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Nishiwaki S, Kurobe T, Baba A, Nakamura H, Iwashita M, Adachi S, Hatakeyama H, Hayashi T, Maeda T. Prognostic outcomes after direct percutaneous endoscopic jejunostomy in elderly patients: comparison with percutaneous endoscopic gastrostomy. Gastrointest Endosc 2021; 94:48-56. [PMID: 33383037 DOI: 10.1016/j.gie.2020.12.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 12/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Direct percutaneous endoscopic jejunostomy (DPEJ) is an alternative method of enteral feeding to percutaneous endoscopic gastrostomy (PEG). Although long-term outcomes of PEG have been reported, little is known regarding the outcomes of DPEJ. METHODS A retrospective cohort study was conducted including 115 and 651 consecutive attempts of DPEJ and PEG, respectively, in a total of 766 elderly patients between April 2004 and March 2019. Patients' clinical background, procedural and long-term outcomes, survival analysis, and cause of death were analyzed. RESULTS Successful placement rates were 93.9% and 97.1% for DPEJ and PEG, respectively. There was no significant difference in procedure-related adverse events (AEs) between the DPEJ and PEG groups. Rates of pneumonia, vomiting, and upper GI bleeding were significantly lower, whereas those of fistula enlargement and ileus were significantly higher in the DPEJ group as long-term AEs. The median survival periods were 694 and 734 days for DPEJ and PEG, respectively, with no significant differences between the 2 groups. Multivariate analysis revealed that age 80 years old or older, C-reactive protein level of 1.0 mg/dL or higher, and the presence of diabetes were independent risk factors for mortality after DPEJ. Respiratory tract infection was the primary cause of death in both groups. CONCLUSIONS DPEJ is considered a safe and feasible method of access for enteral feeding as well as PEG. Although the survival period after DPEJ may be expected to be as long as that with PEG, DPEJ-specific AEs should be kept in mind on long-term feeding.
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Affiliation(s)
- Shinji Nishiwaki
- Department of Internal Medicine, Nishimino Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan; Department of Internal Medicine, Ibi Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan
| | - Takuya Kurobe
- Department of Internal Medicine, Nishimino Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan
| | - Atsushi Baba
- Department of Internal Medicine, Nishimino Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan
| | - Hironori Nakamura
- Department of Internal Medicine, Ibi Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan
| | - Masahide Iwashita
- Department of Internal Medicine, Nishimino Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan
| | - Seiji Adachi
- Department of Gastroenterology, Gihoku Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan
| | - Hiroo Hatakeyama
- Department of Internal Medicine, Nishimino Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan; Department of Internal Medicine, Ibi Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan
| | - Takao Hayashi
- Department of Internal Medicine, Nishimino Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan
| | - Teruo Maeda
- Department of Internal Medicine, Nishimino Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan
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Nishiwaki S, Fujimoto H, Kurobe T, Baba A, Iwashita M, Hatakeyama H, Hayashi T, Maeda T. Use of a Low-carbohydrate Enteral Nutrition Formula with Effective Inhibition of Hypoglycemia and Post-infusion Hyperglycemia in Non-diabetic Patients Fed via a Jejunostomy Tube. Intern Med 2020; 59:1803-1809. [PMID: 32461526 PMCID: PMC7474979 DOI: 10.2169/internalmedicine.4465-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective As direct jejunal feeding often causes great fluctuation in glucose levels, continuous or slow infusion is recommended for jejunal tube-fed patients. However, continuous feeding results in prolonged immobility and the loss of activities of daily living. We investigated whether or not intermittent feeding of a low-carbohydrate high-monounsaturated fatty acid (LC/HM) nutrient formula reduces glucose fluctuation in patients who have undergone jejunotomy. Methods Ten bed-ridden non-diabetic patients receiving enteral feeding via a jejunostomy tube were enrolled in this study. LC/HM formula and standard control formula were infused in cross-over order for each patient at a speed of 160 kcal/h. Blood glucose levels were monitored by a continuous glucose monitoring system during the investigation period. Results The mean and standard deviation of the glucose concentrations and mean amplitude of glucose excursion (MAGE) were markedly lower while receiving LC/HM formula than while receiving control standard formula (104 vs. 136 mg/dL, 18.1 vs. 58.1 mg/dL, 50.8 vs. 160 mg/dL, respectively). The post-infusion hyperglycemia [area under the curve (AUC) >140 mg/dL] and peak value of the glucose level were also significantly lower in patients fed LC/HM than the control (25.7 vs. 880 mg・h/dL and 153 vs. 272 mg/dL, respectively). Reactive hypoglycemia (AUC <70 mg/dL) was also significantly lower (0.63 vs. 16.7 mg・h/dL) and the minimum value of the glucose level higher (78.4 vs. 61.8 mg/dL) in patients fed LC/HM than the control. Conclusion The LC/HM formula is considered to markedly inhibit glycemic spikes and prevent rebound hypoglycemia in patients who receive enteral feeding after jejunostomy.
