Nasojejunal Tube Feeding And Clinical Pharmacy Intervention In The Management of Caustic Esophageal Injury: A Case Report

Provision of enteral nutrition with jejunal feeding in upper gastrointestinal obstruction is highly recommended. Access to jejunum can be obtained surgically, percutaneously, or endoscopically. Our institution routinely and preferentially utilizes a silicone nasojejunal tube that is inserted past the obstruction endoscopically. We use a custom dual channel tube that allows feeding at the distal tip and another channel 40 cm from the tip that enables decompression proximally. This is a report of our experience with this custom nasojejunal tube. This is a prospective observational study of 201 patients who underwent endoscopic nasojejunal wire-guided feeding tube insertions for obstruction of either the esophagus or the stomach including both benign and malignant pathologies between January 2015 to June 2018 in Hospital Sungai Buloh and Hospital Sultanah Aminah, Malaysia. The indications for tube insertion, insertion technique, and tube-related problems were described. The nasojejunal tube was used to establish enteral feeding in patients with obstructing tumors of the distal esophagus in 65 patients (32.3%) and gastric outlet obstruction in 72 patients (35.8%). There were 54 patients (26.9%) who required reinsertion. The most common reason for reinsertion was unintentional dislodgement, where 32 patients (15.9%) followed by tube blockage 20 patients (10.0%). Using our method of advancement under direct vision, we had only 2 cases of malposition due to severely deformed anatomy. We had no incidence of aspiration in this group of patients and overall, the patients tolerated the tube well. The novel nasojejunal feeding tube with gastric decompression function is a safe and effective method of delivery of enteral nutrition in patients with upper gastrointestinal obstruction. These tubes if inserted properly are well tolerated with almost no risk of malposition and are tolerated well even for prolonged periods of time until definitive surgery could be performed.

In order to prevent gastric microbial overgrowth, which may complicate nasogastric feeding, administration of nutrients more distally into the gut has been advocated in intensive care patients, as it offers the advantage of keeping the stomach empty and acid. In this study, we assessed the impact of jejunal feeding upon gastic pH in a group of mechanically ventilated, critically ill patients, with special focus on duodenogastric reflux as a possible cause of gastric alkalinization during jejunal nutrition. Prospective experimental study. Multidisciplinary intensive care unit of a university hospital. Gastric pH was recorded by continuous pHmetry over a 4-h period of fasting followed by a 4-h period of nasojejunal feeding at 100 kcal/h in 21 mechanically ventilated, critically ill patients. To determine the contribution of duodenogastric reflux to modifications of gastric acidity, the diet was traced with [(111)In] DTPA (pentetic acid) in 11 of these 21 patients; gastric contents were aspirated every 30 min, then analysed for measurement of radioactivity, glucose, and bile acid concentration. Median intragastric pH increased slightly from 1.59 (1.20-2.73; interquartile range) (fasting) to 2.33 (1.65-4.64) (feeding) (p = 0.013), and the length of time that the pH was 4 or above increased from 1 (0-24) to 9 (0-142) min (p = 0.026). The variability of pH values and the number of acute alkalinization episodes did not change between the two phases. In 10 of 11 patients in which the diet was labeled with [(111)In] DTPA, reflux was documented at a given time of the feeding period. Bile acid concentrations in the stomach increased from 392 (61-1076) (fasting) to 1446 (320-2770) micromol/l (feeding) (p = 0.010) and mean glucose concentration increased from 59 (28-95) to 164 (104-449) mg/dl (p = 0.006). Duodenogastric reflux is common in mechanically ventilated critically ill patients with nasojejunal feeding tubes. It occurs both during fasting and during nasojejunal feeding. During nasojejunal feeding, moderate alkalinization of the gastric contents occurs as a result of bile and nutrient reflux.

