Nasojejunal Feeding Research Articles

Effect of early and delay starting of enteral feeding in post-pancreaticoduodenectomy patients.

Backgrounds/AimsThis study was undertaken to see the effect of early starting of enteral feeding after pancreatoduodenectomy (PD). The results were compared with existing nutritional practice in which enteral feeding started, usually after 7 to 8 postoperative day (PODs) in our institute.MethodsThirty patients whome underwent a PD from January 2016 to December 2016 were included in the study. They were divided into two groups, I and II. In group I (n=15), enteral feeding was started from the 2nd POD through the nasojejunal feeding tube along with parenteral partial nutrition support. In group II (n=15), no enteral feeding was given up to seventh and eighth PODs, except the perenteral feeding. Post-operatively, serum albumin levels, total lymphocyte count, total bilirubin levels, serum alkaline phosphate levels were measured for two weeks postoperatively in all the patients for assessing nutritional, immunological and cholestasis status. The mortality, morbidity and lengths of post-operative hospital stay were also recorded.ResultsPostoperatively, the serum albumin level and lymphocyte count decreased from the pre-operative level on the third POD and it gradually increased from the seventh POD onwards in both groups. However, they remained persistently higher in group I than group II. The total bilirubin and alkaline phosphatase decreased to normal levels within the seventh POD in Group I. However, they remained higher than normal levels on POD 14 in Group II. The morbidity and hospital stay was significantly lower in group I than group II.ConclusionsEarly enteral feeding should be considered after PD. This is because it will improve nutritional, immunological status and cholestasis. Therefore, it reduces morbidity and shortens the hospital stay.

Major complications of jejunal feeding in children

Aim of the studyThe aim of the study was to identify major gastrointestinal complications associated with direct jejunal feeding. We hypothesized that jejunal feeding may cause life-threatening surgical complications in a minority of patients. MethodsAll patients undergoing jejunal feeding between 1/2008 and 1/2018 at a pediatric surgical unit were identified retrospectively. Data sought from records included demographics, comorbidities, indications, feeding strategies, adverse events, and follow-up. Major surgical complications were defined by Clavien–Dindo grade ≥ IIIb and involving the GI tract (excluding changes of jejunal tube). Main results197 patients were identified (110 female). Median age (IQR) at initiation of jejunal feeding months was 5.6 (6–164) months. 122 were neurologically impaired. The most frequent indications were: GERD/gastroparesis (n = 114), prophylaxis/treatment of Superior Mesenteric Artery (SMA) syndrome (N.B. our center is a national spinal deformity unit) (n = 47), congenital anomalies of aerodigestive anatomy (n = 17), and malignancy (n = 7). 125 patients were managed with nasojejunal feeding alone: gastrojejunal tube (n = 51) and via Roux-en-Y jejunostomy (n = 21). There were 14 significant gastrointestinal complications (n = 11 grade > IIIb) identified among 12 patients, of whom 8 required bowel resections, and 2 died as a result: nonmechanical bowel ischemia (n = 7), intussusception (n = 4), and volvulus (n = 3). ConclusionThis series highlights the major complications of jejunal feeding, including a significant yet underreported risk of gut compromise. Patients undergoing jejunal feeding had a 6.1% risk of developing major surgical complications (of note, 3.6% developed bowel ischemia of unknown etiology). Susceptible children were comorbid, fragile, and neurologically impaired. These findings should influence parental discussions and informed consent before embarking upon jejunal feeding. Level of evidenceLevel IV prognosis study.