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Affiliation(s)
- Shinji Nishiwaki
- Department of Internal Medicine, Nishimino Kosei Hospital, Japan
| | | | - Takuya Kurobe
- Department of Internal Medicine, Nishimino Kosei Hospital, Japan
| | - Atsushi Baba
- Department of Internal Medicine, Nishimino Kosei Hospital, Japan
| | | | - Hiroo Hatakeyama
- Department of Internal Medicine, Nishimino Kosei Hospital, Japan
| | - Takao Hayashi
- Department of Internal Medicine, Nishimino Kosei Hospital, Japan
| | - Teruo Maeda
- Department of Internal Medicine, Nishimino Kosei Hospital, Japan
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Abstract
The use of intravenous nutritional support has increased dramatically in the last 20 years. Although it is not without controversy, administration of nutritional support is common practice in hospitalized patients including critically ill patients. Malnutrition continues to be reported in a significant number of hospitalized patients. The incidence of malnutrition in critically ill patients may be even higher than that reported in hospitalized patients overall. The consequences of malnutrition in a critically ill patient may be severe. Nutritional assessment and nutritional support can present special challenges to the intensivist. Techniques of nutritional assessment in critically ill patients are evaluated. Guidelines for the determination of the nutritional needs of these patients are outlined. Methods of delivery of nutritional support in critically ill patients are reviewed. Complications of nutritional support are discussed.
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Affiliation(s)
- Diana S. Dark
- From the Medical Education Department, St. Luke's Hospital, 4400 Wornall Road, Kansas City, MO 64111
| | - Susan K. Pingleton
- From the Medical Education Department, St. Luke's Hospital, 4400 Wornall Road, Kansas City, MO 64111
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Arnal E, Voiglio EJ, Robert M, Schreiber V, Ceruze P, Caillot JL. [Laparoscopic Janeway gastrostomy: an advantageous solution for self-sufficient enteral feeding]. ANNALES DE CHIRURGIE 2005; 130:613-7. [PMID: 16043114 DOI: 10.1016/j.anchir.2005.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2005] [Accepted: 05/20/2005] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Laparoscopic gastrostomy according to Janeway (LGJ) is an alternative to percutaneous gastrostomy techniques. METHODS A series of 10 LGJ is reported. The laparoscopic technique involves an isoperistaltic tube of 6-7 cm of length and 10-12 mm of diameter is created by 2 applications of linear stapling and cutting device. The tube is led out, opened and fixed to the fascial and cutaneous planes and a Foley catheter is inserted. RESULTS Mean operation time was 35 minutes. There was no complication. The LGJ was indicated in 9 patients with tumour of the pharynx and 1 patient with encephalopathy. CONCLUSION The main drawback of the LGJ is the need of general anaesthesia. The main advantage is the creation by minimal invasive surgery of a permanent gastrostomy equipped with a removable catheter easily changeable by non specialized health professionals, and even by the patient himself.
