Nasoenteric Tube Research Articles

An unforeseen route for a nasoenteral feeding tube

An unforeseen route for a nasoenteral feeding tube

Gastroenteric tube feeding: techniques, problems and solutions.

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.

Radiology of ventilatory, feeding, and circulatory lines and tubes in the critically sick

A variety of supportive ventilatory, feeding and circulatory devices are employed in the management of critically sick patients. The hardware ranges from endotracheal, tracheostomy and chest tubes, nasogastric and nasoenteric feeding tubes, to central venous lines, umbilical venous and arterial catheters, pacers and automatic implantable cardioverter defibrillators, intraaortic balloon pumps and ventricular assist devices. The accurate positioning of this hardware is critical to the well being of a patient. However, these devices may not be positioned appropriately. Faults may occur at the time of their insertion, or the hardware may get dislodged while in use. A portable chest radiograph can be extremely useful in identifying such mishaps. This pictorial review captures some of the critical scenarios which must be known to radiologists and the treating intensivists.

バルーン付き経鼻経腸栄養チューブに起因した小腸出血の1例

バルーン付き経鼻経腸栄養チューブに起因した小腸出血の1例

Magnets in the GI tract

Magnets in the GI tract

Gastrostomy Tube Use after Transoral Robotic Surgery for Oropharyngeal Cancer

Objective. To evaluate factors that influence gastrostomy tube (g-tube) use after transoral robotic surgery (TORS) for oropharyngeal (OP) cancer. Study Design/Methods. Retrospective review of TORS patients with OP cancer. G-tube presence was recorded before and after surgery at followup. Kaplan-Meier and Cox hazards model evaluated effects of early (T1 and T2) and advanced (T3, T4) disease, adjuvant therapy, and free flap reconstruction on g-tube use. Results. Sixteen patients had tonsillar cancer and 13 tongue base cancer. Of 22 patients who underwent TORS as primary therapy, 17 had T1 T2 stage and five T3 T4 stage. Seven underwent salvage therapy (four T1 T2 and three T3 T4). Nine underwent robotic-assisted inset free flap reconstruction. Seventeen received adjuvant therapy. Four groups were compared: primary early disease (PED) T1 and T2 tumors, primary early disease with adjunctive therapy (PEDAT), primary advanced disease (PAD) T3 and T4 tumors, and salvage therapy. Within the first year of treatment, 0% PED, 44% PEDAT, 40% PAD, and 57% salvage patients required a g-tube. Fourteen patients had a temporary nasoenteric tube (48.3%) postoperatively, and 10 required a g-tube (34.5%) within the first year. Four of 22 (18.2%) with TORS as primary treatment were g-tube dependent at one year and had received adjuvant therapy. Conclusion. PED can be managed without a g-tube after TORS. Similar feeding tube rates were found for PEDAT and PAD patients. Salvage patients have a high rate of g-tube need after TORS.

Small bowel tuberculosis by multidetector CT enteroclysis

To prospectively evaluate the role of multidetector computed tomography (CT) enteroclysis in evaluation and diagnostic characterization of suspected small bowel tuberculosis. The study group included 21 human subjects suspected of having small bowel tuberculosis. A nasoenteric tube was positioned into the duodenojejunal junction under fluoroscopic guidance and water was infused by hand injection. After intravenous administration of 120mL of iodinated contrast material, multidetector CT enteroclysis images were obtained with 40×0.625mm collimation and findings were analyzed by three readers working in consensus. Findings were compared with the results of endoscopy, histopathological analysis, and clinical follow up. Multidetector CT enteroclysis was well tolerated in 20 patients; one of the patients complained of vomiting during intubation. Using multidetector CT enteroclysis diagnosis of abdominal tuberculosis was made in sixteen patients, out of which small bowel involvement was seen in 13 patients. Multidetector CT enteroclysis demonstrated Crohn's disease in one patients and normal in four patients. The sensitivity and specificity in diagnosing abdominal tuberculosis by CT enteroclysis came out to be 93.75 and 100% respectively. Multidetector CT enteroclysis is well tolerable and accurate modality for evaluation and diagnostic characterization of small bowel tuberculosis.

Ernährung und Leberversagen

In the critically ill liver patient, nutrition support is not very different from that given for other illnesses. In hyperacute liver failure, nutrition support is of less importance than in the other subtypes of acute liver failure that take a more protracted course. Nasoenteral tube feeding using a polymeric standard formula should be the first-line approach, while parenteral nutrition giving glucose, fat, amino acids, vitamins, and trace elements is initiated when enteral nutrition is insufficient or impracticable. In chronic liver disease, notably cirrhosis, there is frequently protein malnutrition indicating a poor prognosis and requiring immediate initiation of nutrition support. Enteral nutrition ensuring an adequate provision of energy and protein should be preferred. Particular care should be taken to avoid refeeding syndrome and to treat vitamin and trace element deficiency.