Nasojejunal tube (NJT) feeding has demonstrated value in reducing pneumonia in adults who are critically ill who require enteral nutrition (EN) support. This study discusses whether EN support via NJT feeding is more cost-effective than nasogastric tube (NGT) feeding in reducing pneumonia. A decision-tree model was created. The analysis was based on data from a health care provider in China. Model inputs were derived from published data. The end points included incremental cost per pneumonia infection avoided, incremental cost-effectiveness ratio (ICER), net monetary benefit (NMB), and incremental NMB (INMB) associated with prevention of pneumonia. The uncertainty was assessed through one-way and probabilistic sensitivity analysis. The base case analysis showed that EN support via NJT feeding resulted in 0.7453 quality-adjusted life years (QALYs) at a cost of $3018.83 compared with NGT feeding, which resulted in 0.7354 QALYs at a cost of $4788.76. NJT feeding was better than NGT feeding, providing an INMB of $2075.09 and an ICER of -$178,813.96 per QALY gained, and the cost per pneumonia infection prevented was $16,808.51. The probabilistic sensitivity analysis indicated that NJT feeding was more cost-effective in 83.4% of the cases, with a cost below the WTP threshold. The NMB and INMB estimation for different WTP thresholds also indicated that NJT feeding is the optimal strategy. EN support via NJT feeding was a more cost-effective strategy than NGT feeding in preventing pneumonia in adults who are critically ill.

Recently Cheek and Staub reported no serious complications in 46 infants given continuous nasojejunal tube feeding. We observed serious disturbances in 4 of 13 low-birth-weight infants fed in the same manner. In the 13 infants, mean gestational age was 29.61±1.68 wks and mean birth weight was 1, 176.15±208.23 gm. All except one had respiratory distress syndrome and/or other problems. None was able to be fed orally or by nasogastric tube. Nasojejunal tube feeding was initiated from 2 to 9 days of age. Average duration was 16.0±11.78 days. At the termination of nasojejunal feeding, 8 infants were heavier and 5 lighter than their respective birth weight. Six died. In 2 the cause of death was unrelated to nasojejunal feeding. In 4 the causes of death were as follows: (1) necrotizing gastroentero-colitis with possible rupture of intestine, (2) jejunal perforation with diffuse peritonitis, (3) aspiration pneumonia due to distention of jejunum and ilium and vomiting, (4) jejunojejunal intussusception. The safety of this procedure requires careful evaluation by controlled studies before it can be recommended for routine purposes in small low-birth-weight infants.

OBJECTIVE: Studying the influence of early nasogastric (NG) and nasojejunal (NJ) probe feeding in patients with predictors of severe acute pancreatitis on the course and outcome of the disease. MATERIALS AND METHODS: An open randomized controlled study was performed in Neftyanik Occupational Healthcare Facility ICU. 64 patients with predictors of severe acute pancreatitis (APACHE II > 8, CRP > 150 mg/l, SOFA > 2) randomized by the envelope method for early (the first 24 hrs.) nasogastic or nasojejunal feeding. The standard polymer feeding formula enriched with dietary fibers was administered during the first 5 (five) days taking into account its tolerability. Raw data were statistically processed using SPSS-26 software. RESULTS: Comparison of the NG (n = 33) vs. NJ (n = 31) groups produced the following results: the duration (days) of treatment in the hospital was 21 (12; 42) vs. 24 (11; 35), p = 0.715; in ICU — 4 (2; 20) vs. 4 (3; 13), p = 0.803; mechanical ventilation (MV) — 1 (1; 3) vs. 1 (1; 1), p = 0.124; mortality — OR 0.830 (95 % CI 0.201–3.422), p = 0.796; severity (moderately severe or severe) — OR 1.29 (95 % CI 0.483–3.448), p = 0.611; number of patients subjected to surgery during the first period of the disease — OR 0.774 (95 % CI 0.243–2.467), p = 0.665; and second period of the disease — OR 1.682 (95 % CI 0.623–4.546), p = 0.305. CONCLUSIONS: No difference has been found between the groups of patients with severe disease predictors, who received early nasogastric or nasojejunal tube feeding using standard polymer formula with dietary fibers during early acute pancreatitis, as regards duration of treatment in the hospital, in ICU, numbers of mechanically ventilated patients, patients operated during the first and second disease periods, disease severity or mortality.

