Enteral Feeding Tube Placement Research Articles

Nutritional Support Best Practices in Pediatric Blood and Marrow Transplant Patients: An Integrative Review.

Nutrition is vital to the long-term survival of children undergoing blood and marrow transplantation (BMT), but there is no standardization on how to optimize the nutritional status of these patients. A literature search was performed to evaluate nutritional support approaches currently in practice for pediatric patients who are undergoing BMT. CINAHL, Embase, and Cochrane databases were searched for peer-reviewed articles evaluating nutritional interventions for BMT recipients aged 20 or younger. Nine articles published between 2019 and 2023 were found and reviewed. The nutritional support varied between enteral nutrition, parenteral nutrition, a combination of both, and prophylactic feeding tube placement. The post-transplant outcomes identified as associated with alterations in nutritional regimens included length of stay, date of platelet engraftment, incidence of acute graft-versus-host disease, infection rate, and overall survival. The use of any amount of enteral nutrition compared to parenteral alone was beneficial. Complications during BMT can potentially be decreased via prioritizing enteral nutrition over parenteral. The paucity of literature on this topic highlights an unmet need in the field. Future research should focus on ways to optimize the nutritional support of transplant recipients, including increasing the likelihood of enteral feeding tube placement and utilization.

Adjuvant Reirradiation With Proton Therapy in Head and Neck Squamous Cell Carcinoma

BackgroundFor patients with head and neck squamous cell carcinoma (HNSCC), locoregional failure and second primary tumors are common indications for adjuvant re-irradiation (re-RT). Given an absence of clear consensus on the role of adjuvant re-RT, we sought to assess histopathologic risk factors of HNSCC patients and their resulting outcomes after adjuvant re-RT with proton therapy. Methods and MaterialsWe conducted a retrospective analysis of HNSCC patients who underwent salvage surgery at our institution followed by adjuvant re-RT with proton therapy over 1.5 years. All included patients received prior radiotherapy. The Kaplan-Meier method was used to evaluate locoregional recurrence-free survival (RFS) and overall survival (OS). ResultsThe cohort included 22 patients, with disease subsites including oropharynx, oral cavity, hypopharynx, larynx, and nasopharynx. Depending on adverse pathologic features, adjuvant re-RT to 66Gy (32% of cohort) or 60Gy (68%), with (59%) or without (41%) concurrent systemic therapy was administered. The majority (86%) completed re-RT with no reported treatment delay; 3 patients experienced grade >=3 acute Common Terminology Criteria for Adverse Events (CTCAE) toxicity and no patient required enteral feeding tube placement during re-RT. Median follow-up was 21.0 months (IQR 11.7-25.2 months). Five patients had biopsy-proven disease recurrences a median of 5.9 months (IQR 3.8-9.7 months) after re-RT. Locoregional RFS was 95.2%, 70.2%, 64.8% at 6, 12, and 24 months, respectively. OS was 100%, 79.2%, and 79.2% at 6, 12, and 24 months, respectively. Four patients had osteoradionecrosis on imaging a median of 13.2 months (IQR 8.7-17.4 months) after re-RT, with two requiring surgical intervention. ConclusionsAdjuvant re-RT for HNSCC patients was well-tolerated and offered reasonable local control in this high risk cohort, but appears to be associated with a risk of osteoradionecrosis. Further study and longer follow-up could help define optimal patient management in this patient population.

Training in basic gastrointestinal endoscopic procedures: a European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement.

