Surgical jejunostomy in aspiration risk patients

Applying High-Resolution Impedance Manometry for Detecting Swallowing Change in Anterior Cervical Spine Surgery Patients

Background

Objectively detecting perioperative swallowing changes is essential for differentiating the reporting of subjective trouble sensations in patients undergoing anterior cervical spine surgery (ACSS). Swallowing indicates the transmission of fluid boluses from the pharynx (velopharynx, oropharynx, and hypopharynx) through the upper esophageal sphincter (UES). Abnormal swallowing can reveal fluid accumulation at the pharynx, which increased the aspiration risk. However, objective evidence is limited. High-resolution impedance manometry (HRIM) was applied for an objective swallowing evaluation for a more detailed analysis. We aimed to elucidate whether HRIM can be used to detect perioperative swallowing changes in patients undergoing ACSS.

Methods

Fourteen patients undergoing elective ACSS underwent HRIM with the Dysphagia Short Questionnaire (DSQ, score: 0–18) preoperatively (PreOP), on postoperative at day 1 (POD1), and postoperative at day seven (POD7). We calculated hypopharyngeal and UES variables, including hypopharyngeal mean peak pressure (PeakP) and UES peak pressure, representing their contractility (normal range of PeakP, 69–280 mmHg; peak pressure, 149–548 mmHg). The velopharynx-to-tongue base contractile (VTI) was also calculated (normal range, 300–700 mmHg.s.cm), indicating contractility. The swallowing risk index (SRI) from HRIM combined with four hypopharyngeal parameters, including PeakP, represents the global swallowing function (normal range, 0–11). A higher SRI value indicated higher aspiration.

Results

SRI was significantly higher on POD1 (10.88 ± 5.69) than PreOP (6.06 ± 3.71) and POD7 (8.99 ± 4.64). In all patients, PeakP was significantly lower on POD1 (61.8 ± 18.0 mmHg) than PreOP (84.9 ±34.7 mmHg) and on POD7 (75.3 ± 23.4 mmHg). The UES peak pressure was significantly lower on POD1 (80.4 ± 30.0 mmHg) than PreOP (112.9 ± 49.3 mmHg) and on POD7 (105.6 ± 59.1 mmHg). Other variables, including VTI, did not change significantly among the three time points. DSQ scores were 1.36, 3.43, and 2.36 at PreOP, POD1, and POD7 respectively.

Conclusions

With similar trends in DSQ and SRI, swallowing was significantly decreased on POD1 because of decreased hypopharyngeal and UES contractility but recovered to the preoperative state on POD7 after ACSS. Applying HRIM is superior to DSQ in detecting mechanisms and monitoring the recovery from swallowing dysfunction.

Clinical Trial Registration

The study was registered at ClinicalTrials.gov (NCT03891940).

Percutaneous endoscopic gastrostomy with jejunal extension for a post-esophagectomy gastric conduit

Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive procedure providing nutritional benefits to malnourished patients. Although a past history of celiotomy is not a contradiction for PEG construction, this procedure is rarely undertaken in post-esophagectomy patients, for two reasons: anatomically limited gastric spaces and high susceptibility to pulmonary aspiration. To overcome these limitations, we developed an original method of introducing PEG with jejunal extension for esophagectomized patients with retrosternal gastric pull-up reconstruction. The procedures were as follows: (1) confirmation of endoscopic transillumination of the antrum; (2) test puncture of the antral wall and subsequent gastropexy using a double-needle device; (3) insertion of a needle jejunostomy catheter into the antrum; (4) direct catheter cannulation to the pylorus and introduction of a feeding tube into the jejunum. We successfully carried out this procedure in three male patients (70-78 years old): two suffering from repetitive aspiration pneumonia and one with extensive recurrence of esophageal carcinoma. The operative times ranged 15-50 min. There were no PEG-associated complications. Of note, none of the patients experienced aspiration pneumonia after PEG construction. Our novel method appears to be a promising approach to managing esophagectomized patients because of its feasibility and the potential to prevent postoperative pulmonary aspiration.

A selective placement strategy for surgical feeding tubes benefits trauma patients

BACKGROUND

The indications for surgical feeding tube (SFT) placement in trauma patients are poorly defined. Patient selection is critical as complications from SFTs have been reported in up to 70% of patients. A previous analysis by our group determined that 25% of the SFTs we placed were unnecessary and that older patients, patients with head and spinal cord injuries, and patients who needed a tracheostomy were more likely to require long-term SFTs. Following this study, we modified our institutional guidelines for SFT placement. We hypothesized that a more selective placement strategy would result in fewer unnecessary SFTs.

METHODS

A retrospective review of all adult patients from 2012 to 2016 with an intensive care unit length of stay longer than 4 days and an SFT placed during admission was conducted. This group was compared to data collected prior to our change in practice (2007-2010). Data from 2011 were excluded as a washout period. "Necessary" SFT use was defined per established guidelines as either daily use of the SFT through discharge or for 28 days or longer and "unnecessary" SFT use as all others.

RESULTS

Two hundred fifty-seven SFTs were placed from 2007 to 2010 and 244 from 2012 to 2016. Following implementation of our selective SFT placement strategy, unnecessary SFT placement decreased from 25% in 2007 to 2010 to 8% in 2012 to 2016 (p < 0.0001). Significant predictors of necessary SFT placement by univariate regression were as follows: increasing age (odds ratio [OR] 1.03/year; 95% confidence interval [CI], 1.01-1.04), head injury (OR, 2.80; 95% CI, 1.71-4.60), cervical spinal cord injury (OR, 4.42; 95% CI, 1.34-14.50), and need for tracheostomy (OR, 1.41; 95% CI, 2.21-7.67). The overall complication rate was 11% (9% in the selective group vs. 13% in the preselective group, p = 0.2574) and was highest following open SFT placement (22%).

CONCLUSION

A selective placement strategy for SFTs in our trauma population resulted in fewer unnecessary SFTs and a trend toward fewer complications. Surgical feeding tubes should be placed through a percutaneous approach whenever possible.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

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.

