Nasogastric Tube Removal Research Articles

PMO-077 Home enteral tube feeding (HETF): a case burden for the paediatric emergency department (PED)?

IntroductionThe contribution of HETF issues to PED workload is poorly understood. We aimed to evaluate PED attendance records of children receiving HETF (rates, presenting complaints and outcomes). We also aimed...

Short-Term Outcome after Cystectomy: Comparison of Two Different Perioperative Protocols

Aim: To compare the outcome of two perioperative protocols with respect to postoperative management of cystectomy patients. Patients and Methods: Between June 2007 and November 2008, 85 consecutive patients with bladder cancer were treated with cystectomy and urinary diversion. Patients were operated in two hospitals by four urologic surgeons. In protocol A, patients were enterally fed via a postpyloric tube while the nasogastric tube (NGT) was removed directly after cystectomy and selective decontamination of the digestive tract was given until normal oral intake. In protocol B, postcystectomy management consisted of total parenteral nutrition by a central venous line and NGT removal after 24 h. Hospital stay and complications were compared between the two hospitals. Results: More than half of all patients (52%) developed one or more complications within 30 days after surgery, 37% in protocol A and 71% in protocol B (p = 0.002). Higher ASA score and protocol type were the only factors significantly associated with early complications in both uni- and multivariate analyses. Length of stay was significantly shorter with protocol A as compared to protocol B, 13 days versus 19 days (p = 0.006). Conclusions: Cystectomy and urinary diversion is a procedure with considerable risk of complications. Enteral nutrition might be advantageous as compared to parenteral nutrition, showing fewer complications and shorter hospital stay. A high ASA score is associated with more early complications. Selective bowel decontamination may have an additional role in preventing infectious complications after cystectomy.

The clinical role of critical pathway implementation for pancreaticoduodenectomy in 179 patients

In June 2004, a critical pathway for patients undergoing pancreaticoduodenectomy (PD) was introduced. The objective of this study was to determine the clinical value of critical pathway implementation. 256 consecutive patients who underwent PD between 2000 and 2010 were divided into 4 groups by date of operation as follows; group A (n = 77), the pre-pathway group; group B (n = 51), the CP implementation group who were managed according to departmental guidelines; group C (n = 78), the group who had no stenting in the reconstruction of PD; and group D (n = 50), the group who had reinforcement of the pancreaticojejunostomy. The success rates of clinical outcomes and post-operative morbidity were compared between each group, year by year and every 50 patients. The success rates of clinical outcomes, including the timings of nasogastric tube removal, discontinuation of prophylactic anti-microbial agent, drain removal, starting oral intake, and patient discharge, were significantly improved in group B relative to group A, and in group C relative to group B. There were no significant differences in mortality and morbidity between any of the groups. All clinical outcomes reached a plateau at 2-3 years or 100-150 patients' operations after critical pathway implementation. Long-term use of a critical pathway is associated with improved clinical outcomes. A certain period of time or volume of patients is needed for this improvement in clinical outcomes to reach a plateau, which indicates achieving standardization of peri-operative management.

Fast track program for esophagectomy patients.

A fast track (FT) program for esophagectomy patients is rarely used. We streamlined care using an algorithm for the postoperative care of patients who underwent esophagectomy to try to reduce hospital stays to 7 days while maintaining safety and patient satisfaction. A consecutive series of 80 patients with esophageal carcinoma who underwent elective esophageal resection from 2007 to 2008 in our department was taken into the FT program. An algorithm for FT to guide postoperative care was used, featuring avoidance of the intensive care unit, early ambulation, removal of nasogastric tube and oral nutrition starting on postoperative day (POD) 1, with discharge on POD 7. All patients were operated upon through a left posterolateral thoracotomy with a cervical esophagogastrostomy. Seventy-eight (97.5%) patients completed the FT program. Discharge home was proposed for POD7. None was readmitted within 30 days of discharge. None suffered from anastomotic leakage. The time to first passage of flatus was 51.7 ± 8.4 h. The majority of patients with esophageal carcinoma can tolerate FT surgery. Oral nutrition starting on POD1 is safe and FT surgery is feasible for patients scheduled for elective esophageal cancer resections without compromising quality.

