Nasoenteric Tube Research Articles

Causes of nasoenteral tube obstruction in tertiary hospital patients.

Obstruction of the nasoenteral tube is one of the complications of enteral nutrition therapy, and its causes and frequency of occurrence are not well understood. To evaluate the causes of enteral nutrition feeding tube obstruction. To study the time elapsed between the beginning of the nutrition therapy and the obstruction of the tube. This was a retrospective cohort study of 1170 patients aged 18 years or older who were hospitalized at Sírio-Libanês Hospital between January 2015 and October 2017, and who were undergoing enteral nutrition therapy delivered using an infusion pump through a nasogastric or nasoenteral tube. The study population included 683 (58%) men and 487 (42%) women. The median age was 79 years. Of these, 1084 patients received enteral nutrition and medication through the feeding tube, and 86 received medication alone. Variables investigated as causes of feeding tube obstruction were the administration of medication through the tube, type of diet, and use of symbiotics. Obstruction rates were 4% for up to 40 days of observation and 8% for the total observation time. The time for obstruction of 10% of the tubes in patients receiving rivaroxaban, linagliptin, metformin, and nystatin was 16, 19, 20, and 28 days, respectively. The main cause of nasoenteral tube obstruction (odds ratio) was the combination of metformin (2.0), nystatin (3.1), linagliptin (4.3), rivaroxaban (2.4), and a high-protein diet (1.9). Overall, proper tube care and strict compliance with tubal drug delivery guidelines can result in low tube obstruction rates.

The occlusion balloon reduction technique for de novo placement and salvage of malpositioned enteric tubes.

Nasoenteric, gastrojejunostomy, and jejunostomy tubes are methods of enteral nutrition in patients with functioning gastrointestinal tracts who cannot maintain adequate oral intake. Current placements; however, may be complicated by redundant wire and catheter loops within the stomach preventing operators from optimal feeding tube placement and predisposing patients to feeding tube prolapse. This report describes the occlusion balloon reduction technique for salvage of malpositioned tubes and placement of new enteric tubes in the setting of redundant loops. Five patients underwent the occlusion balloon reduction technique for jejunostomy (n = 3), gastrojejunostomy (n = 1), or nasojejunal tube placement (n = 1). All patients (n = 5) had redundant wires coiled within the stomach. In all patients (n = 5), a 9-French × 32mm × 120cm Coda balloon was inserted over the wire and passed into the small bowel. The balloon was inflated after which reduction of redundancy in the upper gastrointestinal tract was performed. Feeding tubes were then placed with tips in the distal jejunum. Technical success of the occlusion balloon reduction technique, successful placement of enteric tube, complications, and follow-up were recorded. The occlusion balloon reduction was technically successful in all patients (n = 5). Feeding tube placement was successful in all patients (n = 5). No minor or major complication occurred. Mean follow-up was 56days. The occlusion balloon reduction technique provides a method for reduction of redundant wire and catheter loops within the stomach during enteric tube placement or repositioning.

Sa1093 – Health Care Costs of Endoscopy and Patient Outcomes in Unplanned Repeat Endoscopically Placed Nasoenteric Tubes At a Tertiary Care Center

Sa1093 – Health Care Costs of Endoscopy and Patient Outcomes in Unplanned Repeat Endoscopically Placed Nasoenteric Tubes At a Tertiary Care Center

Correction: Electromagnetic-Guided Bedside Placement of Nasoenteral Feeding Tubes by Nurses Is Non-Inferior to Endoscopic Placement by Gastroenterologists: A Multicenter Randomized Controlled Trial.

