desired. The Davis FT is a novel device that detachably couples to an ultrathin transnasal gastroscope. The objective of this study was to evaluate the safety and efficacy of Davis FT placement.

METHODS

Fifty consecutive patients requiring transpyloric enteral tube feeding underwent placement of the Davis FT. Placement efficacy was evaluated with postplacement radiographs. Patient demographics, route of tube placement, use of sedation, and complications were abstracted.

RESULTS

The Davis FT was placed successfully in 50 patients. The mean age of the cohort was 52 (+/- 18) years. Sixty-two percent (31/50) were men. The success rate of nonpulmonary placement was 100% (50/50), and the postpyloric success rate was 96% (48/50). IV sedation was used in 72% (36/50) of placements. Eighty-six percent (43/50) of tubes were placed transnasally. The majority (62%) of esophagogastroduodenoscopies and Davis FT placements was performed by a pulmonologist. Forty-four percent (22/50) of patients had an endotracheal tube, 20% (10/50) had a tracheotomy, and 36% (18/50) had no breathing tube at the time of Davis FT placement. There were no complications.

CONCLUSIONS

Transpyloric placement of the Davis FT is safe (100%) and effective (96%). The tube can be placed transorally or transnasally with or without sedation. The data suggest that postplacement radiographs are not necessary to confirm placement. Pulmonologists were successful in performing EGD and Davis FT placement.

Complications of enteral access

Innovation in endoscope design and application of lessons and techniques from minimally invasive surgery is allowing endoscopists to explore new frontiers in enteral access and meet the demands of an increasingly savvy and aging 'baby boomer' population that has high health care expectations. Another small but very labor intensive group of patients that is contributing both to increased awareness and to the demand for specialized nutrition support services, is made up of patients with intestinal failure. With steadily accruing experience in the care of these patients on long term home parenteral and enteral nutrition, as well as the improved outcomes for intestinal transplantation, these services are poised for exponential growth in coming years. The endoscopist whose practice involves enteral access should be capable of providing the whole gamut of enteral access services allowing individualization of approach to ensure the best possible outcomes for a given patient and indication. Experience with management of the many common complications of enteral access is a pre-requisite for successful long-term outcomes. While it would be desirable that such enteral access be provided within a broader multi-disciplinary model of specialized nutrition support, in the current climate of a tightening health care economy that may be counsel for perfection.

Important Facts About Intestinal Feeding Tube Placement

Enteral feeding is desirable when the gastrointestinal tract is functional because it allows better use of nutrients, is safer, and is more cost-effective than parenteral nutrition. Feeding through a gastric tube, however, is often not feasible in severely ill adults and children because of gastric paresis leading to recurrent episodes of gastroesophageal reflux with the risk of subsequent aspiration. Feeding into the small intestine (duodenum or jejunum) through a nasointestinal tube, therefore, is preferred. Unfortunately, no method of enteral feeding is risk free. This literature review addresses the following 10 topics: (a) the reasons why nasointestinal tube feeding is better tolerated by some patients, (b) candidates for nasointestinal tube feeding, (c) options for selecting nasointestinal tubes, (d) recommended methods for predicting the distance to insert nasointestinal tubes, (e) recommended methods for placing nasointestinal tubes, (f) how promotility medications work and whether they facilitate nasointestinal tube placement, (g) nasointestinal tube placement error rate, (h) methods of determining the internal location of nasointestinal tubes, (i) complications associated with nasointestinal tube use, and (j) other pertinent issues surrounding feeding through nasointestinal tubes. The available research evidence is summarized and recommendations for future work are suggested.

Spontaneous transpyloric migration of a ballooned nasojejunal tube: a randomized controlled trial

BACKGROUND

Spontaneous transpyloric migration of a simple nasojejunal tube (NJT) can be expected in only one-third of insertions. Guidance of the tube by radiologic or endoscopic maneuvers is usually required. We believed that locating a 5-mL balloon near the tip of an NJT on which natural peristalsis could act would improve the rate of spontaneous transpyloric migration and facilitate small bowel propagation.

METHODS

Thirty healthy volunteers were randomly assigned to have an inflated or noninflated, ballooned NJT fashioned from a modified 9F Hickman line catheter inserted. The pH of aspirates was measured hourly and the final location of the tube assessed by gastrografin contrast abdominal x-ray (AXR) at the end of 6 hours, at which time the tube was removed.

RESULTS

After 6 hours, spontaneous transpyloric migration occurred in 86.6% of the ballooned and 66.6% of the nonballooned tubes. The final disposition of the ballooned tubes was: stomach, 2 (13.3%); duodenum, 1 (6.7%); and small bowel, 12 (80%). The final disposition of the nonballooned tubes was: stomach, 5 (33%), NS; duodenum, 9 (60%), p < .05; and small bowel, 1 (6.7%), p < .05.

CONCLUSIONS

Ballooned NJT have a higher rate of spontaneous transpyloric migration and are significantly more likely to achieve an optimal small bowel location.

Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial

OBJECTIVE

To evaluate transpyloric feeds as they have been proposed as a means of providing enteric nutrition more rapidly and minimizing morbidity in ventilated trauma patients.

METHODS

Between July of 1994 and June of 1997, 80 adult ventilated trauma patients were enrolled in a randomized controlled trial of duodenal versus gastric feeds. Feeding was initiated within 72 hours of injury.

RESULTS

Forty-three patients received gastric feeds (G), and 37 patients received duodenal feeds (D). Mean age was 34.7+/-15.7 years (G) and 33.6+/-17.5 years (D); the difference in age was not significant (NS). Mean Injury Severity Score was 30.0+/-11 (G), 33.0+/-9.7 (D), NS. Mean Acute Physiology and Chronic Health Evaluation (APACHE II) score was 18.0+/-6.0 (G) and 18.0+/-7.4 (D), NS. Thirty-four of 43 patients were men (G) and 28 of 37 patients were men (D), NS. Use of narcotics and paralytics between the two groups was not significantly different. Energy requirements were 1.4 times basal energy expenditure at 2,127+/-304 Kcal (G) and 2,089+/-274 Kcal (D), NS. Intensive care unit length of stay was a median of 7 days (range, 3-32 days) (G) and 10 days (range, 3-24 days) (D), NS. Number of days on ventilator was a median of 5 days (range, 3-15 days) (G) and 9 days (range, 2-13 days) (D), NS. Hospital length of stay was a median of 25 days (range, 9-88 days) (G) and 30 days (range, 16-47 days) (D), NS. Recorded morbidity was not significantly different. Pneumonia rates were 42% (G) and 27% (D), NS. Time to tolerate full-strength feeds for 24 consecutive hours was 43.8 hours +/-22.6 (G) and 34.3 hours +/-7.1 (D), difference significant at p = 0.02.

CONCLUSION

Length of stay and ventilator days were not significantly different. A larger trial would be required to determine differences in the rates of pneumonia <20%. Transpyloric-duodenal feeds significantly reduce the time required to achieve targeted enteric nutrition.

Enteral feeding techniques

Major technical advances in enteral nutrition include the use of erythromycin or magnetic guidance for the placement of the feeding tube into the duodenum, the development of new enteral tubes, and bedside methods to control the tube position. Percutaneous endoscopic jejunostomy is becoming a safe procedure with a high success rate. Specialized diets offer little or no clinical advantages when compared with standard polymeric diets.