Effect of Presence/Absence of a Nasogastric Tube in the Same Person on Incidence of Aspiration

To determine what effect, if any, the presence or absence of a nasogastric (NG) tube in the same person had on the incidence of anterograde aspiration. Case series with planned data collection. Large, urban, tertiary care teaching hospital. Referred sample of 62 consecutively enrolled adult inpatients for fiber-optic endoscopic evaluation of swallowing (FEES). Group 1 (n = 21) had either small-bore (n = 13) or large-bore (n = 8) NG tubes already in place and had a FEES first with the NG tube in place and a second FEES after NG tube removal. Group 2 (n = 41) did not have an NG tube and had a FEES first without an NG tube and a second FEES after placement of a small-bore NG tube. Time between FEES was approximately 5 minutes. Patients were tested with thin liquid and puree food consistencies. Occurrence of aspiration for each consistency dependent on the presence or absence of an NG tube was recorded. There were no significant differences (P > .05) in aspiration status for both liquid and puree consistencies in the same person dependent on presence or absence of either a small-bore or large-bore NG tube. Since objective swallowing evaluation (eg, FEES) can be performed with an NG tube in place, it is not necessary to remove an NG tube to evaluate for aspiration. Similarly, there is no contraindication to leaving an NG tube in place to supplement oral alimentation until nutritional requirements are achieved.

Quality of Voice Evaluation in Patients Treated by Supracricoid Laryngectomy and Modified Supracricoid Laryngectomy

To compare quality of voice in patients treated by supracricoid laryngectomy and patients treated by modified supracricoid laryngectomy using the sternohyoid muscle for neoglottis reconstruction. Case series. Setting. Teaching hospital. This study was performed between 2004 and 2008 on 28 consecutive patients affected by T1b-T2 laryngeal carcinoma. Eleven patients were treated by supracricoid laryngectomy, and 17 patients were treated by modified supracricoid laryngectomy. For each patient, postoperative parameters such as decannulation time, nasogastric feeding tube, and length of hospitalization were noted. Vocal function, Voice Handicap Index scores, and perceptual voice analysis scores on intelligibility, noise, fluency, and voice scale were evaluated. The postoperative course of the patients treated by modified supracricoid laryngectomy was similar to patients treated by supracricoid laryngectomy. No delay in the length of hospitalization was detected in patients undergoing surgery with the new technique. A significant difference was detected in the nasogastric tube removal time and decannulation time. The data from intelligibility, noise, fluency, and voice scale analyses revealed a better quality of voice in patients treated by modified supracricoid partial laryngectomy with a significant difference in intelligibility, fluency, and voicing. The Voice Handicap Index mean value of physical, functional, and emotional subscales confirmed patients' perceptions of a minor voice handicap in patients treated by modified supracricoid laryngectomy, with a significant difference on the physical subscale. Modified supracricoid laryngectomy seems to be a good way to improve quality of voice and quality of life in patients with early laryngeal cancer.

Roux-en-Y Reconstruction at Greater Curvature in Biliopancreatic Diversion: Effects on Early Postoperative Functional Recovery

Delayed gastric emptying after distal gastrectomy and reconstruction of alimentary tract with a gastroenteric anastomosis can significantly influence early and late postoperative course and the length of hospital stay. The purpose of this study was to compare the effect on postoperative functional recovery of two different Roux-en-Y reconstructions: at the gastric greater curvature and at the transected gastric staple line in the Scopinaro's biliopancreatic diversion. We conducted comparative study; 80 patients were enrolled and divided in two groups: group A (RY-GC) and group B (RY-SL) with 40 patients in each group. We compared the early postoperative functional recovery for both groups measuring four parameters: gastric stasis indicated with the volume of the gastric fluid collected per 24 h, day of removal of the nasogastric tube, day of starting the oral intake, and day of hospital discharge. There was statistically significant (p < 0.001) reduction in gastric fluid volume in favor of the RY-GC group starting from the first postoperative day resulting in earlier removal of nasogastric tube with earlier starting of oral feeding than RY-SL group, with no symptoms of stasis required nutrition suspension; while three patients in RY-SL group experienced persistence of nausea and vomiting and needed nutrition suspension for several days. There was statistically significant (p < 0.001) reduction in the hospital stay for RY-GC group. Roux-en-Y reconstruction at the greater curvature ensures a rapid functional recovery with early hospital discharge. The use of stapler devices made this method easier and safer and no complications have arisen with mechanical anastomoses.

