Laparoscopic gastrostomy and jejunostomy are safe and effective for obtaining enteral access

Laparoscopic T-tube feeding jejunostomy as an adjunct to staging laparoscopy for upper gastrointestinal malignancies: the technique and review of outcomes

Background

In recent years, staging laparoscopy has gained acceptance as part of the assessment of resectability of upper gastrointestinal (UGI) malignancies. Not infrequently, we encounter tumours that are either locally advanced; requiring neoadjuvant therapy or occult peritoneal disease that requires palliation. In all these cases, the establishment of enteral feeding during staging laparoscopy is important for patients’ nutrition. This review describes our technique of performing laparoscopic feeding jejunostomy and the clinical outcomes.

Methods

The medical records of all patients who underwent laparoscopic feeding jejunostomy following staging laparoscopy for UGI malignancies between January 2010 and July 2015 were retrospectively reviewed. The data included patient demographics, operative technique and clinical outcomes.

Results

Fifteen patients (11 males) had feeding jejunostomy done when staging laparoscopy showed unresectable UGI maligancy. Eight (53.3%) had gastric carcinoma, four (26.7%) had oesophageal carcinoma and three (20%) had cardio-oesophageal junction carcinoma. The mean age was 63.3 ± 7.3 years. Mean operative time was 66.0 ± 7.4 min. Mean postoperative stay was 5.6 ± 2.2 days. Laparoscopic feeding jejunostomy was performed without intra-operative complications. There were no major complications requiring reoperation but four patients had excoriation at the T-tube site and three patients had tube dislodgement which required bedside replacement of the feeding tube. The mean duration of feeding tube was 127.3 ± 99.6 days.

Conclusions

Laparoscopic feeding jejunostomy is an important adjunct to staging laparoscopy that can be performed safely with low morbidity. Meticulous attention to surgical techniques is the cornerstone of success.

Gastrostomy Tube Placement Outcomes: Comparison of Surgical, Endoscopic, and Laparoscopic Methods

BACKGROUND

Advances in percutaneous endoscopic gastrostomy (PEG) and laparoscopic (LAP) techniques now allow for less invasive placement of gastrostomy tubes. This study compared morbidities and feeding outcomes of these procedures with standard surgical (OPEN) insertion.

METHODS

Gastrostomy tubes placed in the operating room by the PEG, LAP, and OPEN methods were compared for insertion times, tube insertion and maintenance complications, enteral feeding complications, and feeding start days. Patients with concomitant intra-abdominal procedures were excluded. Patients were followed for 6 days after tube placement.

RESULTS

A total of 91 catheters (PEG = 23, LAP = 39, OPEN = 29) were inserted in the operating room for indications of ventilator-dependent respiratory failure (45), dysphagia (30), head and neck cancer (9), and decreased mental status (7). No patients were fed on the day of the procedure. Insertion times were significantly longer (p < .05) in the OPEN technique (68 minutes) vs LAP (48 minutes) and PEG (30 minutes). Insertion complications occurred in the LAP and PEG cohorts (3 failed LAP, 1 failed PEG), and maintenance complications were higher in the LAP group, including 1 episode each of cellulitis, bleeding, and serous drainage. Twenty enteral feeding complications in 17 patients occurred in all groups (9 in LAP vs 6 in PEG and 5 in OPEN), and included emesis (6), high residual (5), diarrhea (3), ileus (3), nausea (2), and pain after feeding (1). Overall complications were significantly lower in the PEG (7) and OPEN (5) groups compared with the LAP group (15). Feeding start day was significantly delayed in the OPEN technique (2.1 days vs 1.7 in PEG and 1.5 in LAP); however, no difference was found in days to goal among groups (4.4-4.8 days).

CONCLUSIONS

PEG should be the procedure of choice for placement of gastrostomy tubes. If PEG is contraindicated, then OPEN technique may be best due to fewer complications, although insertion time is longer than the LAP technique.

The History of Surgically Placed Feeding Tubes

Although supplemental enteral nutrition may have first been delivered by enema, the modern era of surgically placed feeding tubes began in the mid to late 1800s. Early procedures were generally disastrous, however, techniques rapidly improved. The basic techniques of surgical enteral access have not changed significantly in the last century, although endoscopic, radiologic and laparoscopic modifications have been described and adopted in the last 25 years. This article reviews some of the landmark surgical highlights in the United States and European literature regarding surgical enteral access.