This ESGE Position Statement provides structured and evidence-based guidance on the essential requirements and processes involved in training in basic gastrointestinal (GI) endoscopic procedures. The document outlines definitions; competencies required, and means to their assessment and maintenance; the structure and requirements of training programs; patient safety and medicolegal issues. 1: ESGE and ESGENA define basic endoscopic procedures as those procedures that are commonly indicated, generally accessible, and expected to be mastered (technically and cognitively) by the end of any core training program in gastrointestinal endoscopy. 2: ESGE and ESGENA consider the following as basic endoscopic procedures: diagnostic upper and lower GI endoscopy, as well as a limited range of interventions such as: tissue acquisition via cold biopsy forceps, polypectomy for lesions ≤ 10 mm, hemostasis techniques, enteral feeding tube placement, foreign body retrieval, dilation of simple esophageal strictures, and India ink tattooing of lesion location. 3: ESGE and ESGENA recommend that training in GI endoscopy should be subject to stringent formal requirements that ensure all ESGE key performance indicators (KPIs) are met. 4: Training in basic endoscopic procedures is a complex process and includes the development and acquisition of cognitive, technical/motor, and integrative skills. Therefore, ESGE and ESGENA recommend the use of validated tools to track the development of skills and assess competence. 5: ESGE and ESGENA recommend incorporating a multimodal approach to evaluating competence in basic GI endoscopic procedures, including procedural thresholds and the measurement and documentation of established ESGE KPIs. 7: ESGE and ESGENA recommend the continuous monitoring of ESGE KPIs during GI endoscopy training to ensure the trainee's maintenance of competence. 9: ESGE and ESGENA recommend that GI endoscopy training units fulfil the ESGE KPIs for endoscopy units and, furthermore, be capable of providing the dedicated personnel, infrastructure, and sufficient case volume required for successful training within a structured training program. 10: ESGE and ESGENA recommend that trainers in basic GI endoscopic procedures should be endoscopists with formal educational training in the teaching of endoscopy, which allows them to successfully and safely teach trainees.

EPID-30. DYSPHAGIA-RELATED HEALTHCARE UTILIZATION AMONG OLDER PATIENTS WITH PRIMARY AND METASTATIC BRAIN TUMORS: A NATIONAL STUDY OF MEDICARE BENEFICIARIES

Abstract BACKGROUND Swallowing dysfunction is common among older adults and the presence of a malignant brain tumor (primary or metastatic) may compound the existing burden of dysphagia in this population. We aimed to characterize the dysphagia-specific healthcare utilization among Medicare beneficiaries with malignant brain tumors. METHODS Using a Medicare 5% limited dataset (2013-2018) and ICD-9/10 codes, we identified beneficiaries (≥ 65 years) with primary malignant brain tumors (PMBTs) as well as the five most common solid tumors metastasizing to the brain (lung, breast, melanoma, renal, and colorectal). Those with disorders predisposing to dysphagia were excluded. Healthcare utilization was quantified using CPT codes for hospitalizations, gastroenterology services (endoscopy [EGD]), nutrition consultation, speech language management, radiographic testing, and enteral feeding access, occurring after cancer diagnosis. Comparisons of utilization by dysphagia status were made using chi-square and Wilcoxon rank-sum tests. RESULTS Among 79,926 beneficiaries, we identified 3,184 (4.0%) with malignant PBTs and 1,033 (1.3%) with brain metastases. Of the total cohort, 4.7% (n=3,777) experienced dysphagia. Whereas, 11.0% (n=349) of those with PMBTs and 7.9% (n=82) with brain metastases experienced dysphagia. Those with PMBTs were diagnosed with dysphagia significantly earlier in their disease course compared to other groups (median 20 vs. 36 vs. 58 days for PMBTs, brain metastases, and no brain metastases, respectively; p< 0.01). Speech pathology services use was highest among PMBT patients compared other groups (36.1%; n=126; p< 0.001). Gastroenterology services utilization overall was high among all groups and enteral feeding tube placement was significantly higher among PMBTs (p< 0.001). CONCLUSIONS Dysphagia increases with age and older patients with brain malignancies are at particularly high risk. Those with PMBTs experience dysphagia earlier in their disease course and dysphagia-related healthcare utilization is higher when compared to other cancers. Our findings have important implications as the number of Medicare beneficiaries is expected to increase.

Simulation Based Training: The Next Step in Helping Dietetic Interns with Enteral Feeding Tube Placement

Simulation Based Training: The Next Step in Helping Dietetic Interns with Enteral Feeding Tube Placement

Choosing wisely: Enteral feeding tube selection, placement, and considerations before and beyond the procedure room.