Early removal of nasogastric tube is beneficial for patients undergoing radical cystectomy with urinary diversion

Examine the beneficial effect of early nasogastric tube (NGT) removal in patients undergoing radical cystectomy with urinary diversion. 43 consecutive patients underwent radical cystectomy with urinary diversion and were randomized into 2 groups. In the intervention group (n = 22), the NGT was removed 12 hours after the operation. Comparatively, in the control group (n = 21), the NGT remained in place until the appearance of the first flatus. The appearance of ileus, patient ambulation, time to regular diet, and hospital discharge of the two patient groups were assessed. Patient discomfort due to the NGT was also recorded. The 2 groups showed statistical homogeneity of their baseline characteristics. Two patients (9.09%) from the intervention and 3 patients (14.3%) from the control group developed postoperative ileus and were treated conservatively. No significant differences in intraoperative, postoperative, bowel outcomes or other complications were found between the two groups. All patients preferred the NGT to be removed first in comparison to their other co-existing drains. This is the first randomized, prospective study, to our knowledge, to assess early NGT removal after radical cystectomy. We advocate early removal, independently of the selected type of urinary diversion, since it is not correlated with ileus and is advantageous in terms of patient comfort and earlier ambulation.

Minimally Invasive Surgery Improves Short-term Outcomes in Elderly Colorectal Cancer Patients

Minimally invasive surgery (MIS) for colorectal resection has been shown to improve short-term outcomes compared with open surgery in patients with colorectal cancer. Currently, there is a paucity of data demonstrating similar efficacy between MIS and open colorectal resection in the elderly population. We hypothesized that minimally invasive surgery provides improved short-term outcomes in elderly patients with colorectal cancer. A review of 242 consecutive elderly (≥ 65 y of age) patients who underwent either open or MIS colorectal resection for adenocarcinoma at one institution was conducted. Short-term and oncologic outcomes were analyzed. Continuous variables were analyzed by the Mann-Whitney U test. Categorical variables were compared by χ(2) tests. Survival was compared by the Kaplan-Meier method using the log rank test for comparison. Of the 242 elderly patients with colorectal cancer (median American Society of Anesthesiology score (ASA) scores of 3), 80% (n = 195) of patients underwent open and 20% (n = 47) had MIS colorectal cancer resections. Patients undergoing MIS had a faster return of bowel function, decreased days to nasogastric tube removal, decreased days to flatus and bowel movement, and quicker advancement to clear liquid and regular diets. The overall length of hospital stay in the MIS group was decreased by 40% as well as a trend towards a 50% decrease in SICU stay. Additionally, there was 66% decrease in cardiac complications in the MIS group. When evaluating for oncologic adequacy as measured by number of lymph nodes and surgical resection margins, MIS surgery offered equivalent results as open resection. Furthermore, there was no significant difference in overall survival for MIS versus open colorectal surgery. Minimally invasive colorectal cancer resection leads to improved short-term outcomes as demonstrated by decreased length of hospital stay and faster return of bowel function. Additionally, there appears to be no difference in oncologic outcomes in the elderly. On the basis of our data, age alone should not be a contra-indication to laparoscopic colorectal cancer resection.

