Tips and tricks for deep jejunal enteral access: modifying techniques to maximize success

Nutritional support for the trauma and emergency general surgery patient: What you need to know

ABSTRACT

Decades of research have provided insight into the benefits of nutritional optimization in the elective surgical patient. Patients who are nutritionally prepared for surgery enjoy reduced length of hospital and intensive care unit stays and suffer fewer complications. In the trauma and emergency general surgery patient populations, we are not afforded the preoperative period of optimization and patients often suffer longer lengths of hospital stay, discharge to nonhome destinations, and higher infectious and mortality rates. Nonetheless, ongoing research in this vulnerable and time critical diagnosis population has revealed significant outcomes benefits with the meticulous nutritional support of these patients. However, it is important to note that optimal nutritional support in this challenging patient population is not simply a matter of "feeding more and feeding earlier." In this review, we will address assessing nutritional needs, the provision of optimal nutrition, the timing and route of nutrition, and monitoring outcomes and discuss the management of nutrition in the complex trauma and emergency general surgery patient.

LEVEL OF EVIDENCE

Literature Synthesis and Expert Opinion; Level V.

Jejunal access for enteral nutrition: A practical guide for percutaneous endoscopic gastrostomy with jejunal extension and direct percutaneous endoscopic jejunostomy

For patients requiring long-term (>4 weeks) jejunal nutrition, jejunal medication delivery, or decompression, a percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) or a direct percutaneous endoscopic jejunostomy (DPEJ) may be indicated. PEG-J is the preferred option if a PEG tube is already in place or if simultaneous gastric decompression and jejunal nutrition are needed. DPEJ is recommended for patients with altered anatomy due to foregut surgery, high risk of jejunal extension migration, and whenever PEG-J fails. Successful placement rates are lower for DPEJ but recent publications have reported improvements, partly due to the use of balloon-assisted enteroscopy. Both techniques are contraindicated in cases of active peritonitis, uncorrectable coagulopathy, and ongoing bowel ischaemia, and relative contraindications include, among other, peptic ulcer disease and haemodynamic or respiratory instability. In this narrative review, we present the most recent evidence on indications, contraindications, technical considerations, adverse events, and outcomes of PEG-J and DPEJ.

Endoscopic management of enteral tubes in adult patients - Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.

Jejunal feeding: when is it the right thing to do?

The decision to commence jejunal feeding in patients with structural abnormalities, which prevent oral or intragastric feeding, is usually straightforward. However, decisions surrounding the need for jejunal feeding can be more complex in individuals with no clear structural abnormality, but rather with foregut symptoms and pain-predominant presentations, suggesting a functional origin. This appears to be an increasing issue in polysymptomatic patients with multi-system involvement. We review the differential diagnosis together with the limitations of available functional clinical tests; symptomatic management options to avoid escalation where possible including for patients on opioids; tube feeding options where necessary; and an approach to weaning from established jejunal feeding in the context of a multidisciplinary approach to minimise iatrogenesis.

Percutaneous endoscopic versus radiologic gastrostomy for enteral feeding: a retrospective analysis on outcomes and complications

Background and study aims  Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) are techniques used for long-term enteral feeding. Our primary aim was to analyze procedure-related and 30-day mortality and complications between PEG and PRG in relation to indications. Patients and methods  A single-center retrospective analysis was performed thath included all adult patients receiving initial PEG (January 2008 until April 2016) and PRG (January 2010 until April 2016). Outcomes were mortality (procedure-related, 30-day), complications (early (≤ 30 days) and late) and success rates. Results  A total of 760 procedures (469 PRG and 291 PEG) were analyzed. Most common indications were head and neck cancer (HNC), cerebrovascular accident (CVA) and amyotrophic lateral sclerosis (ALS). Success rates for placement were 91.2 % for PEG and 97.1 % for PRG ( P  = 0.001). Procedure-related mortality was 1.7 % in PEG and 0.4 % in PRG ( P  = 0.113). The 30-day mortality was 10.7 % in PEG and 5.1 % in PRG ( P  = 0.481 after multivariate logistic regression) CVA was associated with higher 30-day mortality, whereas ALS, higher body weight, and prophylactic placements in HNC were associated with lower rates. Tube-related complications were less frequent in PEG, both early (2.7 % vs. 26.4 %, P  ≤ 0.001) and late (8.6 % vs. 31.5 %, P  ≤ 0.001). The percentage of major complications and infections did not differ. Conclusions  With respect to procedure-related and 30-day mortality, PEG and PRG compare equally. PRG had a higher procedural success rate. Tube-related complications and pain are less frequent after PEG compared to PRG. The choice for either PEG or PRG therefore should primarily be based on local facilities and expertise.

Therapeutic strategies in gastroparesis: Results of stepwise approach with diet and prokinetics, Gastric Rest, and PEG-J: A retrospective analysis

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.

When Is Parenteral Nutrition Appropriate?

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

Two port video-assisted gastrostomy and jejunostomy: technical simplification and clinical results

Background

Patients presenting upper gastrointestinal obstruction, difficulty or inability in swallowing, may need nutritional support which can be obtained through gastrostomy and jejunostomy.

Aim

To describe the methods of gastrostomy and jejunostomy video-assisted, and to compare surgical approaches for video-assisted laparoscopy and laparotomy in patients with advanced cancer of the esophagus and stomach, to establish enteral nutritional access.

Methods

Were used the video-assisted laparoscopic techniques for jejunostomy and gastrostomy and the same procedures performed by laparotomies. Comparatively, were analyzed the distribution of patients according to demographics, diagnosis and type of procedure.

Results

There were 36 jejunostomies (18 by laparotomy and 17 laparoscopy) and 42 gastrostomies (21 on each side). In jejunostomy, relevant data were operating time of 132 min vs. 106 min (p=0.021); reintroduction of diet: 3.3 days vs 2.1 days (p=0.009); discharge: 5.8 days vs 4.3 days (p= 0.044). In gastrostomy, relevant data were operative time of 122.6 min vs 86.2 min (p= 0.012 and hospital discharge: 5.1 days vs 3.7 days (p=0.016).

Conclusions

The comparative analysis of laparotomy and video-assisted access to jejunostomies and gastrostomies concluded that video-assisted approach is feasible method, safe, fast, simple and easy, requires shorter operative time compared to laparotomy, enables diet start soon in compared to laparotomy, and also enables lower length of stay compared to laparotomy.