Update on endoscopic enteral access

The Outcomes of Nutritional Support Techniques in Patients with Gastrointestinal Cancers

Gastrointestinal cancers represent a major cause of morbidity and mortality worldwide. A significant issue regarding the therapeutic management of these patients consists of metabolic disturbances and malnutrition. Nutritional deficiencies have a negative impact on both the death rates of these patients and the results of surgical or oncological treatments. Thus, current guidelines recommend the inclusion of a nutritional profile in the therapeutic management of patients with gastrointestinal cancers. The development of digestive endoscopy techniques has led to the possibility of ensuring the enteral nutrition of cancer patients without oral feeding through minimally invasive techniques and the avoidance of surgeries, which involve more risks. The enteral nutrition modalities consist of endoscopy-guided nasoenteric tube (ENET), percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrostomy with jejunal tube extension (PEG-J), direct percutaneous endoscopic jejunostomy (DPEJ) or endoscopic ultrasound (EUS)-guided gastroenterostomy.

Direct percutaneous endoscopic jejunostomy (DPEJ) and percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) technical success and outcomes: Systematic review and meta-analysis

Background and study aims  Endoscopic methods of delivering uninterrupted feeding to the jejunum include direct percutaneous endoscopic jejunostomy (DPEJ) or PEG with jejunal extension (PEG-J), validated from small individual studies. We aim to perform a meta-analysis to assess their effectiveness and safety in a variety of clinical scenarios. Methods  Major databases were searched until June 2021. Efficacy outcomes included technical and clinical success, while safety outcomes included adverse events (AEs) and malfunction rates. We assessed heterogeneity using I ² and classic fail-safe to assess bias. Results  29 studies included 1874 patients (983 males and 809 females); mean age of 60 ± 19 years. Pooled technical and clinical success rates with DPEJ were 86.6 % (CI, 82.1-90.1, I ² 73.1) and 96.9 % (CI, 95.0-98.0, I ² 12.7). The pooled incidence of malfunction, major and minor AEs with DPEJ were 11 %, 5 %, and 15 %. Pooled technical and clinical success for PEG-J were 94.4 % (CI, 85.5-97.9, I ² 33) and 98.7 % (CI, 95.5-99.6, I ²  < 0.001). The pooled incidence of malfunction, major and minor AEs with DPEJ were 24 %, 1 %, and 25 %. Device-assisted DPEJ performed better in altered gastrointestinal anatomy. First and second attempts were 87.6 % and 90.2 %. Conclusions  DPEJ and PEG-J are safe and effective procedures placed with high fidelity with comparable outcomes. DPEJ was associated with fewer tube malfunction and failure rates; however, it is technically more complex and not standardized, while PEG-J had higher placement rates. The use of balloon enteroscopy was found to enhance DPEJ performance.

Diagnostic accuracy of end-tidal carbon dioxide detection in determining correct placement of nasogastric tube: An updated systematic review with meta-analysis

BACKGROUND

Misplacement of the nasogastric tube in the respiratory tract could cause serious complications and even death. Thus, nasogastric tube verification is necessary for optimal patient safety and comfort. Although end-tidal carbon dioxide detection is considered an effective approach to determine nasogastric tube location, there is a paucity of up-to-date evidence.

OBJECTIVES

To review the diagnostic accuracy of end-tidal carbon dioxide detection in determining inadvertent airway intubation and verifying correct placement of nasogastric tubes.

DESIGN

A systematic review and meta-analysis.

METHODS

We searched clinical trials that evaluated the diagnostic accuracy of colorimetric capnometry or capnography in detecting nasogastric tubes located in the airway and differentiating between inadvertent airway intubation and correct nasogastric tube placement in any adult care setting. Four English language databases - Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and CINAHL - and four Chinese language databases - China Biomedical Literature Database, WanFang Data, China National Knowledge Infrastructure, and Airiti Library - were searched from July 2009 to March 2021. Clinical trial registration databases and reference lists of included studies and relevant reviews were also searched. Two reviewers extracted the data of all included studies using a data extraction form. Two reviewers assessed the methodological quality independently with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. We conducted meta-analysis using the hierarchical bivariate model and estimated the pool sensitivity and specificity of capnography and colorimetric capnometry. Forest plots were generated to display the results. Heterogeneity was investigated by meta-regression. The certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluations framework.

RESULTS

Of 1,155 records identified, seven new studies were added to this update and a total of 16 studies were analysed in the systematic review. The total absolute number of true positive, false negative, true negative, and false positive observations were 142, 6, 1,500, and 65 respectively. Low to very low certainty of evidence indicated that the use of colorimetric capnometry or capnography is potentially an effective method in differentiating between respiratory and nasogastric tube placement for critically ill adult patients. Pooled results (13 studies, 1,541 intubations) for sensitivity and specificity were 0.96 (95% confidence interval [0.88, 0.99]) and 0.99 (95% confidence interval [0.96, 1.00]), respectively.

CONCLUSIONS

Colorimetric capnometry and capnography may have the potential to be of high sensitivity and specificity for the detection of inadvertent airway nasogastric tube placements in critically ill adults. More evidence is required to generalize the updated findings to different types of patients and settings.