Endoscopic intervention for enteral access

Endoscopic Enteral Access

Various approaches for enteral access exist, but because there is no single best approach it should be tailored to the needs of the patient. This article discusses the various enteral access techniques for nasoenteric tubes, gastrostomy, gastrojejunostomy, and direct jejunostomy as well as their indications, contraindications, and pitfalls. Also discussed is enteral access in altered anatomy. In addition, complications associated with these endoscopic techniques and how to either prevent or properly manage them are reviewed.

Role of Enteral Nutrition in Advanced Cancer Patients: Indications and Contraindications of the Different Techniques Employed

Over the last 20 years there has been great progress regarding total parenteral nutrition and enteral nutrition for patients who cannot take food by mouth or cannot swallow, or so that controlled feeding can be established in anorexic and malnourished patients. The use and the role of artificial nutrition is still controversial in advanced cancer patients. Such controversies often are due to the fact that these patients have a survival expectancy that varies from one to several months. The present review describes the most frequent techniques used for enteral nutrition (nasoenteral tubes, gastrostomy and jejunostomy), their indications, contraindications and complications, and gives an indication regarding which patients may really benefit from enteral nutrition taking into consideration not only the potential advantages but also the discomfort and distress related to enteral nutrition and the different techniques that are employed.

Supportive therapy of elderly cancer patients

Elderly cancer patients often require supportive care due to the physiologic decline of organs and apparatus linked with the aging process per se, and for the effects of tumor or of anticancer treatments. Pain and nutritional deficits are some clinical aspects requiring supportive care. Lack of studies on these latter topics does not allow an in depth analysis of the problem. The present review deals with literature concerning pain and nutritional problems in the general cancer population with emphasis on aspects typical for elderly cancer subjects. Physiologic and cancer-related changes in body composition, physical function and cognitive capacity of the elderly are presented and, when appropriate, linked with pathogenetic factors of pain and malnutrition, as well as their treatment. Pain demographic data, pain intensity evaluation and currently available techniques to provide pain relief such as etiologic treatment, analgesic pharmacotherapy and invasive analgesic procedures, are extensively discussed. Causes and assessment of malnutrition as well as available nutritional approaches such as oral, enteral and parenteral nutrition are also debated.

Spontaneous transpyloric migration of a ballooned nasojejunal tube: a randomized controlled trial

BACKGROUND

Spontaneous transpyloric migration of a simple nasojejunal tube (NJT) can be expected in only one-third of insertions. Guidance of the tube by radiologic or endoscopic maneuvers is usually required. We believed that locating a 5-mL balloon near the tip of an NJT on which natural peristalsis could act would improve the rate of spontaneous transpyloric migration and facilitate small bowel propagation.

METHODS

Thirty healthy volunteers were randomly assigned to have an inflated or noninflated, ballooned NJT fashioned from a modified 9F Hickman line catheter inserted. The pH of aspirates was measured hourly and the final location of the tube assessed by gastrografin contrast abdominal x-ray (AXR) at the end of 6 hours, at which time the tube was removed.

RESULTS

After 6 hours, spontaneous transpyloric migration occurred in 86.6% of the ballooned and 66.6% of the nonballooned tubes. The final disposition of the ballooned tubes was: stomach, 2 (13.3%); duodenum, 1 (6.7%); and small bowel, 12 (80%). The final disposition of the nonballooned tubes was: stomach, 5 (33%), NS; duodenum, 9 (60%), p < .05; and small bowel, 1 (6.7%), p < .05.

CONCLUSIONS

Ballooned NJT have a higher rate of spontaneous transpyloric migration and are significantly more likely to achieve an optimal small bowel location.

Maximizing tolerance of enteral nutrition in severely injured trauma patients: a comparison of enteral feedings by means of percutaneous endoscopic gastrostomy versus percutaneous endoscopic gastrojejunostomy

BACKGROUND

Intolerance of enteral nutrition interrupts caloric balance and increases hospital costs. This study proposes that enteral feeding by percutaneous endoscopic gastrojejunostomy (PEGJ) provides continuous uninterrupted nutrition with greater consistency than percutaneous endoscopic gastrostomy (PEG).