When an enteral feeding tube (EFT) is placed, it is not always known how long this nutrition support intervention will be needed. As a result, the type of device the patient originally has placed may not match the function it is required to serve or the lifestyle needs of the patient throughout their enteral nutrition journey. Medicare considers an EFT a prosthetic device, as it is replacing a permanently inoperable or nonfunctioning organ. If we think about an EFT the same way we think about a prosthetic limb, one that needs to be customized to meet all of the patient's functional and lifestyle needs, we can also begin to think beyond the procedure room and carefully consider a variety of factors that impact the patient at home receiving enteral nutrition. Proper fit, function, and style is essential in order for the patient to have a positive relationship with their EFT, contributing to their successful home enteral nutrition experience. Clinicians who care for these patients in any setting and in any capacity would benefit from enhancing their understanding of available EFT options, their design components, and available methods of placement. Many home care and outpatient clinicians adopt the role of patient advocate as it relates to a patient's enteral nutrition journey, and this expanded knowledge could be used to benefit the patient by improving their overall enteral nutrition experience and ultimately their relationship with their "prosthetic."

Successful management of a chronic post-surgical gastrocutaneous fistula using as a route for enteral feeding tube placement: A case report

Successful management of a chronic post-surgical gastrocutaneous fistula using as a route for enteral feeding tube placement: A case report

A novel technique for the treatment of radiation-induced acquired esophageal atresia in patients with head and neck cancer

Dysphagia is a common complaint for patients after radiation therapy for head and neck cancer. Chronic dysphagia ensues when the radiation-induced injury matures into a fibrotic stricture, with the severity of symptoms paralleling the degree of stenosis. Most patients experience progressive dysphagia that prompts medical attention before complete esophageal obliteration. Rarely, patients present late with inability to clear their secretions because of complete obstruction, also termed acquired atresia. These patients represent a challenge and require aggressive and unconventional interventions to reestablish lumenal patency. Using a case series, we hereby describe a novel yet simple technique to treat patients with acquired esophageal atresia. Five patients with head and neck cancer in various stages who all underwent nonsurgical treatment with definitive chemotherapy and radiation along with enteral feeding tube placement prior to/during treatment presented with acquired esophageal atresia. All patients underwent an EGD to reestablish lumenal patency. This was accomplished with gentle pressure that was applied in a to-and-fro semi-circular rotational manner as if pushing a corkscrew and twisting it in alternating clockwise and counterclockwise manner. In all cases we were able to reestablish esophageal lumenal patency with a single procedure. There were no adverse events. Four of the 5 patients required additional dilations for symptomatic management. However, all patients' esophageal lumens remained patent. We describe a novel yet simple technique to treat acquired esophageal atresia after radiation for head and neck cancer. This technique allows for generous dilation yielding complete resolution of the stenosis in a single session. When our approach is used, the patient can be discharged home the same day and resume immediate oral intake.

Critical Illness and the Gastrointestinal System.