Octreotide

Octreotide

Removal of a self-knotted feeding jejunostomy tube in a patient with tongue base cancer

The knotting of an intragastric tube is a rare complication, and knotting of a feeding jejunostomy tube is rarer, and the removal or replacement of the tube is difficult. There are many reports on the removal of intragastric knotted tubes, but these methods cannot be applied for the removal of knotted feeding jejunostomy tubes, which do not have a natural orifice as large as the mouth to facilitate the introduction of instruments to correct the complication or remove the knotted tube. This is a stressful situation and doctors have to adopt strategies to resolve this problem safely and effectively in the absence of strong evidence-based knowledge. The author presents the case of a patient with tongue base cancer with a nasogastric feeding jejunostomy tube that knotted during the therapeutic course and describes a simple method to remove the knotted tube using Kelly clamps without additional invasive surgery. A literature review to elucidate methods for the removal of a self-knotted nasogastric tube, especially that occurring in feeding jejunostomy, is also reported.

Supracricoid laryngectomy: oncologic validity and functional safety

The objectives of this study are to elucidate the oncologic validity of the supracricoid laryngectomy (SCL) for locally advanced endolaryngeal cancers and as a salvage procedure, and to determine its safety in maintaining laryngeal physiology. The medical records of 114 patients that underwent SCL were reviewed. We examined whether the extended procedures, salvage procedure, adjuvant treatment, and type of reconstruction were associated with patient survival and the mean time of decannulation and nasogastric tube removal. Postoperative complications were investigated. There was no significant difference in survival according to the extent of the resection of the primary tumors and the presence or absence of previous treatment. However, the survival of patients that received radiation or concurrent chemoradiation after SCL was significantly lower than that of patients without any adjuvant treatment. Decannulation and nasogastric tube removal was possible for all except for two patients, and the mean time required was 18.4 and 26.1 days, respectively. The interval to starting oral feeding was significantly increased in cases that underwent cricohyoidopexy, an extended procedure, and salvage surgery compared to their counterparts. Pulmonary complications, particularly aspiration pneumonia, were the most common postoperative complications. The results of this study suggest that SCL was feasible for locally advanced laryngeal cancers and as a salvage procedure. Active and effective postoperative swallowing rehabilitation, particularly in cases that underwent cricohyoidopexy, an extended procedure, and salvage surgery, is needed to prevent aspiration pneumonia.

S1350 Efficacy of Nasal Bridles in Preventing Nasogastric Tube Displacement. the Royal Berkshire Experience

Introduction Rates of accidental removal of nasogastric feeding tubes (NGT) within hospital can reach up to 60% which exposes patients to risk from repeat procedures as well as consuming resources. Nasal bridles are not routinely used in the UK despite demonstrating a reduction in NGT removal rates, reducing the occurrence of unnecessary percutaneous gastrostomy (PEG) placements and increasing nutrition delivery. At the Royal Berkshire Hospital patients are deemed suitable for bridle placement if three or more NGT have been removed unintentionally, there is no history of nasal trauma and not so confused as to risk causing themselves nasal septal injury. All patients are assessed by a clinical nurse specialist. It is Trust policy to confirm all NGT placements with a chest x-ray. We audited our practice to assess whether bridles are effective and safe. Methods Database records for all patients referred for NG bridles between June 2007 and September 2009 were reviewed. Where additional information was required, case notes were obtained. Radiology exposure was also assessed. Results fifty-one patients were referred for bridle placement during the 27-month audit period. Median age was 72 years (range 36–90). Cerebrovascular accident was the most common reason for referral (82%). All patients had had at least 3 NGT placed prior to referral (median 3 range 3–8). 38 of the 51 patients (74.5%) had bridles attached using 39 devices in total. One patient required bridle replacement and only one experienced significant nasal trauma. The reasons for not placing a bridle included; 2 were too unwell, 6 were already eating, 3 refused and 2 were too difficult to place. Of these 5 went straight to PEG feeding. The 38 bridle patients received 308 days of NGT feeding (median 7 range 1–32). Of these only two required long-term PEG feeding and 21 were able to have their bridles removed as they were no longer required. Fifteen patients with bridles died for reasons unrelated to their bridle. An additional 147 chest x-rays had been used prior to referral while only one additional x-ray was required to confirm NGT position after bridle placement. Conclusion Bridle fixation reduces the number of NGT re-insertions, inappropriate PEG tubes and helps to prevent delay of nutrition restoration. They also reduce repeated radiation exposure from recurrent x-rays and overall hospital costs. Bridles have a very low incidence of complication and help reduce unnecessary PEG insertions in high-risk groups if patients are assessed carefully by trained staff.