Gerritsen, Arja MD, PhD; de Rooij, Thijs BSc; Dijkgraaf, Marcel G. PhD; Busch, Olivier R. MD, PhD; Bergman, Jacques J. MD, PhD; Ubbink, Dirk T. MD, PhD; van Duijvendijk, Peter MD, PhD; Erkelens, Willemien G. MD; Klos, Mariël RN; Kruyt, Philip M. MD; Bac, Dirk Jan MD, PhD; Rosman, Camiel MD, PhD; Tan, Adriaan C. MD, PhD; Molenaar, Quintus I. MD, PhD; Monkelbaan, Jan F. MD; Mathus-Vliegen, Elisabeth M. MD, PhD; Besselink, Marc G. MD, MSc, PhD; Collabolators

225 The Bridle: Optimizing Enteral Nutrition and Decreasing Costs

OBJECTIVE: The objective is to prevent inadvertent nasoenteral tube displacement by using the bridle nasal tube retaining system in the burn patient. BACKGROUND: The burn patient requires high caloric intake and often meets criteria for supplemental nutrition via nasoenteral feeding tubes. Facial burns, altered mental status, and long term use of feeding tubes contribute to nasoenteral tube removal. These removals often result in a gap of nutritional intake, radiation exposure, increased risk for aspiration, patient discomfort, and increased nursing workload. Reinsertion of enteral feeding tubes is also shown to be cost-intensive. These costs are incurred from additional tube use and radiologic procedures. Additional costs of nursing workflow are not quantifiable however. Enteral feeding tube securement is the greatest challenge in preventing tube displacement. The standard securement with twill ties, or tape, has not been proven effective in preventing dislodgement. Bridle education was provided to all burn center nurses via educational in-services, instructional video, and dissemination of a brochure reference tool from the bridle manufacturer. Bridle competency was measured by return demonstration via mannequin and patients, verbal understanding, and troubleshooting scenarios. During the three months prior to bridle initiation, there were seven patients requiring enteral nutrition via nasoenteral tube. A single nasoenteral feeding tube costs $58.80. Each abdominal radiograph and radiograph reading to confirm placement cost $72 and $26 respectively. There were eleven occurrences of inadvertent nasoenteral tube removal during this time period with a total cost of $1,423.26. These eleven occurrences required eleven abdominal radiographs to confirm tube placement. The bridle system was used in the burn center for the following four months. During that time, there were fifteen patients requiring enteral nutrition via nasoenteral tube. There were two occurrences of inadvertent nasoenteral tube removal with a total cost of $316.28. One of the dislodgments was due to user error. Therefore, there were only two abdominal radiographs related to tube dislodgement during this period. The results showed a decreased cost of $1,106.98 and decrease in abdominal radiographs occurrences related to nasoenteric tube placement. Implementation of the nasal bridle tube retaining system reduced burn center costs, decreased the occurrences of nasoenteral tube removal, and lowered patient radiation exposure. This project shows the bridle is a cost effective method of securing feeding tubes in burn patients.

A study protocol for a randomised crossover study evaluating the effect of diets differing in carbohydrate quality on ileal content and appetite regulation in healthy humans

Introduction:A major component of the digesta reaching the colon from the distal ileum is carbohydrate. This carbohydrate is subject to microbial fermentation and can radically change bacterial populations in the colon and the metabolites they produce, particularly short-chain fatty acids (SCFA). However, very little is currently known about the forms and levels of carbohydrate in the ileum and the composition of the ileal microbiota in humans. Most of our current understanding of carbohydrate that is not absorbed by the small intestine comes from ileostomy models, which may not reflect the physiology of an intact gastrointestinal tract.Methods:We will investigate how ileal content changes depending on diet using a randomised crossover study in healthy humans. Participants will be inpatients at the research facility for three separate 4-day visits. During each visit, participants will consume one of three diets, which differ in carbohydrate quality: 1) low-fibre refined diet; 2) high-fibre diet with intact cellular structures; 3) high-fibre diet where the cellular structures have been disrupted (e.g. milling, blending). On day 1, a nasoenteric tube will be placed into the distal ileum and its position confirmed under fluoroscopy. Ileal samples will be collected via the nasoenteric tube and metabolically profiled, which will determine the amount and type of carbohydrate present, and the composition of the ileal microbiota will be measured. Blood samples will be collected to assess circulating hormones and metabolites. Stool samples will be collected to assess faecal microbiota composition. Subjective appetite measures will be collected using visual analogue scales. Breath hydrogen will be measured in real-time as a marker of intestinal fermentation. Finally, anin vitrocontinuous fermentation model will be inoculated with ileal fluid in order to understand the shift in microbial composition and SCFA produced in the colon following the different diets.Registration:ISRCTN11327221.