Enteral feeding in patients with major burn injury: the use of nasojejunal feeding after the failure of nasogastric feeding

Objective To evaluate the clinical application of enteral nutrition by nasojejunal tube insertion and by percutaneous endoscopic gastrostomy (PEG) in elderly patients. Methods A total of 65 elderly patients with dysphagia recruited at our department from January 2010 to November 2014 were divided into the nasojejunal tube feeding group (35 cases) and the PEG feeding group (30 cases). Differences between these two groups in nutritional indexes, immunological indexes, complications and mortality were analyzed retrospectively. Results Serum total protein, albumin and prealbumin and upper arm circumferences all increased after treatment with nasojejunal tube feeding or percutaneous endoscopic gastrostomy (P>0.05). There was overall improvement in nutritional status, as assessed by Nutritional Risk Screening 2002 (NRS2002). Specifically, the before/one month-after-treatment ratio of scores was 3.72±0.91/1.90±0.61 (t=7.24, P 0.05). Although improvement in CD3+ , CD4+ , CD8+ , CD4+ /CD8+ , IgA, IgG, and IgM was seen in both groups after operation, the differences did not reach statistical significance (P>0.05). The incidence of aspiration pneumonia was notably lower (P<0.05) while the incidence of diarrhea was much higher (P<0.05) in the nasojejunal tube feeding group than in the PEG feeding group at one month and three months. The two groups had similar causes of death and mortality rates. Conclusion Both nasojejunal tube and PEG feeding can improve the nutritional status of elderly patients with dysphagia. However, the choice for the route of nutrition should be individualized. Key words: Jejunostomy; Gastroscopes

BackgroundThis study aimed to compare nutritional effectiveness and complication rate between early nasojejunal and nasogastric tube feeding in patients with an intracerebral hemorrhage. MethodsThis was a retrospective study. Eighty patients with an intracerebral hemorrhage were divided into a nasojejunal and a nasogastric tube feeding group. Feeding tubes were placed within 6 h after admission, and enteral feeding began within 2 h after tube placement. The nutritional status and complication rate of the 2 groups were compared before and 2 and 4 weeks after beginning feeding. ResultsSerum prealbumin, serum albumin, and hemoglobin levels were significantly higher in the nasojejunal tube feeding group than in the nasogastric tube feeding group at 2 and 4 weeks after beginning feeding (all, p < 0.05). The incidence of gastric retention, pulmonary aspiration, and pneumonia were lower in the early nasojejunal tube feeding group than in the early nasogastric tube feeding group (all, p < 0.05). There was no significant difference in the incidence of diarrhea between the 2 groups. ConclusionCompared with early nasogastric feeding, early nasojejunal feeding provides better nutritional effectiveness and a lower incidence of gastric retention, pulmonary aspiration, and pneumonia in patients with an intracerebral hemorrhage.

Compared with nasogastric nutrition, nasojejunal nutrition may prevent some complications of critically ill patients by maintaining better nutritional status, and blind placement of nasojejunal dwelling feeding tubes is widely used. However, the visual placement seems to be safer and more effective than the blind placement, and is still seldom reported. We tried to develop visual placement of a nasojejunal feeding tube in intensive care unit patients. A total of 122 patients receiving mechanical ventilation were admitted to the Department of Critical Care Medicine of the Fifth Affiliated Hospital of Wenzhou Medical University and received the placement of nasojejunal feeding tubes. These patients were randomly and evenly assigned into two groups, one group receiving visual placement of nasojejunal dwelling feeding tubes and another group receiving blind placement. Actual tube placement was confirmed by X-ray. The primary outcome included the success rates of first placement of feeding tubes. The secondary outcome included the time of tube placement, complications, the total cost, heart rates and respiratory rates. The primary outcome showed that the success rates of first placement were 96.70% (59 cases/61 cases) in the visual placement group, and two cases failed due to pyloric stenosis and gastroparesis. The success rates were 83.6% (51 cases/61 cases) in the blind placement group and 10 cases failed due to either wrong placement or retrograde tube migration. The success rates in the visual placement group were higher than that in the blind placement group (P = 0.015). The secondary outcome showed that the time of tube placement in the visual placement group was shorter than that in the blind placement group (P < 0.0001). The cost of tube placement in the visual placement group was higher than that in the blind placement group (P < 0.0001). The statistical differences in complications, heart and respiratory rates were insignificant between the two groups (P > 0.05). Compared with the blind placement, the visual placement shortened the time of nasojejunal tube placement and increased success rates of first placement. The visual placement was more efficient, easy to operate, safe, and has potential clinical applications.

