Gastric Feeding Research Articles

Re-insertion of Gastric Feeding Tube via Previous Surgical Gastrostomy in Elderly Sick Patient with Reflux Oesophagitis Secondary to Gastrointestinal Motility Disorder: Case Report

Background: Reflux oesophagitis is an esophageal mucosal injury that occurs secondary to retrograde flux of gastric contents into the esophagus. Here, we reported a case of re-insertion of gastric feeding tube (RIGFT) to an old man who underwent gastrostomy due to progressive Dysphagia secondary to reflux oesophagitis. Methods: We report the case of re-insertion of gastric feeding tube in an elderly man who could not undergo PEG and open surgical gastrostomy. Case presentation: An 85-year-old man with advanced Parkinson dementia, presented with progressive Dysphagia, fever, disorientation and recurrent aspiration pneumonia. He had a history of open abdominal surgical gastrostomy which was performed under spinal anesthesia and gastric tube was inserted successfully. Three months later the patient pulled out the tube and was referred to our teaching hospital and the next day re-insertion was performed. Conclusion: For elderly patients who cannot undergo the percutaneous endoscopic gastrostomy and open surgical gastrostomy under general anesthesia should be recommended for re-insertion of gastric feeding tube via previous surgical orifice under local anesthesia. Therefore, percutaneous re-insertion should be considered as option to all patients who are contraindicated to surgery.

Cachexia in children with chronic kidney disease: challenges in diagnosis and treatment.

Although cachexia is highly prevalent in adult patients with chronic kidney disease (CKD), it is understudied and less well characterized in children. Recent evidence suggests that cachexia is also prevalent in children with CKD but presents challenges in diagnosis and treatment. A study from the CKD in children cohort showed that CKD cachexia or protein-energy wasting, using modified pediatric diagnostic criteria, such as lack of expected weight gain instead of weight loss and BMI for height age, had a prevalence of 7-20%. When growth indices such as height SD score (SDS)/height velocity SDS was included in the criteria, cachexia or PEW correlated with the morbidity outcome of increased hospitalization risk in children with CKD. Conversely, aggressive nutritional supplementation in children with advanced CKD, with nasogastric or gastric tube feeding, led to prevalence of obesity over that of cachexia. Body habitus of underweight and obesity have been shown to be associated with the worst clinical outcomes in both adults and children with CKD. Optimal nutritional therapy remains the mainstay of treatment of cachexia in CKD children with therapeutic goals of maintaining BMI as well as linear growth within the normal range.

Laparoscopic fundoplication in neonates and young infants: Failure rate and need for redo at a high-volume center

Aim of the studyPresent the outcomes of patients younger than 2years who underwent laparoscopic fundoplication, highlighting the failure rate and need for redo fundoplication. MethodsRetrospective review of patients <2years who underwent laparoscopic fundoplication between January 2009 and December 2014. Main results458 infants younger than 2years underwent laparoscopic fundoplication in the 6-year period (360 Nissen, 77 Toupet and 21 Thal fundoplications). Median age at surgery was 5 (1–23) months. Median follow-up was 3 (1–6) years. The conversion rate was 0.87% (4 of 458 cases). Patients did not undergo routine studies to assess the incidence of postoperative GER but were instead followed clinically. Failure of the fundoplication was determined when a patient was unable to gain weight and/or protect the airway while receiving gastric feedings because of GER. The failure rate in our experience was 2.6% (12 redo out of 458 cases [11/360 Nissen, 1/77 Toupet and 0/21 Thal]). All failed cases occurred because of migration of the fundoplication, confirmed preoperatively by a contrast study. Median time between the initial fundoplication and the redo was 13 (5–27) months. There were no failures within a contemporaneous group of 101 patients <2years who underwent open fundoplication. ConclusionThe need for a redo fundoplication after a laparoscopic fundoplication was an uncommon event in our experience (12 of 458 cases). Our results contrast with published studies that report higher failure rates. Case volume per surgeon may explain in part the dissimilar results among studies. Level of evidenceIII.

The role of dietary fat in obesity-induced insulin resistance.