Outcomes of laparoscopic feeding jejunostomy tube placement in 299 patients

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.

Comparison of laparoscopic versus open approach to gastrostomy tubes

BACKGROUND AND OBJECTIVES

Gastrostomy tube insertion for enteral access may be performed through laparotomy (open) or through the laparoscopic approach. This study's purpose is to compare outcomes of these different approaches.

METHODS

A retrospective chart review of all patients (age >18 years) who underwent insertion of a gastrostomy tube as a single elective procedure between 2004 and 2012 was performed. Primary end points included postoperative overall and tube-related morbidity, tube revision rates, and operative time.

RESULTS

During the study period, 71 patients had a gastrostomy tube inserted via either the open (n 46) or the laparoscopic (n 25) approach. Preoperative variables including age, gender, body mass index, albumin, and American Society of Anesthesiologists score were statistically comparable between groups. There was no difference in rates of previous upper abdominal surgery (24% vs 26%, P = .590) or gastric surgery (12% vs 13%, P = .720) in the laparoscopic and open groups, respectively. Previous percutaneous endoscopic gastrostomy tube insertion rates were higher in the laparoscopic group (32% vs 6.5%, P = .005). Operative time was significantly longer in the laparoscopic group (76.8 ± 7 vs 55.8 ± 3, P = .003) but was not affected by previous abdominal surgery or higher body mass index. Overall morbidity, tube-related morbidity, and tube revision rates were similar between groups. However, there was a trend toward increased major complication rates in the open group (6.5% vs 0%, P = .190).

CONCLUSION

Laparoscopic gastrostomy tube insertion is safe and feasible, even in patients who have had prior upper abdominal surgery. Patients with a prolonged prognosis, obesity, and intact neurologic capacity may benefit the most from this approach.

Pyramids and roundtables: a reflection on leadership

By the nature of their career choice, surgeons are leaders at a variety of levels. The rise to leadership positions in surgery often requires scaling a steep pyramid. Many young surgeons are poorly prepared for what is frequently a competition with their peers. Some of the qualities young surgeons must possess to ascend the leadership pyramid are summarized by the "HOPES" of leadership: Honesty, recognition of Opportunity, having a Plan, knowing your Environment, and Self-assessment.

Gastrostomy-to-gastrojejunostomy tube conversion: impact of the method of original gastrostomy tube placement

PURPOSE

To determine the outcome of gastrostomy tube-to-gastrojejunostomy tube conversion on the basis of the method of original gastrostomy tube placement.

MATERIALS AND METHODS

One hundred twenty-four patients (age range, 13-87 years; 72 male and 52 female patients) underwent conversion of a primarily placed gastrostomy tube to a gastrojejunostomy tube at the authors' institution between January 2000 and December 2008. The method of original gastrostomy tube placement was radiologic (n = 27), endoscopic (n = 75), laparoscopic (n = 2), or open surgery (n = 20). The method of placement was correlated with the success rates of gastrostomy-to-gastrojejunostomy tube conversion. Medical records and radiologic images were reviewed to determine the frequency of proximal migration of the jejunostomy tube into the stomach. Follow-up data were available for an average of 136 days after gastrostomy-to-gastrojejunostomy tube conversion (median, 63 days; range, 1-1,300 days).

RESULTS

Of 124 gastrostomy tube-to-gastrojejunostomy tube conversions, 109 (87.9%) were successfully performed. Procedural conversion failure occurred in one of the 27 radiologically inserted gastrostomy tubes (3.7%) compared to 14 of the 97 (14%) nonradiologically inserted gastrostomy tubes (P = .19), of which 12 were inserted endoscopically and two were inserted surgically. Of the 109 patients with successful tube conversion, jejunal tip malposition occurred at follow-up in 18 (16.5%). Of these, four patients developed aspiration pneumonia (22%), which contributed to patient death in two. The frequency of jejunal tip malposition was 3.8% (one of 26 patients) for radiologically placed gastrostomy tubes and 20% (17 of 83 patients) for nonradiologically placed gastrostomy tubes (P = .07). Combined, 32% of gastrostomy tubes placed nonradiologically resulted in either procedural failure or eventual jejunal tip malposition, compared to 7.4% of radiologically placed gastrostomy tubes (P = .01).