Perfil Nutricional de Crianças Portadoras de Tumores Cerebrais com Síndrome Diencefálica ou Síndrome de Russell recebendo Dieta Enteral

Introdução: A síndrome diencefálica é uma doença pediátrica rara, decorrente de tumores hipotalâmicos, caracterizada por failure to thrive. Objetivo: Descrever o estado nutricional e a terapia nutricional por meio de sonda nasoenteral de pacientes com tumores cerebrais com a síndrome diencefálica. Método: Sete pacientes foram acompanhados de julho/1999 a abril/2002 e analisados retrospectivamente, usando os escores-z de peso para idade (P/I), peso para estatura (P/E) e estatura para idade (E/I) no diagnóstico da desnutrição. Todos foram avaliados por meio de composição corporal: prega cutânea triciptal (PCT) e circunferências do braço e muscular do braço (CB e CMB) e receberam alimentação por sonda nasoenteral ou gastrostomia após o diagnóstico da neoplasia. Resultados: A idade variou de 2 meses a 13 anos, cinco do sexo masculino. A duração média da nutrição enteral foi de 7 meses (1,1-18,5) após o diagnóstico, sem diferença estatística significante na evolução dos escores-z, apesar do aumento nas médias de P/I (-4,42 para -3,50) e P/E (-3,06 para -1,99), e dos indicadores de composição corporal (PCT: 2,85 para 4,88; CB: 9,81 para 11,84 e CMB: 8,91 para 10,31). Houve redução na média da E/I, caracterizando o atraso no crescimento dessas crianças. Conclusão: A nutrição enteral demonstrou garantir a oferta nutricional e recuperar em parte os indicadores nutricionais de desnutrição aguda; principalmente a gordura corporal, mais do que massa magra. Entretanto, manteve-se o déficit de crescimento, agravado na maioria dos casos. A terapia nutricional deve ser implantada durante o tratamento oncológico, assegurando sua continuidade.

Complication Versus Consequence: Defining Device-Related Outcomes in Children With Medical Complexity.

In the current issue of Hospital Pediatrics , Nackers et al1 retrospectively reviewed nearly 500 encounters in 98 children with medical complexity (CMC) to identify factors that predicted device-related complications. Results demonstrated that nearly 1 in 3 emergency department visits and nearly 1 in 5 hospitalizations were associated with device complications, proportions that are higher than the 10% seen in previous studies.2 Central venous catheters and feeding tubes (both primary gastrostomy tubes and nasoenteral tubes) accounted for 25% of all emergency department visits. Although certain device types were associated …

Development and validation of a nomogram for predicting self-propelled postpyloric placement of spiral nasoenteric tube in the critically ill: Mixed retrospective and prospective cohort study

Equipment-aided or experience-dependent methods for postpyloric nasoenteric tube placement are not so readily accessible in the critically ill setting. Self-propelled postpyloric placement of a spiral nasoenteric tube can serve as an alternative approach. However, the success rate of this method is relatively low despite using prokinetics. This study aims to develop a user-friendly nomogram incorporating clinical markers to individually predict the probability of successful postpyloric nasoenteric tube placement and facilitate intensivists with improved decision-making before tube insertion. Patients consecutively recruited in the stage between May 2012 through December 2016 constituted the development cohort for retrospective analysis to internally test the nomogram, and patients in the stage between January 2017 through March 2018 constituted the validation cohort for prospective analysis to external validate the nomogram. A multivariate logistic regression analysis was firstly performed in the development cohort by a backward stepwise method to identify the best-fit model, from which a nomogram was obtained. The nomogram was validated in the independent external validation cohort concerning discrimination, calibration. A decision curve analysis was also performed to evaluate the net benefit of insertion decision with the nomogram. A total of 364 and 119 patients, 52.7% and 55.5% with successful postpyloric placement, were included in the development and validation cohort, respectively. Predictors contained in the prediction nomogram included primary diagnosis, APACHE II score, AGI grade. The derived model showed good discrimination, with an area under the receiver operating characteristic curve (AUROC) of 0.809 (95%CI, 0.765-0.853) and good calibration. Application of the nomogram in the validation cohort also gave good discrimination with an AUROC of 0.776 (95%CI, 0.694-0.859) and good calibration. The decision curve analysis of the nomogram provided better net benefit than the alternate options (insert-all or insert-none). A prediction nomogram that incorporates primary diagnosis, together with APACHE II score and AGI grade can be conveniently used to facilitate the pre-insertion individualized prediction of postpyloric nasoenteric tube placement in critically ill patients.