Consumption of excess calories results in obesity and insulin resistance and has been intensively studied in mice and humans. The objective of this study was to determine the specific contribution of dietary fat rather than total caloric intake to the development of obesity-associated insulin resistance. We used an intragastric feeding method to overfeed excess calories from a low-fat diet (and an isocalorically matched high-fat diet) through a surgically implanted gastric feeding tube to generate obesity in wild-type mice followed by hyperinsulinemic-euglycemic clamp studies to assess the development of insulin resistance. We show that overfeeding a low-fat diet results in levels of obesity similar to high-fat diet feeding in mice. However, despite a similar body weight, obese high-fat diet-fed mice are more insulin resistant than mice fed an isocaloric low-fat diet. Therefore, increased proportion of calories from dietary fat further potentiates insulin resistance in the obese state. Furthermore, crossover diet studies revealed that reduction in dietary fat composition improves glucose tolerance in obesity. In the context of the current obesity and diabetes epidemic, it is particularly important to fully understand the role of dietary macronutrients in the potentiation and amelioration of disease.

Roux-en-Y Gastric Bypass Hypoglycemia Resolves with Gastric Feeding or Reversal: Confirmation of a Nonpancreatic Mechanism

Roux-en-Y Gastric Bypass Hypoglycemia Resolves with Gastric Feeding or Reversal: Confirmation of a Nonpancreatic Mechanism

The Long-term Outcome of Early Spine Fusion for Scoliosis in Children With Cerebral Palsy.

Retrospective review of radiographs and charts (case-only). The aim of this study was to describe the long-term outcomes of spine fusion for neuromuscular scoliosis in children below 10 years of age with cerebral palsy (CP). Severely involved children with CP may develop early-onset scoliosis. The outcome of spine fusion is not clear and there are no studies focused on spine fusion in this young patient population. This is a retrospective review of 33 children who underwent spine fusion with unit-rod instrumentation between 1989 and 2006 for CP neuromuscular scoliosis, aged below 10 years at spine fusion, and with follow-up >5 years. Demographic, medical, and radiographic data were retrospectively assessed. Repeated measure analysis of variance and Kaplan-Meier survival estimates were used for data assessment. Thirty-three of 42 patients who underwent spine fusion in this period, 19 boys and 14 girls, met the inclusion criteria. Of 9 patients who were excluded, 3 were lost to follow-up and remaining 6 died within 5 years of surgery. Mean age at surgery was 8.3 years (range, 4.4-9.9 y). Mean follow-up was 9.8 years (range, 5.5-15.8 y). Gross motor function classification system level was V in 31 patients and IV in 2 patients. Thirty-one patients (94%) had seizure disorder, 29 patients (88%) had gastric feeding tubes, and 9 patients (27%) had tracheostomy tubes. Eighty-five percent of the patients had posterior-only surgery. Mean Cobb angles preoperative, immediately postoperative, and at final follow-up were 85, 21, and 24 degrees, respectively. Mean postoperative pelvic obliquity correction was 15±9 degrees (P<0.001). At final follow-up, there was no significant change from the postoperative measurements. Complications included 1 deep wound infection and 10 other problems. Eleven patients (28.2%) died after a mean follow-up of 5.6±3.8 years. In our cohort with early-onset neuromuscular scoliosis, spine fusion was associated with minimal short-term and long-term morbidity, but there was 28% mortality at 10 years of follow-up and 50% predicted mortality at 15 years.

Cyclosporine A disposition, hepatic and renal tolerance in Wistar rat

Cyclosporine A, a potent calcineurin inhibitor, has been widely used in organ transplantation and in the treatment of autoimmune diseases. It has, however, been shown to induce serious renal and hepatic side effects. The drug is also used in preclinical studies, but with little published information on the optimal dose and route of administration in rodents. Objectives of this study were to identify efficient and safe doses of cyclosporine A in rodent and to assess its effects on hepatic and renal functions. For this purpose, we tested the effects of different doses and administration routes of cyclosporine A (5, 2.5 and 1 mg/kg) administered during 28 days intraperitoneally, or by gastric feeding on Wistar rats. Our data indicate that rats injected intraperitoneally with 5 mg/kg/2d (every two days) exhibited trough cyclosporine A levels within known therapeutic range in human, but were subject to blood cyclosporine A accumulation, whereas the 5 mg/kg/d gavage resulted in only a small cyclosporine A accumulation over time. In both cases this accumulation was not deleterious to renal and hepatic functions, as shown by transaminase, urea, creatinine and bilirubin measurements.