CONCLUSIONS

The frequency of procedural failure or eventual jejunal tip malposition with conversion of radiologically placed gastrostomy tubes to gastrojejunostomy tubes is significantly lower with radiologically placed gastrostomy tubes than with nonradiologically inserted gastrostomy tubes.

Endoscopic identification of the jejunum facilitates minimally invasive jejunostomy tube insertion in selected cases

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG), direct percutaneous endoscopic jejunostomy, and laparoscopic feeding tube insertion are established techniques for placing a feeding tube. However, these techniques may be difficult or contraindicated after previous gastric or upper abdominal surgery.

METHODS

A total of 10 patients underwent minimally invasive jejunostomy tube insertion via endoscopic identification of the jejunum. The indications for the procedure were dysphagia, poor nutritional status, prolonged intensive care unit (ICU) admission, and gastroparesis. Eight of the patients had undergone previous upper abdominal surgeries and were rejected for either PEG or direct percutaneous jejunostomy. With the patients under general anesthesia, esophagogastroduodenoscopy was performed. The jejunum was identified and intubated. A small abdominal incision (1 in.) was made. The proximal jejunum was identified easily by the light and digital palpation of the endoscope. The jejunum was delivered in the wound, and the jejunostomy tube was inserted using Witzel's technique. The wound was closed.

RESULTS

All the patients tolerated the procedure well. The mean time for the procedure was 29 +/- 13 min. There was no mortality related to the procedure and no complications. Jejunal feeding started on the first postoperative day.

CONCLUSION

The use of intraoperative endoscopy facilitated identification of the jejunum. Easy, safe, and quick, the procedure saved the patient a formal laparotomy and extensive manipulation.

Mediastinal carcinosis involving the esophagus in breast cancer: the "breast-esophagus" syndrome: report on 25 cases and guidelines for diagnosis and treatment

INTRODUCTION

Breast metastases of mucosal/submucosal layers of the esophagus are extremely rare: esophageal involvement is usually part of a mediastinal carcinosis.

AIM

We report the largest series to date of 25 cases of metastatic esophageal involvement from breast cancer, discussing both diagnostic techniques and treatment options.

MATERIALS AND METHODS

Twenty-five female patients with a history of breast cancer referred for secondary esophageal involvement (1980-2006) were studied.

RESULTS

All patients presented with worsening dysphagia. Twenty-four had undergone surgery for breast cancer a median of 10 years earlier: 1 had received chemoradiotherapy, and 17 had adjuvant radiotherapy/telecobalt therapy following breast surgery. Endoscopic biopsy/cytology were negative for cancer in 17 of 19 patients; in 9 patients, the diagnosis was made with thoracoscopy/laparoscopy. Immunohistochemical staining was done in 10 patients (ER and/or PrR positive). Fifteen patients presented with distant metastatic involvement. Therapy was directed toward dysphagia relief, mostly with endoscopic dilations/prostheses. Complications (4 perforations) occurred only in those 15 patients who had endoscopic dilations/prostheses. Fifteen patients had cytoreductive therapy. Nine of 25 patients are still alive. The median overall survival was 7 months; 1-, 3-, and 5-year survival rates were 44%, 16%, and 8%, respectively.

CONCLUSIONS

A "breast-esophagus" syndrome can be defined: it is often diagnosed only after excluding other diseases or after relief of dysphagia with adequate therapy. The presence of distant metastases helps the diagnosis of esophageal involvement from mediastinal carcinosis, while diagnosis is a problem in case of mediastinal/pleural disease only: in this case, exploratory thoracoscopy is mandatory for a final diagnosis. Given the high related risk of perforation from endoscopic procedures (dilations/prostheses), the treatments of choice are currently hormone therapy or chemotherapy/radiotherapy.

Laparoscopic Witzel gastrostomy—a reappraised technique

BACKGROUND

Laparoscopic gastrostomy is the best alternative for long-term enteral feeding when percutaneous endoscopic gastrostomy is not possible. The aim of the present study was to determine the feasibility, complications, adequacy of feeding support, and tolerability of laparoscopic Witzel gastrostomy (LWG) in head and neck cancer patients. The initial results and the results of extended follow-up were evaluated.