Erythromycin versus metoclopramide for post-pyloric spiral nasoenteric tube placement: a randomized non-inferiority trial

PurposeTo determine whether erythromycin is non-inferior to metoclopramide in facilitating post-pyloric placement of self-propelled spiral nasoenteric tubes (NETs) in critically ill patients.MethodsA prospective, multicenter, open-label, parallel, and non-inferiority randomized controlled trial was conducted comparing erythromycin with metoclopramide in facilitating post-pyloric placement of spiral NETs in critically ill patients admitted to intensive care units (ICUs) of eight tertiary hospitals in China. The primary outcome was procedure success defined as post-pyloric placement (spiral NETs reached the first portion of the duodenum or beyond confirmed by abdominal radiography 24 h after tube insertion).ResultsA total of 5688 patients were admitted to the ICUs. Of these, in 355 patients there was a plan to insert a nasoenteric feeding tube, of whom 332 were randomized, with 167 patients assigned to the erythromycin group and 165 patients assigned to the metoclopramide group. The success rate of post-pyloric placement was 57.5% (96/167) in the erythromycin group, as compared with 50.3% (83/165) in the metoclopramide group (a difference of 7.2%, 95% CI − 3.5% to 17.9%), in the intention-to-treat analysis, not including the prespecified margin of − 10% for non-inferiority. The success rates of post-D1 (reaching the second portion of the duodenum or beyond), post-D2 (reaching the third portion of the duodenum or beyond), post-D3 (reaching the fourth portion of the duodenum or beyond), and proximal jejunum placement and the incidence of any adverse events were not significantly different between the groups.ConclusionsErythromycin is non-inferior to metoclopramide in facilitating post-pyloric placement of spiral NETs in critically ill patients. The success rates of post-D1, post-D2, post-D3, and proximal jejunum placement were not significantly different.

Risk-adjusted prediction models using the specialty-specific head and neck reconstructive surgery NSQIP.

240 Background: With increasing health care costs, risk-adjusted quality outcomes are essential. The American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) is a robust perioperative risk-adjustment platform, but lacks capture of oncologic- and specialty-specific variables and has limited utility for risk adjustment in head and neck oncologic surgery. This study uses the specialty-specific Head and Neck-Reconstructive Surgery (HNSR) NSQIP to develop risk-adjusted models for patients undergoing head and neck oncologic surgery with reconstruction. Methods: Multiple logistic regression modelling using data from patients in the HNSR NSQIP between 8/2012-10/2016 identified predictors of postoperative morbidity. Final models were validated using a cohort of patients treated between 10/2016-12/2017. The concordance index (c-index) was used to evaluate the model performance. Results: The modelling cohort included 1095 patients and the validation cohort included 407. Models were created to predict probability of postoperative complications (presence of fistula, ventilator dependence > 48 hours, pneumonia, deep/superficial surgical site infection); presence of gastrostomy-jejunostomy (GJ), nasoenteric (NE), or tracheostomy tube at 30 days postoperatively; conversion from NE to GJ tube; unplanned return to the operating room; and length of stay > 7 days. Most discriminant models were those predicting presence of GJ tube (model c-index [MCI] = 0.91; validation c-index[VCI] = 0.93), NE tube (MCI= 0.83; VCI= 0.84), and conversion from NE to GJ tube (MCI= 0.86; VCI= 0.80). Prediction models were least discriminant for ventilator dependence (MCI= 0.63; VCI= 0.45), fistula (MCI= 0.58; VCI= 0.54), and unplanned return to the operating room (MCI= 0.59; VCI= 0.51). Conclusions: Reliable and discriminant risk prediction models were able to be created for a variety of perioperative complications incorporating oncologic- and specialty-specific variables in the HNSR NSQIP. These models help inform risk stratification strategies for patients undergoing head and neck reconstructive surgery and the development of a specialty-specific preoperative risk calculators.