Study of Feeding Jejunostomy as an Add on Procedure in Upper Gastrointestinal Surgeries

Jejunostomy is usually indicated as an additional procedure during major surgery of upper digestive tract to administer enteral nutrition in post-operative period. Complications associated with it can be mechanical, infectious, gastrointestinal or metabolic. The aim of the study was to evaluate safety of post-operative feeding jejunostomy in different types of major upper gastrointestinal surgeries. It was a prospective study conducted during the period between August 2009 and September 2011. Post-operative cases of major upper gastrointestinal surgeries who receive jejunostomy feeds were included in the study. Sampling was done by convenient method with sample size of 50 cases. Post-operatively, patients were monitored according to standard orders of enteral nutrition. Total calorie and protein intake through feeding jejunostomy was calculated regularly, and complications were assessed in terms of frequency, type, duration, management, and final outcome in different types of upper gastro intestinal surgeries. Analysis was done using chi square test with the help of statistical package SPSS vers.13. P < 0.05 was considered as significant. Complications observed were gastrointestinal -8 (16 %), mechanical -6 (12 %), infectious -4 (8 %) and metabolic -4 (8 %). Duration of complications ranged from 1 to 7 days (mean, 4 days). All types of complications observed during study were less severe and could be managed by simple measurements. Haemoglobin, serum albumin and weight of the patient at the time of discharge were improved for all patients when compared to pre-operative values. All patients received target calories and proteins through feeding jejunostomy. Considering benefits of enteral feeding via jejunostomy tube with minor and acceptable complications, we conclude that feeding jejunostomy is a preferred route of nutritional administration in those who undergo major upper gastro intestinal surgeries.

Feeding jejunostomy tube placement in patients undergoing pancreaticoduodenectomy: an ongoing dilemma

BACKGROUND

Concomitant placement of feeding jejunostomy tubes (FJT) during pancreaticoduodenectomy is common, yet there are limited data regarding catheter-specific morbidity and associated outcomes. This information is crucial to appropriately select patients for feeding tube placement and to optimize perioperative nutrition strategies.

METHODS

A review of all patients undergoing pancreaticoduodenectomy with FJT placement was completed. Patients were grouped by the occurrence of FJT-related morbidity. Multivariable logistic regression was performed to identify predictors of FJT morbidity; these complications were then further defined. Finally, associated postoperative outcomes were compared between groups.

RESULTS

In total, 126 patients were included, of which 18 (14 %) had complications directly related to their FJT, including pericatheter infection (n = 6), pneumatosis intestinalis (n = 4), severe tube feed intolerance (n = 3), and primary catheter malfunction (n = 7). Following adjustment with logistic regression, preoperative hypoalbuminemia was identified as the only independent predictor of FJT complications (OR 2.23, p = 0.035). Patients with FJT complications were more likely to be initiated on total parenteral nutrition (TPN; 55.6 vs. 7.4 %, p -0.035) and to require TPN at discharge (16.7 vs. 0%, p = 0.003). Correspondingly, these patients resumed an oral diet later (14 vs. 8 days, p = 0.06). Both reoperation (50.0 vs. 6.5%, p < 0.001) and readmission (50.0 vs. 22.4%, p = 0.041) rates were higher among patients with FJT complications.

CONCLUSIONS

FJT-related morbidity is common among patients undergoing pancreaticoduodenectomy and is associated with inferior outcomes and other performance metrics. Preoperative malnutrition appears to predict FJT complications, creating an ongoing dilemma regarding FJT placement. In the future, it will be important to better define criteria for FJT placement during pancreaticoduodenectomy.

Percutaneous jejunostomy

Direct percutaneous jejunostomy is considered in patients where percutaneous gastrostomy is not feasible (stomach removed or inaccessible). Percutaneous jejunostomy is more difficult than gastrostomy techniques. Direct jejunostomy is performed under fluoroscopic guidance, using a nasojejunal tube to distend the jejunum. The jejunal loop is punctured using a Cope suture anchor, under ultrasound guidance. Water-soluble contrast material is injected through the needle to document intralumenal position, and an anchor is inserted. With the guide wire in place, the track is dilated and a 10-F pigtail catheter inserted into the proximal jejunum. Fluoroscopy can also be used to aid puncture using dilute contrast material, if used via the nasogastric tube. Antiperistaltic agents can also be used to aid jejunal puncture. The cumulative procedure-related mortality from the three reported series in the literature is 2.4%, with minor complications occurring in 10 to 11%. Although jejunostomy is not performed frequently, this is a feasible procedure for interventional radiology.

Button-loop feeding jejunostomy

INTRODUCTION

Post-pyloric feeding via a surgical jejunostomy allows for enteral nutrition in patients that cannot receive oral or gastric feeding. Regardless of the technique used to create a jejunostomy, complications such as tube dislodgement, jejunostomy closure, or bowel obstruction can occur.

SURGICAL TECHNIQUE

We present a simple and efficient jejunostomy technique that does not require a sewn anastomosis and employs an easily exchangeable feeding button.

DPEJ tube placement prevents aspiration pneumonia in high-risk patients

Percutaneous endoscopic gastrostomy (PEG) or PEG tube with transgastric jejunostomy tube (PEG-J) feeding has not been shown to decrease aspiration pneumonia. The aim of this study was to determine if direct percutaneous endoscopic jejunostomy (DPEJ) tube placement results in a decreased incidence of aspiration pneumonia in high-risk patients. The design was a retrospective review of all patients receiving DPEJ tube for aspiration pneumonia from 1999 to 2005. Demographics, incidence of aspiration pneumonia, and outcomes were collected and compared before and after the DPEJ placement. Eleven patients (4 women, 7 men) were identified; their mean age was 44.9 years (range, 18-94 years). The etiologies for recurrent aspiration pneumonia were neurologic disease (9), esophageal surgery (1), and severe debilitation (1). The mean follow-up was 20.9 months (range, 6-48 months). The patients' mean weight increased from 43.8 kg (range, 19-55 kg) to 48.3 kg (range, 30-65 kg) after placement (P < .001). The total number of documented aspiration pneumonia episodes for all patients decreased from 29 (mean, 3.64; range, 1-6) before DPEJ placement to 3 (mean, 0.27; range, 0-2) after DPEJ placement (P < .001). The mean number of aspiration pneumonia events per month prior to the DPEJ placement was 3.39 and postplacement was 0.42 (P < .001). DPEJ placement appears to decrease recurrent aspiration pneumonia in patients with history of aspiration pneumonia.