Critical illness can sometimes develop within the gastrointestinal (GI) system. This symposium series describes GI illnesses and phenomena seen within the organs of the GI system in hospitalized adults, particularly those who require critical care. The articles present state-of-the-science information for critical care and advanced practice nurses in the area of GI illnesses and their management, including providing nutrition to the critically ill. These topics are covered with a focus on pathophysiology, advanced assessment and evidence-based interventions, and cutting-edge therapies to allow nurses to innovate and strategize the care of patients with these difficult conditions.Patients of all ages can develop liver disease as a result of various illnesses; this liver disease can take the form of acute liver disease, end-stage liver disease (ESLD), or hepatocellular carcinoma. All of these disorders have significant and life-threatening aspects that require advanced knowledge of the disease processes and the application of interventions to thwart progression of the disease. Pryzbyl et al provide a timely update on the newest therapies to treat and, in some cases cure, the chronic form of liver disease and also analyze cutting-edge strategies to manage acute and acute-on-chronic hepatic failure. They review medical management, including when medical management fails and patients with life-threatening ESLD or acute liver failure undergo liver transplantation. Finally, they describe the most up-to-date preoperative and postoperative management strategies and therapies for transplant patients and examine the evidence on trends in liver transplantation, including methods to expand the donor pool as well as guidance and updates on recipient (candidate) selection.1Bloom and Seckel provide an update on the often-controversial topic of feeding tube insertion and care. They present detailed evidence about methods of insertion and recommendations on how to ensure that tubes are correctly placed and safely maintained. This is important information for acute and critical care nurses, as studies have shown a lack of standardization of clinical practice in feeding tube placement verification,2 checking gastric residuals, holding feedings, and other practices related to enteral nutrition management. Bloom and Seckel discuss best practices for enteral nasogastric feeding tube placement and care, with a focus on preventing the complications associated with this intervention.Finally, in the third article of the series, I describe the physiologic response to the infectious and inflammatory conditions of severe acute pancreatitis and fulminant colitis caused by Clostridium difficile. Patients hospitalized in acute care settings carry risk factors for developing either of these conditions, presenting critical care and advanced practice nurses with significant challenges to their identification and treatment. Severe sequelae of these diseases, including sepsis and systemic inflammatory response syndrome, correlate with the onset of organ failure and poor outcomes.3 The few interventions available to treat severe acute pancreatitis and fulminant colitis caused by C difficile are, for the most part, supportive in nature, but there are some evidence-based strategies described that may improve outcomes in patients experiencing the most severe form of these diseases and for whom there are few effective solutions. Although some of these strategies are still under investigation, they may prove valuable in improving the care available for these patients.Diseases of the GI tract and of the auxiliary organs of the GI system are highly prevalent, and patients with these diseases are seen in adult acute and critical care units. Despite their prevalence, GI system illnesses are often challenging to recognize. These diseases may be chronic in nature, such as with ESLD or acute-on-chronic liver disease, or may develop rapidly, as with acute liver failure or acute infectious/inflammatory conditions of organs of the GI tract. Critical care and advanced practice nurses are at the forefront in identifying and managing these complex disorders with the most state-of-the science strategies available, many of which are presented in this symposium. In addition, there is a clear need for knowledge and experience in nutrition in critical care and in the safe insertion of feeding tubes and their management. This is another area in which advanced practice nurses can be instrumental in forging needed change and updated standards.

Small bowel feeding: do you pay the price for bypassing the stomach?

Hydration and nutritional support is a vital part of medical care, thus a clear understanding of the optimal approach is vital for medical professionals. This is a particularly pertinent issue for patients admitted to a critical care setting. This article aims to define the advantages and disadvantages of gastric and postpyloric feeding in the critical care setting, thus aiding decision-making for clinicians. Within the article, the main themes covered are those relating to enteral feeding tube placement, the impact of enteral feeding route on ventilator-associated pneumonia, optimization of enteral tube feeding in critical care and the impact that a chosen route may have upon gastrointestinal function. The value of enteral feeding in critical illness is proven beyond doubt and the simplest approach has long been 'if the gut works, use it'. If gastric feeding is not able to be established or is not tolerated then jejunal feeding should be considered as a preferable alternative to parenteral nutrition. Improving access to service or techniques for postpyloric tube placement would assist in optimizing nutritional support in the critical care setting.

