Percutaneous endoscopic gastrostomy feeding of locally advanced oro-pharygo-laryngeal cancer patients: Blenderized or commercial food?

The effect of blended tube feeding compared to conventional formula on clinical outcomes in adults: A systematic review

AIM

To explore the effect of blended tube feeding compared to conventional formulas on nutritional status, quality of life, anthropometry, diarrhoea and tube blockages in adults receiving tube feeding.

METHODS

The protocol was registered (PROSPERO CRD42022372443). Five databases (MEDLINE, EMBASE, CINAHL, Scopus, CENTRAL) were searched from commencement of database to 14th June 2023 to identify studies comparing blended tube feeding to conventional formulas in adults receiving tube feeding. Certainty assessment was conducted using the Cochrane Risk of Bias Tools and the Grading of Recommendations, Assessment, Development and Evaluations framework, and a narrative synthesis of results is provided.

RESULTS

From 4227 studies screened, eight were included (total n = 763 patients, 9-215 patients). Three studies were hospital-based and five were home-based with duration from 8 days-8 months. Blended tube feeding and conventional formulas were nutritionally equivalent in only three studies; energy and protein concentration of formulas ranged from 1.7-7.1 kJ/mL and 21-68.5 g/L for the blended tube feeding groups, and 4.2-6.7 kJ/mL and 39-100 g/L for the conventional groups. No studies assessed nutrition status or quality of life using validated measures. Blended tube feeding was associated with a clinically relevant reduction in diarrhoea with a low level of certainty. For remaining outcomes, there were inconclusive findings and an overall very low certainty of evidence for each.

CONCLUSION

The effect of blended tube feeding compared to conventional formulas on all outcomes remains uncertain. Blended tube feeding may reduce the incidence of diarrhoea. Future research using nutritionally equivalent comparisons and validated outcome measures is required.

Clinical outcomes associated with blenderized tube feedings in adults: A systematic review

Nearly half a million individuals in the United States are dependent on enteral nutrition to meet their nutrition needs. Public interest in blenderized tube feeding (BTF) has increased over the past decade; however, medical professionals indicate a lack of knowledge about these products and their effects. The purpose of this review is to analyze clinical outcomes in adults who use a BTF formula as their primary nutrition source. A literature search was conducted in PubMed, Scopus, and CINAHL using search terms "adult," "enteral nutrition," "tube feeding," "BTF," blenderized," "blended," "homemade," and "pureed." Nine studies met the inclusion criteria and were analyzed in the review. Under close monitoring, BTF does not pose a higher risk for deterioration in anthropometric measurements. Furthermore, BTF use is consistently associated with improvements in diarrhea. As such, clinicians should consider the use of these formulas in the acute care or rehabilitation settings. Additional research is needed in patients with diverse clinical backgrounds in free-living communities. Larger populations sizes and longer intervention time frames are crucial to providing statistically significant results needed to strengthen the quality of evidence on this topic.

The Effect of Hospital-Based Liquid Diet and Commercial Formulas on Laboratory Parameters and Postoperative Complications in Patients with Head and Neck Cancer

Background: Patients with head and neck cancer (HNC) are at high risk of malnutrition. The aim of this study was to compare the effect of polymeric formulas available commercially and a high-protein liquid diet prepared in the hospital on laboratory parameters and postoperative complications in patients undergoing surgery for HNC. Methods: This single-center retrospective study included 149 patients who underwent surgery for HNC between 2008 and 2017. The following data were collected: patient and tumor characteristics, postoperative complications, and laboratory parameters measured at baseline and after surgery, including creatinine, alanine transaminase (ALT), aspartate transaminase (AST), and blood glucose levels. Correlations between the duration of enteral nutrition and blood parameters were assessed. Results: After surgery, patients receiving commercial formulas had lower creatinine and blood glucose levels and higher ALT and ASP levels than those on the hospital-based diet. The longer duration of feeding with commercial formulas before surgery was associated with enhanced preoperative levels of ALT and ASP and with lower postoperative blood glucose. Patients on the hospital-based diet had a higher rate of postoperative complications than those receiving commercial formulas (16.1% vs. 3.3%). Conclusions: There were no clinically important differences in blood parameters among patients with HNC depending on the type of preparations used for enteral feeding. However, increased levels of liver enzymes in patients fed with commercial formulas were notable. The early initiation of enteral nutrition before surgery helped achieve normal blood glucose levels after surgery. The use of commercial preparations contributed to reducing the number and incidence of postoperative complications.

