Complications of Post-pyloric Enteral Nutrition in Acute Pancreatitis: Four Year Experience at a Tertiary Institution

Abstract

Purpose: Post-pyloric enteral nutrition (PPEN) is often initiated in patients with severe acute pancreatitis (AP) who are unable to tolerate an oral diet to maintain gut mucosal barrier and prevent local and systemic infections. However, the types and frequencies of PPEN-related complications are unknown. We studied these complications, their frequencies and the subsequent interventions that were required in patients with AP at our institution. Methods: A retrospective review of patients admitted to Mayo Clinic Rochester with AP from 2005-2008 who had post-pyloric feeding tubes placed by GI endoscopy or by interventional radiology (IR) was performed. Their charts were individually reviewed to identify any complications that arose with the tube feedings and the interventions that followed. Tube blockage was defined as any feeding tube blockage that prevented PPEN. Tube displacement was defined as any displacement from the original location as stated in the procedure note, and/or confirmed by post-procedure imaging. Any patient-initiated dislodgement was considered unauthorized removal, and was excluded from the tube displacement group. Results: Between January 2005 and December 2008, 49 patients received a post-pyloric feeding tube (44 by endoscopy and 5 by IR). Of these, 28 (57%) had one or more PPEN-related complication(s), which were tube blockage (9/49 or 18%), tube displacement (14/49 or 29%), and unauthorized removal (7/49 or 14%). Four patients had a combination of 2 or more complications. In the tube blockage group, 1 patient had the tube successfully unclogged by conservative measures, 6 required replacement (4 by endoscopy, 1 by IR, and 1 underwent both procedures for 2 separate blockages) and 2 had their tubes removed as they were able to resume an oral diet. Tube displacement occurred in 14 out of the 49 patients (29%). Eight required replacement by endoscopy, 1 by IR and 1 received a surgical jejunostomy (Witzel jejunostomy). The remaining 3 patients tolerated an oral feeding and required no intervention. Unauthorized removal occurred in 7 out of the 49 patients (14%). Of these, 3 required replacement by endoscopy, while the remaining 4 patients were able to tolerate an oral diet. Overall, 18 replacement procedures were performed (15 by endoscopy and 3 by IR) affecting 16 out of the 28 patients (57%) with PPEN-related complications. Conclusion: PPEN-related complications affected 28 out of the 49 patients with AP who received PPEN at this institution (57%). Of these, a replacement procedure was necessary in 16 patients (57%). Future studies should address methods aimed at preventing these complications, and thus avoid the costs associated with a repeated procedure.