Do we need new prokinetics to reduce enteral feeding intolerance during critical illness?

Gastrointestinal feeding intolerance and critical illness-associated gastric motility dysfunction are common. Although recent guidelines recommend not interrupting gastric feeding when gastric residual volume (GRV) is lower than 500 mL or to completely abandon measurement of GRV, it may seem that the relevance of prokinetics is reduced.In patients at risk for aspiration and in multimodal strategies to enhance feeding performance, however, use of prokinetics is still advocated. Metoclopramide and erythromycin are commonly used promotility agents, although with relevant side effects.Potential targets for new agents and early study results are addressed.

How does post-pyloric compare with gastric tube feeding in critically ill adults?

How does post-pyloric compare with gastric tube feeding in critically ill adults?

Percutaneous endoscopic transgastric jejunostomy (PEG-J): a retrospective analysis on its utility in maintaining enteral nutrition after unsuccessful gastric feeding

Background/aimsAlthough percutaneous endoscopic gastrostomy (PEG) is the method of choice for long-term enteral nutrition, feeding-related adverse events such as aspiration pneumonia and peristomal leakage can impede the use of PEG....

Glycogen storage disease type III: diagnosis, genotype, management, clinical course and outcome.

Glycogen storage disease type III (GSDIII) is a rare disorder of glycogenolysis due to AGL gene mutations, causing glycogen debranching enzyme deficiency and storage of limited dextrin. Patients with GSDIIIa show involvement of liver and cardiac/skeletal muscle, whereas GSDIIIb patients display only liver symptoms and signs. The International Study on Glycogen Storage Disease (ISGSDIII) is a descriptive retrospective, international, multi-centre cohort study of diagnosis, genotype, management, clinical course and outcome of 175 patients from 147 families (86 % GSDIIIa; 14 % GSDIIIb), with follow-up into adulthood in 91 patients. In total 58 AGL mutations (non-missense mutations were overrepresented and 21 novel mutations were observed) were identified in 76 families. GSDIII patients first presented before the age of 1.5 years, hepatomegaly was the most common presenting clinical sign. Dietary management was very diverse and included frequent meals, uncooked cornstarch and continuous gastric drip feeding. Chronic complications involved the liver (hepatic cirrhosis, adenoma(s), and/or hepatocellular carcinoma in 11 %), heart (cardiac involvement and cardiomyopathy, in 58 % and 15 %, respectively, generally presenting in early childhood), and muscle (pain in 34 %). Type 2 diabetes mellitus was diagnosed in eight out of 91 adult patients (9 %). In adult patients no significant correlation was detected between (non-) missense AGL genotypes and hepatic, cardiac or muscular complications. This study demonstrates heterogeneity in a large cohort of ageing GSDIII patients. An international GSD patient registry is warranted to prospectively define the clinical course, heterogeneity and the effect of different dietary interventions in patients with GSDIII.Electronic supplementary materialThe online version of this article (doi:10.1007/s10545-016-9932-2) contains supplementary material, which is available to authorized users.

Efficacy of azithromycin and metronidazole combined therapy on rats’ gingival overgrowth induced by cyclosporine-A: An experimental animal study