PS01.239: MINIMALLY INVASIVE ESOPHAGECTOMY FOR CANCER IN PATIENTS WITH AIDS: AN ENTITY ON THE RISE

Abstract Background Recently it was reported by World Health Organization that over 36 million people are living with HIV globally; for the first time ever life expectancy in people with HIV exceeds the average. This is mainly due to the development of highly active antiretroviral medication that have turned AIDS from a life threatening disease to a chronic condition. HIV patients are as prone as the general population to developing esophageal cancer. We aim to describe our experience and factors for consideration whilst treating HIV patients with esophageal cancer. Methods In 2017, 77 cases were surgically treated for esophageal and gastroesophageal junction cancer in our tertiary referral centre. n = 2 (2.5%) were HIV positive. Their disease, demographic and surgical characteristics were analyzed and the outcomes are presented. Results A 62 and 65-year-old HIV male patients had 2-stage esophagectomy for gastro-esophageal junction adenocarcinoma. They both had similarities with locally advanced tumours and late presentation with dysphagia and > 10% total body weight loss. Clinical staging revealed T3N2M0 tumours in both cases. Viral load was low (< 40 copies/mL) and both had neoadjuvant chemotherapy as first line of treatment. Both had a 2-stage esophagectomy; one had laparoscopic-assisted and the other had totally minimally invasive. Histological staging was ypT3N1 and ypT3N3 respectively. Antiretroviral medications were in both started enterally on day 1; in the first case via a triple-lumen nasojejunal feeding tube and in the second via a single-lumen nasogastric tube. No feeding jejunostomies were placed. No immediate post-operative complications were noted. Length of stay was 14 and 8 days respectively. Conclusion AIDS patients with esophageal cancer can present late, with advanced tumors, as dysphagia is common due to fungal esophagitis and tends to be underestimated. Where indicated, this cohort of patients should receive full multimodality treatment, like the general population, as results are no different. Multidisciplinary approach with involvement of an HIV specialist doctor from the beginning of treatment planning is of paramount importance as optimization prior to surgery is commonly necessary. Antiretroviral medications are needed immediately post-operatively in all cases and a clear plan for enteral route administration should be in place. Disclosure All authors have declared no conflicts of interest.

Nasojejunal tube feeding in children: knowledge and practice

Nasojejunal tubes (NJ) are used in small numbers of children outside of neonatal and paediatric intensive care units. There is limited evidence on which to base practice aside from insertion techniques. Ongoing care and management is largely based on historical practice and extrapolation from nasogastric tube practice. This paper presents the historical caseload data for 36 babies and children over a five year period. The children ranged from 0 to 13 years of age, and 95% were less than 2 years old. They had a median of 4 tubes each (range 1 - 46). The paper presents data from two surveys of health professionals that demonstrate a lack of consistency in practice. There are concerns about ongoing position checks and about the radiation burden in these children. Local practice is described that aims to reduce dependence on x-ray procedures and to stimulate debate. Finally, an argument is made for a better evidence base for future practice.

Comparative study of Nasogastric Feeding and Nasojejunal Feeding routes of Enteral Nutrition in Acute Pancreatitis

Comparative study of Nasogastric Feeding and Nasojejunal Feeding routes of Enteral Nutrition in Acute Pancreatitis

Home enteral nutrition after minimally invasive esophagectomy can improve quality of life and reduce the risk of malnutrition.

The potential benefits of home enteral nutrition (HEN) and the effects of HEN on quality of life (QOL) after esophagectomy remain unclear. The aim was to investigate the effect of 3 months HEN on health related QOL and nutritional status of esophageal cancer patients who were preoperatively malnourished. 142 malnourished (PG-SGA stage B or C) patients with esophageal cancer were assigned to receive Ivor Lewis minimally invasive esophagectomy (MIE group) with laparoscopic jejunal feeding tube placement or open esophagectomy (OE group) with nasojejunal feeding tube placement. After discharge, patients in the MIE group received HEN with 500-1000 kcal/d for 3 months, while the OE group patients did not receive HEN, as nasojejunal feeding tubes had been removed. QLQ-C30 and PG-SGA questionnaires were used to evaluate the QOL and the risk of malnutrition. 67 patients were enrolled in the MIE group and 75 patients were enrolled in the OE group. Symptoms related to fatigue, nausea, vomiting, pain, and appetite loss were significantly decreased in the patients treated with 3 months HEN. Similarly, patients treated with 3 months HEN had a lower risk of malnutrition than patients did not receive HEN (PG-SGA score, 5.7 vs 7.9, p<0.01). More patients in the MIE group (received 3 months HEN) were able to complete postoperative chemoradiotherapy than patients in the OE group (p<0.01). MIE and subsequent treatment with 3 months HEN can improve the QOL and reduce the risk of malnutrition in preoperatively malnourished patients.