METHODS

A consecutive series of 48 patients with stenotic head and neck or esophageal cancer were referred for laparoscopic gastrostomy. The patients consisted of 42 men and 6 women aged 36 to 82 years (mean, 54 years). After laparoscopic placement of a Foley catheter of 16 F into the stomach, a seromuscular tunnel 4 cm in length is created, embedding the catheter by interrupted sutures. Three stay sutures for gastropexy are fixed and tied on the abdominal skin at the end of the procedure. The mean duration of the procedure was 62.4 +/- 11 min (52-124 min).

RESULTS

Laparoscopic Witzel gastrostomy could be performed successfully in all patients with aerodigestive cancer. None of the laparoscopic gastrostomy tube placement procedures was converted to an open surgery, and none of the 48 patients in this series died as a result of the laparoscopic procedure. All LWG complications (11%) were minor, consisting of superficial wound infections, balloon rupture, and chronic granulation. No major complications were encountered. The mean usage time of gastrostomy was 6.3 +/- 5.3 months.

CONCLUSIONS

Current techniques of LWG could be an alternative to percutaneous endoscopic gastrostomy (PEG) for long-term enteral access, because it has proved to be safe and reproducible with relatively few complications.

[Surgical access routes in enteral nutrition]

There are many known routes of access to the digestive tract for enteral nutrition (EN) and significant advances have been made in recent years. Administration techniques and nutritional products have also improved. Placement of these systems may be temporary or permanent. Indications often overlap. If feasible, the enteral route is preferred over the parenteral route. When enteral nutrition will last < or = 6 weeks, nasoenteral tubes are the best option. In NE > or = 6 weeks, enterostomy tubes are indicated and the procedure of choice is percutaneous endoscopic gastrostomy. Postpyloric access should be considered in patients with a high risk of aspiration. Finally, needle catheter jejunostomy during interventions in the upper gastrointestinal tract is the ideal technique for initiating early EN. All these techniques continue to be valid and the choice of procedure will be determined by the patient's clinical status and the experience of the team. The present article is divided into two parts. In the first part, surgical access techniques for EN, their indications and contraindications and the most frequent complications related to the technique, the care of the stoma and the intubation material are analyzed. In the second part, we report data from our personal experience of the various techniques we have performed and describe the patients, results and complications. A total of 287 procedures were performed: 48 surgical gastrostomies, 40 using the technique of Fontan or Stamm, and 8 Janeway gastrostomies; 27 of these procedures were permanent. There were 169 jejunostomy catheters, with a mean dwelling time of 29.05 +/- 21.9 days, and 72 double lumen nasojejunal tubes.

Laparoscopic Feeding Jejunostomy Technique as Part of Staging Laparoscopy

Placement of a feeding jejunostomy tube is indicated for patients who need enteral access but where a gastrostomy is not feasible. This paper presents the technique and results of laparoscopic placement of feeding jejunostomy tubes in patients presenting with esophagogastric cancer. From December 2002 to February 2004, patients diagnosed with esophagogastric cancer with a potentially resectable lesion underwent staging laparoscopy. Laparoscopic feeding jejunostomy was performed on patients who were potential candidates for chemotherapy with palliative intent or neoadjuvant treatment prior to resection surgery. Surgical technique, recovery of bowel function, commencement of feeding jejunostomy, total time tube was in situ, and perioperative complications were analyzed. Of the 22 patients who underwent staging laparoscopy, a feeding jejunostomy tube was placed in 18. The remaining 4 patients were deemed to have advanced disease precluding any therapeutic options and underwent placement of esophageal stents. Feeding tubes remained in situ for a median time period of 76 days. Fourteen patients required enteral support and tubes were used for a median of 30 days. Complications from tube placement included 2 cases of wound infections, 1 of minor leak and 1 tube dislodgment. Patients were followed up for a median time of 112 days. Findings from current series suggest that placement of a feeding jejunostomy tube at the time of staging laparoscopy is a safe and reliable means of providing and maintaining nutrition for patients presenting with esophagogastric cancers.

Laparoscopic feeding jejunostomy: a systematic review

BACKGROUND

Enteral feeding devices have gained popularity since the beneficial effects of enteral nutrition have been clarified. Laparoscopic placement of a feeding jejunostomy is the most recently described enteric access route. In order to classify current surgical techniques and assess evidence on safety of laparoscopic feeding jejunostomy, a systematic review was performed.