METHODS

This prospective nonrandomly assigned study was conducted at a Level I trauma center from December of 1997 through October of 1998. All feeding tubes were placed by trauma/critical care surgeons for nutritional support. Feeding course was monitored for 14 days from time of tube placement. Demographic data and outcome variables compared were age, sex, Injury Severity Score, Abbreviated Injury Score, hospital length of stay, number of days to reach nutritional goal feedings, caloric goal, protein goal, cc/hr at goal, total parenteral nutrition usage, complications, and hospital charges. Statistical analyses used the independent samples t test, Cox regression, and Pearson chi2 with significance level set at 0.05.

RESULTS

Patients receiving enteral nutrition by PEGJ reached nutritional goal sooner than patients who received enteral nutrition by PEG (p = 0.02). Thirty-seven of 46 PEGJ patients (80%) were at goal rate at day 3, whereas 28 of 43 PEG patients (65%) were at goal on day 3. Nine of 43 PEG patients (21%) and 3 of 46 PEGJ patients (7%) failed to reach goal within 14 days.

CONCLUSION

This study suggests that enteral nutrition delivered by means of PEGJ is better tolerated than enteral nutrition delivered by means of PEG in trauma patients with no abdominal conditions that preclude percutaneous feeding tube placement.

Postpyloric enteral feeding costs for patients with severe head injury: blind placement, endoscopy, and PEG/J versus TPN

This study describes the advantages and disadvantages of several forms of enteral nutrition for patients with severe head injury (Glasgow Coma Scale Score [GCS], <12). Included in the study are nasoenteric nutrition delivery using blind, endoscopic, percutaneous endoscopic gastrostomy (PEG) and PEG with jejeunostomy (PEG/J), and open jejeunostomy tube placement methods. These methods are compared with parenteral delivery of nutrition. The study constituted a retrospective analysis of the success rate of early enteral feedings by blind, endoscopic PEG and PEG/J and by open jejeunostomy placement of small-bowel feeding tubes for 57 patients with severe head injury. The delivery cost of enteral nutrition per intensive care unit day was compared to the delivery cost of parenteral nutrition per intensive care unit day in the same group of patients. Fifty-three percent of patients were adequately maintained nutritionally with nasoenteric delivery alone and did not require parenteral feeding. The average number of days for initiation of either enteral or parenteral feedings was 1.8 +/- 0.2 days from injury [standard error of mean (SEM); range, 0-10 days]. An average of 3.3 days (range, 0-23 days) was required for feeding tube placement in all patients. For 70% of patients, tube placement was completed within 48 h after injury. Full-strength, full-rate enteral feedings were achieved by a mean of 4.9 days after injury. A total of 128 feeding tubes were placed while the patients were in the intensive care unit (ICU; 2.2 +/- 0.2 tubes per patient). Blind placement of feeding tubes into the small bowel was rarely achieved without repositioning. Endoscopic tube placement into the duodenum was achieved in 50% of patients, into the jejunum for 33% of patients, and into the stomach for 18% of patients. While in the intensive care unit, patients received an average of 77 +/- 2% of their measured energy expenditure (range, 57-114%). Eleven percent of patients experienced severe gastrointestinal problems. Other problems were associated with the inability to achieve or maintain access: dislodged tubes (30%), clogged or kinked tubes (21%), and mechanical access problems (7 %). Seventy-one percent of patients in barbiturate coma were able to tolerate early nasoenteric feedings. Aspiration pneumonitis occurred equally among patients fed nasogastrically and those fed nasoenterically. The overall aspiration rate was 14%. The cost of acute enteral feeding was $170 per day and that for parenteral feeding, $308 per day. We conclude that blind transpyloric feeding tube placement is difficult to achieve in patients with severe head injury; endoscopically guided placement is a better option. Endoscopic feeding tube placement most consistently allows for early enteral nutritional support in severe head injured patients. Limitations include the inability to establish and/or maintain enteral access, increased intracranial pressure, unstable cervical spinal injuries, facial fractures, and dedication of the physician to tube placement and monitoring.

Percutaneous endoscopic gastrostomy in paediatric practice: complications and outcome

PURPOSE

The aim of this study was to establish the morbidity and mortality of percutaneous endoscopic gastrostomy (PEG) in a tertiary referral paediatric practice and to identify risk factors for developing complications after a PEG.

METHODS

The medical records of all patients who had a percutaneous endoscopic gastrostomy attempted over a 5-year period (1990 to 1995) were reviewed.