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Affiliation(s)
- E Arnal
- Service d'urgence chirurgicale, centre hospitalier Lyon-Sud, chemin du Petit-Revoyet, 69495 Pierre-Bénite, France
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Hsu TC, Leu SC, Su CF, Huang PC, Tsai LF, Tsai SL. Assessment of intragastric pH value changes after early nasogastric feeding. Nutrition 2000; 16:751-4. [PMID: 10978856 DOI: 10.1016/s0899-9007(99)00246-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Studies have suggested that early feeding after injury decreases morbidity and mortality. Few reports, however, have focused on the change in pH inside the stomach after early tube feeding. The aim of the present study was the assessment of 1) the change in intragastric pH after surgery, and 2) the effect of early nasogastric tube feeding on intragastric pH value. From April 1997 to February 1998, 80 patients who underwent colon resection for colorectal cancer by a single surgeon entered the study and were randomized into four groups. Twenty patients (group I) were kept on NPO for 1 wk, and 20 patients per group (groups II, III, and IV) were fed through a nasogastric tube from the second to the seventh postoperative day with low-residual (Osmolite HN), high-fat (Pulmocare), and glutamine-containing (AlitraQ) enteral formulas. Feeding started at 500 kcal/500 cc/d. If the patient tolerated the formula well, feeding increased to 1500 kcal/1500 cc(-1)/d(-1) the following day. Intragastric pH was measured preoperatively and then twice daily until the sixth postoperative day. The pH value of intragastric juice increased significantly once feeding started (3. 67 +/- 1.33 on the third postoperative day; 4.28 +/- 1.26 on the six postoperative day). The pH value seemed only mildly affected by the patient's tolerance for tube feeding (poorly tolerated group, pH 3. 52 +/- 1.75 versus 3.75 +/- 1.21 in the well-tolerated group on the third postoperative day; poorly tolerated group, pH 3.67 +/- 1.02 versus 4.45 +/- 1.27 in the well-tolerated group on the sixth postoperative day). The pH value of intragastric juice was higher in group II than in groups III and IV (4.51 +/- 1.57, 3.90 +/- 1.20, 4. 42 +/- 0.89 respectively, on the sixth postoperative day). This series suggests that early nasogastric feeding can significantly elevate the intragastric pH value in patients after resection of colorectal cancer. Nasogastric feeding may decrease the incidence of stress ulceration by elevating the pH value of intragastric juice.
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Affiliation(s)
- T C Hsu
- Nutrition Support Service, Mackay Memorial Hospital, Taipei, Taiwan.
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7
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Holmes JH, Brundage SI, Yuen P, Hall RA, Maier RV, Jurkovich GJ. Complications of surgical feeding jejunostomy in trauma patients. THE JOURNAL OF TRAUMA 1999; 47:1009-12. [PMID: 10608526 DOI: 10.1097/00005373-199912000-00004] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the complication rate of feeding jejunostomy (FJ) performed as an adjunct to trauma celiotomy. METHODS Retrospective analysis of 222 patients from January of 1988 to May of 1998. RESULTS Thirty-seven total FJ-related complications occurred in 22 patients (10%). Major FJ-related complications occurred in nine patients (4%): two small bowel perforations, two small bowel volvuli with infarction, two intraperitoneal leaks, and three small bowel necroses. Patients suffering major FJ-related complications were similar to those without complications, except for the FJ type. Patients with major FJ-related complications were more likely to have had a Witzel tube jejunostomy than a needle catheter jejunostomy (p = 0.03). Three deaths were related to major FJ complications, for a FJ-related mortality rate of 1.4%. CONCLUSIONS FJ has a major complication rate of 4% in severely injured patients. Major complications occur more frequently with larger, Witzel-type tubes. Needle catheter jejunostomy appears to be a safer method of surgical jejunal access in trauma patients.
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Affiliation(s)
- J H Holmes
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
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Abstract
The enteral route is the preferred method of nutritional support in patients with functional gastrointestinal tracts. Many techniques for obtaining enteral access are available, and the decision regarding which one to use depends on several issues, including the functional integrity of each part of the gastrointestinal tract, the duration of anticipated nutritional support, and the risk of aspiration and gastroesophageal reflux. Nasoesophageal tubes are useful for short-term supplementation; however, patients needing nutritional support for longer than 2 weeks may be better served with a more permanent tube. Blenderized pet food diets are recommended for nutritional support because these diets do not need to be supplemented with protein or micronutrients. Commercial human enteral formulas provide a useful alternative for patients with specific nutrient requirements or for feeding via nasoesophageal or jejunostomy tubes.
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Affiliation(s)
- S L Marks
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, USA
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Dassonville JM. Nutrition artificielle et agression : quelles méthodes d'apport et de surveillance? NUTR CLIN METAB 1998. [DOI: 10.1016/s0985-0562(98)80005-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Pulmonary aspiration of gastric contents can cause a spectrum of sequelae that spans from relatively minor to rapidly lethal disease. To emphasize the extent of this spectrum and to encompass both noninfectious complications and infection, we use the term “aspiration-induced pulmonary injury” rather than “aspiration pneumonia.” In this article we review the relevant literature, focusing on more recent insights into the pathogenesis of lung injury, the natural history of aspiration, risk factors, the relationship between aspiration and infection, and recommendations for management. The relevance to human disease of studies using intra-airway acid instillation in animals is questioned. We discuss the difficulties in predicting the clinical course after aspiration. We identify risk factors for aspiration-induced pulmonary injury that are commonly encountered in the intensive care unit, and discuss in detail factors of special interest to the intensivist, including the impact of tracheal intubation; the effects of enteric intubation, particularly the comparison between pre- and postpyloric routes of enteric feeding administration; and the relative risks associated with particular feeding protocols. We conclude with recommendations regarding treatment and prevention strategies.