METHODS

The electronic databases Medline, Cochrane, and Embase were searched. Reference lists were checked and requests for additional or unpublished data were sent to authors. Outcome measures were surgical technique and catheter-related complications.

RESULTS

Enteral access for feeding purposes can be effectively achieved by laparoscopic jejunostomy. Laparoscopic jejunostomy can be accomplished by either total laparoscopic or laparoscopic-aided techniques. The most experience was obtained with total laparoscopic placement. Which technique to apply should depend on the surgeon's expertise. Conversion rate is similar to other laparoscopic procedures. Complications can be serious and therefore strict patient selection should be warranted.

CONCLUSION

Laparoscopic feeding jejunostomy is a viable method to obtain enteral access with the advantages of minimally invasive surgery.

Evaluation of laparoscopic-assisted placement of jejunostomy feeding tubes in dogs

OBJECTIVE

To evaluate feasibility of performing laparoscopic-assisted placement of a jejunostomy feeding tube (J-tube) and compare complications associated with placement, short-term feedings, and medium-term healing with surgically placed tubes in dogs.

DESIGN

Prospective study.

ANIMALS

15 healthy mixed-breed dogs.

PROCEDURES

Dogs were randomly allocated to undergo open surgical or laparoscopic-assisted J-tube placement. Required nutrients were administered by a combination of enteric and oral feeding while monitoring for complications. Radiographic contrast studies documented tube direction and location, altered motility, or evidence of stricture.

RESULTS

Jejunostomy tubes were successfully placed in the correct location and direction in all dogs. In the laparoscopic group, the ileum was initially selected in 2 dogs, 2 dogs developed moderate hemorrhage at a portal site, and 2 J-tubes kinked during placement but were successfully readjusted postoperatively. All dogs tolerated postoperative feedings. All dogs developed minor ostomy site inflammation, and 1 dog developed bile-induced dermatitis at the ostomy site. Despite mild, transient neutrophilia, no significant difference was noted in WBC counts between groups. No dog had altered gastric motility or evidence of stricture, although the jejunopexy site remained identifiable in several dogs at 30 days.

CONCLUSIONS AND CLINICAL RELEVANCE

Requirements for successful J-tube placement were met by use of a laparoscopic-assisted technique, and postoperative complications were mild and comparable to those seen with surgical placement. Laparoscopic-assisted J-tube placement compares favorably to surgical placement in healthy dogs and should be considered as an option for dogs requiring enterostomy feeding but not requiring a celiotomy for other reasons.

Mini-laparoscopically guided percutaneous gastrostomy and jejunostomy

BACKGROUND

Percutaneous endoscopic tube placement can be problematic under certain circumstances: absence of transillumination of the abdominal wall, percutaneous jejunostomy in patients with a PEG tube and recurrent aspiration, enteral feeding access after gastrectomy, and obstruction of the upper GI tract. As an alternative in these problematic situations, a technique was developed for placing feeding tubes under visual control by using mini-laparoscopy.

METHODS

Placement of a feeding tube with mini-laparoscopy with the patient under conscious sedation was considered for 17 patients in whom standard PEG placement was impossible. Techniques used were the following: combined mini-laparoscopy/endoscopy for placement of a percutaneous gastrostomy or jejunostomy, and mini-laparoscopic-guided direct tube placement in cases of obstruction of the upper GI tract.

OBSERVATIONS

In 13 patients, mini-laparoscopic-assisted tube placement was successful. In 4 patients, adhesions or peritoneal carcinomatosis prevented laparoscopic visualization of the stomach or small bowel. The combined mini-laparoscopic/endoscopic approach allowed a successful insertion of gastric tubes in 6 patients and jejunal tubes in 4 patients. Direct insertion of a percutaneous endoscopic jejunostomy tube without enteroscopy was feasible in all 3 patients with obstruction of the upper GI tract. No complication occurred.

CONCLUSIONS

Mini-laparoscopy-assisted tube placement is a simple and safe alternative when endoscopic percutaneous tube placement is problematic or not feasible.