An Unusual Cause of Gastric Outlet Obstruction

An 84-year-old woman presented with 2-days of epigastric pain accompanied by nausea and coffee-ground emesis. Physical examination revealed mild tenderness in the epigastrium and a succussion splash. Computed tomography of the abdomen demonstrated findings consistent with a gastric outlet obstruction and a large irregular fluid and gas-filled collection centered on the first and second portions of the duodenum (Figure A, arrow). On esophagogastroduodenoscopy, a fistula was found in the gastric antrum (Figure B) with evidence of a large gallstone within the fistula tract (Figure C). This case illustrates Bouveret syndrome, a rare complication of cholelithiasis manifested by gastric outlet obstruction secondary to gallstone impaction in the stomach or proximal duodenum as a result of acquired fistulous communication between the gallbladder and proximal gastrointestinal tract. In this case, surgical management was deferred given the patient’s multiple coexistent medical conditions. Electrohydraulic lithotripsy was performed along with stenting of the fistula under fluoroscopic guidance to prevent further stone impaction (Figure D) and a nasojejunal feeding tube was placed for nutritional support. The patient has returned for routine endoscopic exchange of cholecystogastric fistula stents without recurrence of symptoms related to gastric outlet obstruction.

Short-term outcome after cystectomy: comparison of early oral feeding in an enhanced recovery protocol and feeding using Bengmark nasojejunal tube

PurposeCystectomy for bladder cancer is associated with a high risk of postoperative complications. Standardized perioperative protocols, such as enhanced recovery after surgery (ERAS) protocols, aim to improve postoperative outcome. Postoperative feeding strategies are an important part of these protocols. In this two-centre study, we compared complications and length of hospital stay (LOS) between an ERAS protocol with early oral nutrition and a protocol with early enteral feeding with a Bengmark nasojejunal tube.MethodsWe retrospectively reviewed 154 consecutive patients who underwent cystectomy for bladder cancer in two hospitals (Hospital A and B) between 2014 and 2016. Hospital A uses an ERAS protocol (n = 45), which encourages early introduction of an oral diet. Hospital B uses a fast-track protocol comprising feeding with a Bengmark nasojejunal tube (Bengmark-protocol, n = 109). LOS and complications according to Clavien classification were compared between protocols.ResultsOverall 30-day complication rates in the ERAS and Bengmark protocol were similar (64.4 and 67.0%, respectively; p = 0.463). The rate of postoperative ileus (POI) was significantly lower in the Bengmark protocol (11.9% vs. 34.4% in the ERAS protocol, p = 0.009). This association remained significant after adjustment for other variables (odds ratio 0.32, 95% confidence interval 0.11–0.96; p = 0.042). Median LOS did not differ significantly between protocols (10 days vs. 11 days in the ERAS and Bengmark protocols, respectively; p = 0.861).ConclusionsEarly oral nutrition in Hospital A was well tolerated. However, the Bengmark protocol was superior with respect to occurrence of POI. A prospective study may clarify whether the lower rate of POI was due to the use of early nasojejunal tube feeding or other reasons.

Superior Mesenteric Artery Syndrome: An Under-Diagnosed Condition With Potentially Serious Implications

