Gastroenteric tube feeding: Techniques, problems and solutions

Malnutrition management in children with chronic kidney disease

Chronic kidney disease (CKD) encompasses diverse conditions such as congenital anomalies, glomerulonephritis, and hereditary nephropathies, necessitating individualized nutritional interventions. Early detection is pivotal due to the heightened risk of adverse outcomes, including compromised growth and increased healthcare costs. The nutritional assessment in pediatric CKD employs a comprehensive, multidisciplinary approach, considering disease-specific factors, growth metrics, and dietary habits. The prevalence of malnutrition, as identified through diverse tools and guidelines, underscores the necessity for regular and vigilant monitoring. Nutritional management strategies seek equilibrium in calorie intake, protein requirements, and electrolyte considerations. Maintaining a well-balanced nutritional intake is crucial for preventing systemic complications and preserving the remaining kidney function. The nuanced landscape of enteral nutrition, inclusive of gastrostomy placement, warrants consideration in scenarios requiring prolonged support, with an emphasis on minimizing risks for optimized outcomes. In conclusion, the ongoing challenge of managing nutrition in pediatric CKD necessitates continuous assessment and adaptation. This review underscores the significance of tailored dietary approaches, not only to foster growth and prevent complications but also to enhance the overall quality of life for children grappling with CKD.

The effect of abdominal massage and in-bed ROM exercise on gastrointestinal complications and comfort in intensive care unit patients receiving enteral nutrition: A randomized controlled trial

AIM

Abdominal massage facilitates gastric and colonic motility, reduces intra-abdominal distension and increases circulation. In-bed range of motion (ROM) exercise has effects on muscle strength, cardiac parameters and excretion. The aim of this study was to assess the effects of abdominal massage and in-bed ROM exercise on gastrointestinal complications and patient comfort in intensive care patients receiving enteral nutrition.

METHODS

This randomized controlled trial was conducted in the internal intensive care units of two tertiary public hospitals. The sample consisted of 130 patients randomly assigned to three groups (abdominal massage = 44, in-bed ROM exercise = 43, control = 43). The individuals received abdominal massage and in-bed ROM exercises every morning before enteral feeding for 3 days. We assessed gastrointestinal complications and comfort levels of the patients 24 h after each intervention.

RESULTS

While the differences in abdominal distention, defecation status, constipation, and gastric residual volume complications were significant (p < .05), there was no significant difference in diarrhea and vomiting (p > .05). Comfort level showed a statistically significant change in the experimental groups in the in-group comparison (p < .05).

CONCLUSION

Abdominal massage and in-bed ROM exercise reduce abdominal distention, constipation and gastric residual volume. Abdominal massage affects the frequency of defecation; and, both interventions increase the comfort while reducing the pain level over time.

Reducing Lung Injury from Blind Insertion of Small-Bore Feeding Tubes

ABSTRACT

Using a blind insertion technique to insert small-bore feeding tubes can result in inadvertent placement in the lungs, leading to lung perforation and even mortality. In a Magnet-designated, 500-bed, level 2 trauma center, two serious patient safety events occurred in a four-week period due to nurses blindly inserting a small-bore feeding tube. A patient safety event review team convened and conducted an assessment of reported small-bore feeding tube insertion events that occurred between March 2019 and July 2021. The review revealed six lung perforations over this two-year period. These events prompted the creation of a multidisciplinary team to evaluate alternative small-bore feeding tube insertion practices. The team reviewed the literature and evaluated several evidence-based small-bore feeding tube placement methods, including placement with fluoroscopy, a two-step X-ray, electromagnetic visualization, and capnography. After the evaluation, capnography was selected as the most effective method to mitigate the complications of blind insertion. In this article, the authors describe a quality improvement project involving the implementation of capnography-guided small-bore feeding tube placement to reduce complications and the incidence of lung perforation. Since the completion of the project, which took place from December 13, 2021, through April 18, 2022, no lung injuries or perforations have been reported. Capnography is a relatively simple, noninvasive, and cost-effective technology that provides nurses with a means to safely and effectively insert small-bore feeding tubes, decrease the incidence of adverse events, and improve patient care.

Successful Undergoing Esophagogastric Anastomosis with Right Gastroepiploic Vessels Congenital Absence: A Case Report

A 60-year-old male farmer was admitted to the hospital with dysphagia for 2 months, and minimally invasive McKeown esophagectomy with lymphadenectomy was initially planned. However, congenital absence of the right gastroepiploic vessels (RGEVs) was blocked surgical procedure. Fortunately, we successfully performed esophagectomy and unconventional gastric remnant reconstruction without RGEVs, and intraoperative cervical venous superdrainage.