Care bundles in the management of nasal intestine for the cerebral apoplexy patients with dyspinic dysfunction

Objective The study was aimed to explore the effect of care bundles on the management of nasal intestine for the cerebral apoplexy patients with dyspinic dysfunction. Methods A total of 102 cerebral apoplexy patients with dyspinic dysfunction, who were administrated with nasal intestine, were recruited in Qianfoshan Hospital of Shandong Province from August, 2016 to June, 2017. Random number table was applied to analyze the separate two groups, experimental group and control group, in which, the patients were administrated with care bundles and usual care. Various parameters, like one-time catheterization, complications of nasal intestine administration, hospital stay, cost and the patients' satisfaction degree, were compared between two groups. Results The success rate of once placed tube in the test group was 78.4% (40/51), which was significantly higher than that in the control group [54.9% (28/51)], and the difference was statistically significant (χ2= 6.353, P < 0.05). The incidence of complications of indwelling nasoenteric tube, including unplanned extubation, reflux aspiration, tube-feeding associated diarrhea, were 9.8% (5/51), 17.6% (9/51), 11.8% (6/51), respectively. All of them were significantly lower than those of the control group, which were 37.3% (19/51), 41.2% (21/51), 31.4% (16/51), respectively, indicating that there was a statistical difference (χ2= 10.679, 6.800, 5.795). The days and costs of hospitalization were (11.0 ± 2.5) d, (9 645.35±193.30) yuan, respectively, which weresignificantly lower than those of the control group [(17.0 ± 4.2) d, (12 523.79 ± 190.28) yuan], indicating that there was a statistical difference (t= 8.767, 10.612, P < 0.01). Patients' satisfaction was 90.2% (46/51), which was significantly higher than that of the control group [68.6% (35/51)]. The difference was statistically significant (χ2= 7.256, P < 0.01). Conclusions The administration of care bundles for the cerebral apoplexy patients with dyspinic dysfunction can effectively increase the success rate of one-time catheterization, alleviate the complications, and therefore reduce the risk of aspiration pneumonia development. In addition, care bundles can remarkably alleviate the medical burden on the patients, shorten the hospital stays and improve the survival quality of the patients. Key words: Stroke; Care bundles; Dyspinic dysfunction; Nasal intestine

Bedside electromagnetic-guided placement of nasoenteral feeding tubes among critically Ill patients: A single-centre randomized controlled trial

PurposeWe aimed to compare the effectiveness of EM-guided and endoscopic nasoenteral feeding tube placement among critically ill patients. Materials and methodsWe performed a single-center, randomized controlled trial among 161 adult patients admitted to intensive care units (ICUs) requiring nasoenteral feeding. Patients were randomly assigned to EM-guided or endoscopic nasoenteral feeding tube placement (1:1). The primary end point was the total success rate of correct jejunal placement. ResultsThis was achieved in 74/81 and 76/80 patients who underwent EM-guided and endoscopic jejunal tube placements, respectively (91.4% vs. 95%; relative risk, 0.556; [CI], 0.156–1.980; P = 0.360). The EM-guided group had more placement attempts, longer placement time, and shorter inserted nasal intestinal tube length. However, they had shorter total placement procedure duration and physician's order–tube placement and order–start of feeding intervals. The EM-guided group had higher discomfort level and recommendation scores and lesser patient costs. This trial is registered at Chinese Clinical Trials Registry (ChiCTR-IOR-17011737). ConclusionBedside EM-guided placement is as fast, safe, and successful as endoscopic placement and may be considered the preferred technique in critically ill patients.