Introduction: Given the relative obscurity of superior mesenteric artery (SMA) syndrome, it is a condition that tends to be missed and is therefore often under-identified. Given the potentially serious complications of SMA syndrome, it is important to clarify and raise practitioner awareness of this condition. We present this case of a young woman, who came to the ED complaining of nausea and vomiting and was ultimately diagnosed with this rare syndrome. Case Presentation: A 32-year-old woman presented with nausea and non-bloody vomiting for few days. She described experiencing acute pain (8/10) that had worsened with time and was sharp, constant, and non-radiating in nature. Stool work-up was unremarkable, and laboratory tests were within normal limits. The patient's symptoms improved with showering and were initially attributed to cannabis induced hyperemesis. A Computerized Tomography (CT) scan of abdomen ruled out an acute abdominal process but identified a superior mesenteric artery to aorta angle that was diminished and consistent with superior mesenteric artery syndrome. The aortomesenteric angle and aortomesenteric distance were 15° and 4mm respectively in this patient (Figure 1). Patient's nausea and vomiting subsided but she reported persistent right lower quadrant pain, diarrhea, anorexia, and unintentional weight loss (> 10 pounds in the preceding month). A diagnostic colonoscopy was non-contributory.Figure: Aorta (red), Celiac (yellow), SMA (blue), left renal vein (green), duodenum (purple). Normally, the aortomesenteric angle and aortomesenteric distance are 25-60° and 10-28 mm, respectively. These parameters were 15° and 4mm in this patient.Discussion: SMA syndrome, also known as Wilkie's syndrome, occurs when the SMA develops a severe angulation and subsequently compresses upon the third portion of the duodenum, which extends from the SMA to the abdominal aorta. This new acute angulation of the SMA is usually due to a loss of retroperitoneal fat between the superior mesenteric artery and the abdominal aorta. It is estimated that the incidence of SMA syndrome is only around 0.1 to 0.3%. The typical aorto-mesenteric angle should be between 25-60°, and the distance between aorta and SMA is usually between 10-28 mm. An angle of < 20° and a distance of < 6 mm is often diagnostic of SMA syndrome. Patients with SMA syndrome tend to present with nausea, vomiting, and abdominal pain with contextual weight loss. SMA syndrome should first be treated conservatively though nasojejunal feeding. If this fails, it can be managed surgically with a duodenal derotation or a duodenojejunostomy.

A Rare Case of Gastric Outlet Obstruction due to Large Intramural Duodenal Hematoma Following Endotherapy for Bleeding Duodenal Ulcer in a Patient with End-stage Renal Disease

ABSTRACTWe report a very rare case and probably the first from India of gastric outlet obstruction due to a large intramural duodenal hematoma following combination endotherapy with hemoclipping and injection adrenaline 1:10,000 for actively bleeding duodenal ulcer in an elderly male patient with diabetes, hypertension, and end.stage renal disease on maintenance hemodialysis. The patient improved to approximately 6 weeks of conservative treatment with nasojejunal feeding.

Over-the-scope-clip system secured nasojejunal tube feeding in refractory hyperemesis gravidarum

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting in pregnancy. It complicates up to 2% of all pregnancies and can be associated with adverse outcomes. Its management...

Nutritional management of acute pancreatitis.

Acute pancreatitis is one of the most common causes for hospitalization related to a gastrointestinal disorder. It carries significant morbidity, and when severe, significant mortality. Multiple interventions have been studied to treat pancreatitis. Of all these interventions, none is more important or impactful than nutrition. High-quality evidence along with society guidelines have recommended the use of enteral nutrition over parenteral nutrition in patients with pancreatitis. Recent systematic reviews and meta-analyses have been published and will be reviewed here. The use of enteral nutrition has been demonstrated to decrease mortality and infectious complications compared with parenteral nutrition. The ideal timing of initiating enteral nutrition is not clear, however, early nutrition (within 48 h) appears to be safe and tolerated. Most studies have utilized nasojejunal feeding tubes; however, some patients may tolerate nasogastric or even oral refeeding. Clinicians who manage patients with pancreatitis must be aware of the critical role of nutrition in preventing pancreatitis-related complications.