Complications of and controversies associated with percutaneous endoscopic gastrostomy: report of a case and literature review

CONTEXT

Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly performed gastrointestinal procedures, despite absence of benefit in many patients and risks associated with the procedure. Increased education of primary care physicians about the shortcomings of PEG may allow for better selection of patients to be referred for PEG placement.

EVIDENCE ACQUISITION

We performed a comprehensive literature review by searching PUBMED using the search headings percutaneous enteral gastrostomy, PEG, complications, dementia, stroke, dysphagia, malnutrition, and complications. We identified English language articles from 1980 onward. The highest quality data were considered to be randomized controlled trials although given the paucity of trials in this area, we used all of the various types of literature.

EVIDENCE SYNTHESIS

We based the major conclusions of this review, where possible, on the most robust literature, namely, controlled trials. However, the majority of the available literature in this field is based on case series. We attempted to maximize the use of larger case series with longer term follow-up. Case reports were used only to report on rare complications where no other literature was available.

CONCLUSIONS

Despite more than 30 years of experience with PEG, numerous questions remain regarding the utility of nutrition support in many of the clinical scenarios in which PEG placement is contemplated. There is a multitude of evidence that artificial nutrition does not improve outcome or quality of life in patients with dementia who have decreased oral intake. It is likely that ethical, moral, religious, and legal considerations of family members and caregivers play a role in the decision to place a PEG in a patient with dementia despite the medical evidence demonstrating lack of benefit.

Endoscopic approaches to enteral nutritional support

Enteral is preferred to parenteral nutritional support for acute and chronic diseases because it is more physiological and associated with fewer infection complications. Nasal tube feedings are generally used for 30 days or less and percutaneous access for the longer-term. Feeding by naso-gastric tubes is appropriate for most critically ill patients. However, trans-pyloric feeding is indicated for those with regurgitation and aspiration of gastric feeds. Deep naso-jejunal tube feeding is appropriate for patients with severe acute pancreatitis. There are several methods for endoscopic placement of naso-enteric tubes. Percutaneous endoscopic gastrostomy is used for most persons requiring long-term support. Long-term jejunal feeding is most often used for persons with chronic aspiration of gastric feeds, chronic pancreatitis intolerant to eating, or persons in need of concomitant gastric decompression. Percutaneous endoscopic gastrostomy with a jejunal tube extension is fraught with tube dysfunction and dislocation. Direct percutaneous endoscopic jejunostomy tubes may be more robust, but are less commonly performed.

Postoperative jejunal feeding and outcome of pancreaticoduodenectomy

Complications following pancreaticoduodenectomy are common, partly because of nutritional debilitation. The aim of this study was to evaluate the impact of early postoperative tube feeding on outcome of pancreaticoduodenectomy and determine the best method for delivering enteral feeding. A retrospective review of 180 consecutive patients undergoing Whipple operations from 1994 to 2000 was performed. Two nonrandomized patient groups were retrospectively studied: those with early postoperative tube feeding vs. those with no planned feeding. Ninety-eight patients (54%) received postoperative jejunal feeding, whereas 82 patients (46%) did not. Jejunal feeding was delivered via a bridled nasojejunal tube in 55 patients (56%) and a gastrojejunal tube in 43 (44%). Vomiting (10% vs. 29%; P=0.002) and use of total parenteral nutrition (6% vs. 27%; P < 0.0001) were less in the jejunal feeding group as well as rates of readmission (12% vs. 27%; P=0.022), early (52% vs. 62%; P=0.223) and late (12% vs. 31%, P=0.005) complications, and infections (13% vs. 20%, P=0.014). Tube-related complications occurred in 6 of 98 patients, all of which were associated with gastrojejunal tubes (P=0.021). Early postoperative tube feeding after pancreaticoduodenectomy is associated with significantly less use of total parenteral nutrition and lower rates of readmission and complications. A bridled nasojejunal feeding tube appears to be a safe and reliable method of short-term enteral feeding.

Future considerations in aspiration pneumonia in the critically ill patient: what is not known, areas for future research, and experimental methods

The medical literature supports the use of enteral feeding to provide nutrition and improve patient outcomes. A major complication of enteral feeding is aspiration and associated morbidity and mortality. Many knowledge gaps exist that inhibit our ability to define and diagnose aspiration, identify patients at risk, and develop prevention techniques. Several areas of inquiry should be explored to help us define and prevent the disorder--for instance, standardized criteria should be developed for diagnosing aspiration pneumonia and for differentiating it from other types of pneumonia, and accurate tests should be devised for detecting it. Research also is needed to evaluate the influence of (1) various enteral feeding sites on aspiration risk, (2) the effects of risk reduction techniques such as selective decontamination and use of promotility agents, and (3) potential benefits of immunonutrition. Current parameters used in decisions about when to initiate enteral feeding in critically ill patients are defined.

Evaluation of patients with jejunostomy tubes: imaging findings

PURPOSE

To determine the frequency and nature of abnormalities observed on radiographs after placement of jejunostomy (J) tubes for enteral nutrition.

MATERIALS AND METHODS

Radiology database review revealed that 280 studies of the J tube or of the small bowel with water-soluble contrast material and/or barium sulfate were performed in patients during 10 years. Review of the radiologic reports revealed abnormalities related to the placement of tubes in 105 (38%) cases. Images were reviewed to determine abnormalities in these 105 cases. Radiologic, medical, and surgical records were also reviewed to determine the clinical course and any subsequent interventions.