PTH-055 Efficacy of nasal bridles in preventing nasogastric tube displacement. The Royal Berkshire experience

<h3>Introduction</h3> Rates of accidental removal of nasogastric feeding tubes (NGT) within hospital can reach up to 60% which exposes patients to risk from repeat procedures as well as consuming resources. Nasal bridles are not routinely used in the UK despite demonstrating a reduction in NGT removal rates, reducing the occurrence of unnecessary percutaneous gastrostomy (PEG) placements and increasing nutrition delivery. At the Royal Berkshire Hospital patients are deemed suitable for bridle placement if three or more NGT have been removed unintentionally, there is no history of nasal trauma and not so confused as to risk causing themselves nasal septal injury. All patients are assessed by a clinical nurse specialist. It is Trust policy to confirm all NGT placements with a chest x-ray. We audited our practice to assess whether bridles are effective and safe. <h3>Methods</h3> Database records for all patients referred for NG bridles between June 2007 and September 2009 were reviewed. Where additional information was required, case notes were obtained. Radiology exposure was also assessed. <h3>Results</h3> fifty-one patients were referred for bridle placement during the 27-month audit period. Median age was 72 years (range 36–90). Cerebrovascular accident was the most common reason for referral (82%). All patients had had at least 3 NGT placed prior to referral (median 3 range 3–8). 38 of the 51 patients (74.5%) had bridles attached using 39 devices in total. One patient required bridle replacement and only one experienced significant nasal trauma. The reasons for not placing a bridle included; 2 were too unwell, 6 were already eating, 3 refused and 2 were too difficult to place. Of these 5 went straight to PEG feeding. The 38 bridle patients received 308 days of NGT feeding (median 7 range 1–32). Of these only two required long-term PEG feeding and 21 were able to have their bridles removed as they were no longer required. Fifteen patients with bridles died for reasons unrelated to their bridle. An additional 147 chest x-rays had been used prior to referral while only one additional x-ray was required to confirm NGT position after bridle placement. <h3>Conclusion</h3> Bridle fixation reduces the number of NGT re-insertions, inappropriate PEG tubes and helps to prevent delay of nutrition restoration. They also reduce repeated radiation exposure from recurrent x-rays and overall hospital costs. Bridles have a very low incidence of complication and help reduce unnecessary PEG insertions in high-risk groups if patients are assessed carefully by trained staff.

The effect of arytenoid resection on functional results of cricohyoidopexy

Objective The aim of this study was to evaluate the influence of arytenoid resection on voice and swallowing function in patients who undergo supracricoid laryngectomy with cricohyoidopexy. Study Design A case series with chart review. According to the arytenoid number, patients were divided into two groups: 11 patients with two arytenoids and 9 patients with one arytenoid. The decannulation, nasogastric tube removal, and hospitalization times were noted. Maximum phonation time, average fundamental frequency, percent jitter, percent shimmer, and noise-to-harmonic ratio were measured. Grade, roughness, breathiness, asthenicity and strain scale (for the perceptual evaluation of vocal quality), Voice Handicap Index (for self-assessment of the voice), and dysphagia score were used. Results The mean decannulation, nasogastric tube removal, and hospitalization time was 18.4, 40.2, and 32.7 days in patients with one arytenoid, whereas 8.8, 20.8, and 25.3 days in patients with two arytenoids, respectively. The differences were statistically significant. For all of the parameters that are associated with voice function and dysphagia, there was no statistically significant difference between one arytenoid and two arytenoids. Conclusion Arytenoid resection may affect the swallowing function in the early postoperative period, but for voice and deglutition functions there was no difference between cricohyoidopexy with one arytenoid and two over the course of time.