Surgical management of pancreatic ascites

Background: Pancreatic ascites is a challenging problem faced by clinicians. The management requires a multidisciplinary approach. Timely surgical intervention is the key especially in patients with chronic pancreatitis and pancreatic ascites where conservative and endoscopic treatments were not successful.Methods: The data was retrieved from a prospectively maintained database for a period of 4 years. A total of 14 patients were included. They were initially optimized with ascitic fluid drainage, nutritional supplementation either enteral or parenteral. Endoscopic retrograde cholangio pancreatography (ERCP) was done in patients with failed conservative treatment after 2 weeks. Endoscopic pancreatic stenting was attempted in proximal ductal disruptions. Nonresponders were taken up for surgery. The type of surgery was based on the site of leak and associated pancreatic pathology like pseudocyst.Results: Initially three patients were responded to conservative management. ERCP was done in 9/14 patients. ERCP demonstrated leak of contrast into peritoneal cavity in 3 (3/9), leaking pancreatic pseudocyst in 3 (3/9) and non-visualisation of distal duct in 2 (2/9). ERCP and stenting of pancreatic duct was attempted in three patients and was successful in resolution of symptoms in one. Nine out of fourteen needed surgical intervention. Surgery was based on site of leak and presence of pseudocyst.Conclusions: Majority of the patients in our study were ethanolics and a change in life style early in the course can prevent this morbid disease. Nasojejunal tube feeding with blendarized home feeds will improve the nutritional status. CECT abdomen and ERCP will give a road map in deciding the type of intervention. For proximal ductal disruption endoscopic stenting should be tried before going for a major surgical intervention. Surgery provides definitive cure.

Enteral nutrition in patients with severe acute pancreatitis: Nasogastric versus nasojejunal feeding?

Enteral nutrition in patients with severe acute pancreatitis: Nasogastric versus nasojejunal feeding?

Complications related with postoperative enteral nutrition in patients with massive cerebellar infarction

Objective To investigate the complications of different enteral nutrition in patients after surgery for massive cerebellar infarction, so as to guide rational application of enteral nutrition in patients. Methods Forty-nine patients with massive cerebellar infarction were divided into three groups randomly: conventional nasogastric tube feeding group (group A, n=12), nasogastric tube feeding plus gastric motor drug group (group B, n=18), and nasojejunal tube feeding group (group C, n=19). The incidences of diarrhea, reflux, aspiration, upper gastrointestinal bleeding and aspiration pneumonia within 3 weeks after initiation of enteral nutrition were observed and compared among the groups. Results The incidence of diarrhea showed no statistically significant difference among the 3 groups(χ2=0.092, P=0.955). Compared with group A, the incidences of reflux, aspiration and aspiration pneumonia were significantly lower in group B and group C (P<0.05), and lower in group C compared with group B(P<0.05). Compared with group C, the incidence of upper gastrointestinal bleeding was significantly lower in group C than in group A and group B(χ22=4.748, P2=0.029; χ32=4.284, P3=0.038), but the difference between group A and group B was not significant(χ12=0.000, P1=1.000). Conclusions Because of the unique pathophysiological features in patients after surgery for massive cerebellar infarction, early enteral nutrition by conventional nasogastric tube feeding may be inappropriate. Nasogastric tube feeding plus gastric motor drug may be applied in mild case with short course of disease. Nasojejunal tube feeding may be the approach of choice for enteral nutrition in critical patients with massive cerebellar infarction for its association with lower incidence of complications. Key words: Cerebellar infarction; Enteral nutrition; Complication; Nasogastric tube; Nasojejunal tube

Double Pigtail Stent Insertion for Healing of Leaks Following Roux-en-Y Gastric Bypass. Our Experience (with Videos).

Roux-en-Y gastric bypass (RYGB) is complicated by a leak in 0-4.3% of cases. Treatment by fully covered stents has been reported to be associated with some life-threatening complications. We report our experience of insertion of double pigtail stents. Thirty-three patients (20M, 43years-20/65), presenting with a leak at an average of 10days after RYGB (4-35), were treated by double pigtail stent insertion and a nasojejunal feeding tube. Sixty percent of these patients had undergone surgical drainage prior to stenting for control of sepsis. Thirty leaks were located at the top of staple line and three at the gastro-jejunal anastomosis. At a 4-weekly follow-up, ablation or re-stenting was performed depending on status of fistula closure and patients were placed on normal diet. At the first follow-up, 10/33 fistulae healed, one patient presented with clinical failure (3%) and needed surgery, and 22/33were re-stented. Twenty-one out of these 22 developed a secondary sub-clinical gastro-gastric fistula and one, instead, developed complex (gastro-gastric, gastro-colic) fistula. All (22) primary fistulae healed following four more weeks of treatment. Average treatment duration was of 61days (28-99). Thirty-two patients (97%) at a follow-up of 1-33months are asymptomatic. Leaks following RYGB can be successfully and safely managed by double pigtail stents. Upper gastric staple line leaks are responsible for the formation of a secondary sub-clinic gastro-gastric fistula which needs no additional treatment.