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Affiliation(s)
- Judith E. Nelson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Marvin Lesser
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY
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Abstract
Comprehensive care of patients in hospitals includes assessment of nutritional status and provision of appropriate support. This approach is facilitated by knowledge of the essential differences in metabolism between starved and stressed states. Nutritional assessment and care of patients in a hospital are based on answers to the following questions: Who gets it? When do they get it? How much do they get? What route is used to administer it? What kind do they get? What are common complications of enteral and parenteral support? What nutritional aspects are pertinent to common diseases?
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Affiliation(s)
- B A Mizock
- Department of Medicine, Cook County Hospital, Chicago, Illinois, USA
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12
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Beier B, Bergman EA, Morrissey MJ. Factors related to the use of early postoperative enteral feeding in thoracic and abdominal surgery patients in the United States. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION 1997; 97:293-5. [PMID: 9060947 DOI: 10.1016/s0002-8223(97)00075-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- B Beier
- Department of Family and Consumer Sciences, Central Washington University, Ellensburg 98926-7565, USA
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13
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Crowe DT, Devey JJ. Clinical Experience With Jejunostomy Feeding Tubes In 47 Small Animal Patients. J Vet Emerg Crit Care (San Antonio) 1997. [DOI: 10.1111/j.1476-4431.1997.tb00040.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cech AC, Morris JB, Mullen JL, Crooks GW. Long-term enteral access in aspiration-prone patients. J Intensive Care Med 1995; 10:179-86. [PMID: 10155182 DOI: 10.1177/088506669501000404] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Aspiration pneumonia is a serious complication of enteral feeding. Many critically ill patients are particularly at risk for aspiration. Few studies have rigorously compared various access devices. Risk factors for aspiration and studies examining aspiration associated with enteral feeding devices are reviewed. We recommend a surgical jejunostomy for all patients at high risk for aspiration who require more than 3 weeks of enteral nutrition support.
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Affiliation(s)
- A C Cech
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA
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15
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Beau P. Nutrition entérale pré et postopératoire en chirurgie réglée de l'adulte. Techniques, avantages et inconvénients. NUTR CLIN METAB 1995. [DOI: 10.1016/s0985-0562(95)80017-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Parasher VK, Abramowicz CJ, Bell C, Delledonne AM, Wright A. Successful placement of percutaneous gastrojejunostomy using steerable glidewire--a modified controlled push technique. Gastrointest Endosc 1995; 41:52-5. [PMID: 7698625 DOI: 10.1016/s0016-5107(95)70275-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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17
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Beau P. [Pre- and post-operative enteral nutrition in elective surgery in adults. Techniques, advantages and adverse effects]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1995; 14 Suppl 2:121-6. [PMID: 7486328 DOI: 10.1016/s0750-7658(95)80111-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This review examined the techniques for enteral nutrition (routes and methods of administration and choice of enteral diets) in the perioperative period of elective surgery in adults. Only few controlled studies have assessed the efficiency of techniques according to the indication of enteral feeding (pre or postoperative period, digestive or non-digestive surgery). The nasogastric tube remains the most appropriate method to deliver short-term enteral feeding during the preoperative period. Today percutaneous endoscopic gastrotomy is the preferred method of gastrostomy. It is indicated in long term enteral nutrition, for example in the perioperative period of cancer surgery of head and neck. In the postoperative period of digestive surgery, intrajejunal feeding is usually delivered by a surgical jejunostomy or by a nasojejunal tube. Controlled studies comparing these two methods are still lacking. An important limitation of intrajejunal feeding is the poor tolerance of enteral diet during the first postoperative days after major upper abdominal surgery. The choice of enteral diet in the perioperative period remains controversial. There is no clinical evidence to support the hypothesis that the use of pre-digested diets in jejunostomy feeding has a better nutritional benefit and a better tolerance than polymeric diets. Small peptides offer some metabolic advantages, however, the clinical superiority of these nutrients over polymeric diets is not definitively proven. Continuous administration of enteral nutrition is usually required in case of jejunal feeding. In the other cases, some data suggest that enteral nutrition is more efficient using an intermittent feeding regimen.