Current and Emerging Radiotherapy Options for Uveal Melanoma

What treatment options are there for patients having uveal melanoma? A randomized, prospective, multi-institutional clinical trial (COMS) showed no difference in survival between brachytherapy and enucleation for medium-sized lesions. With the obvious benefit of retaining the eye, brachytherapy has flourished and many different approaches have been developed such as low-dose-rate sources using alternate low-energy photon-emitting radionuclides, different plaque designs and seed-loading techniques, high-dose-rate brachytherapy sources and applicators, and low- and high-dose-rate beta-emitting sources and applicators. There also have been developments of other radiation modalities like external-beam radiotherapy using linear accelerators with high-energy photons, particle accelerators for protons, and gamma stereotactic radiosurgery. This article examines the dosimetric properties, targeting capabilities, and outcomes of these approaches. The several modalities examined herein have differing attributes and it may be that no single approach would be considered optimal for all patients and all lesion characteristics.

Body composition and dietary intake in patients with head and neck cancer during radiotherapy: a longitudinal study

OBJECTIVES

To investigate the body composition and dietary intake in the patients with head and neck cancer (HNC) during radiotherapy (RT), and explore the relationship between them.

METHODS

This was a prospective, longitudinal observational study. Adult patients with HNC undergoing RT between March 2017 and August 2018 were recruited. Patients' body compositions were evaluated by bioelectrical impedance analysis, and dietary intake was recorded by 24-hour dietary recall at three time points, including baseline (T1), mid-treatment (T2) and post-treatment (T3). Patients were divided into low, middle and high energy intake groups based on the average daily energy intake (DEI). Changes in body weight (BW), fat mass (FM), fat-free mass (FFM) and skeletal muscle mass (SMM) among these three groups were compared.

RESULTS

From T1 to T3, the median loss of patients' BW, FM, FFM and SMM was 4.60, 1.90, 2.60 and 1.50 kg, respectively. The loss of BW was more dramatic from T2 to T3 than that from T1 to T2. BW loss was mainly contributed by SMM loss from T1 to T2 and by FM loss from T2 to T3. Meanwhile, patients' dietary intake reduced during treatment. High DEI group had a significantly attenuated loss of patients' BW, FFM, SMM and FM compared with the low DEI group.

CONCLUSION

Patients' BW, FM, FFM and SMM all significantly reduced, especially from T2 to T3, with decreased DEI during RT, which stresses the importance of nutrition intervention during the whole course of RT.

Homemade blenderized tube feeding improves gut microbiome communities in children with enteral nutrition

Enteral nutrition for children is supplied through nasogastric or gastrostomy tubes. Diet not only influences nutritional intake but also interacts with the composition and function of the gut microbiota. Homemade blenderized tube feeding has been administered to children receiving enteral nutrition, in addition to ready-made tube feeding. The purpose of this study was to evaluate the oral/gut microbial communities in children receiving enteral nutrition with or without homemade blenderized tube feeding. Among a total of 30 children, 6 receiving mainly ready-made tube feeding (RTF) and 5 receiving mainly homemade blenderized tube feeding (HBTF) were analyzed in this study. Oral and gut microbiota community profiles were evaluated through 16S rRNA sequencing of saliva and fecal samples. The α-diversity representing the number of observed features, Shannon index, and Chao1 in the gut were significantly increased in HBTF only in the gut microbiome but not in the oral microbiome. In addition, the relative abundances of the phylum Proteobacteria, class Gammaproteobacteria, and genus Escherichia-Shigella were significantly low, whereas that of the genus Ruminococcus was significantly high in the gut of children with HBTF, indicating HBTF altered the gut microbial composition and reducing health risks. Metagenome prediction showed enrichment of carbon fixation pathways in prokaryotes at oral and gut microbiomes in children receiving HBTF. In addition, more complex network structures were observed in the oral cavity and gut in the HBTF group than in the RTF group. In conclusion, HBTF not only provides satisfaction and enjoyment during meals with the family but also alters the gut microbial composition to a healthy state.