RESULTS

One or more complications were detected in 40 (14%) of 280 cases: small-bowel obstruction in 17 (6%) cases, nonobstructive small-bowel narrowing in six (2%), extraluminal tracks or collections in seven (2%), extravasation of contrast material to the skin in 11 (4%), jejunal hematomas in five (2%), and intussusceptions in four (1%). Mechanical problems related to the tube were detected in 52 (19%) cases, including coiling, kinking, or knotting of the tube in 38 (14%), malpositioning in five (2%), retrograde flow in four (1%), occlusion in four (1%), and a hole in one (<1%). Focal thickening of small-bowel folds was detected in 24 (9%) cases.

CONCLUSION

Radiographs in 280 patients with J tubes revealed one or more complications that resulted from tube placement (40 [14%] cases), mechanical problems related to location or function of the tube (52 [19%] cases), and development of focally thickened small-bowel folds (24 [9%] cases).

Feeding the gut early after digestive surgery: results of a nine-year experience

BACKGROUND AND AIMS

Early enteral nutrition (EEN) after surgery should be preferred to parenteral feeding, but its clinical use is limited for concerns about possible gastrointestinal (GI) adverse effects and feeding tube-related complications. Thus we evaluated our experience focusing on safety and tolerance of early postoperative jejunal feeding and possible risk factors for gastrointestinal adverse effects.

METHODS

650 subjects treated with EEN after major digestive surgery for cancer were prospectively studied. EEN was started within 12 hours after operation via a naso-jejunal (NJ) feeding tube or a catheter-feeding jejunostomy. The rate of infusion was progressively increased to reach the nutritional goal (25 kcal/kg/day) within the 4th postoperative day. Rigorous treatment protocols for diet delivery and EEN-related GI adverse effects were applied.

RESULTS

402 patients had a jejunostomy and 248 patients a NJ tube. EEN-related GI adverse effects were observed in 194/650 patients (29.8%). In 136/194 patients, these events were successfully handled by treatment protocols. Overall the nutritional goal was achieved in 592/650 patients (91.1%). Fifty-eight (8.9%) subjects had to be switched to parenteral feeding because of refractory intolerance to EEN. Intra-abdominal surgical complications and low serum albumin (<30 g/L) were the two major factors affecting tolerance. Severe jejunostomy-related complications occurred in 7/402 (1.7%) patients. EEN-related mortality was 0.1% (1/650).

CONCLUSIONS

The use of the gut early after surgery is safe and well-tolerated and it should represent the first choice for nutritional support in this type of patients.

Migrating motility complexes persist after severe traumatic shock in patients who tolerate enteral nutrition

BACKGROUND

Postinjury small bowel ileus is poorly characterized and may be an important factor in intolerance to enteral nutrition (EN). We, therefore, placed jejunal manometry catheters in high-risk trauma patients. Our hypothesis was that the presence of "fasting migrating motility complex (MMC)" activity and conversion to a "fed pattern" at goal rate of EN would be present in those patients who tolerate jejunal feeding.

METHODS

After obtaining baseline fasting manometry pressure tracings, jejunal feeding was advanced stepwise to a set goal while tolerance was monitored and intolerance was treated by a standard approach.

RESULTS

Of the 10 study patients, 7 were able to be maintained on EN. Five (50%) had "fasting MMCs" and had good tolerance to early advancement of EN. The remaining five patients did not exhibit "fasting MMCs" and four had poor tolerance to early advancement of EN. Overall, nine patients reached goal rate of EN of which four converted to a "fed pattern." This, however, was not associated with later tolerance to EN.

CONCLUSION

EN is feasible following severe traumatic shock. Surprisingly, half of the patients had fasting MMCs. This requires intact neural and motor function and was associated with good tolerance of early EN.

A multicenter, prospective study of the placement of transpyloric feeding tubes with assistance of a magnetic device. The Magnet-Guided Enteral Feeding Tube Study Group

BACKGROUND

Placement of feeding tubes in the transpyloric position can be helpful in the management of enterally fed patients with pancreatitis, gastric atony, enterocutaneous fistulae, or pulmonary aspiration risk. The attainment of transpyloric position is difficult, and numerous techniques have been proposed to help in achieving this location. Recently, the use of a magnet-tipped feeding tube, dragged into proper position with an external magnet, has been described with an excellent success rate.

METHODS

At 10 participating institutions, practitioners were trained in the use of the device. Successful tube placement was determined by abdominal radiograph.

RESULTS

One hundred fifty-six tube placements were attempted. Transpyloric position was obtained in 60%. Placement into the third portion of the duodenum or distal was obtained in only 32%. Analysis of the data did not reveal a learning curve at the institutions, and 7 of 10 had a 50% or lower success rate.

CONCLUSIONS

Placement of feeding tubes with the assistance of a magnetic device was infrequently successful at the majority of institutions where it was attempted. We report a lower success rate than the original article, which described an 88% success rate of transpyloric intubation. Although this technique has a high failure rate, some individuals seem to be very successful using it, which could reduce the need for endoscopy or transport for the placement of feeding tubes.

US and fluoroscopic-guided percutaneous jejunostomy: experience in 49 patients

PURPOSE

To assess the feasibility and safety of a variety of techniques for percutaneous jejunostomy.

MATERIALS AND METHODS

Percutaneous jejunostomy was attempted on 53 occasions in 49 patients under US and fluoroscopic guidance. During the study period, thicker needles, Cope anchors, and intravenous glucagon were introduced to improve access, dilate, and immobilize the jejunum. Technical success rates, complications, catheterization period, and reasons for catheter removal were prospectively studied. Prognostic factors for successful procedures and complications were determined.

RESULTS

Forty-six (87%) procedures were technically successful. Previous gastrointestinal surgery (P = .01) and a combination of thicker needles, Cope anchors, and intravenous glucagon (P = .0001) were associated with a higher technical success rate. Complications (n = 6; pericatheter leakage in four of six) were observed more frequently in older patients (P = .01). The 30-day mortality rate was 17%, one death may have been procedure related. Forty-three catheters were removed (elective, n = 36; other, n = 7) after 1-597 days (median, 49). Three catheters remained in situ for 139-482 days (median, 410).