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Affiliation(s)
- P Beau
- Service d'Hépatogastroentérologie et d'Assistance Nutritive et Centre Agréé de Nutrition Parentérale à Domicile, CHU, Poitiers
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MacFadyen BV, Ghobrial R, Catalano M, Raijman I. Concomitant placement of percutaneous endoscopic gastrostomy and jejunostomy. Surg Endosc 1992; 6:289-93. [PMID: 1448749 DOI: 10.1007/bf02498862] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Percutaneous endoscopic gastrostomies have gained wide use for long-term enteral nutrition. However, gastroesophageal reflux and aspiration pneumonia have occurred following this procedure. Initial enthusiasm concerning the ability of intrajejunal feeding to negate the risk of aspiration has been challenged by some reports. In this report, a new method is described for concomitant placement of endoscopic gastrostomy and feeding jejunostomy wherein the tip of the feeding jejunostomy is placed at least 40 cm distal to the pylorus while the gastrostomy tube is used for drainage. Twenty critically ill patients underwent the procedure utilizing general or local anesthesia. Sixty-day follow-up showed one uneventful episode of pulmonary aspiration (5%) after retrograde migration of the jejunal tube into the duodenum. All but two patients (90%) tolerated their tube feedings well. This technique can be easily performed with accurate placement of the PEJ tube distal to the pylorus and is associated with minimal risk of aspiration.
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Affiliation(s)
- B V MacFadyen
- Department of Surgery, University of Texas Medical School, Houston 77030
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Abstract
Nutrient deprivation has previously been shown to cause alterations in muscle and nerve function. Although an effect has never been studied in the neuromusculature of deglutition, the authors argue that an effect is likely. The proposed result is an increase in swallowing impairment in dysphagic individuals and associated risk of aspiration. Research studying the relationship between malnutrition and dysphagia is needed to verify clinical significance. Until controlled studies are completed, the authors suggest alternative alimentation in repleting severely malnourished dysphagic patients prior to attempting oral diet. A review of nutritional status indices is included to aid in identifying dysphagic patients at nutritional risk. Early identification of nutritional compromise and intervention can prevent malnutrition and its deleterious effects.
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Affiliation(s)
- M S Veldee
- University of Washington Medical Center, Food and Nutrition Services, Seattle 98195
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22
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Abstract
One hundred patients underwent laparotomy for independent jejunal feeding tube placement. Neurologic disease was present in 50%, and obtundation (28) and oropharyngeal dysmotility (25) were the most common indications for enteral feeding. The post-pyloric route was chosen because of aspiration risk in almost all (94%) patients. Postoperative (30-day) mortality rate was 21%, because of cardiopulmonary failure in most (18). One death resulted directly from aspiration of tube feeds. Two surgical complications required reoperation: one wound dehiscence and one small bowel obstruction. Four wound infections occurred. Two patients underwent reoperation after tube removal, and four tubes required fluoroscopically guided reinsertion for peritubular drainage (2), removal (1), and occlusion (1). Aspiration pneumonia was present in 18 patients preoperatively and in eight postoperatively. None of the patients with feeding-related preoperative aspiration pneumonia (13) had a recurrence while fed by jejunostomy. Three patients developed postoperative aspiration pneumonia before initiation of jejunostomy feedings. Jejunostomy may be performed with low morbidity rate and substantial reduction of feeding-related aspiration pneumonia, and is the feeding route of choice in aspiration risk patients.