Comparison of Home-Blenderized Formula and Commercial Enteral Formulas for Gastrostomy Tube-Fed Children: A Retrospective, Prospective Cohort Study

Background Blenderized gastrostomy tube feedings (BGTFs) consist of pureed table foods and liquids that are administered as enteral tube feedings. Compared to commercial enteral formulas (CEFs), BGTF has been shown to have fewer side effects. Despite these results, apprehensions have been raised about microbial contamination, nutritional deficiencies or surplus, risk of gastrostomy tube (GT) blockages, and lack of consistency in clinical outcomes. The goal of this retrospective, prospective, 18-month-long study is to report the clinical and nutritional outcomes of GT-dependent pediatric patients who attended a multidisciplinary feeding clinic. Methodology After Institutional Review Board (IRB) approval and consent were obtained, 25 children who were receiving tube feeding via G were enrolled in a retrospective, prospective, observational, cohort study from August 2019 to February 2021. A multidisciplinary team was formed, and multivariate logistic regression was performed comparing subjects on BGTF versus CEF, per os diet versus nil per os, CEF versus homemade blenderized tube feeding (HBTF) versus blenderized tube feeding (BTF), and how they compared at the beginning and end of the study. Results The mean age of the patients was 4.4 years (SD ±2.2). Gastroesophageal reflux disease (GERD) and short bowel syndrome (SBS) were the most common comorbid gastrointestinal (GI) conditions. Of the 25 patients enrolled in the study, seven were initially on BGTF, while 14 ended the study on BGTF. There were no statistically significant differences in malnutrition status, feeding intolerance, emergency room visits, hospitalizations, and GT blockages between all different comparison groups when comparing between the CEF versus HBTF versus commercial blenderized tube feeding (CBTF) groups. Of the patients who were in the BGTF group, there was a resolution of vitamin A deficiency, vitamin D deficiency, and anemia (n = 1). In total, two patients had resolved vitamin deficiencies, namely, vitamins A and D. Conclusions When comparing BGTF and CEF, there was no statistically significant difference in outcomes. This study suggests that BGTF is at least equivalent to CEF in clinical outcomes, meaning BGTF should be considered standard nutrition for GT-dependent patients.

Blenderized Tube Feeding and Enterostomy Tube Occlusions Among Adults with Amyotrophic Lateral Sclerosis and Primary Lateral Sclerosis

Adults with amyotrophic lateral sclerosis (ALS) and primary lateral sclerosis (PLS) may develop swallowing difficulties and elect to receive an enterostomy feeding tube for nutrition support. Blenderized tube feeding (BTF) appeals to those interested in a homemade enteral nutrition option, but there are concerns of feeding tube occlusion and limited research on this potential risk. Therefore, our purpose was to determine the frequency of, and risk factors for, feeding tube occlusions among adults with ALS or PLS who use BTF. For this retrospective study, the electronic medical records of tube-fed adults with ALS or PLS who received outpatient care at a provincial ALS clinic during a two-year period were reviewed (n = 651). There were 97 tube-fed patients identified, of which 20 (21%) used BTF. Average duration of BTF use was 11.25 ± 7.5 months. Seven subjects (35%) used BTF exclusively, while 13 (65%) used a combination of BTF and commercial enteral formula. All received BTF by gastrostomy tube, sized 14 to 24 French. BTF administration methods and compliance with water flush recommendations varied. Despite the perceived risk of feeding tube occlusions with blenderized tube feeding, no occlusions were found to have occurred in this study.

ESPEN practical guideline: Home enteral nutrition

This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers in a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also inform interested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline is based on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered, along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels are indicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.

Blenderized food tube feeding in patients with head and neck cancer

Background

Patients with headand neck cancer (HNC) are at high risk for malnutrition before and during chemoradiation treatment. Many will also require tube feeding to address declines in energy intake, weight, and quality of life (QOL) caused by the impact of treatment on gastrointestinal (GI) symptoms. Blenderized tube feeding (BTF) may ameliorate these adverse conditions.

Methods

In this open‐label, prospective pilot study, 30 patients with HNC who required feeding tube placement were recruited to switch from standard commercial formula after 2 weeks to a commercially prepared BTF formula. Weight, body mass index (BMI), GI symptoms, and QOL scores were tracked for 6 weeks from the first week of feeding tube placement.

Results

Of the 16 patients who completed the 6‐week assessment period, weights and BMI scores for 15 patients trended upward. For most patients, QOL and oral intake increased and GI symptoms decreased over the 6‐week period, particularly during weeks 3 and 4, when the impact of treatment is particularly exacting on patients with HNC.

Conclusion

BTF effectively mitigated weight loss, GI symptoms, QOL scores, and total energy intake in this group of patients with HNC who received tube feeding for 6 weeks.

An Evaluation of the Nutritional Value and Physical Properties of Blenderised Enteral Nutrition Formula: A Systematic Review and Meta-Analysis

Background: Although there are merits in using commercial “enteral nutrition formula” (ENF) compared with blended ENF, there is a growing preference for the use of blended ENF in many countries globally. However, the nutritional value and physical properties of blended ENF compared with commercial ENF may be limiting its use. We have not found any evidence of a meta-analysis on the nutritional value of blended diets in the adult population. Aim: The aim of this review was to compare the nutritional value, physical properties, and clinical outcomes of blended ENF with commercial ENF. Methods: The preferred reporting items for systematic reviews and meta-analyses were used for this review. The search strategy was based on a Population, Intervention, Comparator, Outcome framework. The following databases; Pubmed, EMBASE, PSYCInfo, and Google scholar were searched for articles of interest using keywords, Medical Subject Heading (MeSH) and Boolean operators (AND/OR) from the inception of each database until 23 February 2020. The articles were evaluated for quality. Results: Based on the systematic review and meta-analysis, four distinct themes were identified; Nutritional value, Physical properties, Clinical outcomes; and Adverse events. The findings of this review showed inconsistencies in the macronutrient and micronutrient values of the blenderised ENF compared with the commercial ENF. The results of the meta-analysis demonstrated that there were no significant differences (p > 0.05) between the blenderised ENF and the commercial ENF in relation to the fat and protein contents of the diets. However, the blenderised ENF was significantly lower (p < 0.05) than the commercial ENF regarding the energy content of the diets, with an overall mean difference of −29.17 Kcal/100 mL (95% CI, −51.12, −7.22) and carbohydrate content with an overall mean difference of -5.32 g/100 mL (95% CI, −7.64, −3.00). In terms of sodium, potassium, and vitamin A, there were no significant differences (p > 0.05) between the blenderised and commercial ENF, although significant differences (p < 0.05) were observed between the two diets with respect to calcium, phosphorus, magnesium, zinc, iron, and vitamin C contents. Furthermore, the blenderised ENF showed significantly higher levels (p < 0.05) of viscosity and osmolality than the commercial ENF. The significantly lower levels of some of the macro-nutrients and micro-nutrients in the blenderised ENF compared with the commercial ENF and the difference in the expected nutritional values may be due to the fact blenderised ENF is produced from common foods. Thus, the type of foodstuffs, cooking, and processing methods may lead to loss of nutrients and energy density. The deficits in the energy content and some of the macro- and micro-nutrients in the blenderised ENF compared with commercial ENF may have implications for patients’ health and clinical outcomes. The clinical implications of the underdelivering of nutrients may include increased risk of undernutrition, including energy malnutrition, which could have a negative effect on body composition and anthropometric parameters, morbidity, mortality, length of hospital stay, and costs. For outpatient care, this could increase the risk of hospital re-admission and homecare costs. Additionally, the higher viscosity and osmolality of the blenderised ENF compared with the commercial ENF can increase the risk of complications, including tube blockage, and impaired delivery of feed, water, and medications, with significant implications for patients’ nutritional status and health outcomes. Conclusion: The results of this systematic review and meta-analysis identified significant variability in the nutritional value of blenderised ENF compared with commercial ENF. Furthermore, the nutritional values of the blenderised ENF do not meet the expected recommended levels compared with commercial ENF and these may have implications for patients’ nutritional status and health outcomes, including the effect on body composition, morbidity, mortality, hospital re-admission, and costs. Further studies are needed to elucidate the nutritional value of blenderised ENF on patients’ clinical outcomes.

Clinical Outcomes Associated With Commercial and Homemade Blenderized Tube Feedings: A Literature Review

There is emerging evidence in the pediatric population that blenderized tube feeding (BTF) may improve gastrointestinal intolerance; however, not much is known about the impact of BTF on clinical outcomes in adults. This article presents a review of the literature published in the past 10 years that explored the impact of BTF on nutrition status (ie, weight status, body mass index, and upper-arm circumference) and nutrition adequacy in adults. The results indicate that BTF, compared with commercial enteral formula (CEF), may be inadequate in calories, macronutrients, and some micronutrients, given variability in BTF formula composition. As a result, BTF may result in significantly more weight loss than CEF. Thus, BTF may not be appropriate for adult patients who are malnourished or are at risk for malnutrition due to the potential worsening of clinical outcomes.