Radical Cystectomy for Bladder Cancer: Morbidity of Laparoscopic Versus Open Surgery

We compared the morbidity and mortality of laparoscopic vs open surgery in radical cystectomy for bladder cancer. This prospective, nonrandomized study was conducted between January 2003 and July 2007 in 68 patients (7 women and 61 men) who underwent radical cystectomy for bladder cancer. A total of 38 cystectomies were performed laparoscopically and 30 by open surgery. Mean patient age was 68.0 +/- 9.0 years. Median preoperative American Society of Anesthesiologists score was 2 (range 1 to 3) in both groups. Intraoperative blood loss and transfusion rate were significantly lower in the laparoscopic surgery group. Postoperatively the incidence of minor complications and mortality were also significantly lower. Postoperative opioid consumption was significantly less in the laparoscopic surgery group in amount and duration. Resumption of oral fluid and solid intake as well as return to normal bowel function were significantly more rapid in the laparoscopic surgery group, and mean hospital stay was significantly shorter. Mean patient followup was 30.5 +/- 17.2 months. Laparoscopic radical cystectomy for bladder cancer has a lower morbidity rate than cystectomy by open surgery. It allows more rapid resumption of oral fluid and solid intake as well as return to normal bowel function and shorter hospital stay.

Gastrointestinal Tract Recovery in Patients Undergoing Bowel Resection

To investigate the efficacy and safety of alvimopan, 12 mg, administered orally 30 to 90 minutes preoperatively and twice daily postoperatively in conjunction with a standardized accelerated postoperative care pathway for managing postoperative ileus after bowel resection. This multicenter, randomized, placebo-controlled, double-blind, phase 3 trial enrolled adult patients undergoing partial bowel resection with primary anastomosis by laparotomy and scheduled to receive intravenous, opioid-based, patient-controlled analgesia. A standardized accelerated postoperative care pathway including early ambulation, oral feeding, and postoperative nasogastric tube removal was used to facilitate gastrointestinal (GI) tract recovery in all of the patients. The primary end point was time to GI-2 recovery (toleration of solid food and first bowel movement). Secondary end points included time to GI-3 recovery (toleration of solid food and first flatus or bowel movement), hospital discharge order written, and actual hospital discharge. Postoperative length of hospital stay based on calendar day of hospital discharge order written, opioid consumption, and overall postoperative ileus-related morbidity were recorded. Alvimopan, 12 mg, was well tolerated and significantly accelerated GI-2 recovery, GI-3 recovery, and actual hospital discharge compared with a standardized accelerated postoperative care pathway alone (hazard ratio = 1.5, 1.5, and 1.4, respectively; P < .001 for all). Time to hospital discharge order written as measured by hazard ratio (1.4) and by postoperative calendar days (mean for alvimopan, 5.2 days; mean for placebo, 6.2 days) was also accelerated. Opioid consumption was comparable between groups, and alvimopan was associated with reduced postoperative ileus-related morbidity compared with placebo. Alvimopan, 12 mg, administered 30 to 90 minutes before and twice daily after bowel resection is well tolerated, accelerates GI tract recovery, and reduces postoperative ileus-related morbidity without compromising opioid analgesia.

Timing of Roux-en-Y Limb Reconstruction for Pediatric Live Donor Liver Transplantation

Roux-en-Y (R-Y) hepaticojejunostomy is usually accepted as the standard method of choice for biliary reconstruction in pediatric cases though the potential risks for gastrointestinal complications are higher. In this study, we examined gastrointestinal complications in pediatric patients by comparing two different strategies of R-Y reconstruction with respect to the portal clampage time. Forty-three pediatric recipients who underwent Live Donor Liver Transplantation with R-Y for biliary reconstruction between March 2001 and December 2006 in our transplantation center were divided into two groups regarding the time of dissection and creation of the roux limb. R-Y limb reconstruction was performed before clampage of the portal vein in group A-preclampage group. In group B, because of prolonged catheterization period, R-Y limb was reconstructed after implantation of the graft (Group B- postclampage group). Overall, seven patients (16%) had gastrointestinal bleeding in the postoperative period, all in group B (0/20 vs. 7/23, P<0.01). One of those three cases who were diagnosed after endoscopy and one another were performed surgical treatment. Although remaining three cases had multiple bleeding episodes but no diagnostic findings by endoscopic/colonoscopic interventions, conservative treatment was successful and therefore, plausible R-Y limb bleeding was considered for these cases. The timing of removal of nasogastric tube and postoperative oral intake were also significantly earlier (P<0.01) in Group A than in Group B. In Live Donor Liver Transplantation, if recipient team may have enough time until the donor team got ready for the recovery of the graft, dissection and preparation of the R-Y limb should be performed. This approach can be helpful to avoid gastrointestinal complications due to the reconstruction of the R-Y limb.