CONCLUSIONS

Percutaneous jejunostomy is a feasible and relatively safe technique for long-term feeding. Leakage is the main problem, which warrants additional study.

Minimally invasive surgery. Bedside tracheostomy and gastrostomy

Minimally invasive surgical techniques have gathered tremendous momentum. Most patient benefit is realized in the ambulatory setting. Smaller incisions result in less pain and earlier return to activities. Critically ill patients typically do not benefit from minimally invasive techniques in this manner; however, they do benefit from other aspects of minimally invasive tracheostomy and gastrostomy. Small tracheostomy wounds are associated with reduced wound problems (infection and breakdown). The small stab wounds of minimally invasive gastrostomy are associated with less pain and with an absence of fascial dehiscence. Furthermore, because these procedures are performed easily and safely at the bedside, transport and operating room costs are avoided. Although these procedures are minimally invasive, they are major procedures. Devastating complications can become life-threatening. Attention to detail is required to avoid or respond promptly to complications. In this way, patients receive maximal benefit at minimal risk.

Complications of surgical feeding jejunostomy in trauma patients

OBJECTIVE

To determine the complication rate of feeding jejunostomy (FJ) performed as an adjunct to trauma celiotomy.

METHODS

Retrospective analysis of 222 patients from January of 1988 to May of 1998.

RESULTS

Thirty-seven total FJ-related complications occurred in 22 patients (10%). Major FJ-related complications occurred in nine patients (4%): two small bowel perforations, two small bowel volvuli with infarction, two intraperitoneal leaks, and three small bowel necroses. Patients suffering major FJ-related complications were similar to those without complications, except for the FJ type. Patients with major FJ-related complications were more likely to have had a Witzel tube jejunostomy than a needle catheter jejunostomy (p = 0.03). Three deaths were related to major FJ complications, for a FJ-related mortality rate of 1.4%.

CONCLUSIONS

FJ has a major complication rate of 4% in severely injured patients. Major complications occur more frequently with larger, Witzel-type tubes. Needle catheter jejunostomy appears to be a safer method of surgical jejunal access in trauma patients.

Efficacy of Jejunogram after Jejunostomy Insertion

The era of managed care has spawned a national debate over the allocation of health care resources. We hypothesized that routine postjejunostomy jejunogram rarely provides additional clinical information or changes patient management and, therefore, is unwarranted. We retrospectively reviewed the charts of 128 consecutive patients undergoing feeding jejunostomy tube insertion between January 1995 and December 1996. All patients had postinsertion jejunograms. Eighty-five (66%) of the jejunograms were performed after operative insertion of the jejunostomy, and 43 (33%) were performed after percutaneous reinsertion of a previously placed jejunostomy. Data extracted from the charts include age, sex, indication for jejunogram, length of time prior jejunostomy was in place at time of reinsertion, and results of jejunogram. There were no patients (0%) with misplaced jejunostomy or extravasation of dye, as noted on jejunogram. There were no management changes implemented as a result of jejunogram readings (P < <0.05). The use of routine jejunogram after operative insertion or reinsertion of a prior jejunostomy that has become dislodged or occluded does not alter patient management, incurs unnecessary costs, and, therefore, is unwarranted.

The cup is half full

BACKGROUND

The clinical outcomes following feeding tube procedures are infrequently studied because most patients have other incurable conditions.

METHODS

Multiple electronic databases were used to track clinical outcomes following all gastrostomies and jejunostomies performed at a single institution from October 1, 1992, through December 31, 1995. Preoperative risk factors and postoperative morbidity were available for all 104 cases; long-term status was available for all but 2 of 104.

RESULTS

The in-hospital mortality was 11.4%. Mortality was lower in those receiving feeding tubes as primary procedures (7.4%) than in those who had a feeding tube placed during other major procedures (24%, P <0.05). Postoperative pneumonia was frequent (24.7%), and was associated with preoperative gastroesophageal reflux (odds ratio 4.2, P = 0.01) and history of aspiration (odds ratio 3.9, P = 0.01). Although 14.5% of the patients were newly discharged to care facilities, the majority (74%) returned to their previous residence. Median survival was just over 6 months, with 18% surviving more than 2 years. Survival was inversely related to do-not-resuscitate status (odds ratio 4.6, P <0.001), metastatic tumor (odds ratio 2.7, P <0.001), dementia (odds ratio 2.3, P = 0.005), and unresectable tumor (odds ratio 2.1, P <0.001), but was unrelated to type of feeding tube.

CONCLUSIONS

Significant morbidity and mortality follow feeding enterostomies, but the majority of patients benefit and can return to their previous residence. Am J Surg. 1999;178:406-410. 1999 by Excerpta Medica, Inc.

Postpyloric enteral feeding costs for patients with severe head injury: blind placement, endoscopy, and PEG/J versus TPN

This study describes the advantages and disadvantages of several forms of enteral nutrition for patients with severe head injury (Glasgow Coma Scale Score [GCS], <12). Included in the study are nasoenteric nutrition delivery using blind, endoscopic, percutaneous endoscopic gastrostomy (PEG) and PEG with jejeunostomy (PEG/J), and open jejeunostomy tube placement methods. These methods are compared with parenteral delivery of nutrition. The study constituted a retrospective analysis of the success rate of early enteral feedings by blind, endoscopic PEG and PEG/J and by open jejeunostomy placement of small-bowel feeding tubes for 57 patients with severe head injury. The delivery cost of enteral nutrition per intensive care unit day was compared to the delivery cost of parenteral nutrition per intensive care unit day in the same group of patients. Fifty-three percent of patients were adequately maintained nutritionally with nasoenteric delivery alone and did not require parenteral feeding. The average number of days for initiation of either enteral or parenteral feedings was 1.8 +/- 0.2 days from injury [standard error of mean (SEM); range, 0-10 days]. An average of 3.3 days (range, 0-23 days) was required for feeding tube placement in all patients. For 70% of patients, tube placement was completed within 48 h after injury. Full-strength, full-rate enteral feedings were achieved by a mean of 4.9 days after injury. A total of 128 feeding tubes were placed while the patients were in the intensive care unit (ICU; 2.2 +/- 0.2 tubes per patient). Blind placement of feeding tubes into the small bowel was rarely achieved without repositioning. Endoscopic tube placement into the duodenum was achieved in 50% of patients, into the jejunum for 33% of patients, and into the stomach for 18% of patients. While in the intensive care unit, patients received an average of 77 +/- 2% of their measured energy expenditure (range, 57-114%). Eleven percent of patients experienced severe gastrointestinal problems. Other problems were associated with the inability to achieve or maintain access: dislodged tubes (30%), clogged or kinked tubes (21%), and mechanical access problems (7 %). Seventy-one percent of patients in barbiturate coma were able to tolerate early nasoenteric feedings. Aspiration pneumonitis occurred equally among patients fed nasogastrically and those fed nasoenterically. The overall aspiration rate was 14%. The cost of acute enteral feeding was $170 per day and that for parenteral feeding, $308 per day. We conclude that blind transpyloric feeding tube placement is difficult to achieve in patients with severe head injury; endoscopically guided placement is a better option. Endoscopic feeding tube placement most consistently allows for early enteral nutritional support in severe head injured patients. Limitations include the inability to establish and/or maintain enteral access, increased intracranial pressure, unstable cervical spinal injuries, facial fractures, and dedication of the physician to tube placement and monitoring.

Prophylactic jejunostomy: a reappraisal

BACKGROUND

The effectiveness of enteral feeding in maintaining postoperative nutrition has led some investigators to recommend prophylactic jejunostomy at the time of any high-risk abdominal operation. A failed procedure in this setting weighs heavily on the side of risk without identifiable benefit.

METHODS

A benefit/risk analysis comparing complication rate, avoidance of parenteral nutrition, and discontinuation of jejunostomy feeding was performed in 92 patients. These patients were judged retrospectively to be undergoing either a prophylactic jejunostomy placed at the time of operation for another serious condition (group A) or therapeutic jejunostomy alone (group B) during a 3-year period (1993 to 1996). Classification as prophylactic or therapeutic was determined by the surgeon's preoperative intent.

RESULTS

Avoidance of parenteral nutritional support, a goal of prophylactic jejunostomy, was not achieved in 39% of the patients. Patients in group A had a 5-fold increase in the risk of premature discontinuation of enteral feeds when compared with group B (P < .03). The complication rate was higher in group A (41%) than in group B (26%). Four life-threatening complications occurred in group A; all required reversal of the feeding jejunostomy.

CONCLUSIONS

This study suggests that the benefit/risk ratio of prophylactic jejunostomy is low. This adds weight to the notion that this procedure be abandoned in favor of other forms of nutritional support.

Enteral feeding: an overview of indications and techniques

Most patients requiring nutritional support can be successfully managed using enteral feeding, i.e. the provision of nutritional support via the gastrointestinal tract. Various routes of access are available and patients should be assessed on an individual basis by the multidisciplinary team to select the most appropriate method and decide on a suitable regimen. Careful management and regular monitoring of enteral feeding are required in order to ensure safe and cost-effective nutritional support; the use of standard protocols and guidelines is recommended. With appropriate training, monitoring and support, enteral feeding is best provided in the community for many patients, and the use of home enteral feeding is rapidly increasing.

The principles and practical application of enteral nutrition

The enteral route is the preferred method of nutritional support in patients with functional gastrointestinal tracts. Many techniques for obtaining enteral access are available, and the decision regarding which one to use depends on several issues, including the functional integrity of each part of the gastrointestinal tract, the duration of anticipated nutritional support, and the risk of aspiration and gastroesophageal reflux. Nasoesophageal tubes are useful for short-term supplementation; however, patients needing nutritional support for longer than 2 weeks may be better served with a more permanent tube. Blenderized pet food diets are recommended for nutritional support because these diets do not need to be supplemented with protein or micronutrients. Commercial human enteral formulas provide a useful alternative for patients with specific nutrient requirements or for feeding via nasoesophageal or jejunostomy tubes.

Nursing strategies to prevent ventilator-associated pneumonia

Critically ill patients who require mechanical ventilation are at high risk for development of pneumonia during the course of treatment. Ventilator-associated pneumonia leads to higher rates of mortality and morbidity, increased length of hospital stay, and higher hospital costs. The intubation that is necessary for mechanical ventilation impairs the patient's normal defense mechanisms for fighting infection. Impaired defenses, along with such risk factors as age of the patient, equipment used, and failure of the staff to wash hands increase the likelihood of colonization of the lower airways. Colonization and subsequent pneumonia commonly occurs from microaspiration of secretions from the oropharynx and gastrointestinal tract. In this article, the mechanism of microaspiration, diagnosis of ventilator-associated pneumonia, and nursing strategies to reduce the incidence of pneumonia are described.

Aspiration-Induced Pulmonary Injury

Pulmonary aspiration of gastric contents can cause a spectrum of sequelae that spans from relatively minor to rapidly lethal disease. To emphasize the extent of this spectrum and to encompass both noninfectious complications and infection, we use the term “aspiration-induced pulmonary injury” rather than “aspiration pneumonia.” In this article we review the relevant literature, focusing on more recent insights into the pathogenesis of lung injury, the natural history of aspiration, risk factors, the relationship between aspiration and infection, and recommendations for management. The relevance to human disease of studies using intra-airway acid instillation in animals is questioned. We discuss the difficulties in predicting the clinical course after aspiration. We identify risk factors for aspiration-induced pulmonary injury that are commonly encountered in the intensive care unit, and discuss in detail factors of special interest to the intensivist, including the impact of tracheal intubation; the effects of enteric intubation, particularly the comparison between pre- and postpyloric routes of enteric feeding administration; and the relative risks associated with particular feeding protocols. We conclude with recommendations regarding treatment and prevention strategies.