AimsTo evaluate the therapeutic efficacy of azithromycin (azm) and/or metronidazole (mtz) on the histopathological features of rats’ gingival overgrowth (GO) induced by cyclosporine-A (CsA) in an animal model. MethodsNinety male albino rats were divided randomly into six equal groups. The rats of group I received corn oil via gastric feeding for 7 weeks. Group II rats were administered CsA for the same period. Groups III, IV, and V rats received CsA for 6 weeks and simultaneously in the 7th week received a monotherapy of placebo gel, azm suspension, mtz gel, respectively. Group VI rats were handled as groups III, IV, and V and instead received a combined therapy of azm suspension, and mtz gel. Rats were euthanized at the end of the experiment and routine tissue processing was carried out. The obtained specimens were stained with H&E, TGF-β, MMP-1, and IL-6 antibodies. ResultsOne-way MANOVA test for TGF-β, MMP-1, and IL-6 revealed an overall significant difference between the different groups (P=0.000). LSD post hoc test for multiple comparisons of TGF-β revealed nonsignificant difference between groups I and VI and between groups IV and V. Nonsignificant difference was found between groups II and III considering the amount of MMP-1 immune expression. In addition, nonsignificant difference was found between groups V and VI regarding the amount of immune expression for IL-6. ConclusionCombined therapy of azm suspension and mtz gel significantly improved the histopathological features of CsA-induced GO better than a monotherapy of azm suspension or mtz gel.

Revisão integrativa: atuação fonoaudiológica com recém-nascidos portadores de cardiopatia em unidade de terapia intensiva neonatal

RESUMO O objetivo deste estudo foi identificar e analisar, por meio de levantamento bibliográfico, a atuação fonoaudiológica em Unidades de Terapia Intensiva Neonatal (UTINs) em casos de cardiopatia congênita. Como fonte de dados foram utilizadas as seguintes plataformas: Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Medical Literature Analysis and Retrieval Sistem on-line (MEDLINE), Scielo e o serviço de pesquisa da National Library of Medicine nas bases de dados Pubmed, sistema de procura do Google Acadêmico (HTTP//scholar.google.com.br). Foram pesquisados trinta e dois trabalhos, sendo a atuação fonoaudiológica em UTINs descrita em vinte e oito deles, os quais apresentam como procedimentos avaliação e estimulação do sistema sensório-motor-oral, com uso de técnicas de sucção não-nutritiva e nutritiva, além de triagem auditiva. Porém, as características dos neonatos com cardiopatia congênita e a inserção do fonoaudiólogo em UTIN cardíaca não são citadas, pouco se caracterizando os objetivos e a prática desse profissional. Apenas uma publicação obedeceu aos critérios de inclusão do presente estudo. Trata-se de um trabalho que descreve a transição da alimentação enteral direta para o seio materno em recém-nascidos pré-termo cardiopatas, com idade corrigida, em um centro de terapia intensiva neonatal. Foi possível constatar então a escassez de trabalhos publicados sobre intervenção fonoaudiológica com RN cardiopatas, o que indica a necessidade de novos estudos sobre o tema, já que a atenção a esses pacientes deve ser diferenciada, visto que apresentam particularidades que podem comprometer o desempenho na alimentação.

Intercenter Cost Variation for Perinatal Hypoxic-Ischemic Encephalopathy in the Era of Therapeutic Hypothermia

To quantify intercenter cost variation for perinatal hypoxic ischemic encephalopathy (HIE) treated with therapeutic hypothermia across children's hospitals. Prospectively collected data from the Children's Hospitals Neonatal Database and Pediatric Health Information Systems were linked to evaluate intercenter cost variation in total hospitalization costs after adjusting for HIE severity, mortality, length of stay, use of extracorporeal support or nitric oxide, and ventilator days. Secondarily, costs for intensive care unit bed, electroencephalography (EEG), and laboratory and neuroimaging testing were also evaluated. Costs were contextualized by frequency of favorable (survival with normal magnetic resonance imaging) and adverse (death or need for gastric tube feedings at discharge) outcomes to identify centers with relative low costs and favorable outcomes. Of the 822 infants with HIE treated with therapeutic hypothermia at 19 regional neonatal intensive care units, 704 (86%) survived to discharge. The median cost/case for survivors was $58 552 (IQR $32 476-$130 203) and nonsurvivors $29 760 (IQR $16 897-$61 399). Adjusting for illness severity and select interventions, intercenter differences explained 29% of the variation in total hospitalization costs. The widest cost variability across centers was EEG use, although low cost and favorable outcome centers ranked higher with regards to EEG costs. There is marked intercenter cost variation associated with treating HIE across regional children's hospitals. Our investigation may help establish references for cost and enhance quality improvement and resource utilization projects related to HIE.