P-OGC93 Weight Loss and Complications in Oesophagectomy and Gastrectomy Patients

Abstract Background Oesophagectomy and gastrectomy are major surgeries which often involve patients fasting for prolonged periods of time post operatively thus requiring alternative nutrition regimens. In addition, patients often suffer dysphagia, anorexia, chemotherapy side effects and significant weight loss prior to surgery. Post-operative concerns include delayed gastric emptying, refeeding syndrome and dumping syndrome. Whilst placement of enteral feeding tubes aids the transition back to normal diet there are often still social, physical and dietary challenges that hinder nutrition. The aim of this study was to review weight loss in patients post operatively and to optimise post-operative nutrition. Methods The records of 113 patients who had undergone an oesophagectomy (43) or gastrectomy (64) between June 2018 and November 2019 at a single regional cancer centre were retrospectively examined. These patients’ contemporaneous weights had been recorded at set peri operative timelines and the greatest percentage weight loss calculated. The percentage weight loss was matched to the highest Clavien-Dindo post-operative complication. Results 89 patients had weights routinely reviewed post operatively, with the remainder not having regular post operative weights documented. The median weight loss was 7.53. For patients undergoing a total gastrectomy (27) weight loss ranged from 7.36-29.2%. Median weight loss was 11.45%. Patients who underwent subtotal gastrectomy (26) had between 0.37-18.5% with a median of 7.83% weight loss. Those who underwent an oesophagectomy (36) had between 0 - 28.67% weight loss with the median being 7.21%. 6 patients had their operations abandoned. Post-operative complications, inclusive of Grade II and above, occurred in 16.8% of cases. Majority of complications occurred in those undergoing an oesophagectomy (64%), however complications did not correlate with percentage weight loss. The most common complication was grade IIIb (Grade I: 8, Grade II: 1, Grade IIIa: 1, Grade IIIb: 14, Grade IVa: 2, Grade V: 2). Conclusions Significant post-operative weight loss is common after oesophagectomy or gastrectomy surgery. Postoperative weight loss did not correlate with complications. Furthermore, there did not appear to be a correlation with weight loss and type of procedure. Nutritional status plays an important prognostic role in patients undergoing oesophagectomy or gastrectomy. Optimising nutrition perioperatively and post operatively is important to enhance post-operative recovery and reduce post operative risk. Reviewing a larger cohort of patients would improve the robustness of this study.

Multivariate analysis of factors associated with first-pass success in blind placement of a post-pyloric feeding tube: a retrospective study

BackgroundTrans-jejunal nutrition via a post-pyloric enteral feeding tube has a low risk of aspiration or reflux; however, placement of the tube using the blind method can be difficult. Assistive devices, such as fluoroscopy or endoscopy, are useful but may not be suitable for patients with hemodynamic instability or severe respiratory failure. The aim of this study was to explore factors associated with first-pass success in the blind placement of post-pyloric enteral feeding tubes in critically ill patients.MethodsData were obtained retrospectively from the medical records of adult patients who had a post-pyloric enteral feeding tube placed in the intensive care unit between January 1, 2012, and December 31, 2018. Logistic regression analysis was performed to assess the association between first-pass success and the independent variables. For logistic regression analysis, the following 13 variables were defined as independent variables: age, sex, height, fluid balance from baseline, use of sedatives, body position during the procedure, use of cardiac assist devices, use of prokinetic agents, presence or absence of intestinal peristalsis, postoperative cardiovascular surgery, use of renal replacement therapy, serum albumin levels, and position of the greater curvature of the stomach in relation to spinal levels L1 − L2.ResultsData obtained from 442 patients were analyzed. The first-pass success rate was 42.8% (n = 189). Logistic regression analysis demonstrated that the position of the greater curvature of the stomach cephalad to L1 − L2 was only associated with successful placement (odds ratio for first-pass success, 0.62; 95% confidence interval: 0.40 − 0.95).ConclusionsIn critically ill patients, the position of the greater curvature of the stomach caudal to L1 − L2 may be associated with a lower first-pass success rate of the blind method for post-pyloric enteral feeding tube placement. Further studies are needed to verify our results because the position of the stomach was estimated by radiographs after enteral feeding tube placement.Trial registration: University Hospital Medical Information Network Clinical Trials Registry (UMIN000036549; April 20, 2019).

Surgical approach and short-term outcomes in adults and children undergoing total pancreatectomy with islet autotransplantation: A report from the Prospective Observational Study of TPIAT