Nutritional Support of Cancer Patients without Oral Feeding: How to Select the Most Effective Technique?

BACKGROUND

Digestive tumours are among the leading causes of morbidity and mortality. Many cancer patients cannot maintain oral feeding and develop malnutrition. The authors aim to: review the endoscopic, radiologic and surgical techniques for nutritional support in cancer patients; address the strategies for nutritional intervention according to the selected technique; and establish a decision-making algorithm to define the best approach in a specific tumour setting.

SUMMARY

This is a narrative non-systematic review based on an electronic search through the medical literature using PubMed and UpToDate. The impossibility of maintaining oral feeding is a major cause of malnutrition in head and neck (H&N) cancer, oesophageal tumours and malignant gastric outlet obstruction. Tube feeding, endoscopic stents and gastrojejunostomy are the three main nutritional options. Nasal tubes are indicated for short-term enteral feeding. Percutaneous endoscopic gastrostomy (PEG) is the gold standard when enteral nutrition is expected for more than 3-4 weeks, especially in H&N tumour and oesophageal cancer patients undergoing definite chemoradiotherapy. A gastropexy push system may be considered to avoid cancer seeding. Radiologic and surgical gastrostomy are alternatives when an endoscopic approach is not feasible. Postpyloric nutrition is indicated for patients intolerant to gastric feeding and may be achieved through nasoenteric tubes, PEG with jejunal extension, percutaneous endoscopic jejunostomy and surgical jejunostomy. Oesophageal and enteric stents are palliative techniques that allow oral feeding and improve quality of life. Surgical or EUS-guided gastrojejunostomy is recommended when enteric stents fail or prolonged survival is expected. Nutritional intervention is dependent on the technique chosen. Institutional protocols and decision algorithms should be developed on a multidisciplinary basis to optimize nutritional care.

CONCLUSIONS

Gastroenterologists play a central role in the nutritional support of cancer patients performing endoscopic techniques that maintain oral or enteral feeding. The selection of the most effective technique must consider the cancer type, the oncologic therapeutic program, nutritional aims and expected patient survival.

Effect of lower esophageal gastric tube implantation in postoperative enteral nutritional support in patients with laryngeal cancer: A study protocol for a randomized controlled trial

BACKGROUND

For a long time, postoperative nutritional support for laryngeal cancer patients has depended on the gastric tube for enteral nutrition. Silica gel gastric tube is often used in clinical practice; however, the gastric tube placed in the conventional depth often leads to various complications in the stomach, thus damaging the nutritional status of patients and leading to the poor prognosis.

METHODS/DESIGN

A total of 80 patients with laryngeal cancer in otolaryngology, head and neck surgery department of Deyang people's hospital from May 2020 to April 2022 will be selected and randomly divided into control group and experimental group according to the numerical table. Patients in the control group will receive conventional gastric tube placement, with a depth of 45 to 55 cm, which can extract gastric juice. B-ultrasound accurately positioned the gastric tube in the stomach instead of the cardia, and postoperative nasal feeding nutrition will be provided. In the experimental group, the gastric tube will be pulled out 10 cm after conventional placement and no gastric juice will be extracted. B-ultrasonography verified that the gastric tube will be located below the esophagus or above the cardia, and routine nasal feeding will be performed postoperatively. Analysis for comfort and prognosis were performed by general comfort questionnaire and various index including height, body mass index, albumin value, electrolyte, wound healing, pharyngeal fistula.

DISCUSSION

In this study, visual simulation scale and general comfort questionnaire developed by Kolaba, an American comfort nursing specialist, were used to evaluate the comfort level of the 2 groups of patients, including pain, acid reflux, upper abdominal burning sensation, and hiccup. Objective indexes such as height, body mass index, albumin value, electrolyte, wound healing, and pharyngeal fistula were used to evaluate the prognosis of the 2 groups of patients. The visual simulation scale can preliminarily judge the subjective feelings of patients.

TRIAL REGISTRATION

It has been registered at http://www.chictr.org.cn/listbycreater.aspx (Identifier: ChiCTR2000030378), Registered February 29, 2020.