Impaired oral health: a required companion of bacterial aspiration pneumonia

Laryngotracheal aspiration has a widely-held reputation as a primary cause of lower respiratory infections, such as pneumonia, and is a major concern of care providers of the seriously ill orelderly frail patient. Laryngeal mechanical inefficiency resulting in aspiration into the lower respiratory tract, by itself, is not the cause of pneumonia. It is but one of several factors that must be present simultaneously for pneumonia to develop. Aspiration of oral and gastric contentsoccurs often in healthy people of all ages and without significant pulmonary consequences. Inthe seriously ill or elderly frail patient, higher concentrations of pathogens in the contents of theaspirate are the primary catalyst for pulmonary infection development if in an immunocompromised lower respiratory system. The oral cavity is a complex and ever changing eco-environment striving to maintain homogeneity among the numerous microbial communities inhabiting its surfaces. Poor maintenance of these surfaces to prevent infection can result inpathogenic changes to these microbial communities and, with subsequent proliferation, can altermicrobial communities in the tracheal and bronchial passages. Higher bacterial pathogen concentrations mixing with oral secretions, or with foods, when aspirated into an immunecompromised lower respiratory complex, may result in bacterial aspiration pneumonia development, or other respiratory or systemic diseases. A large volume of clinical evidence makes it clear that oral cleaning regimens, when used in caring for ill or frail patients in hospitals and long-term care facilities, drastically reduce the incidence of respiratory infection and death. The purpose of this narrative review is to examine oral health as a required causative companionin bacterial aspiration pneumonia development, and the effectiveness of oral infection control inthe prevention of this disease.

Effectiveness of Heat Application on Gastric Variables Among Patients With Nasogastric Tube Feeding Admitted in the Intensive Care Units at a Selected Hospital: A Randomized Control Trial

BACKGROUND

Heat application, a nonpharmacological intervention, can relieve abdominal distension (AD), high stomach residual volume, and other specific gastrointestinal (GI) functions. It promotes peristaltic movement, which reduces intra-abdominal pressure and aids in the nutritional transition through the GI tract. It has also been demonstrated to be a noninvasive, safe, effective, and side-effect-free approach without needing medication.

OBJECTIVES

The objective of the study was to ascertain if heat application may improve stomach residual volume, AD, and GI functioning in patients who were hospitalized in intensive care units (ICUs) and were receiving nasogastric tube feeding.

METHODS

The study used a quantitative research approach and experimental research design. Subjects were ICU patients hospitalized during data collection who were fed via nasogastric tubes. They were divided into two groups of 30 people each, with one group as the experimental group and the other as the control group. The groups were determined through random sampling using the coverslip method. A selected hospital ICU served as the study's setting.

RESULTS

Analyses of stomach residual volume, AD, and GI performance revealed a statistically significant improvement in the study group compared to the control group. Research groups experienced significantly fewer vomiting episodes regularly compared to the control group.

CONCLUSION

 In conclusion, all patients receiving nasogastric tube feedings should have local heat application treatment administered as part of their usual nursing care to reduce stomach residual volume, relieve AD, and reduce vomiting.

Cost-effectiveness of ambroxol in the treatment of Gaucher disease type 2

Objective

Our aim was to compare the costs and efficacy of ambroxol in combination with imiglucerase with the costs and efficacy of imiglucerase only in the treatment of Gaucher disease type 2 (GD2) in the socio-economic settings of the Republic of Serbia, an upper-middle-income European economy.

Methods

The perspective of the Serbian Republic Health Insurance Fund was chosen for this study, and the time horizon was 6 years. The main outcomes of the study were quality-adjusted life years gained with ambroxol + imiglucerase and comparator, and direct costs of treatment. The study was conducted through the generation and simulation of the Markov chain model. The model results were obtained after Monte Carlo microsimulation of a sample with 1,000 virtual patients.

Results

Treatment with ambroxol in combination with imiglucerase was cost-effective when compared with imiglucerase only and was associated with positive values of net monetary benefit regardless of the onset of the disease. Such beneficial result for ambroxol and imiglucerase combination is primarily driven by the low cost of ambroxol and its considerable clinical effectiveness in slowing the progression of neural complications of GD2.

Conclusion

If ambroxol and imiglucerase are used in combination for the treatment of GD2, it is more cost-effective than using imiglucerase alone.