BackgroundTotal pancreatectomy with islet autotransplantation (TPIAT) is a viable option for treating debilitating recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) in adults and children. No data is currently available regarding variation in approach to operation. MethodsWe evaluated surgical techniques, islet isolation and infusion approaches, and outcomes and complications, comparing children (n = 84) with adults (n = 195) enrolled between January 2017 and April 2020 by 11 centers in the United States in the Prospective Observational Study of TPIAT (POST), which was launched in 2017 to collect standard history and outcomes data from patients undergoing TPIAT for RAP or CP. ResultsChildren more commonly underwent splenectomy (100% versus 91%, p = 0.002), pylorus preservation (93% versus 67%; p < 0.0001), Roux-en-Y duodenojejunostomy reconstruction (92% versus 35%; p < 0.0001), and enteral feeding tube placement (93% versus 63%; p < 0.0001). Median islet equivalents/kg transplanted was higher in children (4577; IQR 2816-6517) than adults (2909; IQR 1555-4479; p < 0.0001), with COBE purification less common in children (4% versus 15%; p = 0.0068). Median length of hospital stay was higher in children (15 days; IQR 14–22 versus 11 days; IQR 8–14; p < 0.0001), but 30-day readmissions were lower in children (13% versus 26%, p = 0.018). Rate of portal vein thrombosis was significantly lower in children than in adults (2% versus 10%, p = 0.028). There were no mortalities in the first 90 days post-TPIAT. ConclusionsPancreatectomy techniques differ between children and adults, with islet yields higher in children. The rates of portal vein thrombosis and early readmission are lower in children.

Video-assisted placement of enteral feeding tubes using the Integrated Real-Time Imaging System (IRIS)-technology in critically ill patients

In critically ill patients, nasogastric (NG) and nasojejunal (NJ) feeding tube placements are standard procedures. However, about 1.9% of blind tube insertions are malpositioned in the tracheopulmonary system, whereas guided procedures may result in a significant delay in nutritional delivery. Guided methods, such as Cortrak and fluoroscopy, have success rates of 82.6-85% and 93% respectively. The current study aims to investigate the performance of video-assisted feeding tube placement in the post-pyloric position using Integrated Real Time Imaging System (IRIS-) technology. A prospective cohort study in patients requiring enteral feeding was conducted in a mixed medical-surgical intensive care unit (ICU). The primary outcome was the post-pyloric placement of IRIS feeding tubes, as confirmed by X-ray. Secondary study objectives included gastric placement, ease of use and adverse events. Thirty-one feeding tubes were placed using IRIS-technology; one patient was excluded for analysis due to protocol violation. One procedure was terminated due to significant bleeding (epistaxis) and desaturation. Only eighteen (58%) feeding tubes were placed in post-pyloric position (including two past the ligament of Treitz). In subjects who needed post-pyloric placement due gastroparesis, IRIS was mostly unsuccessful (success rate of 25%). However, when gastric placement was the primary objective, 96.8% of tubes were correctly placed. During insertion, tracheal visualization occurred in 27% of cases, and the IRIS feeding tube was repositioned early in the procedure without causing patient harm. Real-time video-assisted post-pyloric feeding tube placement in critically ill ICU patients was only successful in 58% of cases and therefore currently cannot be recommended for this indication. However, a high success rate (96.8%) for gastric placement was achieved. IRIS tube placement detected tracheal misplacement immediately and had few adverse events.

A nutritional management algorithm in older patients with locally advanced esophageal cancer.

e16038 Background: Esophageal cancer primarily affects older adults, who are at highest risk for poor nutritional status due to medical comorbidities, physiological changes of aging and geriatric issues such as altered cognition and mobility. Malnutrition is correlated with poor outcomes in patients with esophageal cancer; however, standardized nutritional interventions are not commonly utilized. Therefore, we performed a feasibility study of a nutritional management algorithm with risk-based guidelines for older patients with esophageal cancer receiving chemoradiation (CRT). Methods: Elderly patients (age ≥ 65 years old) with locally advanced esophageal or gastroesophageal junction (GEJ) cancer receiving induction chemotherapy and preoperative or definitive CRT were eligible for enrollment on this single center study. Patients completed baseline nutritional assessment using the Mini Nutritional Assessment (MNA) screening scale, and patients who were at risk for malnutrition or malnourished were referred to a clinical dietician for evaluation and counseling. Nutritional status was reassessed after induction chemotherapy, and patients with severe malnutrition were to be referred for enteral feeding tube placement prior to CRT. The primary objective was to determine the feasibility of the nutritional management algorithm based on completion rates of nutritional assessment, clinical dietician referral and enteral feeding. Secondary endpoints included toxicity, functional status and quality of life assessment. Results: Twenty elderly patients with locally advanced esophageal cancer were enrolled, and fourteen patients met criteria for clinical dietitian referral based on poor baseline nutritional status. Induction chemotherapy was associated with improved dysphagia, with 92% of patients reporting improvement or resolution of symptoms. There were no patients who met criteria for enteral feeding prior to CRT based on the guidelines, and only one patient (5%) required feeding tube placement during CRT. In total, 17 patients (85%) completed the nutritional management algorithm and finished the planned treatment course. Rates of hospitalization, grade ≥2 esophagitis, grade ≥3 toxicity and early CRT discontinuation were similar between patients with normal and abnormal baseline nutrition. Conclusions: This study demonstrates that a risk-based nutritional management algorithm is feasible in elderly patients with esophageal cancer. The induction chemotherapy approach may ameliorate dysphagia, reduce the need for enteral feeding and facilitate CRT completion in this nutritionally vulnerable population. Clinical trial information: NCT02027948.