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Affiliation(s)
- C R Weltz
- Division of Gastrointestinal Surgery, University of Pennsylvania School of Medicine, Philadelphia
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Hamaoui E, Lefkowitz R, Olender L, Krasnopolsky-Levine E, Favale M, Webb H, Hoover EL. Enteral nutrition in the early postoperative period: a new semi-elemental formula versus total parenteral nutrition. JPEN J Parenter Enteral Nutr 1990; 14:501-7. [PMID: 2122024 DOI: 10.1177/0148607190014005501] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Several studies have reported that gastrointestinal (GI) intolerance symptoms are the limiting factor to enteral alimentation in the immediate postoperative period and often the reason for resorting to total parenteral nutrition (TPN). We postulated that Reabilan HN (a recently developed small peptide-based formula, in part obtained by enzyme hydrolysis of proteins) might be better absorbed and better tolerated so as to avoid the need for TPN. Accordingly, 19 patients undergoing major abdominal surgery were randomly assigned to receive Reabilan HN via jejunostomy or an equicaloric isonitrogenous TPN regimen. Both were begun 6 hr postoperatively at 25 ml/hr and increased by 25 ml/hr at 12-hr intervals up to the rate providing 1.5 times the calculated REE. GI tolerance to enteral feeding was excellent during the first three postoperative days, allowing the progression of the feeding rate to 99% of goal. During the next 3 days (starting on average 1.7 days after the return of bowel sounds), GI intolerance symptoms required a reduction in feeding rate to 52% on average. Subsequently, the symptoms resolved and the feeding rate reached 96% of goal. Although overall mean daily calorie and nitrogen intakes were lower for the enteral than for the TPN group (79.6 +/- 10.2% vs 94.6 +/- 3.8% of goal; p less than 0.01), the enteral group was nevertheless in positive caloric and nitrogen balance, and maintained similar serum albumin, prealbumin, and plasma transferrin levels. Average daily cost of supplies was $44.36 for enteral vs $102.10 for parenteral nutrition (p less than 0.001). We conclude that enteral feeding using this formula is well tolerated and cost-effective in the immediate postoperative period.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- E Hamaoui
- Nutrition Section and Surgical Service, Veterans Administration Medical Center, Brooklyn, NY 11209
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Wolfsen HC, Kozarek RA, Ball TJ, Patterson DJ, Botoman VA. Tube dysfunction following percutaneous endoscopic gastrostomy and jejunostomy. Gastrointest Endosc 1990; 36:261-3. [PMID: 2114339 DOI: 10.1016/s0016-5107(90)71019-x] [Citation(s) in RCA: 110] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Percutaneous endoscopic gastrostomy (PEG) and jejunostomy (PEJ) have supplanted their surgical counterparts in many institutions. Previous reports have claimed advantages in placing PEJ tubes because of reduced gastroesophageal reflux, prevention of aspiration, and improved tube anchoring distally. We reviewed the records of 191 patients who underwent placement of PEG/J tubes. Data collected included incidence of tube dysfunction, need for tube replacement or removal, and aspiration after PEG or PEJ tube placement. Tube dysfunction, defined as peritube leakage, plugging, fracture, or migration, occurred in 36% of patients over a mean follow-up period of 275 days and was significantly more common and likely to necessitate tube replacement in PEJ patients. Tube trade-out or removal and aspiration within a 30-day period after tube placement occurred in 28% and 10% of patients, respectively. These complications were significantly more common in PEJ patients than in PEG patients. Because of the increased incidence of tube dysfunction and the failure to prevent aspiration in predisposed patients, PEJ tube placement is not routinely indicated in patients requiring tube feedings.
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Affiliation(s)
- H C Wolfsen
- Section of Therapeutic Endoscopy, Virginia Mason Clinic, Seattle, Washington 98101
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25
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Lewis BS, Mauer K, Bush A. The rapid placement of jejunal feeding tubes: the Seldinger technique applied to the gut. Gastrointest Endosc 1990; 36:139-41. [PMID: 2110541 DOI: 10.1016/s0016-5107(90)70969-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- B S Lewis
- Division of Gastroenterology, Mount Sinai Medical Center, New York, New York
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Kudsk KA, Campbell SM, O'Brien T, Fuller R. Postoperative jejunal feedings following complicated pancreatitis. Nutr Clin Pract 1990; 5:14-7. [PMID: 2107378 DOI: 10.1177/011542659000500114] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Some surgeons avoid placing a jejunostomy in patients with complications, fearing either exacerbation of the disease during enteral feedings or complications from the jejunostomies. Eleven patients with hemorrhagic pancreatitis (four), pancreatic abscess (five), or infected pseudocyst (two) underwent placements of needle (five) or Red Robinson (six) jejunal catheters during laparotomy. Five patients had been given 30.8 +/- 16 liters of TPN over 25 +/- 12 days preoperatively. Only two patients received TPN postoperatively because of progressive sepsis with enteral intolerance to feedings. One of these patients developed a jejunal leak near the placement of the Red Robinson catheter. Both patients died of complications from their pancreatic disease. The remaining nine patients received 35.6 +/- 8.6 liters of enteral feedings over 31 +/- 6.8 days before resuming oral intake. Glucosuria and hyperglycemia were common, but easily managed. No catheters were lost, and diarrhea necessitating slowing and diluting the diet was unusual after the first week. Enteral feeding did not elevate amylase values. Therefore, jejunal feedings can be given safely in patients with severe acute pancreatic disease to provide prolonged nutrition without aggravating the disease.