PS01.035: ILEOCOLONIC INTERPOSITION GRAFT: A SAFE AND FEASIBLE CONDUIT AFTER ESOPHAGOGASTRECTOMY

Abstract Background Restoration of gastrointestinal tract continuity with a suitable conduit is a vital step in esophagectomy. An adequate length of conduit, preservation of a good blood supply and functionality are keys to a successful outcome Methods We report two cases of successful ileocolonic interposition graft after esophagogastrectomy for caustic injury. Results Both patients were female with mean age of 45. They presented with progressive dysphagia and weight loss after alleged corrosive ingestion. Both had good functional status with no significant comorbidities. OGDS revealed long complex esophageal stricture and biopsy showed acute on chronic esophagitis. CT scan showed diffuse thickening of mid-distal esophagus and gastric stenosis. Both patients had refractory strictures with unsuccessful serial endoscopic dilatation. One patient had endoscopic nasoenteric tube insertion for enteral feeding while the other had laparoscopic feeding jejunostomy placed due to tight strictures. A 3-stage esophagogastrectomy with ileocolonic interposition graft was performed after optimization. Intra-operatively findings were dense fibrotic esophagus with diffuse gastric strictures. Ileocolonic graft comprising of the distal 15cm of terminal ileum, ascending colon and transverse colon was constructed based on middle colic arterial supply via marginal artery of Drummond. Vascularity and length of graft were confirmed before transection. Graft pull through was done via orthotopic posterior mediastinal route and isoperistaltic end-to-side esophago-ileocolonic anastomosis was performed at the neck. Contrast studies showed no anastomotic leak and both patients were discharged well on postoperative day 10. They had good oral intake with satisfactory weight gain with no functional disorders during follow up. Conclusion Ileocolonic interposition graft is a safe and feasible option if a gastric conduit is not available. In addition to the advantages of long length, reflux resistance and good blood supply, the smaller caliber of the ileum eases the pull through and the anastomosis due to a smaller size discrepancy. Disclosure All authors have declared no conflicts of interest.

Use of naso-enteric tubes for short-term enteral nutrition support

Use of naso-enteric tubes for short-term enteral nutrition support

La ecografía como método simple y rápido para evaluar la correcta colocación de sondas de alimentación enteral en pacientes críticos con ventilación mecánica

La radiografía (Rx) abdominal, el método diagnóstico utilizado para verificar la posición de la sonda de alimentación enteral (SAE), es una fuente de irradiación y de potenciales efectos adversos para los pacientes. Hay pocos estudios sobre colocación de SAE y ecografía. Los autores estudiaron 41 pacientes con inserción de SAE y mantenimiento de la guía hasta la comprobación de su correcta colocación con ecografía, detectando una correcta colocación en 38 pacientes frente a 3 pacientes con una inadecuada posición de la SAE, con una sensibilidad del 97% (IC 95%: 84.9-99.8%) y una especificidad del 100% (IC 95%: 19.7-100%). La evaluación de la posición de la SAE a través del abdomen mediante ecografía es práctica y segura, asociándose con resultados diagnósticos satisfactorios. ABSTRACT Abdominal X-rays (AXRs) is the classic radiological procedure used to assess placement of a nasoenteric tube (NET). As a disadvantage, AXRs expose the patient to a dose of ionizing radiation and can cause potential adverse effects in the future. There are few studies about NET placement and ultrasound (US) assessment. Authors studied 41 patients undergoing NET placement keeping the wire until correct placement US assessment. Correct placement occurred in 38 patients, with a 97% sensitivity (confidence interval, 95%: 84.9-99.8%) and a 100% specificity (CI 95%: 19.7-100%). NET placement evaluation with abdominal US is a safe and practical procedure, associated with accurate diagnostic outcomes.

Technical Aspects of Fecal Microbial Transplantation (FMT).