Percutaneous Enteral Feeding in Patients With 22q11.2 Deletion Syndrome

To describe the incidence of percutaneous enteral feeding in patients with 22q11.2 deletion syndrome (22q11.2 DS) and determine factors associated with the need for percutaneous enteral feeding tube placement. Retrospective chart review. The records of a 22q11.2 DS clinic and pediatric otolaryngology clinic at a tertiary pediatric hospital were reviewed from January 1, 2009, to December 31, 2019. All patients with confirmed 22q11.2 deletion were identified. Cardiac, otolaryngological, and feeding characteristics were recorded along with surgical history. A patient was defined to have a G-tube if the history was significant for any percutaneous gastric feeding tube placement, including a gastrostomy tube, gastrostomyjejunostomy tube, or a Mickey button. One hundred ninety patients with confirmed 22q11.2 DS by genetic testing were included. Thirty-three percent (n = 63) required G-tube placement. G-tube placement was associated with cardiac diagnosis (P < .01), history of cardiac surgery (P < .01), aspiration (P < .01), nasopharyngeal reflux (P < .01), subglottic stenosis (P < .01), laryngeal web (P = .003), and tracheostomy (P < .01). This suggests these conditions are associated with higher rates of G-tube placement in the 22q11.2 DS population. Patients with 22q11.2 DS often require supplemental nutritional support in the form of G-tube feeding, most often in the first year of life. Congenital heart abnormalities and surgery along with tracheostomy, subglottic stenosis, laryngeal web, aspiration, and nasopharyngeal reflux are significantly associated with the need for G-tube placement. Understanding associations between comorbid conditions and G-tube placement, especially those involving the head and neck, may assist with counseling of patients with 22q11.2 DS.

Bedside postpyloric enteral tube placement using Kangaroo IRIS technology: a single-center case series

ObjectivesPostpyloric enteral feeding tubes (PPTs) are often placed endoscopically. This carries cost and capacity implications for hospitals with additional strain on endoscopy units during the SARS-CoV-2 pandemic. The Kangaroo Feeding Tube with IRIS Technology (IRIS) uses optical visualization to guide bedside placement, obviating the need for endoscopy. We describe a case series of bedside postpyloric enteral feeding tube placement using the IRIS tube. MethodsThis was a prospective, single-center case series over 12 mo. Conscious and sedated adult participants were included. Exclusion criteria were altered anatomy and need for endoscopy for other indications. IRIS placement was confirmed by contrast radiograph. ResultsTwenty attempts were made in 19 participants (13 women). The primary indication was intolerance of gastric feeding. The overall success rate was 75%. In sedated participants, 5 (83%) of 6 tubes were successful in 5 participants. In conscious participants, 10 (71%) of 14 tubes were successful in 14 participants. Placement failure in conscious participants was due to intolerance of the camera tip during nasal passage. The median procedure time was 13.5 min. In all cases, correct position as deemed by the operator was confirmed with contrast radiograph. No complications were observed. ConclusionsTo our knowledge, this is the largest single series of bedside postpyloric enteral feeding tube placement using the IRIS tube to date. The success rate and safety profile reported here, together with the potential benefits (reduced feeding delays, costs, and need for endoscopy) suggest that further, large-scale studies are warranted.