Aspiration pneumonia. Strategies for early recognition and prevention

Aspiration is the result of dysfunction during the oral, pharyngeal, or esophageal stage of deglutition. Depending on the type of aspirate, the resultant lung injury may include chemical or bacterial inflammation or obstruction of the airways. Tools for evaluation include roentgenography, upper GI tract studies, bronchoscopy, and esophageal pH studies. Medical management is primarily supportive. Because aspiration pneumonia has a high morbidity rate, prevention involving early recognition and modification of predisposing factors whenever possible is critical for improving outcomes.

Early intragastric feeding of seriously burned and long-term ventilated patients: a review of 55 patients

Aims of this retrospective study were: (1) to evaluate the feasibility of a protocol for early intragastric feeding: (2) to examine whether the caloric needs can be provided via the intragastric route within 72 h postburn; (3) to determine the influence of a delayed onset of feeding on the success of the feeding protocol; (4) to evaluate whether delayed feeding has any impact on morbidity and mortality. Fifty-five long-term ventilated patients were enrolled in the study. Their mean age was 37.6 years and mean total body surface area burned 44.2 per cent. The mean duration of ventilation amounted to 24.8 days. Intragastric tube feeding was initiated as early as possible after admission. Forty-five patients (81.8 per cent) could be fed successfully and their caloric needs were met within 72 h. In these patients the mean interval between burn injury and the initiation of tube feeding was 11.5 h. The mean interval was 32.4 h in the 10 patients, demonstrating failure of early intragastric feeding. Only four of the 48 patients who had enteral feeding within 18 h postburn failed to meet the caloric needs. The patients fed successfully showed a significantly decreased mortality. Early intragastric feeding after serious burns can be initiated successfully. A time interval of more than 18 h is unfavourable and significantly decreases the success rate.

Complications of long-term jejunostomy in children

The authors reviewed 64 jejunostomies performed in 57 patients. Data were collected regarding complications and performance of the catheters. Patient diagnoses were grouped as follows: cystic fibrosis (25), neurological impairment (14), and miscellaneous other (25). Indications were malnutrition (43), inability to feed (17), and gastroesophageal reflux (4). Complications were compared between these groups. The age range was 7 days to 23 years. There were 251 tube changes over 142 years of cumulative site patency, for an average of 1.8 tube changes per year and an average life of 2.2 +/- 2.4 years per site. The longest duration was 11.7 years. Four tube changes resulted in intraperitoneal insertion (6.2% of changes). The overall complication rate was 37.5%. The major and minor complication rates were 21.9% each. Some patients had more than one complication. Stratification of complications by diagnosis showed that the highest incidence was among the neurologically impaired children (64%), followed by those with cystic fibrosis (32%) and then others (28%). Sixty-four percent of major and 54% of minor complications occurred within the first 6 months. The mortality rate was 4.7%. Infections requiring intravenous antibiotics occurred in 9.4% of the sites, at an average site age of 8.7 +/- 7.7 months. Tube dislodgment requiring surgical replacement occurred in 9.4% of the patients. Our mortality and complication rates compare favorably to those of previously reported series. Surgical jejunostomy is a reliable long-term solution to feeding but is associated with a significant risk of complications, especially in neurologically impaired children. The risk is greatest in the first 6 months after insertion, then decreases as the site "matures."

Surgically placed gastro-jejunostomy tubes have fewer complications compared to feeding jejunostomy tubes

OBJECTIVE

During laparotomy, jejunostomy tubes (J tubes) are often placed to provide access for enteral nutrition in the immediate postoperative period. However, the placement of such tubes may be associated with potentially devastating intra-abdominal complications possibly related to the tenuous security of a tube through the small bowel wall. An alternative method for enteral nutrition access is to surgically place a "PEG-J" tube (i.e., surgical G/J tube) thus providing for jejunal feedings via a gastrotomy without a jejunotomy. The purpose of this study is to assess whether surgically placed G/J tubes reduce the postoperative complications in comparison to feeding J tubes.

METHODS

Over the past 18 months, 92 J tubes and 56 G/J tubes were placed during laparotomy at a single institution and the method chosen by surgeons' preference. The frequency of complications associated with each tube was determined by review of the postoperative medical records.

RESULTS

There was no enteric leakage in those patient given G/J tubes (p < 0.05). Furthermore 10% of the patients receiving J tubes required operative repair of a J tube complication while no patient with an access complication following G/J tube placement required surgical repair (p < 0.05).

CONCLUSIONS

These results demonstrate that operative positioning of a jejunal feeding tube through a gastrostomy tube (surgical G/J tube) provides a safer route for enteral nutrition than does direct tube placement via the jejunal wall, by significantly reducing both the incidence of enteric leakage and the requirement for operative repair.

Aspiration pneumonia following surgically placed feeding tubes

BACKGROUND

The enteral route is preferred in surgical patients requiring nutritional support; however, controversy surrounds the choice of location of feeding tube placement. Although jejunostomy has been commonly accepted as superior to gastrostomy for long-term nutritional support because of an assumed lower risk of aspiration pneumonia, recent studies suggest that reevaluation of common practices of surgical tube placement is warranted.

PATIENTS AND METHODS

We conducted a retrospective chart review of gastrostomy and jejunostomy procedures from 1986 to 1993. Demographic information and complications related to the procedure were reviewed. Aspiration pneumonia was defined as respiratory symptoms, leukocytosis, and infiltrate on chest radiograph.

RESULTS

Sixty-nine gastrostomies and 86 jejunostomies were performed during the study period. Six patients were diagnosed with aspiration pneumonia; 2 cases of which occurred with jejunostomy and 4 cases occurred with gastrostomy (P = not significant).

CONCLUSIONS

There was no difference in rates of pulmonary aspiration or other complications between gastrostomy and jejunostomy. We suggest that when a surgically placed feeding tube is required, the determination of appropriate procedure be based on clinical factors such as the technical difficulty of the operation or long-term feeding goals.