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Abstract
When oral intake is unsatisfactory or contraindicated, maintenance of nutrition by tube feeding is an alternative to the parenteral route. A large volume of research data supports the decision to use the enteral route whenever possible. Entry of food into the alimentary tract is a stimulus to structural and functional maintenance of that tract. Enteral nutrition can be given via indwelling nasoesophageal, pharyngostomy, esophagostomy, percutaneous or surgical gastrostomy, or enterostomy tube. Use of an appropriate catheter, familiarity with the technique used, and careful patient selection and monitoring are important factors in successful tube feeding. Blenderized pet food diets should be fed whenever possible; commercially available liquid diets provide an alternative when tube caliber or patient factors preclude the use of blenderized foods.
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Affiliation(s)
- P J Armstrong
- Department of Companion Animal and Special Species Medicine, North Carolina State University College of Veterinary Medicine, Raleigh
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Abstract
The gastrointestinal tract is metabolically active, requires specific nutrients, and is important both for substrate redistribution and barrier function. The provision of optimal support can be expected to obviate the stress-related response associated with increased gut permeability and bacterial translocation. Enteral feeding is the preferable technique whenever it is possible. It should be used to provide whatever level of nutrients the gut will accommodate, even when it may not immediately support full feeding. Parenteral administration of gut-specific nutrients may be an option in the near future. Judicious consideration of the effects of antibiotics and other drugs on indigenous flora is also important.
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Affiliation(s)
- C P Page
- Department of Surgery, University of Texas Health Science Center, Audie L. Murphy Memorial Veterans Hospital, San Antonio 78284
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Abstract
In patients who cannot or will not eat, nutrition can be provided by enteral feeding through a gastrostomy or jejunostomy tube (or a nasogastric tube if use is to be brief). Endoscopic placement of tubes is increasing in popularity. Numerous enteral formulas have been devised to provide complete nutrition in a variety of circumstances, and special formulas are available for patients with malabsorption or hepatic, renal, or lung disease. Mechanical, metabolic, and gastrointestinal complications of enteral feeding are possible, but taking precautions by ordering specific techniques can reduce the risk.
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Affiliation(s)
- R Cogen
- Albert Einstein Medical Center, Willowcrest-Bamberger Division, Philadelphia, PA 19141
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Payne-James J, Silk D. Enteral nutrition: background, indications and management. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1988; 2:815-47. [PMID: 3149904 DOI: 10.1016/0950-3528(88)90037-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Enteral nutrition is only part of the wider field of clinical nutrition in which great advances in both theory and practice have been made over the last decade. We have attempted to summarize what we consider to be the advances that have most relevance to the clinical practice of enteral nutrition. This chapter reviews our present understanding of the processes of digestion and absorption of protein, carbohydrate and fats, and examines how this theoretical understanding can be applied to patients in the clinical situation. A broad classification of the different enteral diets is undertaken, and the reasons for the development of particular diets are discussed. The clinical value of these diets is assessed. The wide variety of indications for enteral (as opposed to parenteral) nutrition are discussed and the specific benefits of enteral nutrition for the patient are highlighted. Techniques of administration of enteral nutrition are reviewed in detail, and the methods by which enteral nutrition should be monitored are outlined. Finally, complications of enteral nutrition are summarized and advice given on how to prevent or treat them.
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Bentz ML, Tollett CA, Dempsey DT. Obstructed feeding jejunostomy tube: a new method of salvage. JPEN J Parenter Enteral Nutr 1988; 12:417-8. [PMID: 3138456 DOI: 10.1177/0148607188012004417] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The jejunostomy tube is an important means of access for enteral feeding in the surgical and medical patient. A common complication of this technique is tube occlusion. Once a mature tract has formed the tube can be removed and replaced, following by contrast radiologic documentation of its intraluminal position. With an immature tract, this option is not available. We report a safe, simple, and cost-effective method of unblocking a clogged jejunostomy using an arterial embolectomy catheter.
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Affiliation(s)
- M L Bentz
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania 19140
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Abstract
To study the optimal means of postoperative energy supply, three glucose loads (5 g, 15 g, 40 g) were given via the enteral or the parenteral route before and immediately after abdominal surgery. Pre- and post-operatively, glucose and insulin concentrations were strongly dose-related after both kinds of administration. But the postoperative insulin concentrations were higher than the preoperative ones. Likewise, in both test situations the 'insulinogenic index' was significantly higher postoperatively than preoperatively. After the enteral glucose load, however, the index was 3 to 10 times higher than after the parenteral one. According to these results, even in the early postoperative period the enteral route of glucose administration is not only feasible but seems also to be superior to the parenteral one.
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Affiliation(s)
- R Bittner
- Dept. of General Surgery, University of Ulm, FRG
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Cogen RE. Tube feeding in patients with advanced and terminal neurological disease. J Am Geriatr Soc 1988; 36:574. [PMID: 3131411 DOI: 10.1111/j.1532-5415.1988.tb04035.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Boland MP, Patrick J, Stoski DS, Soucy P. Permanent enteral feeding in cystic fibrosis: advantages of a replaceable jejunostomy tube. J Pediatr Surg 1987; 22:843-7. [PMID: 3118004 DOI: 10.1016/s0022-3468(87)80651-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A feeding jejunostomy constructed by the Witzel technique has been used to supplement 12 wasted patients with cystic fibrosis during 260 patient months. None of the patients has stopped the nocturnal feeding once started on the program. The preferred tube was the Entriflex enteral feeding tube, which, when placed without internal fixation, could be easily changed as necessary. There have been no major complications. Minor complications include tube blockage, dislodgement, local infection, and leakage around the tube causing granuloma formation. We have not lost the use of any of the jejunostomies because of inability to replace the tube when it has been dislodged.
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Affiliation(s)
- M P Boland
- Department of Paediatric Surgery, Children's Hospital of Eastern Ontario, University of Ottawa, Canada
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Ota DM, Kleman G, Diamond K. Practical considerations in the nutritional management of the cancer patient. Curr Probl Cancer 1986; 10:345-98. [PMID: 3089692 DOI: 10.1016/s0147-0272(86)80013-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Boland MP, Stoski DS, MacDonald NE, Soucy P, Patrick J. Chronic jejunostomy feeding with a non-elemental formula in undernourished patients with cystic fibrosis. Lancet 1986; 1:232-4. [PMID: 2868253 DOI: 10.1016/s0140-6736(86)90772-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ten patients with cystic fibrosis, moderate to severe lung disease (forced expiratory flow % predicted 26.0, 15.7 [SD]), and undernutrition resistant to oral supplementation have been treated for 10 to 36 months with night-time feeds of a non-elemental formula given via a jejunostomy. All patients gained some weight and showed a significant increase in weight for height (change % wt/ht 8.1, 6.0 [SD] and mid-arm muscle circumference (change MAMC % standard 6.2, 5.7 [SD]). Although the forced expiratory flow indicated progression of the small airways disease during the period of feeding, the forced vital capacity did not significantly decline. In nine patients improvement in % wt/ht was maintained. One patient tolerated the feeding poorly and died of severe pulmonary disease after 10 months. The non-elemental formula used cost less than half that of an elemental formula. The jejunostomy tubes were unobtrusive and secured with only a small transparent dressing, which facilitated replacement. No serious complications resulted from jejunostomy feeding.
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Abstract
Twenty patients underwent placement of a jejunal catheter for early postoperative feeding at the time of upper abdominal operations, and a control group of 11 patients underwent operative procedures of similar magnitude without jejunostomy. Advancement of the rate of feeding to target intake over 6 to 7 days was attempted. Complications from the feeding led to cessation or curtailment of intake in 65 percent of the patients. Specific complications included abdominal pain and distention, diarrhea, and retrograde reflux of the feeding into the stomach. No statistically significant difference in nitrogen balance was demonstrated between the fed and unfed groups, presumably due to the limitations of nutrient delivery or absorption in the fed groups or elevated breath hydrogen excretion in patients with abdominal pain and distention suggests that the nature of the nutrients, particularly complex carbohydrates, is a factor in the development of feeding complications. Caution must be exercised in advancing the rate of postoperative jejunal feeding.
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