Comparison of the use of a spiral nasojejunal tube and transendoscopic enteral tubing in washed microbiota transplantation via the mid-gut route

Background

Methods for washed microbiota transplantation (WMT) through the mid-gut include transendoscopic enteral tubing (TET) and manual spiral nasojejunal tube (SNT) placement have not been studied.

Methods

This prospective interventional study was performed at a single centre. Patients were divided into the SNT and mid-gut TET groups based on their conditions and wishes. In the SNT group, an SNT was passively inserted into the stomach, and abdominal X-rays were taken within 24 h to confirm tube placement in the small intestine. In the mid-gut TET group, mid-gut TET was placed in the small intestine for gastroscopy. Data on the clinical efficacy of WMT, intubation time, cost, overall comfort score, adverse reactions, etc., were collected from the two groups.

Results

Sixty-three patients were included in the study (SNT group (n = 40) and mid-gut TET group (n = 23)). The clinical efficacy of WMT in the SNT and mid-gut TET groups was 90 % and 95.7 %, respectively (P = 0.644). Compared with the mid-gut TET group, the SNT group showed a shorter operation time (120 s vs. 258 s, P = 0.001) and a lower average cost (641.7 yuan vs. 1702.1 yuan, P = 0.001). There was no significant difference in the overall comfort score or the incidence of common discomfort symptoms between the two groups.

Conclusion

The different implantation methods have different advantages; compared with mid-gut TET placement, manual SNT placement provides some benefits.

Nomogram to predict ventilator-associated pneumonia in large vessel occlusion stroke after endovascular treatment: a retrospective study

Background

Ventilator-Associated Pneumonia (VAP) severely impacts stroke patients' prognosis after endovascular treatment. Hence, this study created a nomogram to predict the occurrence of VAP after endovascular treatment.

Methods

The individuals with acute ischemic stroke and large vessel occlusion (AIS-LVO) who received mechanical ventilation and endovascular therapy between July 2020 and August 2023 were included in this retrospective study. The predictive model and nomogram were generated by performing feature selection optimization using the LASSO regression model and multifactor logistic regression analysis and assessed the evaluation, verification and clinical application.

Results

A total of 184 individuals (average age 61.85 ± 13.25 years, 73.37% male) were enrolled, and the rate of VAP occurrence was found to be 57.07%. Factors such as the Glasgow Coma Scale (GCS) score, duration of stay in the Intensive Care Unit (ICU), dysphagia, Fazekas scale 2 and admission diastolic blood pressure were found to be associated with the occurrence of VAP in the nomogram that demonstrating a strong discriminatory power with AUC of 0.862 (95% CI, 0.810-0.914), and a favorable clinical net benefit.

Conclusion

This nomogram, comprising GCS score, ICU duration, dysphagia, Fazekas scale 2 and admission diastolic blood pressure, can aid clinicians in predicting the identification of high-risk patients for VAP following endovascular treatment in large vessel occlusion stroke.

Integrated Sensors for Soft Medical Robotics

Minimally invasive procedures assisted by soft robots for surgery, diagnostics, and drug delivery have unprecedented benefits over traditional solutions from both patient and surgeon perspectives. However, the translation of such technology into commercialization remains challenging. The lack of perception abilities is one of the obstructive factors paramount for a safe, accurate and efficient robot-assisted intervention. Integrating different types of miniature sensors onto robotic end-effectors is a promising trend to compensate for the perceptual deficiencies in soft robots. For example, haptic feedback with force sensors helps surgeons to control the interaction force at the tool-tissue interface, impedance sensing of tissue electrical properties can be used for tumor detection. The last decade has witnessed significant progress in the development of multimodal sensors built on the advancement in engineering, material science and scalable micromachining technologies. This review article provides a snapshot on common types of integrated sensors for soft medical robots. It covers various sensing mechanisms, examples for practical and clinical applications, standard manufacturing processes, as well as insights on emerging engineering routes for the fabrication of novel and high-performing sensing devices.

Evidence-Based Investigation of Nurses' Nutrition Interventions in Intensive Care Patients Regarding Enteral Nutrition

AIM

The aim of this study was to examine the practices and knowledge levels of nurses regarding enteral nutrition interventions in intensive care unit patients in terms of evidence.

METHOD

This cross-sectional study was conducted in 2 hospitals between May and August 2021. A total of 136 nurses working in the intensive care units of the hospitals completed online questionnaires including demographic characteristics and questions about enteral nutrition.

RESULTS

According to the nurses' knowledge level about the indication of enteral nutrition formulas, the following were incorrect or incomplete: their knowledge about transition to parenteral nutrition in case of nutritional contraindications, what to do when the amount of gastric residual volume in tolerance is >500 mL every 6 hours, the conditions for starting enteral nutrition, and which formulas are appropriate to use. Regarding their knowledge about enteral feeding tubes/sets, their knowledge about radiologic imaging after tube placement, measurement of gastric pH level, and marking the tube location was insufficient. Differently, the correct answer percentages of the nurses in 11 of the 13 questions regarding the principles of enteral nutrition practice were above 70%.

CONCLUSION

Nurses had adequate knowledge of the principles of enteral nutrition practice, but their knowledge of the indication of enteral nutrition formulas and the evidence for enteral feeding tubes/sets varied. The results showed that nurses need to gain information about the indication of enteral nutrition formulas and evidence related to enteral feeding tubes/sets.

Longitudinal cytokine and multi-modal health data of an extremely severe ME/CFS patient with HSD reveals insights into immunopathology, and disease severity

Introduction

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) presents substantial challenges in patient care due to its intricate multisystem nature, comorbidities, and global prevalence. The heterogeneity among patient populations, coupled with the absence of FDA-approved diagnostics and therapeutics, further complicates research into disease etiology and patient managment. Integrating longitudinal multi-omics data with clinical, health,textual, pharmaceutical, and nutraceutical data offers a promising avenue to address these complexities, aiding in the identification of underlying causes and providing insights into effective therapeutics and diagnostic strategies.

Methods

This study focused on an exceptionally severe ME/CFS patient with hypermobility spectrum disorder (HSD) during a period of marginal symptom improvements. Longitudinal cytokine profiling was conducted alongside the collection of extensive multi-modal health data to explore the dynamic nature of symptoms, severity, triggers, and modifying factors. Additionally, an updated severity assessment platform and two applications, ME-CFSTrackerApp and LexiTime, were introduced to facilitate real-time symptom tracking and enhance patient-physician/researcher communication, and evaluate response to medical intervention.

Results

Longitudinal cytokine profiling revealed the significance of Th2-type cytokines and highlighted synergistic activities between mast cells and eosinophils, skewing Th1 toward Th2 immune responses in ME/CFS pathogenesis, particularly in cognitive impairment and sensorial intolerance. This suggests a potentially shared underlying mechanism with major ME/CFS comorbidities such as HSD, Mast cell activation syndrome, postural orthostatic tachycardia syndrome (POTS), and small fiber neuropathy. Additionally, the data identified potential roles of BCL6 and TP53 pathways in ME/CFS etiology and emphasized the importance of investigating adverse reactions to medication and supplements and drug interactions in ME/CFS severity and progression.

Discussion

Our study advocates for the integration of longitudinal multi-omics with multi-modal health data and artificial intelligence (AI) techniques to better understand ME/CFS and its major comorbidities. These findings highlight the significance of dysregulated Th2-type cytokines in patient stratification and precision medicine strategies. Additionally, our results suggest exploring the use of low-dose drugs with partial agonist activity as a potential avenue for ME/CFS treatment. This comprehensive approach emphasizes the importance of adopting a patient-centered care approach to improve ME/CFS healthcare management, disease severity assessment, and personalized medicine. Overall, these findings contribute to our understanding of ME/CFS and offer avenues for future research and clinical practice.

Appropriate handling and storage reduce the risk of bacterial growth in enteral feeding systems reused within 24 hours

BACKGROUND

Enteral tube feeding can require considerable amounts of plastic equipment including delivery sets and containers, often disposed of after a single feeding session because of bacterial contamination concerns. The aim of this research was to assess whether reuse of delivery sets and containers for up to 24 h is safe from a microbiological perspective.

METHODS

Four enteral tube feeding systems (FS) were tested under hygienic controlled or repeated inoculation challenge conditions using key foodborne pathogens, to assess bacterial growth over time (FS1: ready-to-hang, closed 1-L system with delivery set reused, stored at room temperature [RT]; FS2: a prepared, powdered, open 1-L system with delivery set and container reused, stored at RT; FS3 and FS4: prepared, powdered, open 200-ml bolus systems with delivery set and container reused, stored at RT [FS3] and refrigeration [FS4]). Feed samples were cultured at 0.5, 6.5, 12.5, 18.5, and 24.5 h with >2 Δlog considered significant bacterial growth.