The Endoscopic Purse-string Suture (EPSS) technique has gained attention for its potential in closing large defects following gastrointestinal procedures. However, its application in fistula closure is not as widely reported. This study aims to evaluate the safety and efficacy of EPSS and naso-jejunal tube feeding in the closure of duodenal cutaneous fistulas and gastric cutaneous fistulas. This single-center retrospective study, conducted from September 2020 to September 2023 at Tongji University in Shanghai, China, examined the outcomes of EPPS and nasojejunal feeding for patients with gastric and duodenal cutaneous fistulas (n = 10). Demographic data, fistula characteristics, procedure technique and outcomes were evaluated. In this study, the average size of a fistula opening was 7.9 ± 4.6mm. The operations took an average of 25.8 ± 5.6min. Patients typically needed naso-jejunal tube feeding for a median of 14.0days, with an interquartile range (IQR) of 7.7-19.0days. The median duration of hospital stay post-operation was 16.5days, with an IQR of 7.0-25.0days. Nine patients were successful in their initial fistula closure using the EPSS technique. The other patient underwent a second EPSS and, ultimately, all patients experienced complete healing and fully recovered. There were no major adverse events reported. EPSS and naso-jejunal tube feeding are a safe and effective treatment option for duodenal and gastric cutaneous fistulas. Larger, prospective studies are needed to validate these findings and establish the long-term safety and efficacy of this approach.

To assess the success rate of a self-propelling nasojejunal feeding tube in patients with acute pancreatitis. All patients admitted for acute pancreatitis were included. A self-propelling nasojejunal feeding tube was introduced into the stomach, and gastrointestinal motility was stimulated using metoclopramide. If the tube failed to advance to the ligament of Treitz, a nasojejunal tube was placed endoscopically. A total of 108 patients, 94 with necrotizing pancreatitis (Balthazar D/E) and 14 with nonnecrotizing pancreatitis (Balthazar B/C), were referred for artificial nutrition. In 11 cases, ileus persisted and parenteral nutrition was initiated. Among the remaining 97 patients, 5 refused tube placement. The self-propelling feeding tube was inserted in 92 patients with successful migration to the ligament of Treitz in 61% (n = 56) and failure in 39% (n = 36). Of the 36 patients with an initial failed placement, endoscopic placement of a nasojejunal tube was successful 80% of the time (29 patients). The success rate of a nasojejunal self-propelling feeding tube placement correlated directly with the severity of the acute pancreatitis (92% in B/C vs 61% in D vs 48% in E; P < .05). Use of a self-propelling nasojejunal tube is a simple technique that can be successfully performed in the majority of patients with acute pancreatitis. The utility of this procedure in the most severe cases of acute pancreatitis continues to pose a challenge.