RESULTS

One hundred thirty percutaneous gastrostomies were placed in 120 paediatric patients. Indications for insertion were inability to swallow (n = 74, of which, 52 were neurologically impaired), inadequate calorie intake (n = 30), special feeding requirements (n = 12), continuous enteral feeding in short gut (n = 2), and malabsorption (n = 2). All the children had complex medical problems, and 80% of the patients were rated as "high risk" for general anaesthesia (> or = ASA grade 3). Major complications developed in 21 children (17.5%) and minor complications in 27 (22.5%). Of the 17 children in whom gastroesophageal reflux (GOR) became symptomatic, 10 required a Nissen fundoplication. Nine of these 10 children were neurologically impaired (19% of the neurologically impaired children). One postrenal transplant patient on immunosuppression died 54 days after the procedure of intraabdominal sepsis. Thirty-one patients required secondary surgical procedures.

CONCLUSIONS

PEG is associated with significant morbidity. Neurologically impaired children are at risk of acquiring symptomatic GOR, but the risk does not warrant routine fundoplication. Major complications are common and need urgent surgical consultation with many requiring secondary surgical procedures. PEG in paediatric patients should be considered a major surgical undertaking.

Therapeutic strategies for motility disorders. Medications, nutrition, biofeedback, and hypnotherapy

Gastrointestinal motility is regulated by a complex balance of inhibitory and excitatory neuronal, humoral, and mechanical factors. The goal in the management of motility disorders is to maintain adequate nutrition while decreasing symptoms. This can be accomplished by medications and support of nutrition and biofeedback; the application of these therapeutic strategies to patients with gut motility disorders is reviewed.

Surgical palliation of head and neck cancer

Palliative care in head and neck cancer has not been studied systematically. Patients with incurable head and neck tumors may live months and even years. Ideal palliation should enable them to engage in a normal life before death ensues. It is likely that our improving ability to treat these tumors without achieving cures will cause people to live longer with their cancer. Hence, the need for palliation will probably increase. Also, treatments that cure patients produce conditions that require palliation. Achievement of the best possible function is the major consideration in dealing with head and neck tumors. Difficulty with speech, swallowing, oral hygiene, and laodorous tumors are all common. Depression too should be addressed in a comprehensive fashion by the "head and neck team". The surgeon, radiotherapist, and medical oncologist will need help from dentists, prosthodontists, dental hygienists, psychiatrists, physiatrists, occupational and physical therapists, visiting nurses, nutritionists, and social workers. Palliative care in the hospital is the least desirable, although often unavoidable. Proper hospice support will benefit patients and their families.

Laparoscopic procedures for small bowel disease

Small bowel procedures such as placement of feeding jejunostomy, diagnosis of small bowel ischaemia and obstruction, bowel resection and lysis of adhesions can all be performed laparoscopically. Diagnostic laparoscopy can be performed with low complication rates, and can help avoid unnecessary laparotomy. The open method of trocar placement is preferred in patients with adhesions or distended bowel due to obstruction or ileus. Feeding jejunostomy can be placed by laparoscopically assisted methods, pulling the jejunum out or completely laparoscopically. The latter requires fixation of the jejunum to the abdominal wall by transabdominal sutures or T-fasteners. The T-fastener technique for feeding jejunostomy is simple to perform, safe and effective. Small bowel ischaemia can be difficult to diagnose laparoscopically. Fluorescein and ultrasound Doppler examination of the small bowel may be as useful as in laparotomy, but there is little clinical experience with these techniques. Laparoscopically assisted small bowel resection involves intraperitoneal division of the mesenteric vessels and exteriorization of the small bowel through a small abdominal incision, followed by resection and anastomosis. The causes of small bowel obstruction can be diagnosed laparoscopically, and adhesions can be lysed under laparoscopic guidance. The laparoscopic approach is replacing laparotomy for many small bowel procedures. Improvements in instruments and experience in laparoscopic procedures will continue to make these procedures easier and safer to perform.

Gastrostomy techniques and devices

Gastrostomies play an important role in the management of a wide variety of surgical and nonsurgical conditions of childhood. Many techniques and gastrostomy devices are available. In our experience, percutaneous endoscopic gastrostomy has proved safe and effective, and the gastrostomy button has eliminated most of the catheter-related problems. Candidates for gastrostomy, particularly children with foregut dysmotility, must be carefully selected, undergo preoperative studies aimed at determining the degree of gastroesophageal reflux, and have appropriate long-term follow-up. Attention to technical detail is essential to avoid operative complications. A good working relationship between the surgeon, gastroenterologist, nurse, and patient's family is essential to minimize long-term morbidity, particularly stoma-related problems.