Circadian Rhythm of Energy Expenditure and Oxygen Consumption

This study aimed to evaluate the effect of continuous and intermittent methods of enteral nutrition (EN) administration on circadian rhythm. Thirty-four individuals, aged between 52 and 80 years, were fed through a nasoenteric tube. Fifteen individuals received a continuous infusion for 24 hours/d, and 19 received an intermittent infusion in comparable quantities, every 4 hours from 8:00 to 20:00. In each patient, 4 indirect calorimetric measurements were carried out over 24 hours (A: 7:30, B: 10:30, C: 14:30, and D: 21:30) for 3 days. Energy expenditure and oxygen consumption were significantly higher in the intermittent group than in the continuous group (1782 ± 862 vs 1478 ± 817 kcal/24 hours, P = .05; 257 125 vs 212 117 ml/min, P = .048, respectively). The intermittent group had higher levels of energy expenditure and oxygen consumption at all the measured time points compared with the continuous group. energy expenditure and oxygen consumption in both groups were significantly different throughout the day for 3 days. There is circadian rhythm variation of energy expenditure and oxygen consumption with continuous and intermittent infusion for EN. This suggests that only one indirect daily calorimetric measurement is not able to show the patient's true needs. Energy expenditure is higher at night with both food administration methods. Moreover, energy expenditure and oxygen consumption are higher with the intermittent administration method at all times.

1:54 PM Abstract No. 209 - Interventional treatment of thoracostomach-airway fistula after esophagogastrectomy with covered stents

Purpose To evaluate the clinical value of treating thoracostomach-airway fistula after esophagogastrectomy with covered stents. Materials and Methods Through SCT and digital radiography with water-soluble medium, We diagnosed 22 patients with thoracostomach-airway fistula (6 thoracostomach-tracheal fistulas, 2 thoracostomach-carina fistulas, 13thoracostomach-left principal bronchial fistulas, 1 thoracostomach-right principal bronchial fistula). Covered stents were selected on the base of the site, size and number of thoracostomach-airway fistula.Under the fluoroscopic guidance, 24 stents were implanted in the 22 patients with thoracostomach-airway fistulas. Results Stent placement was technically successful in all patients. The stent completely sealed off the fistula in 18 of 22 patients, choking after drinking and eating vanished as soon as the fistula was closed and a normal diet could be swallowed after the placement of the stents. 4 of 22 patients had persistent aspiration symptoms due to incomplete closure (initial clinical failure). During follow-up, the fistula reopened in 11 of 22 patients with initial clinical success. 8 reopened fistulas were sealed off with stent placement and 3 were inserted a feeding nasoenteric tube and a nasogastric decompression tube. All patients died during follow-up, and mean survival was 14±4.56 weeks (range, 1-42 weeks) after stent placement. Conclusion The airway covered stent placement is an effective and safe treatment for thoracostomach-airway fistula.

Gastrointestinal tract access for enteral nutrition in critically ill and trauma patients: indications, techniques, and complications.

Enteral nutrition (EN) is a widely used, standard-of-care technique for nutrition support in critically ill and trauma patients. To review the current techniques of gastrointestinal tract access for EN. For this traditional narrative review, we accessed English-language articles and abstracts published from January 1988 through October 2012, using three research engines (MEDLINE, Scopus, and EMBASE) and the following key terms: "enteral nutrition," "critically ill," and "gut access." We excluded outdated abstracts. For our nearly 25-year search period, 44 articles matched all three terms. The most common gut access techniques included nasoenteric tube placement (nasogastric, nasoduodenal, or nasojejunal), as well as a percutaneous endoscopic gastrostomy (PEG). Other open or laparoscopic techniques, such as a jejunostomy or a gastrojejunostomy, were also used. Early EN continues to be preferred whenever feasible. In addition, evidence is mounting that EN during the early phase of critical illness or trauma trophic feeding has an outcome comparable to that of full-strength formulas. Most patients tolerate EN through the stomach, so postpyloric tube feeding is not needed initially. In critically ill and trauma patients, early EN through the stomach should be instituted whenever feasible. Other approaches can be used according to patient needs, available expertise, and institutional guidelines. More research is needed in order to ensure the safe use of surgical tubes in the open abdomen.

Sonographic confirmation of the correct placement of a nasoenteral tube in a woman with hyperemesis gravidarum: Case report

Hyperemesis gravidarum is a serious systemic disorder of pregnant women characterized by intractable vomiting resulting in metabolic, biochemical, and hematologic changes. Enteral nutrition has been used successfully and has a lower complication rate than parenteral nutrition. Tube feeding requires location of the feeding tube tip before the infusion of nutritional substance is started. We report a case of assisted feeding tube tip location using real time sonography in a pregnant women treated for hyperemesis gravidarum. Sonographic examination may be used as an alternative to x-ray for the confirmation of feeding tube location in pregnant women and thus eliminate exposure of the fetus to ionizing radiation.

Knotted nasoenteric feeding tube in an infant

This is a case report, with review of the literature, of an infant in the neonatal intensive care unit (NICU) with the complication of a nasoenteric weighted feeding tube that assumed an overhand knot configuration. Knotting of the feeding tube is a rare occurrence related to the use of feeding tubes, and should be considered if the tube becomes nonfunctional, if there are clinical factors that might lead to displacement or malposition of the tube, or if there is excessive resistance or sudden onset of respiratory distress in association with attempted removal.

Nasoenteric Tube Complications

The use of nasoenteric tubes (NETs) is ubiquitous, and clinicians often take their placement, function, and maintenance for granted. NETs are used for gastrointestinal decompression, enteral feeding, medication administration, naso-biliary drainage, and specialized indications such as upper gastrointestinal bleeding. Morbidity associated with NETs is common, but frequently subtle, mandating high index of suspicion, clinical vigilance, and patient safety protocols. Common complications include sinusitis, sore throat and epistaxis. More serious complications include luminal perforation, pulmonary injury, aspiration, and intracranial placement. Frequent monitoring and continual re-review of the indications for continued use of any NET is prudent, including consideration of changing goals of care. This manuscript reviews NET-related complications and associated topics.

Effectiveness of MR Enterography for the Assessment of Small-Bowel Diseases beyond Crohn Disease

The use of cross-sectional imaging techniques for the noninvasive evaluation of small-bowel disorders is increasing. The effectiveness of magnetic resonance (MR) enterography for the evaluation of Crohn disease, in particular, is well described in the literature. In addition, MR enterography has an evolving though less well documented role to play in the evaluation of other small-bowel diseases, including various benign and malignant neoplasms arising in isolation or in polyposis syndromes such as Peutz-Jeghers, inflammatory conditions such as vasculitis and treatment-induced enteritis, infectious processes, celiac disease, diverticular disease, systemic sclerosis, and bowel duplication. MR enterography may be useful also for the evaluation of intermittent and low-grade small-bowel obstructions. Advantages of MR imaging over computed tomography (CT) for enterographic evaluations include superb contrast resolution, lack of associated exposure to ionizing radiation, ability to acquire multiplanar primary image datasets, ability to acquire sequential image series over a long acquisition time, multiphasic imaging capability, and use of intravenous contrast media with better safety profiles. MR enterography also allows dynamic evaluations of small-bowel peristalsis and distensibility of areas of luminal narrowing and intraluminal masses by repeating sequences at different intervals after administering an additional amount of the oral contrast medium. Limitations of MR enterography in comparison with CT include higher cost, less availability, more variable image quality, and lower spatial resolution. The advantages and disadvantages of MR enterography performed with ingestion of the oral contrast medium relative to MR enteroclysis performed with infusion of the oral contrast medium through a nasoenteric tube are less certain.

MR Imaging of the Small Bowel

Small-bowel radiology has undergone dramatic changes in the past 2 decades. Despite important recent advances in small-bowel endoscopy, radiologic imaging remains important for patients suspected of having or with established small-bowel disease. Cross-sectional imaging techniques (computed tomography and magnetic resonance [MR] imaging), used to investigate both extraluminal abnormalities and intraluminal changes, have gradually replaced barium contrast examinations, which are, however, still used to examine early mucosal disease. MR imaging techniques clearly highlight endoluminal, mural and extramural enteric details and provide vascular and functional information, thereby enhancing the diagnostic value of these techniques in small-bowel diseases. Two MR imaging based techniques are currently utilized: MR enteroclysis and MR enterography. In enteroclysis, enteric contrast material is administered through a nasoenteric tube, whereas in enterography, large volumes of enteric contrast material are administered orally. MR enteroclysis ensures consistently better luminal distention than does MR enterography in both the jejunum and the ileum and more accurately depicts endoluminal abnormalities and early disease, particularly at the level of the jejunal loops. Moreover, MR enteroclysis provides a high level of accuracy in the diagnosis and exclusion of small-bowel inflammatory and neoplastic diseases and can be used for the first radiologic evaluation, while MR enterography may effectively be used to follow up both Crohn disease patients without jejunal disease and in pediatric patients where nasogastric intubation might be a problem. MR enteroclysis may also reveal subtle transition points or an obstruction in the lower small bowel, which may escape detection when more routine methods, including enterography, are used. MR imaging offers detailed morphologic information and functional data of small-bowel diseases and provides reliable evidence of normalcy, thereby allowing the diagnosis of early or subtle structural abnormalities and guiding treatment and decisions in patient care.

Endoscopic Clip-Assisted Feeding Tube Placement Reduces Repeat Endoscopy Rate: Results from a Randomized Controlled Trial

To determine whether endoscopic clip-assisted nasoenteral feeding tube placement is more effective than standard feeding tube placement with transnasal endoscopy. Between August 2009 and February 2011, 143 patients referred for endoscopic nasoenteral feeding tube placement were randomized between clip-assisted and standard nasoenteral tube placement. Endoscopies were performed in the endoscopy unit and intensive care unit in a tertiary referral center in the Netherlands. For the clip-assisted procedure, the feeding tube was introduced with a suture fixed to the tip, picked up in the stomach with an endoclip and attached (as distal as possible) to the duodenal wall. In the standard group, a guide wire was placed in the duodenum using a transnasal endoscope, followed by blind insertion of a feeding tube over the guide wire. Primary end point was a repeat endoscopy for incorrect tube placement or spontaneous retrograde tube migration. Secondary end points were incorrect tube placement, spontaneous migration of feeding tube, directs medical costs, and procedure-related (serious) adverse event (SAE). Of the 143 patients included, 71 were randomly assigned to clip-assisted tube placement, and 72 to standard tube placement. Four (5.6%) repeat endoscopies were performed in the clip-assisted group vs. 19 (26.4%) in the standard group (relative risk reduction (RRR) 0.79; 95% confidence interval (CI) 0.40-0.92). The number needed to clip to avoid one repeat endoscopy was 4.8 (95% CI 3.1-11.3). Repeat endoscopies were mostly performed for incorrectly placed tubes, 3 (4.2%) in the clip-assisted group vs. 16 (22.2%, RRR 0.81; 95% CI 0.38-0.94) in the standard group. Spontaneous retrograde tube migration occurred in one (1.4%) clip-assisted placement and three (4.2%) standard tubes. Median costs were higher for clip-assisted tube placement (€519 vs. €423, P<0.01). Four (5.6%) SAEs occurred after clip-assisted feeding tube placement vs. one (1.4%) after standard feeding tube placement (P=0.21). Clip-assisted endoscopic nasoenteral feeding tube placement results in fewer repeat endoscopies than standard endoscopic nasoenteral tube placement, due to a higher success rate of initial placement. When tubes are adequately placed, retrograde tube migration rarely occurs.

Transnasal esophagogastroduodenoscopy for placement of nasoenteric feeding tubes in patients with severe upper gastrointestinal diseases

To evaluate the feasibility and efficacy of small-caliber transnasal esophagogastroduodenoscopy for the placement of nasoenteric feeding tubes (NET) in patients with severe upper gastrointestinal (GI) diseases. Between January 2007 and March 2010, 51 patients underwent transnasal endoscopy for the placement of NET in Peking University Third Hospital. Indications for NET included esophageal stricture or gastric outlet obstruction because of corrosive esophagitis or gastritis, partial obstruction due to malignancy, stenosis in stoma or efferent loop, gastroparesis, metallic stent in upper GI tract, tracheoesophageal fistula, severe acute pancreatitis, anorexia nervosa and intensive care patients. The tubes were endoscopically placed using the guidewire technique. The position of the tube was confirmed by the immediate second endoscopy or abdominal X-ray. If the initiate placement was not correct, an adjustment or a second placement was conducted immediately. Initial post-pyloric placement of NET was achieved in 43 of 51 patients (84.3%), but the total success rate reached 98.0% (50/51) after the second placement. The time required for the procedure ranged from 10 to 35 min, with a median time of 20.4 min. Epistaxis occurred in 2 patients. There were no complications of hemorrhage, perforation or aspiration. The transnasal endoscopic placement of NET was feasible in patients with upper GI diseases, especially in those with changed anatomy.