A Cross-sectional Survey of Enteral Feeding Tube Placement and Gastric Residual Aspiration Practices

Background: Preterm infants routinely require enteral feeding via nasogastric or orogastric tubes as an alternative to oral feeding to meet their nutritional needs. Anecdotal evidence suggests variations in practice related to correct tube placement and assessment of feed intolerance. Purpose: To determine the current practices of enteral feeding tube placement confirmation and gastric residual (GR) aspiration of neonatal clinicians in Australia. Methods: A cross-sectional online survey comprising 24 questions was distributed to nursing and medical health professionals working in Australian neonatal care units through 2 e-mail listservs made available by professional organizations. Findings: The survey was completed by 129 clinicians. A single method was practiced by 50% of the clinicians in confirming tube placement, and most common practice was assessing the pH of GR aspirate. The majority of respondents (96%) reported that they relied on GR aspiration and clinical signs to determine feeding tolerance and subsequent decisions such as ceasing or decreasing feeds. However, the frequency of aspiration, the amount and color of aspirate considered to be normal/abnormal, and decisions on whether to replace gastric aspirate or whether aspiration should be performed during continuous tube feeding varied. Implication for practice: This study demonstrated considerable variability in clinical practice for enteral feeding tube placement confirmation and GR aspiration despite most respondents reporting using a unit-based clinical practice guideline. Our study findings highlight the need for not only developing evidence-based practice guidelines for safe and consistent clinical practice but also ensuring that these guidelines are followed by all clinicians. Implication for research: Further research is needed to establish evidence-based methods both for enteral feeding tube placement confirmation and for the assessment of feeding intolerance during tube feeding. In addition, the reasons why evidence-based methods are not followed must be investigated.

Swallowing dysfunction after minimally invasive oesophagectomy

ObjectivesPatients undergoing oesophagectomy frequently experience malnutrition, which in combination with the catabolic effects of surgery can result in loss of muscle mass and function. Safe swallowing requires preservation of muscle...

S1272 Impact of Institutional Enteral Feeding Tube Policy on Medical Nutrition Utilization

INTRODUCTION: Neurodegenerative diseases (ND) are a group of diseases affecting brain neurons. Patients with ND have difficulty self-feeding1. Enteric feeding tubes, including Percutaneous endoscopic gastrostomy (PEG) tubes are placed for patients at risk for severe malnourishment. There is extensive evidence showing PEG placement is associated with increased complications and provides no mortality or palliation benefit2. In 2017 NYU Winthrop Hospital implemented a policy where patients with ND require a palliative care consultation prior to enteric tube placement. This study was performed to determine if implementation of the hospital policy had a significant effect on the number of PEG tubes placed in patients with ND. METHODS: All patients who received an enteral feeding tube were studied. The number and percentage of PEG tubes to total enteral tubes placed in patients with ND between the years 2017 (before hospital policy implementation) and 2018 (after hospital policy implementation) were compared. PEG placement percentages were compared between patients with ND who received Palliative Care (PC) consult and those who did not to examine if there is a correlation between PC consult and decrease in PEG placement. Categorical data was compared via Fisher’s exact test. Binomial percentages were computed along with 95% exact confidence intervals. SAS 9.4 was used for all analyses. RESULTS: In 2017, 70.5% (241/342) subjects had PEG tubes placed compared to 67.1% (177/264) in 2018 (P = 0.377) which represented no significant difference. There were 84 Patients who had ND and PEG placed. Among patients who had PEG placed, 20.6% (48/233) had neurodegenerative disease in 2017 compared to 20.5% (36/176) in 2018, P = 1.00 which represented no significant difference. There was a significant reduction in overall enteral feeding tube placement in patient who received PC consult compared to those who did not [56.6% vs. 89.0%, Odds Ratio(95% CI) = 0.16(0.10–0.25), < 0.0001]. CONCLUSION: There was no statistical significance in the number tubes placed in patients with ND after the policy was implemented. These findings were due to incomplete compliance with or knowledge of the policy. There was a significant reduction in enteral tube placements in patients who received palliative care consults. Palliative care consultation appears to be an important component of the policy. We suggest discussions to broaden the scope of this policy to impact patients with other medical conditions who are the end of life.