Primary Abbe Flap for Median Cleft Lip Deformity: New Trends on an Old Concept.

The authors present our experience using primary Abbe flaps for median cleft lip. The records of 9 patients who underwent primary Abbe flaps were reviewed for indications, operative details, and complications. Flap design is discussed, including the "W" method to facilitate columellar reconstruction. Maxillomandibular fixation was not used. From 2004 to 2015, 9 patients with median cleft lip received primary Abbe flaps. Mean age was 10.2 ± 6.2 months. Lobar holoprosencephaly was confirmed by imaging in 5 of the 9 patients. Operative time averaged 70 ± 22 minutes. Flap division was performed at a mean of 3.6 ± 0.9 weeks. Patients were followed for a mean of 45 ± 49 months. No flaps were lost to vascular compromise and no dehiscences or infections were noted after initial repair. Five patients required prolonged intubation ranging from 4 to 7 days and 3 required transition to gastric feedings postoperatively. One patient with holoprosencephaly expired for reasons independent of surgery. Four patients have undergone 5 lip revisions to date. Patients with holoprosencephaly-spectrum disorder and median cleft lip have more favorable prognoses today. The Abbe flap may be safely and advantageously used for the primary repair of median cleft lip with extreme prolabial tissue deficiency.

Gastric Versus Small Bowel Feeding in Critically Ill Adults.

Critically ill patients often require enteral feedings as a primary supply of nutrition. Whether enteral nutrition (EN) should be delivered as a gastric versus small bowel feeding in the critically ill patient population remains a contentious topic. The Society of Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN), the European Society for Parenteral and Enteral Nutrition (ESPEN), and the Canadian Clinical Practice Guidelines (CCPG) are not in consensus on this topic. No research to date demonstrates a significant difference between the two feeding routes in terms of patient mortality, ventilator days, or length of stay in the intensive care unit (ICU); however, studies provide some evidence that there may be other benefits to using a small bowel feeding route in critically ill patients. The purpose of this paper is to examine both sides of this debate and review advantages and disadvantages of both small bowel and gastric routes of EN. Practical issues and challenges to small bowel feeding tube placement are also addressed. Finally, recommendations are provided to help guide the clinician when selecting a feeding route, and suggestions are made for future research.

Intraday glucose fluctuation is common in preterm infants receiving intermittent tube feeding.

We previously reported on three preterm infants with blood glucose abnormalities after reaching full enteral feeding. Recently, it has been shown that clinically stable preterm infants may have large fluctuations in blood glucose after the establishment of enteral nutrition. We hypothesized that intraday glucose fluctuation is a common finding in preterm infants, but improves at term post-conceptual age. This report describes a case series. From June 2010 to July 2012, 13 preterm infants (29.5 ± 2.1 post-conceptual weeks, 1144 ± 319 g) were enrolled in this study. Continuous glucose monitoring (CGM) was conducted on average at 33.5 ± 1.4 post-conceptual weeks, when they received gastric tube feeding every 3 h in the absence of i.v. glucose supply. Eight infants (62%) had large intraday glucose fluctuation with repeated hyperglycemic (>150 mg/dL) and hypoglycemic (<50 mg/dL) events. In five infants, follow-up CGM at 36-38 weeks post-conceptual age showed more stable glycemic changes without any abnormal glucose levels. On CGM, in some preterm infants intermittent tube feeding resulted in large intraday glucose fluctuation at 31-35 post-conceptual weeks, but the pattern disappeared before discharge (36-38 post-conceptual weeks).