Current strategies for preventing or ameliorating postoperative ileus: A multimodal approach

Internal and external factors that contribute to postoperative ileus (POI), the efficacy and safety of various nonpharmacologic and pharmacologic interventions that have been evaluated for the prevention or amelioration of POI, and the current multimodal approach used in patients undergoing major abdominal surgery are described. Catecholamine and cytokine release associated with the stress response to surgery and the use of certain antiemetic medications, opioid analgesics, and inhaled anesthetics are among the factors that contribute to POI. Early ambulation does not affect the duration of POI, although it has other benefits for patients undergoing abdominal surgery. Clinical experience supports the use of laparoscopy instead of laparotomy if possible, removal of nasogastric tubes shortly after surgery, restriction of intravenous fluids, and initiation of clear oral liquids and ambulation on the first postoperative day. The recommended therapeutic approach for patients undergoing major abdominal surgery involves thoracic epidural analgesia using a local anesthetic with or without an epidural opioid analgesic, and systemic nonsteroidal anti-inflammatory drugs for their opioid-sparing effect if systemic opioid analgesics are used. Buprenorphine may be preferred if a systemic opioid analgesic is used, because it has little effect on gastrointestinal smooth muscle. Metoclopramide, erythromycin, beta blockers, laxatives, neostigmine, naloxone, and gum chewing are not useful for treating POI. Most pharmacologic interventions that have been tried in an effort to prevent or ameliorate POI are ineffective or cause intolerable adverse effects. Research is needed to identify and develop new drug therapies for POI.

Effect of Tactile Stimulation on Lingual Motor Function in Pediatric Lingual Dysphagia

The study by Lamm et al. [1] consisted of 45 patients who did not swallow because of multiple congenital anomalies and gastroenterologic dysfunctions before and after corrective surgery and who also had histories of unsuccessful traditional feeding intervention. The purpose of their study was to ‘‘(1) isolate the specific regional mechanical functions of the tongue during swallowing; (2) identify the specific controlling variables that induce physiologic mechanical actions as varied tongue positions and tone during a swallow in young children fed through artificial means who had not swallowed food before treatment; (3) replicate (our) 26 preliminary results of inducing and maintaining a swallow reflex across a large number of young children with lingual dysphagia; and (4) provide an alternative procedure to surgical gastrostomy placement and removal of gastrostomy button or nasogastric tube.’’ The various procedures implemented were found to be ‘‘useful across the board for all patients with severe dysphagia.’’ The various procedures employed resulted in independent swallows in 96% or 43 of 45 of the patients studied, with 42 of the 45 patients also demonstrating a 100% transfer from gastrostomy or nasogastric tube feedings to oral hydration and nutrition. Lamm et al. concluded that the various procedures they implemented ‘‘although intense and lengthy in systematic components, yield prudent results in 5–7 days of inpatient treatment. They are feasible for patients with lingual dysphagia who do not swallow and for whom aspiration is a real danger. These outcomes provide an empiric preventative procedure to surgical gastrostomy placement and may facilitate the timely removal of a gastrostomy button and nasogastric tube in candidate patients.’’ The members of the Pediatric Swallowing Disorders and Oral Feeding Clinic programs at the Children’s Hospital, Denver, CO, were intrigued by Lamm et al. article [1]. The level of success detailed in the article in transforming nonoral feeders into full oral feeders over a five-day span is nothing short of astounding. To our knowledge it is not an achievement that is mirrored in other behavioral feeding programs currently operating within the United States nor is it an achievement that our own feeding program has been able to obtain. Despite the impressive outcomes described, there were aspects of this article that are of concern and/or contrary to our clinical experience for which we seek clarification, specifically: