Postpyloric Feeding Tube Research Articles

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

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

Efficacy and safety of a modified method for blind bedside placement of post-pyloric feeding tube: a prospective preliminary clinical trial.

ObjectiveTo compare the efficacy and safety of a new modified method of bedside post-pyloric feeding tube catheterization with the Corpak protocol versus electromagnetic-guided catheterization.Materials and MethodsWe conducted a single-center, single-blinded, prospective clinical trial. Sixty-three patients were treated with a non-gravity type gastrointestinal feeding tube using different procedures: modified bedside post-pyloric feeding tube placement (M group), the conventional Corpak protocol (C group), and standard electromagnetic-guided tube placement (EM group).ResultsThe success rate in the M group, C group, and EM group was 82.9% (34/41), 70.7% (29/41), and 88.2% (15/17), respectively, with significant differences among the groups. The time required to pass the pylorus was significantly shorter in the M group (26.9 minutes) than in the C group (31.9 minutes) and EM group (42.1 minutes). The proportion of pylorus-passing operations completed within 30 minutes was significantly higher in the M group than in the C group and EM group. No severe complications occurred.ConclusionThis modified method of bedside post-pyloric feeding tube catheterization significantly shortened the time required to pass the pylorus with no severe adverse reactions. This method is effective and safe for enteral nutrition catheterization of patients with dysphagia and a high risk of aspiration pneumonia.

Ultrasound-Guided Postpyloric Feeding Tube Placement in Critically Ill Pediatric Patients.

Various methods to insert postpyloric feeding tubes at the bedside have been reported, but the optimal method remains controversial. The objective of this study was to evaluate the effect of ultrasound-guided postpyloric feeding tube placement in critically ill children. Single-center retrospective observational study. PICU of tertiary children's hospital. Children under the age of 16 who underwent postpyloric feeding tube placement in our PICU between September 2017 and August 2019. None. A total of 115 patients were included in this study: 30 patients underwent ultrasound-guided postpyloric feeding tube placement and 85 patients underwent blind postpyloric feeding tube placement; the insertion attempts were 32 and 93, respectively. There were no significant differences in patient demographics between the ultrasound-guided group and the blind group. The first-pass success rate of the ultrasound-guided group was higher than that of the blind group (94% [30/32] vs 57% [53/93]; p < 0.001). The median insertion time in the ultrasound-guided group with successful postpyloric feeding tube insertion was 18 minutes (interquartile range, 15-25; range, 8-45; n = 21). There were no complications or adverse events during the placement. In this single-center study, ultrasound-guided postpyloric feeding tube placement was feasible and a significantly high first-pass success rate was observed for critically ill children. Additional investigation with a larger pool of operators and randomized controlled patient assignment is required.

Electromagnetic-guided versus endoscopic placement of post-pyloric feeding tubes: a systematic review and meta-analysis of randomised controlled trials

BackgroundCurrent evidence supporting the utility of electromagnetic (EM)-guided method as the preferred technique for post-pyloric feeding tube placement is limited. We conducted a meta-analysis to compare the performance of EM-guided versus endoscopic placement.MethodsWe searched several databases for all randomised controlled trials evaluating the EM-guided vs. endoscopic placement of post-pyloric feeding tubes up to 28 July 2020. Primary outcome was procedure success rate. Secondary outcomes included reinsertion rate, number of attempts, placement-related complications, tube-related complications, insertion time, total procedure time, patient discomfort, recommendation scores, length of hospital stay, mortality, and total costs.ResultsFour trials involving 536 patients were qualified for the final analysis. There was no difference between the two groups in procedure success rate (RR 0.97; 95% CI 0.91–1.03), reinsertion rate (RR 0.84; 95% CI 0.59–1.20), number of attempts (WMD − 0.23; 95% CI − 0.99–0.53), placement-related complications (RR 0.78; 95% CI 0.41–1.49), tube-related complications (RR 1.08; 95% CI 0.82–1.44), total procedure time (WMD − 18.09 min; 95% CI − 38.66–2.47), length of hospital stay (WMD 1.57 days; 95% CI − 0.33–3.47), ICU mortality (RR 0.80; 95% CI 0.50–1.29), in-hospital mortality (RR 0.87; 95% CI 0.59–1.28), and total costs (SMD − 1.80; 95% CI − 3.96–0.36). The EM group was associated with longer insertion time (WMD 4.3 min; 95% CI 0.2–8.39), higher patient discomfort level (WMD 1.28; 95% CI 0.46–2.1), and higher recommendation scores (WMD 1.67; 95% CI 0.24–3.10).ConclusionsNo significant difference was found between the two groups in efficacy, safety, and costs. Further studies are needed to confirm our findings.Systematic review registrationPROSPERO (CRD42020172427)

Bedside Post-Pyloric Feeding Tube Placement Using Direct Visualisation: A Single Centre Case Series

Rationale: Post-pyloric feeding tubes (PPTs) are usually placed endoscopically in the UK. This carries cost and capacity implications for hospitals with additional strain on endoscopy units during the SARS-CoV-2 pandemic. The Kangaroo Feeding Tube with IRIS Technology (IRIS) uses optical visualisation to guide placement at the bedside, without the need for endoscopy. We describe a case series of bedside PPT placement using the IRIS tube. Methods: This was a prospective, single-centre case series over 12 months. Both ward-based conscious and ITU-based sedated adult patients were included. Exclusion criteria included altered anatomy and need for endoscopy for other reasons. IRIS tubes were placed by 2 operators only with placement confirmed by contrast radiograph. Data was collected as described below. Results: 20 attempts were made in 19 patients (13 female). The most common indication was intolerance of gastric feeding. The overall success rate was 75% (15/20 attempts). In sedated patients, 5/6 tubes (83%) were successful in 5 patients. In conscious patients, 10/14 tubes (71%) were successful in 14 patients. Placement failure in conscious patients was most commonly due to intolerance of the camera tip through the nasal cavity. The median procedure time for successful tubes was 9.2 minutes. In all successful cases, correct position as deemed by the operator was confirmed with contrast radiograph. Feeding was commenced within 24hours, with 15 endoscopic procedures saved. No complications were observed. Conclusion: This is the largest single series of PPT placement using the IRIS tube to date. The success rate in sedated patients is in line with other reports1,2. The slightly lower success rate in conscious patients was mainly due to the calibre and inflexibility of the camera through the nasal passage. However, the safety profile and potential benefit (reduced feeding delays, costs and need for endoscopy) suggest further, large scale studies may be warranted.

Evidence-Based Review and Discussion Points.

Evidence-Based Review and Discussion Points.

Electromagnetic Versus Blind Guidance of a Postpyloric Feeding Tube in Critically Ill Children

Postpyloric feeding tube placement is a time-consuming procedure associated with multiple attempts and radiation exposure. Our objective with this study is to compare the time, attempts, and radiation exposure using the electromagnetic versus blind method to place a postpyloric feeding tube in critically ill children. Our hypothesis is that using electromagnetic guidance decreases the procedure time, number of x-rays, and number of attempts, compared to the blind method. Eleven pediatric nurses participated in a randomized controlled intention-to-treat study at an academic pediatric medical, surgical, and congenital cardiac ICU. University of Texas Health Epidemiology and Biostatistics generated a randomization sequence with sealed envelopes. A standard (2-sided) F-test of association between the electromagnetic and blind method yielded 40 subjects with 86% power. Data were analyzed with Fisher's exact test for categorical variables and the Wilcoxon rank test for continuous variables, with data documented as median (interquartile range [IQR]). We randomly assigned 52 patients to either the electromagnetic (n = 28) or blind method (n = 24). The number of attempts and radiographs was at a median of 2 (IQR: 1-2.25) using the blind method, compared to the electromagnetic method at a median of 1 (IQR: 1.0-1.0; P = .001). Successful guidance was 96.4% with the electromagnetic method, compared to only 66.7% with the blind technique (P = .008). The total time required was 2.5 minutes (IQR: 2.0-7.25) with the electromagnetic method, compared to 19 minutes (IQR: 9.25-27.0) for the blind method (P = .001). Electromagnetic guidance is a superior, faster, and overall safer method to place a postpyloric feeding tube in critically ill children.

Enough is enough: Radiation doses in children with gastrojejunal tubes

IntroductionMany children with gastric feeding intolerance require postpyloric tube feeding via a gastrojejunal (GJ) tube. Placement or positioning of these tubes is typically a procedure with a low dose of radiation. Although the risk of developing cancer from radiation exposure owing to computed tomography scans is well-documented in children, the risk of cumulative radiation exposure owing to frequent GJ tube replacement often goes unnoticed in the clinical decision-making process. We sought to define the frequency and cost of GJ tube replacement, quantify the radiation doses associated with the initial placement and replacements, and assess the number of conversions to surgical jejunostomies. MethodsAll pediatric patients who underwent GJ tube placement or replacement by Interventional Radiology (IR), surgery, and gastroenterology between 2010 and 2018 at a single center were reviewed. We evaluated the total cost of the initial placement and replacement of each GJ tube, the total number of replacements, and the cumulative radiation dose (mGy). ResultsWe identified 203 patients who underwent GJ tube placement and/or replacement, of which 150 had radiation data available. Patients underwent a median of five GJ tube replacement procedures, and there was a wide range in the number of replacements per patient, from zero to 88. Patients were exposed to a median cumulative dose of 6.0 mGy (IQR: 2.2, 22.6). Nine percent of patients with available radiation data were exposed to more than 50 mGy, solely from GJ tube replacements. The median cost per replacement was $1170. The sum of the cost of the replacements for dislodged GJs translated to more than $1.4 million during the study period. ConclusionsOverall, the average dose per GJ replacement was 3.50 mGy among all patients with available data. Nine percent of patients (14/150) were exposed to greater than 50 mGy cumulative radiation solely from GJ replacements. Patients who receive more than 50 mGy of cumulative radiation dose, who undergo seven GJ tube replacements in one year, or two consecutive GJ tube replacement procedures with radiation doses exceeding 10 mGy (per replacement) should be considered for a surgical jejunostomy. Level of evidenceIV Type of studyTreatment study.

Novel Feeding Method Allows Enteral Nutrition in Infants and Children Undergoing Advanced Endoscopic Esophageal Therapy

Abstract Objectives To describe a novel method of feeding infants and children undergoing treatment for esophageal perforation. Endoscopic vacuum sponge (EVAC) therapy is a modified wound vacuum device that is inserted via gastrostomy site into the esophageal lumen in order to treat perforation. EVAC generally requires gastrostomy tube removal and loss of access for enteral nutrition (EN), obligating parenteral nutrition (PN) for the duration of therapy. In these patients, EN is preferable to PN as their distal GI tracts are functional. Our team devised a novel feeding tube device to allow for post-pyloric EN during EVAC therapy. Our hypothesis was that the feeding tube modification to the EVAC could safely and feasibly reduce PN use, avoid central line placement, and increase EN delivery. Methods Retrospective chart review of medical records in our cohort of pediatric patients who received EN during EVAC therapy for esophageal perforation between August 2018 and November 2019. Reason for EVAC therapy, delivery and timeline of prescribed EN, and complications were recorded. Results During this study period, 10 cases received EN support during EVAC therapy. Six (60%) underwent EVAC placement due to esophageal perforation encountered during planned endoscopy. All six avoided central line placement and none received PN. Four (40%) received EVAC therapy after identification of unexpected post-surgical perforation; all required a central line and two received PN initially until the feeding tube device was placed during EVAC exchange. Of the full cohort of 10 cases, 7 (70%) reached prescribed EN rate by POD#2 and received a mean of 72% prescribed volume. Two (20%) did not reach prescribed EN rate before EVAC removal. Complications included tube migration into the stomach (1 case, 10%) and excessive leaking of gastric contents (1 case, 10%). Conclusions Our novel EVAC and post-pyloric feeding tube device allows for safe and feasible provision of EN and has become the new standard for our infants and children undergoing EVAC therapy for esophageal perforation. Increased ability to provide EN may reduce infection risk, lower hospital costs, and support normal gut structure and function. This device shows promise in reducing the need for PN and central line as well as increasing EN delivery. A larger study with historical controls is planned. Funding Sources None.

Bedside Postpyloric Tube Placement and Enteral Nutrition Delivery in the Pediatric Intensive Care Unit.

Enteral nutrition (EN) delivery may be more effective via a postpyloric (PP) feeding tube in critically ill children, but tube placement can be challenging. We aimed to describe PP tube placement and EN practices in a multidisciplinary pediatric intensive care unit (PICU) after the implementation of a nurse-led bedside PP tube-placement program. In a single-center retrospective study, we identified 100 consecutive patients admitted to the PICU for >48 hours and for whom PP tube placement was attempted. Demographics, clinical characteristics, and details of PP tube placement and EN delivery were examined. The study cohort had a median age (25th, 75th percentiles) of 3.89 years (0.55, 14.86); 66% were male. Respiratory illness was the primary diagnosis of admission (55%); 92% were on respiratory support. Risk of aspiration was the primary indication for PP tube placement (48%). Bedside placement was the initial technique for PP tube placement in 93% of patients (successful for 84.9%) and was not associated with serious complications. Eighty-seven patients with a PP tube started EN and received a median 73.9% (12.3%, 100%) of prescribed energy goal on day 3 after EN initiation. PP EN allowed 14 of 39 patients receiving parenteral nutrition (PN) to transition off PN 7 days after EN initiation. Thirty-five percent of EN interruptions were due to feeding-tube dysfunction. Bedside PP tube placement is safe and feasible and allows for effective EN delivery and decreased PN use when applicable. Interruptions in PP EN due to tube malfunction are prevalent.

Volume-Based Protocol Improves Delivery of Enteral Nutrition in Critically Ill Trauma Patients.

Critically ill patients on enteral nutrition (EN) often do not receive goal nutrition support. Factors impeding delivery of EN include interruption for procedures, tube dislodgement, and high gastric residuals. A volume-based feeding protocol (VP) is designed to adjust the infusion rate to compensate for interruptions. We hypothesize that implementation of a VP would increase delivery of EN over the conventional hourly rate method (CM). This study compared patients on CM to those on VP. The primary outcome measured was percentage of goal EN delivered during the entire intensive care unit (ICU) stay. Inclusion criteria for the study consisted of patients aged >18 years, traumatic mechanism of injury and admission to the ICU >72 hours, hemodynamic stability to receive EN per the trauma ICU standard of practice, and EN via nasogastric or post-pyloric feeding tube. We evaluated 227 patients over a 20-month period. Seventy-nine patients in the VP group were compared with the control group of 148 patients. Patients on VP received a significantly higher percentage of goal EN than those on CM (73.3% vs 65%, P = .0002). There was no difference in the incidence of diarrhea (CM 4.16% vs VP 5.19%; P = .29) or tube dislodgment (CM 2.04% vs VP 1.61%; P = .51). Implementation of a VP significantly increased delivery of EN by 8.3% over that given by the CM in critically ill trauma patients with no difference in feeding-related complications.

Endoscopic Insertion of Nasojejunal Feeding Tube at Bedside for Critically Ill Patients: Relationship between Tube Position and Intragastric Countercurrent of Contrast Medium

Background and Oblectives: We evaluated the success rate of endoscopically positioned nasojejunal feeding tubes and the intragastric countercurrent of contrast medium thereafter. Method: This retrospective observational study investigated patients who were admitted to a single intensive care unit and required endoscopic placement of a post-pyloric feeding tube between January 2010 and June 2016. The feeding tube was grasped with forceps via a transoral endoscope and inserted into the duodenum or jejunum. Thereafter, we assessed the position of the tube and the intragastric countercurrent using abdominal radiography with contrast medium. Results: The tube tip was inserted at the jejunum and the duodenal fourth portion in 55.8 and 33.6% of patients, respectively. The tip of the inserted tube had moved into the jejunum of 71.7% of patients by the following day. The countercurrent rate was significantly lower among patients with a tube inserted into the duodenal fourth portion or more distal than among those with tubes inserted more proximally (8.4 vs. 45.4%, p = 0.0022). Conclusions: The endoscopic insertion and positioning of a nasojejunal feeding tube seemed effective because the rate of tube insertion into the duodenal fourth portion or more distal was about 90%. The findings of intragastric countercurrents indicated that feeding tubes should be inserted into the duodenal fourth portion or beyond to prevent vomiting and the aspiration of enteral nutrients.

Description of a simple technique of non-endoscopic insertion of a post-pyloric feeding tube in critically ill patients.

Description of a simple technique of non-endoscopic insertion of a post-pyloric feeding tube in critically ill patients.

Auscultation-assisted bedside postpyloric placement of feeding tube in critically ill patients: a prospective, observational study.

To assess the efficacy and safety of auscultation-assisted bedside postpyloric feeding tube (ABPFT) placement in early enteral nutritional support for critically ill patients. A prospective observational study was conducted and 92 critically ill patients who met the inclusion criteria undergoing ABPFT placement after the intravenous injection of 10 mg of metoclopramide were included. Abdominal X-ray was performed to confirm the location of the catheter tip. End points investigated were the success rate of tube placement, rate of jejunal tube placement, duration of the procedure, length of insertion, and number of attempts. Operational-related adverse events or complications were also documented and evaluated. The total success rate of postpyloric feeding tube implantation was 97.8% (90/92), among which, 89.1% (82/92) of the tubes were placed proximal to the jejunum. The first-attempt success rate was 91.3% (84/92) and the mean attempt per individual patient was 1.11±0.38 times. The mean operation time was 28.6±17.7 minutes, and the mean insertion length of tube was 106±9.6 cm. A total of 27 adverse events occurred in 19.6% (18/92) patients and there was no serious adverse events or complications during the study period. Assistance by auscultation can significantly improve the success rate of nasal feeding tube placement. This simple, safe and fast approach is feasible for the application among health practitioners in the intensive care unit.

Early Initiation of Post-Pyloric Feeding in Patients with Major Burns: Experience in Taiwan Formosa Water Park Dust Explosion Disaster.

Early initiation of enteral nutrition improves clinical outcomes in critical patients with serious burns. Post-pyloric tube feeding is a valuable therapeutic option for severely burned patients with poor gastric emptying. How early post-pyloric feeding can be initiated to provide more benefits to patients has not yet been examined. A fire erupted at a recreational water park in New Taipei City, Taiwan, on June 27, 2015. The results of early initiation versus delayed post-pyloric feeding in severely burned patients in this mass-casualty incident were compared. Door-to-post-pyloric feeding time ≤ 24 h was considered as early post-pyloric feeding (EPF) and that > 24 h was considered as delayed post-pyloric feeding (DPF). Thirteen patients with severe burn injuries (> 40% of the total body surface area) were assigned to undergo either EPF (five patients) or DPF (eight patients). This study is a "fortuitously controlled" study, and the authors were able to formulate and test whether EPF is better than DPF by comparing the two groups. In patients in the EPF, the intake of calories increased rapidly and was maintained throughout the study period. In addition, rapid restoration of plasma magnesium concentrations as well as pronounced recovery of platelet count in the EPF group was observed. In conclusion, our findings indicate that the time from injury to the onset of post-pyloric feeding is crucial, and EPF allows for the administration of calculated caloric needs. Therefore, EPF can be successfully initiated with beneficial outcomes of nutritional reconstruction in severely burned patients.

Postpyloric Versus Gastric Tube Feeding for Preventing Pneumonia and Improving Nutritional Outcomes in Critically Ill Adults.

What is the effectiveness and safety of postpyloric feeding versus gastric feeding for critically ill adults who require enteral tube feeding?Adequate nutrition is a key component to providing holistic care to critically ill patients. Assessing the need for nutritional support and providing early intervention can have many beneficial outcomes for patients, including improved disease progression and recovery time, improved immune response, and decreased overall complications.1 Early feeding for critically ill patients may be provided via enteral or parenteral routes. According to international guidelines,1–3 enteral feeding is the preferred method for patients who have a functioning gastrointestinal (GI) tract but who cannot maintain adequate oral intake. The advantages of enteral nutrition include prevention of GI atrophy and the systemic spread of GI bacteria.As with any intervention, potential challenges and side effects need to be taken into consideration. One main issue with feeding via the enteral route is the reduction in gastric motility including decreased gastric emptying and weakening of the gastric sphincters. This reduction in gastric motility can in turn can lead to gastroesophageal reflux (GER) and the risk of aspiration pneumonia. In addition, overall caloric intake can be an issue related to gastric intolerance, large residual volumes, and interruptions to continual feeding. Postpyloric feeding, in which the feeding tube is placed directly into the duodenum or the jejunum, could solve these issues by decreasing GER and residual volumes.Although gastric and postpyloric feeding in critical care patients have been compared in several meta-analyses,4 investigators reached different conclusions regarding the benefits and complications of using a postpyloric feeding tube. These discrepancies affect both standard guidelines and clinical practice. The purpose of this systematic review was to evaluate the potential benefits and adverse effects of using early postpyloric feeding in the adult critical care setting.This summary is based on a Cochrane systematic review that included individual patient data from 14 randomized controlled trials, with a total of 1109 participants.4 The systematic review examined both primary and secondary outcomes.The authors independently assessed the risk of bias for each study, including selection bias, performance bias, detection bias, attrition bias, reporting bias, and publication bias. The authors resolved any disagreements by reviewing and discussing the data.Risk ratio (RR) or mean differences (MD) were used as the measure of treatment effect between different comparisons and outcomes. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to provide a level of the quality of evidence for each outcome (very low, low, moderate, or high).5This systematic review and meta-analysis found moderate-quality evidence suggesting that postpyloric feeding decreases incidences of pneumonia by 30% and low-quality evidence suggesting that postpyloric feeding may lead to an increase in the amount of total nutrition delivered compared with gastric tube feeding. This review also found low-quality evidence suggesting that insertion of a postpyloric feeding tube is a safe intervention and is not associated with any more complications such as epistaxis and GI bleeding than gastric tube insertion. Therefore, using a postpyloric feeding tube may be preferred for ICU patients when feasible.Placement of a postpyloric feeding tube, however, can be challenging, often requiring expertise and a variety of radiological devices. Because the findings of this review do not recommend a best method for placing the postpyloric feeding tube, nurses should use their clinical judgment as to which method is best for their clinical scenario. If nurses lack skill in postpyloric feeding tube placement, consider additional training so that placing a postpyloric feeding tube is among the options they can choose from.As nurses caring for critically ill patients, we should advocate for the best evidence-based treatment for our patients. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine if we should implement it in our unit.

Cortrak® duodenal tube placements: A solution for more patients? A preliminary survey to the introduction of electromagnetic-guided placement of naso-duodenal feeding tubes

The Cortrak® feeding tube, an electromagnetic (EM) guided feeding tube which is placed by a trained nurse at the patient's bedside, is reported to be a safe, patient friendly and cost effective answer to the disadvantages of endoscopic placement of naso-duodenal feeding tubes. However, this procedure requires a learning curve and regular practice. This study aims to evaluate whether introducing Cortrak® feeding tube placement would be profitable in a tertiary referral academic hospital. We re-evaluated all endoscopically placed post-pyloric feeding tubes in the years 2012-2013. Taking into consideration training for nurses to learn how to place Cortrak® feeding tubes, strict inclusion criteria were formulated for the initial retrospective analysis: age 18 years or older, normal GI anatomy and non-ICU admitted patients. As a secondary analysis we also evaluated ICU patients (age >18 and normal upper GI tract). Patient records of 487 duodenal feeding tube placements in 331 patients were evaluated; 125 non-ICU placements (in 90 patients) and 84 ICU placements (in 75 ICU patients) fulfilled the inclusion criteria. Main reasons for exclusion were: abnormalities of the upper GI tract (n=176) and endoscopy for diagnostic reasons (n=74). Main indications for placements were gastroparesis (37%) or insufficient food intake (20%). For secondary analysis, 84 placements in 75 ICU patients were re-evaluated, with main indication gastroparesis (62%). In our hospital, at least one quarter of the duodenal tube placements would qualify for Cortrak® placement in the initial phase. Once routine has been built up and also ICU patients could be considered, half or more patients requiring a naso-duodenal feeding tube would qualify for Cortrak® placement, adding up to 3 placements per week. The findings of this study may help to decide on the profitability of introducing this method in our own hospital. The next step will be to perform a cost-benefit analysis to study whether implementing Cortrak® in practice is cost-effective and feasible.

Diagnosis and treatment of gastric antral webs in pediatric patients.

Gastric antral webs are mucosal structures, varying from fenestrated diaphragms to mucosal crescents, resulting in varying degrees of foregut obstruction. Patients commonly present with vomiting, failure to thrive, and abdominal pain. Prevalence is unknown, and diagnosis can be difficult. We performed an IRB-approved retrospective review of patients from 4/1/2015-4/1/2018at a Level I Children's Surgery Center undergoing gastric antral web resection. Data obtained included demographics, preoperative workup, surgical repair, and outcomes. Twenty-one patients were identified; 67% were male with an average age of 30months at diagnosis. Initial diagnosis was established by a combination of fluoroscopy and esophagogastroduodenoscopy (EGD) in all patients. Patients presented with emesis (76%), failure to thrive (57%), need for post-pyloric tube feeds (33%), and abdominal pain (14%). Web localization without intraoperative EGD (n = 3) was initially challenging. As a result, intraoperative EGD was combined with operative antral web resection to facilitate web localization (n = 18). Web marking techniques have evolved from marking with suture (n = 1) and tattoo (n = 2), to endoscopic clip application (n = 12). All 21 patients underwent web resection, 2 were performed laparoscopically. Twenty underwent Heineke-Mikulicz pyloroplasty during the initial surgery. Average length of stay was 5.5days. There were no intraoperative complications or deaths. Permanent symptom resolution occurred in 90% of patients immediately, with a statistically significant decrease in emesis (p < 0.001), failure to thrive (p < 0.001), and need for post-pyloric tube feeding (p = 0.009) within 6months of surgery. Gastric antral webs should be considered in the differential diagnosis for a child with persistent vomiting. Web resection with the use of intraoperative endoscopic localization can result in permanent symptom resolution in the majority of these patients.

Erythromycin for Promoting the Postpyloric Placement of Feeding Tubes: A Systematic Review and Meta-Analysis.

Background Critically ill patients can benefit from enteral nutrition with postpyloric feeding tubes, but the low success rate limits its wide use. Erythromycin could elevate the success rate of tube insertion, but its clinical efficiency still remains controversial. Methods Included studies must be RCTs which assessed the success rate of postpyloric feeding tube insertion using erythromycin. Results 284 patients were enrolled in six studies. Meta-analysis showed that erythromycin significantly increases the rate of successful postpyloric feeding tube placement (RR 1.45, 95% CI (1.12, 1.86)) and did not increase the risk of adverse effects (RR 2.15, 95% CI (0.20, 22.82)). Subgroup analysis showed that unweighted feeding tubes (RR 1.47, 95% CI (1.03, 2.11)) could significantly increase the success rate. Country of study, intravenous route of erythromycin, and year of participant enrollment did not influence these results. Conclusions Erythromycin significantly increases the success rate of postpyloric feeding tube placement. This suggests that erythromycin can be used as an auxiliary method to improve the success rate of bedside insertion.

Electromagnetically guided bedside placement of post-pyloric feeding tubes in critical care.

Post-pyloric feeding is recommended in critically ill patients with gastro-intestinal intolerance. However, traditional placement methods are logistically difficult and carry potential risks. The authors retrospectively compared the position of post-pyloric feeding tubes (PPFTs) using an electromagnetic device that demonstrated by X-ray and analysed the complication rates, proportion of lung placements avoided and the time taken to establish enteral feeding. Forty placements in 37 mechanically ventilated patients were analysed; there was a success rate of 87.5%. Sensitivity and specificity were 77% (95% CI 59.9-89.6%) and 100% (95% CI 48.0-100%). Five lung placements were identified in real time and therefore avoided. The mean (SD) time from PPFT placement to X-ray was 134 minutes (± 139 minutes) and, to feeding, 276 minutes (± 213 minutes). In conclusion, placement of PPFT using an electromagnetic device carries a high success rate, is safe and feasible to undertake at the bedside in mechanically ventilated patients.