The aim of this study was to compare nasogastric (NG) feeding with nasojejunal (NJ) feeding when treating pediatric patients with acute pancreatitis (AP). We performed a single-center, prospective, randomized, active-controlled trial involving 77 pediatric patients with AP from April 2014 to December 2017. The patients were randomized into two groups: the NG tube feeding group (34 patients) and the NJ tube feeding group (33 patients). The primary outcome measures included the enteral nutrition intolerance, the length of tube feeding time, the recurrent pain of pancreatitis and complications. A total of 62 patients with AP (31 patients for each group) came into the final analysis. No differences were found in baseline characteristics, pediatric AP score and computed tomography severity score between the two groups. Three (9.7%) patients in the NG group and one (3.2%) patient in the NJ group developed intolerance (relative risk = 3.00, 95% confidence interval 0.33-27.29, P = 0.612). The tube feeding time and length of hospital stay of the NG group were significantly shorter than those of the NJ group (P = 0.016 and 0.027, respectively). No patient died in the trial. No significant differences were found in recurrent pain, complications, nutrition delivery efficacy, and side effects between the two groups. NG tube feeding appears to be effective and safe for acute pediatric pancreatitis compared with NJ tube feeding. In addition, high qualified, large sample sized, randomized controlled trials in pediatric population are needed.

Background and Aim Carcinoma of the stomach is one of the leading causes of mortality worldwide. Surgery for gastric cancer in the form of total or distal gastrectomy is definitive treatment. Feeding jejunostomy (FJ) though improves postoperative nutritional status and outcome, it is not devoid of its complications. In this study, we present the outcomes of nasojejunal (NJ) feeding and FJ and complications associated with them. Materials and Methods It is both retrospective and prospective observational study in patients with gastric cancer undergoing surgery. Patients were divided into two groups: those who underwent FJ and those who underwent NJ route of feeding placed intraoperatively. Results A total of 279 patients of gastric cancer who underwent surgery were taken into study, of which, 165 were male and 114 females. FJ was done in 42 and NJ in 237 patients, respectively. Gastrectomy + NJ was done in 128 patients, gastrectomy + FJ in 27 patients, gastrojejunostomy + NJ in 109 patients, and FJ in 15 patients. We had three patients of bile leaks in FJ group, of which one patient had intraperitoneal leak who needed re-exploration; rest of the two had peri-FJ external leaks, who were managed conservatively. Most of the complications of NJ group were minor. Conclusion Our study of 279 patients in gastric cancer has shown that FJ is sometimes associated with major complications with increased hospital stay and morbidity when compared with NJ tube feeding without any difference in nutritional outcomes. Hence, NJ route of postoperative enteral nutrition can be considered as an alternative to FJ wherever feasible in view of its technical safety and minor complications and morbidity.

Comparison of tolerance and change of intragastric pH between early nasogastric and nasojejunal feeding following resection of colorectal cancer

Purpose: Post-ampullary, Nasojejunal feedings have been shown to be an important component in the management of critically ill patients and patients with pancreatitis. However, proximal migration or dislodgement of the tubes can occur, limiting the effectiveness of the feeding in ICU patients. Methods: Intensive care unit (ICU) patients undergoing placement of nasojejunal feeding tubes (NJT) from January 2000 to December 2005 were prospectively identified. The feeding tube was positioned endoscopically into the post ampullary duodenum. After feeding tube placement, the NJT was “bridled” with umbilical tape to the posterior nasal septum. Bridling was performed using an NG tube, advanced to the posterior pharynx and pulled out through the mouth. Umbilical tape was secured to the NG tube which was then pulled back through the nose. The bridle was then created by securing the end of the umbilical tape to the feeding tube, with the nasal septum anchoring the tube in position, limiting displacement of the NJT when pulled. Results: A total of 153 NJT were placed and bridled in 139 patients. Positioning of the feeding tube was performed using snare (32%) and rat-tooth forceps (68%). Feeding tube position was confirmed to be post pyloric endoscopically and with abdominal xray after placement. All included patients had undergone repeat abdominal films from 5–19 days after initial placement, at which time feeding tube position was reassessed. Accidental tube dislodgement or gastric proximal migration occurred in 6 cases (4%) and tube occlusion or malfunction in 3 cases (2%). There was mild nosebleeding in 2 patients (1.5%) and perinasal ulceration in 3 patients (2%). Goal tube feedings were achieved within 72 hrs. in 142 cases (93%). Conclusions: Nasal Bridling of endoscopically placed NJT maintains post pyloric feeding tube position at a high rate (94%), with very few complications. This allows for rapid delivery of optimal nutrition in ICU patients.