Jejunal feeding is followed by a greater rise in plasma cholecystokinin, peptide YY, glucagon-like peptide 1, and glucagon-like peptide 2 concentrations compared with gastric feeding in vivo in humans: a randomized trial

Jejunal feeding is preferred instead of gastric feeding in patients who are intolerant to gastric feeding or at risk of aspiration. However, the impact of gastric feeding compared with that of jejunal feeding on postprandial circulating plasma glucose and amino acid concentrations and the associated endocrine response in vivo in humans remains largely unexplored. We compared the impact of administering enteral nutrition as either gastric feeding or jejunal feeding on endocrine responses in vivo in humans. In a randomized, crossover study design, 12 healthy young men (mean ± SD age: 21 ± 2 y) received continuous enteral nutrition that contained noncoagulating proteins for 12 h via a nasogastric tube or a nasojejunal tube placed 30-40 cm distal to the ligament of Treitz. Blood samples were collected during the 12-h postprandial period to assess the rise in plasma glucose, amino acid, and gastrointestinal hormone concentrations. No differences were observed in the postprandial rise in circulating plasma amino acid and glucose concentrations between regimens. Jejunal feeding resulted in higher peak plasma insulin concentrations than did gastric feeding (392 ± 53 compared with 326 ± 54 pmol/L, respectively; P < 0.05). The postprandial rise in plasma cholecystokinin, peptide YY (PYY), glucagon-like peptide 1 (GLP-1), and glucagon-like peptide 2 (GLP-2) concentrations was greater after jejunal feeding than after gastric feeding, with higher peak concentrations and a greater postprandial incremental AUC for GLP-1 and cholecystokinin (all P < 0.05). Plasma ghrelin concentrations did not differ between regimens. Enteral nutrition with gastric or jejunal feeding in healthy young men results in similar postprandial plasma amino acid and glucose concentrations. However, the endocrine response differs substantially, with higher peak plasma cholecystokinin, PYY, GLP-1, and GLP-2 concentrations being attained after jejunal feeding. This effect may result in an improved anabolic response, greater insulin sensitivity, and an improved intestinotropic effect. Nevertheless, it may also lead to delayed gastric emptying. This trial was registered at trialregister.nl as NTR2801.

Bedside placement of small-bowel feeding tube in Intensive Care Unit for enteral nutrition.

Enteral nutrition is the preferred mode of nutrition in critically ill patients whenever feasible as it has a number of advantages over parenteral feeding. Both gastric and small-bowel feeding can effectively deliver calories. In patients with gastroparesis, small-bowel feeding can help avoid parenteral feeding. We carried out a retrospective observational study to assess the ability to insert the Tiger 2 tube into the small bowel at the bedside in 25 patients who failed to tolerate gastric feeds. The time taken, rate of successful insertion, and ability to feed these patients using a standardized feeding protocol were noted. Success rate of insertion was 78% and feeding could be established. This method reduced the delays and risks associated with transportation and dependence on other specialties.

Usefulness of intra-procedural cone-beam computed tomography in modified balloon-occluded retrograde transvenous obliteration of gastric varices.

To evaluate whether intra-procedural cone-beam computed tomography (CBCT) performed during modified balloon-occluded retrograde transvenous obliteration (mBRTO) can accurately determine technical success of complete variceal obliteration. From June 2012 to December 2014, 15 patients who received CBCT during mBRTO for treatment of portal hypertensive gastric variceal bleeding were retrospectively evaluated. Three-dimensional (3D) CBCT images were performed and evaluated prior to the end of the procedure, and these were further analyzed and compared to the pre-procedure contrast-enhanced computed tomography to determine the technical success of mBRTO including: Complete occlusion/obliteration of: (1) gastrorenal shunt (GRS); (2) gastric varices; and (3) afferent feeding veins. Post-mBRTO contrast-enhanced CT was used to confirm the accuracy and diagnostic value of CBCT within 2-3 d. Intra-procedural 3D-CBCT images were 100% accurate in determining the technical success of mBRTO in all 15 cases. CBCT demonstrated complete occlusion/obliteration of GRS, gastric varices, collaterals and afferent feeding veins during mBRTO, which was confirmed with post-mBRTO CT. Two patients showed incomplete obliteration of gastric varices and feeding veins on CBCT, which therefore required additional gelfoam injections to complete the procedure. No patient required additional procedures or other interventions during their follow-up period (684 ± 279 d). CBCT during mBRTO appears to accurately and immediately determine the technical success of mBRTO. This may improve the technical and clinical success/outcome of mBRTO and reduce additional procedure time in the future.