RESULTS

Under hygienic control, FS1, FS3, and FS4 were below the level of enumeration (<5 CFU/g) for all bacteria tested, at all time points. In FS2, significant bacterial growth was observed from 18.5 h. Under repeated bacterial inoculation challenge, no significant growth was observed in FS1 and FS4 over 24.5 h; however, significant growth was observed in FS2 after 6.5 h and in FS3 after 10-12 h.

CONCLUSION

With hygienic handling technique, there is limited bacterial growth with reuse of delivery sets and containers over 24 h. Refrigeration between feeding sessions and using boluses of reconstituted powdered feed reduce bacterial growth risk.

Gastrostomy Tubes: Indications, Types, and Care

Gastrostomy tube insertion has become a more common practice in pediatric patients. An increasing number of children both in health-care facilities and at home are relying on temporary or long-term enteral feeding. Gastrostomy tube placement can be accomplished by various methods and by a variety of specialists. Despite the overall safety of these procedures, both early and late complications can occur. It is important for pediatricians and pediatric subspecialists to be familiar with and aware of the indications, safety, and management of gastrostomies. This paper provides a comprehensive overview of the topic.

Best evidence summary for prevention and management of enteral feeding intolerance in critically ill patients

AIM

To evaluate and summarize the evidence for prevention and management of enteral feeding intolerance in critically ill patients and provide reference for clinical practice.

DESIGN

This study was an evidence summary followed by the evidence summary reporting standard of Fudan University Center for Evidence-based Nursing.

METHODS

Current literatures were systematically searched for the best evidence for prevention and management of enteral feeding intolerance in critically ill patients. Literature types included clinical guidelines, best practice information sheets, expert consensuses, systematic reviews, evidence summaries and cohort studies.

DATA SOURCES

UpToDate, BMJ Best Practice, Joanna Briggs Institute, Guidelines International Network, National Institute for Health and Care Excellence, Registered Nurses Association of Ontario, Scottish Intercollegiate Guidelines Network, the Cochrane Library, Embase, PubMed, Sinomed, Web of Science, Yi Maitong Guidelines Network, DynaMed, MEDLINE, CNKI, WanFang database, Chinese Medical Journal Full-text Database, European Society for Clinical Nutrition and Metabolism website, the American Society for Parenteral and Enteral Nutrition website were searched from January 2012 to April 2023.

RESULTS

We finally identified 18 articles that had high-quality results. We summarized the 24 pieces of best evidence from these articles, covering five aspects: screening and assessment of the risk of enteral nutritional tolerance; formulation of enteral nutrition preparations; enteral nutritional feeding implementation; feeding intolerance symptom prevention and management; and multidisciplinary management. Of these pieces of evidence, 19 were 'strong' and 5 were 'weak', 7 pieces of evidence were recommended in level one and 4 pieces of evidence were recommended in level two.

CONCLUSION

The following 24 pieces of evidence for prevention and management of enteral feeding intolerance in critically ill patients were finally recommended. However, as these evidences came from different countries, relevant factors such as the clinical environment should be evaluated before application. Future studies should focus on more specific symptoms of feeding intolerance and more targeted prevention design applications.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The clinical medical staffs are recommended to take evidence-based recommendations for the implementation of standardized enteral nutrition to improve patient outcomes and decrease gastrointestinal intolerance in critically ill patients.

IMPACT

The management of enteral nutrition feeding intolerance has always been a challenge and difficulty in critically ill patients. This study summarizes 24 pieces of the best evidence for prevention and management of enteral nutrition feeding intolerance in critically ill patients. Following and implementing these 24 pieces of evidence is beneficial to the prevention and management of feeding intolerance in clinical practice. The 24 pieces of evidence include five aspects, including screening and assessment of the risk of enteral nutritional tolerance, formulation of enteral nutrition preparations, enteral nutritional feeding implementation, feeding intolerance symptom prevention and management and multidisciplinary management. These five aspects constitute a good implementation process. Screening and assessment of enteral nutritional tolerance throughout intervention are important guarantees for developing a feasible nutrition program in critically ill patients. This study will be benefit to global medical workers in the nutritional management of critically ill patients.