Fecal microbial transplantation (FMT) has become established as an effective therapeutic modality in the treatment of antibiotic-refractory recurrent Clostridium difficile colitis. A number of formulations and methods of delivery of FMT are currently available, each with distinct advantages. This review aims to review donor and patient selection for FMT as well as procedural aspects of FMT to help guide clinical practice. FMT can be obtained in fresh, frozen, lyophilized, and capsule-based formulations for delivery by oral ingestion, nasoenteric tube, colonoscopy, or enema (depending on the formulation used). Choosing the optimal method relies heavily on patient-related factors, including underlying pathology and severity of illness. As potential applications for FMT expand, careful donor screening and patient selection are critical to minimizing risk to patients and physicians. FMT represents an excellent therapeutic option for treatment of recurrent Clostridium difficile colitis and holds promise as a possible treatment modality in a variety of other conditions. The wide array of delivery methods allows for its application in various disease states in both the inpatient and outpatient setting.

Application of bronchoscope for the placement of nasoenteric feeding tube: new ideas from old ways

The novel technique of nasoenteric feeding tube (NET) placement with bronchoscope proposed by Cao et al . (1) is an interesting report and deserve in depth discussion and further study. In spite of limited case numbers, Cao et al . validate that placing nasojejunal tube with bronchoscope is safe and feasible in post esophagectomy patients.

977 ENDOSCOPIC VACUUM THERAPY FOR ESOPHAGEAL POST-MEGASTENT PERFORATION.

We report a case of a 55 years-old female patient who underwent a sleeve gastrectomy due to class III obesity. She had a past medical history of a kidney transplant due to end-stage chronic kidney disease. Seven days after surgery after the bariatric procedure, the drain output increased suddenly and after ingestion of methylene blue, we could identify bluish output, suggesting gastric fistula. The patient was clinically stable so we decided for conservative treatment. We promptly put the patient on broad-spectrum antibiotics and NPO and referred her to Endoscopy unit for stent placement. A large bariatric self-expandable metallic stent (28mmx24cm) was chosen and successfully deployed to completely occlude the orifice at the proximal corpus. We initiated liquid diet a day after SEMS placement but she experienced another increase in the drain output. Therefore, we kept her on NPO and endoscopically placed a nasoenteral feeding tube. She was discharged one week after SEMS placement and returned for clinical consultation three days later. She complained of the darkish and high volume drain output. She was readmitted for endoscopic assessment of the SEMS. During the procedure, we identified a large perforation in the distal esophagus where the SEMS was anchored. The patient was then conducted to emergency surgery. Intraoperatively, we could identify both esophageal perforation and gastric fistula. We were able to repair both defects and place mediastinum and peritoneal drains. Also, we performed a jejunostomy for feeding. Postoperatively, she was referred to ICU and needed vasoactive drugs for 4 days. Ten days after surgery, we performed an endoscopy to remove the SEMS, and we were able to identify the esophageal perforation and the mediastinum drain. Then, we pulled out the drain from the leak and initiated the endoscopic vacuum therapy for the perforation with drain exchanges every 3-5 days. Eight drain exchanges and fifty days were needed to achieve complete closure of the esophageal perforation. The treatment of the gastric fistula entailed removal of staples and two sessions of septotomy. Control EGD and upper GI contrast series showed no signs of leaks. The patient was discharged three months after the sleeve gastrectomy with oral diet and asymptomatic.

Nasoenteric feeding discharge planning for cancer patients in a Brazilian teaching hospital: a best practice implementation project.

The objective of this project was to improve local practice in nasoenteric feeding discharge planning for cancer patients in a cancer teaching hospital in São Paulo, Brazil. Nasoenteric tubes are commonly used for enteral nutrition in patients with cancer for over seven days during their recovery and this may be continued at home, with clear benefits. Baseline audit results indicated poor compliance (between 0% and 22%) with the current evidence, although good compliance (100%) was observed for three audit criteria. Implementation of the strategies, including changes to achieve higher participation of caregivers, resulted in an improvement of the audited criteria (100% compliance was maintained for three criteria, compliance increased from 22% to 67% for a further three criteria, with 0% compliance for one criterion). Despite the short time frame of this study, an increase in compliance with best practices proposed by the Joanna Briggs Institute was observed. Implementing a multidisciplinary meeting before patient discharge remains a challenge.