Tu1727 Nasoenteral Feeding Tube Placement Using Ultra-Thin Endoscopy in Daily Clinical Practice Is Associated With Low Success Rates

Nasoenteral Feeding Tube Placement Using Ultra-Thin Endoscopy in Daily Clinical Practice Is Associated With Low Success Rates Meike M. Hirdes*, Lily Nagtzaam, Elisabeth M. Mathus-Vliegen, Frank P. Vleggaar, Jan J. Koornstra, Peter D. Siersema, Jan F. Monkelbaan Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, Netherlands; Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, Netherlands; Gastroenterology & Hepatology, University Medical Center Groningen, Groningen, Netherlands Background and Aim: In case of short term intolerance to gastric feeding, nasoenteral feeding tubes are commonly used to provide nutritional support. Tube placement over a guide wire using transnasal endoscopy is a minimally invasive technique for post-pyloric feeding tube placement at the bedside, with a reported success rate of 90% in experienced hands. In daily clinical practice, transnasal endoscopic tube placement is often performed by less experienced trainee endoscopists, which may affect success rates. The aim of this study was to determine success rate of transnasal endoscopic feeding tube placement in teaching hospitals and to identify independent patient and procedure-related predictors of successful tube placement. Methods: From January October 2011, all consecutive patients referred for first nasoenteral feeding tube placement with ultra-thin endoscopy were included. Exclusion criteria were altered anatomy of the upper gastrointestinal tract, alternative strategy of endoscopic tube placement, and no abdominal X-ray made within 3 hours after endoscopy. Abdominal X-rays were evaluated by radiologists not involved in the study. Multivariable logistic regression analysis was performed to identify independent predictors of successful tube placement. Successful nasoenteral tube placement was defined as a post-pyloric location of the tip of the feeding tube on abdominal radiograph. Results: In total, 175 patients (95 males, mean age 59 17 years) were included from 3 Dutch teaching hospitals. Patients were mostly admitted to the ward (48%) or intensive care unit (ICU, 36%). Common indications for nasoenteral tube feeding included gastroparesis due to critical illness (31%) or surgery (21%). Most endoscopic tube placements were performed by trainee endoscopists (81%) and under conscious sedation (74%). Radiographic control revealed that 26% of the tubes were placed in the stomach, 9% in the proximal duodenum, 16% in the distal duodenum and 49% in the jejunum. Multivariable logistic regression showed that use of sedation was the only independent predictor of successful feeding tube placement (OR 2.4 (95% CI 1.1-5.1)). Tube placement by a trainee instead of staff endoscopist, ICU admission or the presence of large gastric residuals ( 300 cc) were not associated with an increased risk of incorrect tube placement. Conclusions: In daily clinical practice, success rate of endoscopic nasoenteral feeding tube placement is much lower than reported in previous ‘study settings,’ however, this cannot be explained by the difference in experience between staff and trainee endoscopists. We recommend routine use of an abdominal X-ray after transnasal endoscopic tube placement to verify correct placement. The use of sedation can be considered as this may prevent incorrect tube placement.

Evaluation of acute radiation effects on mandibular movements of patients with head and neck cancer

To evaluate radiotherapy effects (RT) on mandibular movements of patients with head and neck cancer (H&NC) and associate them to the variables: functional capacity, radiation field, disease staging, type of feeding, concomitant chemotherapy and total dose of RT. Twenty-six patients with H&NC were followed up at the RT service. Physical examination was performed in 3 follow up time points: before the beginning of RT (T0), between 14th and 17th session of RT (T1) and after the last session of RT (T2). The physical examination consisted of the assessment of the following variables: mouth opening without pain (MO), maximum mouth opening (MMO), right lateral excursion (RLE), left lateral excursion (LLE) and protrusion (PR) of the jaw. The feeding type and the Karnofsky Performance Status Scale (KPS) were evaluated in each follow up time point. Data with regards to the tumor lesion and the RT were collected from the patient's clinical notes. There was a statistical significant reduction in the values of MO (p=0.006), MMO (p=0.001), LLE (p=0.006) and KPS (p=0.001). There was significant a statistical association among the reduction in KPS and decreased measure of MO (r=0.390, p=0.048) and MMO (r=0.435, p=0.026). The mouth and oropharynx radiation fields when combined showed a significant reduction for both the measure of MO (p=0.005) and for MMO (p=0.004). Patients who used nasoenteric tube feeding (NTF) had greater reduction in the measurement of MMO (p=0.031). The remaining variables showed no statistically significant difference. Patients with H&NC present reduction of the measures of MO and MMO during the RT, especially if they present reduced functional capacity, have radiation in the mouth and oropharynx fields and used NTF.