REPORTING METHOD

This evidence summary followed the evidence summary reporting specifications of Fudan University Center for Evidence-based Nursing, which were based on the methodological process for the summary of the evidence produced by the Joanna Briggs Institute (JBI). The reporting specifications include problem establishment, literature retrieval, literature screening, literature evaluation, the summary and grading of evidence and the formation of practical suggestions. This study was based on the evidence summary reporting specifications of the Fudan University Center for the Evidence-based Nursing, the register name is 'Best evidence summary for prevention and management of enteral feeding intolerance in critically ill patients', the registration number is 'ES20231823'.

Anthropometric parameters as a predictor for abdominal wall thickness in a patient with gastrostomy

BACKGROUND

Enteral feeding tubes play essential roles in clinical management and nutritional support. Knowledge of the abdominal wall is beneficial in surgical practice and safe for gastrostomy. Anthropometric parameters are currently used for clinical assessment in many clinical applications. That might be beneficial if we applied anthropometric measurement for thickness prediction of the abdominal wall to the schedule of patients' gastrostomy care. This study aimed to evaluate the anthropometric parameters of abdominal wall thickness (AWT).

METHODS

We conducted a cross-sectional study with anthropometric parameters and CT-measured anterior AWT were assessed and analyzed.

RESULTS

The data are collected from January 2020 to March 2021. Arm circumference and body mass index were strongly correlated with AWT at left upper quadrant area and anterior AWT at middle area. The data was created in an TAWT (Thammasat AWT) chart to represent body parameters to AWT.

CONCLUSIONS

Arm circumference is related to AWT. A TAWT chart is designed to help medical personnel evaluate the thickness of the abdominal wall and could guide estimating the gastrostomy tube length.

Ultrasound (US)-guided percutaneous thrombin injection for stoma-site bleeding after PEG tube insertion: a case series and review of the literature

BACKGROUND

Post-gastrostomy bleeding sequelae are acknowledged, with reported approaches focusing on conservative measures or surgical repair. Nonetheless, Percutaneous Thrombin Injections (PTI) role in PEG-site-related bleeding remains underexplored. PTI under ultrasound guidance is an advocated management strategy for stoma-site bleeding following gastrostomy in high-risk patients, particularly those on direct oral anticoagulants.

CASE PRESENTATION

This study presents three cases with multiple comorbidities who underwent PTI. Resulting in immediate resolution of bleeding, no systemic\local effect, and no reported complications or rebleeding after a 3-6-month follow-up.

CONCLUSION

The findings highlight the safety, direct complete resolution, and absence of sequelae associated with PTI, suggesting its potential as a promising technique in managing PEG stoma-related bleeding.

Levodopa-Entacapone-Carbidopa Intestinal Gel Treatment in Advanced Parkinson's Disease: A Single-Center Study of 30 Patients

BACKGROUND

Levodopa-entacapone-carbidopa intestinal gel (LECIG) is a novel device assisted treatment option for advanced Parkinson's disease (PD). It has been available in Finland since 2020. There is paucity of scientific studies considering LECIG treatment in clinical practice.

OBJECTIVES

Objectives of this study were to evaluate the changes in medication, adverse events and early discontinuations of LECIG treatment in real life clinical practice.

METHODS

The records of 30 consecutive patients, who received LECIG between years 2020 and 2022 in Helsinki University Hospital, were retrospectively analyzed. Data considering changes in medication, discontinuations, and adverse events during the first six months of LECIG treatment was collected.

RESULTS

Mean levodopa equivalent daily dose (LEDD) rose significantly between baseline before LECIG and six months with treatment (1230 mg vs. 1570 mg, P = 0.001). Three patients were discarded during nasojejunal tube test phase and seven discontinued the treatment during six-month follow-up. Most common reasons for discontinuation were difficulty in finding suitable infusion rate and neuropsychiatric problems. Safety issues encountered were similar to those reported with levodopa-carbidopa intestinal gel (LCIG) treatment. One case of rhabdomyolysis due to severe dyskinesia during LECIG treatment was observed. Patients were satisfied with the small size of the pump system.

CONCLUSIONS

LEDD seems to increase during the first months of LECIG treatment. When compared to studies on LCIG, safety profile of LECIG appears similar, but early discontinuation rate is higher than expected. However, long-term studies are lacking. Only clear advantage to LCIG appears to be the smaller LECIG pump size.

Proportion of unplanned tube replacements and complications following gastrostomy: A systematic review and meta-analysis

AIMS

Gastrostomy feeding represents a vital component of supportive care provided to people with swallowing or feeding difficulties; however, the rate of specific long-term complications is currently unknown in the adult population. This study aimed to determine the prevalence of specific long-term gastrostomy-related complications and unplanned replacements in adults.