Annals for Educators - 4 October 2016

<i>Annals</i> for Educators - 4 October 2016

Superior Mesenteric Artery Syndrome: An Unusual Cause of Small Bowel Obstruction

Superior mesenteric artery (SMA) syndrome is an uncommon cause of duodenal outlet obstruction due to acquired anatomical defects. Often, weight loss precedes obstruction, causing narrowing of the fat pad between the SMA and aorta leading to intestinal compression, usually the 3rd part of the duodenum. SMA syndrome should be considered in patients with rapid weight loss, narrowed vascular angles on imaging, and no other obvious cause of small bowel obstruction (SBO). Our patient is a 51 year-old female with a past medical history of end stage renal disease and hepatitis C. She presented with a recent 30-pound weight loss and complaints of diffuse abdominal pain associated with nausea and vomiting undigested food. The pain was described as constant, pressure-like, increased by oral intake and relieved by left lateral decubitus positioning. A CT scan demonstrated an angle between the SMA and aorta measuring 21 degrees, an aortomesenteric (fat-pad) distance of less than 8 mm and duodenal dilation proximally. A nasogastric tube was placed and symptomatic relief was achieved. Total parental nutrition followed by a nasojejunal feeding tube resulted in weight gain and a subsequent ability to tolerate soft foods prior to discharge. Initially described in 1842, SMA syndrome has prevalence between 0.013 and 0.3%. A high level of suspicion should be maintained in patients with symptoms of obstruction in the setting of rapid weight loss or recent spinal surgery. Diagnosis is based on history and radiographic evidence of obstruction involving the 3rd portion of the duodenum. Computer tomography angiography or magnetic resonance angiography is required to identify vascular measurements of angulation and aortomesenteric distance. The angle between the SMA and aorta is typically 38-65 degrees and the aortomesenteric distance is normally 10-28 mm. In SMA syndrome, both parameters are reduced to 25 degrees (most sensitive measurement) and 2-8 mm respectively. Initial treatment involves correction of electrolyte abnormalities, symptomatic relief including gastric decompression and reconstitution of nutrition and weight. In cases refractory to conservative management or symptoms persisting beyond 3-4 weeks, surgical intervention should be considered. Available options include laparoscopic procedures such as duodenojejunostomy and gastrojejunostomy, or open such as Strong's procedure.Figure 1Figure 2

Safety of nasogastric tube versus nasojejunal tube feeding in early enteral nutrition in acute pancreatitis :a Meta-analysis

Objective To evaluate the safety of nasogastric tube feeding and nasojejunal tube feeding in early enteral nutrition treatment of acute pancreatitis. Methods Using key words, subject headings, and citation tracing, we searched literatures reporting randomised controlled trials on early enteral nutrition treatment of acute pancreatitis through nasojejunal tube and nasogastric tube in the following databases: PubMed, Embase, Cochrane library, Wanfang, China National Knowledge Infrastructure (CNKI), and VIP published since the founding of the databases up to 2016. Meta-analysis was performed with the selected literature. Results Seven randomised controlled trials with 367 patients were included. Meta-analysis showed that the nasogastric tube group was not inferior to the nasojejunal tube group in the incidence of recurrent abdominal pain, gastrointestinal adverse reaction, the total length of hospital stay, and mortality. Conclusion Enteral nutrition via nasogastric tube is safe and well tolerated, may be a safe approach of nutrition treatment for acute pancreatitis. Key words: Intubation, gastrointestinal; Enteral nutrition; Acute pancreatitis

Comparison of nasojejunal tube insertion and percutaneous endoscopic gastrostomy for enteral nutrition in elderly patients

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