Complications of needle catheter jejunostomy in 2,022 consecutive applications

BACKGROUND

We commonly use needle catheter jejunostomy (NCJ) for early enteral feeding in selected patients. Review of our approach was prompted by the suggestion that enteral feeding represents a "stress test" for the bowel and may be associated with a high complication rate.

MATERIALS AND METHODS

We reviewed patients with NCJ inserted over the past 16 years by prospective database, chart review, and conference minutes, with emphasis on complications.

RESULTS

During the conduct of 28,121 laparotomies, 2,022 NCJs inserted in 1,938 patients (7.2%) resulted in 34 NCJ-related complications in 29 patients (1.5%) The most common complication was premature loss of the catheter from occlusion or dislodgment (n = 15; 0.74%), and the most serious was bowel necrosis (n = 3; 0.15%).

CONCLUSIONS

Needle catheter jejunostomy may be inserted and used with a low complication rate. Most complications were preventable through greater attention to detail and better monitoring of physical examination of patients with marginal gut function.

Long-term enteral access in aspiration-prone patients

Aspiration pneumonia is a serious complication of enteral feeding. Many critically ill patients are particularly at risk for aspiration. Few studies have rigorously compared various access devices. Risk factors for aspiration and studies examining aspiration associated with enteral feeding devices are reviewed. We recommend a surgical jejunostomy for all patients at high risk for aspiration who require more than 3 weeks of enteral nutrition support.

Transverse Witzel-T-tube feeding jejunostomy

BACKGROUND

In patients prone to recurrent aspiration, a feeding jejunostomy is only performed to ensure adequate nutrition. A popular method for placement of the jejunostomy tube is the Witzel procedure, employing a sersosal tunnel on the antimesenteric border. The Witzel procedure, however, frequently suffers from the complication of tube dislodgement and obstruction due to narrowing of the intestinal lumen.

METHODS

To minimize the complications associated with the standard Witzel method, we modified the procedure wherein a T-tube is substituted for a standard French rubber catheter, and transversely sutured to the mesenteric border. We believe that the placement of the Witzel line in the transverse plane minimizes the risk of obstruction, and substitution of a T-tube for a standard French catheter should reduce the incidence of tube dislodgement.

RESULTS

The Transverse Witzel T-tube feeding jejunostomy has been performed successfully in 30 patients without any complications of tube dislodgement or leaks, and no tube to date has been difficult to remove. Length of tube use has ranged from 1 to 6 months, and no postoperative complications have been observed in this group.

CONCLUSIONS

The Transverse Witzel T-tube jejunostomy is an effective and rapid technique for placement of a feeding tube. No serious complications have been observed, and the complication of tube dislodgement appears to be decreased compared to the standard Witzel procedure.

Use of a feeding jejunostomy after oesophagogastric surgery

Over a 5-year period, 58 patients with oesophageal or gastric malignancy underwent surgical resection with oesophagogastric or oesophagojejunal anastomosis. All were fed temporarily with a catheter feeding jejunostomy placed at the time of surgery. All patients tolerated the feeding well. There were no catheter-related deaths and only one serious complication, formation of an abscess following catheter dislodgement. Experience with this technique suggests that it is safe and cheap method of feeding patients after oesophagogastric surgery. Such patients are particularly suitable for a feeding jejunostomy as they are frequently malnourished, rarely have prolonged postoperative ileus and may develop complications that delay the onset of oral intake.

Percutaneous endoscopic gastrojejunostomy: a dual center safety and efficacy trial

Although jejunal tube placement through a percutaneous endoscopic gastrostomy (PEG) has not been proven to be preferable to PEG feeding, it would be theoretically advantageous for those patients prone to gastrointestinal aspiration. However, reliable placement of a small bowel feeding tube through a PEG has been technically difficult. We have previously reported successful placement of a percutaneous endoscopic gastrojejunostomy (PEG/J) with minimal complications. These results are in contrast to other series that report technical difficulty, frequent tube dysfunction and gastric aspiration. We describe an over-the-wire PEG/J technique performed by multiple operators at two medical centers. Gastrostomy tube placement was successful in 94% of patients. Initial placement of the jejunal tube was successful in 88% of patients. Second attempts were 100% successful. The average procedure time was 36 minutes. The distal duodenal and jejunal placement of the jejunal tube resulted in no episodes of gastroduodenal reflux. Complications included jejunal tube migration (6%), clogging (18%), and unintentional removal (11%). The majority of patients were ultimately converted to either oral or intragastric feedings. We conclude that the PEG/J system is a reliable, reproducible method of small bowel feeding and is associated with no episodes of tube feeding reflux when the jejunal tube is positioned in the distal duodenum or beyond. Furthermore, it provides a temporary nutritional bridge for those patients who are later transitioned to either PEG or oral feeding.

Laparoscopic procedures for small bowel disease

Small bowel procedures such as placement of feeding jejunostomy, diagnosis of small bowel ischaemia and obstruction, bowel resection and lysis of adhesions can all be performed laparoscopically. Diagnostic laparoscopy can be performed with low complication rates, and can help avoid unnecessary laparotomy. The open method of trocar placement is preferred in patients with adhesions or distended bowel due to obstruction or ileus. Feeding jejunostomy can be placed by laparoscopically assisted methods, pulling the jejunum out or completely laparoscopically. The latter requires fixation of the jejunum to the abdominal wall by transabdominal sutures or T-fasteners. The T-fastener technique for feeding jejunostomy is simple to perform, safe and effective. Small bowel ischaemia can be difficult to diagnose laparoscopically. Fluorescein and ultrasound Doppler examination of the small bowel may be as useful as in laparotomy, but there is little clinical experience with these techniques. Laparoscopically assisted small bowel resection involves intraperitoneal division of the mesenteric vessels and exteriorization of the small bowel through a small abdominal incision, followed by resection and anastomosis. The causes of small bowel obstruction can be diagnosed laparoscopically, and adhesions can be lysed under laparoscopic guidance. The laparoscopic approach is replacing laparotomy for many small bowel procedures. Improvements in instruments and experience in laparoscopic procedures will continue to make these procedures easier and safer to perform.