METHODS

A prospective systematic review of Medline, CINAHL and Embase databases was performed. Key complications of hypergranulation, infection and displacement among studies relevant to percutaneous endoscopic gastrostomy tubes, radiologically inserted gastrostomy tubes and balloon replacement tubes were critically appraised by two independent reviewers. Results were synthesised quantitatively in a meta-analysis using random effects where the population and condition were sufficiently homogeneous.

RESULTS

In total, 453 studies were identified, of which 17 met inclusion criteria. 8.5% of adults with a gastrostomy were found to have had an infection ≥42 days after initial tube insertion (p < 0.01), while 13% had hypergranulation (p < 0.01). Displacement occurred in 10.8% of adults (p < 0.01), with age (p < 0.001) and sex (p < 0.001) presenting as a risk factor (R2  = 75%) following meta-regression.

CONCLUSIONS

Approximately 1 in 10 people with a gastrostomy will experience a complication related to either hypergranulation, infection or dislodgement. Age, in combination with sex, may provide a guide for risk of displacement among adult female cohorts, though further studies reporting prevalence of gastrostomy-related complications along with participant demographics are required.

Food Processing and Nutrition Strategies for Improving the Health of Elderly People with Dysphagia: A Review of Recent Developments

Dysphagia, or swallowing difficulty, is a common morbidity affecting 10% to 33% of the elderly population. Individuals with dysphagia can experience appetite, reduction, weight loss, and malnutrition as well as even aspiration, dehydration, and long-term healthcare issues. However, current therapies to treat dysphagia can routinely cause discomfort and pain to patients. To prevent these risks, a non-traumatic and effective treatment of diet modification for safe chewing and swallowing is urgently needed for the elderly. This review mainly summarizes the chewing and swallowing changes in the elderly, as well as important risk factors and potential consequences of dysphagia. In addition, three texture-modified food processing strategies to prepare special foods for the aged, as well as the current statuses and future trends of such foods, are discussed. Nonthermal food technologies, gelation, and 3D printing techniques have been developed to prepare soft, moist, and palatable texture-modified foods for chewing and swallowing safety in elderly individuals. In addition, flavor enhancement and nutrition enrichment are also considered to compensate for the loss of sensory experience and nutrients. Given the trend of population aging, multidisciplinary cooperation for dysphagia management should be a top priority.

[Prevalence of mucosal injuries during flexible endoscopic evaluation of swallowing in the presence of a nasogastric tube]

BACKGROUND

The flexible endoscopic evaluation of swallowing (FEES) is an established low-risk examination method to assess the risk of penetration or aspiration in patients with dysphagia. FEES might be more difficult or of higher-risk when a nasogastric tube is in place.

OBJECTIVE

This study aims to identify whether the prevalence of mucosal lesions is higher when the endoscopy is carried out with a nasogastric tube in place. Pre-existing mucosal lesions were also documented.

METHODS

In a retrospective, monocentric study, a total of 918 FEES procedures routinely performed in hospitalized patients of a university hospital from January 2014 to March 2019 were evaluated. Mucosal lesions were identified and characterized for descriptive statistics.

RESULTS

In the video material analysed here, no endoscopy-related injuries were identified. However, pre-existing mucosal lesions, which often occurred as multiple lesions, were detected in 48.6% of the endoscopies. Further analysis showed that these pre-existing lesions were not worsened by the endoscopy performed.

CONCLUSION

The results demonstrate that transnasal flexible endoscopy is a safe, low-risk examination method, even in patients with a nasogastric tube. A very high number of pre-existing mucosal lesions were found, which is probably related to the previous insertion of the nasogastric tube. Due to the high number of pre-existing lesions, strategies should be developed to minimize injuries when placing nasogastric tubes.

On the Discontinuation of Enteral Feeding in Head and Neck Cancer: A Case Report

Introduction

The goal of palliative care is to preserve the quality of life or patient "comfort" in patients with serious diseases. Palliative care providers serve a wide range of patients: from those who seek curative treatment to those who are actively dying. Given this range, palliative care must mirror the dynamic goals of the patient at different stages of life and treatment. Throughout these stages, a goal of the palliative care provider would be to avoid hastening death; however, this often leads to clinical decisions that directly pit the patient's comfort against the patient's life span. This is most salient with clinical decisions of withdrawing treatments that prolong life even at the expense of comfort. An example of this dichotomy can be seen when providers use enteral nutrition to treat head and neck cancer patients.