Spread of a pharyngeal cancer to the abdominal wall after percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy is frequently used in patients with head and neck cancer to establish enteral access for feeding. Spread of head and neck cancer to the gastrostomy site is a rare but increasingly reported complication after percutaneous endoscopic placement. We report the 13th such case in the literature, occurring in a 51-year-old black man with squamous cell carcinoma of the hypopharynx. The mode of tumor spread to the gastrostomy site remains debatable. Evidence exists for hematogenous dissemination and direct implantation. We think percutaneous endoscopic techniques for enteral access in this patient population are contraindicated, and we advocate a laparoscopic approach for gastrostomy placement.

Laparoscopic gastrostomy: results of 121 patients over 7 years

Laparoscopic gastrostomy was introduced in various technical variants 7 years ago. However, larger series and long-term results of these new methods are still lacking. In a prospective study, laparoscopic gastrostomies were performed by two institutions in 121 patients (88 men, 33 women; mean age, 58.3 +/- 11.16 years [range, 24-82]) with esophageal stenosis in locally advanced hypopharyngeal or oropharyngeal carcinoma, incurable esophageal carcinoma, and cerebral dysphagia. Operating time was 40 +/- 22 (range, 10-160) minutes. Procedure-related mortality was 0%, early mortality was 1.6%, the overall intraoperative complication rate was 7.4%, and the early complication rate was 9.9%. During a cumulative usage time of 1086.2 months, the complication rate in 1000 usage days was 0.8, and the stoma infection rate was 0.65. Laparoscopic gastrostomy is a reliable method for safe and economic establishment of enteral nutrition, even in patients for whom long-term nutrition by gastrostomy is expected.

Percutaneous replacement jejunostomy after esophagogastrectomy

A surgically placed jejunostomy tube is a safe and effective means of delivering nutritional support for the postesophagogastrectomy patient. We have previously described a method that permits percutaneous replacement of surgically placed jejunostomy feeding tubes, and now present our results with the use of this technique in 350 consecutive esophagogastrectomy patients. Replacement jejunostomy as required in 17 patients (4.9%). All patients had successful percutaneous jejunostomy replacement. There were no procedural complications or deaths. The timing of feeding tube replacement following esophagogastrectomy was predictive of the indication. Before 16 weeks, the indication for feeding tube replacement was intubation and inability to eat (1 patient) or anorexia with weight loss and dehydration (7 patients). At or after 16 weeks, the indications for feeding tube replacement were all related to symptoms resulting from recurrent carcinoma. We conclude that the technique of percutaneous jejunostomy allows the surgeon tremendous flexibility in the management of the postesophagogastrectomy patient as it preserves the advantages of an adjuvant surgically placed feeding tube over the lifetime of the patient. The technique is safe, and the success rate is excellent.

Enteral nutrition access devices

During the past decade a concerted effort has been made to use enteral nutrition instead of parenteral nutrition for hospitalized patients. Enteral nutrition has major advantages over parenteral nutrition in terms of cost and fewer serious complications. A clinician interested in initiating enteral nutrition may be limited by a lack of familiarity with the variety of options for enteral access and the difficulty of choosing among them. This paper reviews the different enteral access routes and devices available to the clinician.

Endoscopic placement of jejunal feeding catheters in critically ill patients by a "push" technique

BACKGROUND

Enteral nutrition is less expensive and often preferred to parenteral nutrition in the critically ill or injured patient. Gastric feedings are poorly tolerated in some patients, however, and postpyloric access is frequently difficult to obtain. In this report, we describe our experience with a new technique for bedside endoscopic placement of small intestinal feeding tubes.

METHODS

Using both prospective and retrospective analysis, we studied our results with endoscopically placed postpyloric feeding tubes in intensive care unit (ICU) patients. In this method, a 7F nasobiliary tube is passed via an endoscope into the proximal small bowel by a "push" technique. We recorded the demographic data of the patients, the feeding regimens subsequently used for these patients, and the overall feasibility and complications of the procedures themselves.

RESULTS

The technique was performed on 71 occasions in 61 ICU patients. The entire procedure averaged 29 minutes in a prospectively evaluated subset of patients. Small intestinal cannulation was successful in every case, including cases in which fluoroscopic attempts had failed. No complications developed from placement of the feeding tubes.

CONCLUSION

This report demonstrates that our bedside method of endoscopic placement of proximal small-bowel feeding tubes may be safely and expediently performed in ICU patients. Although not yet formally compared with other techniques, this procedure may have some advantages over traditional methods of small-bowel feeding tube placement.