Case Presentation

We describe a patient with stage IV pancreatic cancer with metastases to her head and neck. The patient was experiencing increased morbidity related to her percutaneous endoscopic gastrostomy (PEG) tube feeding. These complications included tube-related concerns such as infection, leakage, and diarrhea but also decreased intended benefits as she lost weight and functionality while maintaining enteral feeding. Despite the patient experiencing a common and expected disease course, she remained unsure and was fearful about considering discontinuation of her enteral feeding. However, the care team who understood the risks, benefits, and harms related to withdrawal provided a foundation of discussion and mitigated patient fears, allowing for the successful removal of her PEG tube and increased quality of life at the end of life.

Conclusion

To care for a patient in their entirety is also to care for them at all stages of disease. Care is not limited to those who might be cured of disease, but should also consider those who continue to live with disease and the downstream effects of medical interventions used to support them. Discontinuing treatments whose harms outweigh the benefits to patients is a moral imperative to providers; yet, how providers approach discontinuing life-prolonging treatment is seen as morally distressing. Our patient did not see the discussion as morally distressing and continued to benefit from active discussions even at the end of her life.

Medication delivery errors in outpatients with percutaneous endoscopic gastrostomy: effect on tube feeding replacement

Patients with enteral access usually receive oral drugs via feeding tubes and correct drug administration remains a challenge. The aim of this study was to identify common medication delivery errors (MDEs) in outpatients with percutaneous endoscopic gastrostomy (PEG) and evaluate their association with the need for tube replacement due to deterioration or clogging. A 2-year retrospective study that comprised adult outpatients with a placed/replaced PEG tube and whose electronic medical record included home medication was carried out. Treatment with medication that should not be crushed and administered through an enteral feeding tube was considered an MDE. We included 269 patients and 213 MDEs (20% of oral prescriptions) were detected in 159. Ninety-two percent of the medications associated with MDEs could be substituted by appropriate formulations. Tube replacement due to obstruction was needed in 85 patients. MDEs were associated with increased risk for tube replacement (OR 2.17; 95% CI 1.10-4.27). Omeprazole enteric-coated capsules were associated with the greatest risk (OR 2.24; 95% CI 1.01-4.93). PEG outpatients are highly exposed to MDEs, leading to a significant increase in the odds of tube replacement, mainly when treated with omeprazole. The use of appropriate alternative therapies would prevent unnecessary adverse events.

Aspiration pneumonia in enteral feeding: A review on risks and prevention

Enteral feeding plays a critical role in the management of hospitalized patients, especially in intensive care units. In addition to delivering important nutrients, it also maintains the integrity of the gut and microbiota. Enteral feeding is also associated with complications and adverse events, some are related to access placement, metabolic and electrolytes disturbances, and aspiration pneumonia. In tube-fed patients, aspiration pneumonia has a prevalence ranging from 4% to 95% with a mortality rate of 17%-62%. Our review has not showed any significant difference in the incidence of aspiration pneumonia between gastric and postpyloric feeding and, given the ease of gastric access, we therefore suggest using gastric feeding as an initial strategy for the delivery of nutrition unless postpyloric access is otherwise indicated for other clinical reasons.

Feeding Tube Placement, Complications, and Treatment Responses in a Large Eosinophilic Esophagitis Patient Population

OBJECTIVES

Feeding tubes can provide a temporary or long-term solution for nutritional therapy. Little is known regarding the use of feeding tubes in patients with eosinophilic esophagitis (EoE). We sought to describe the characteristics and outcomes in EoE patients requiring tube feeding.

METHODS

This was a retrospective cohort study of EoE patients at a large tertiary care health system. Demographics, clinical characteristics, and endoscopic findings were extracted from medical records, and patients who had a feeding tube were identified. Patients with and without a feeding tube were compared. Details about the tube, complications, and treatment were extracted. Growth, global symptomatic, endoscopic, and histopathologic (<15 eos/hpf) responses were compared before and after the initiation of feeding tube therapy.

RESULTS

We identified 39 of 1216 EoE patients who had a feeding tube (3%). Feeding tube patients were younger (mean age 6.3 years), reported more vomiting, and had a lower total endoscopic reference score than non-feeding tube patients ( P < 0.01 for all). Tubes were used for therapy for an average of 6.8 years, with most patients (95%) receiving both pharmacologic and formula treatment for EoE. An emergency department visit for a tube complication was required in 26%. Tube feeding improved body mass index z score ( P < 0.01), symptomatic response (42%), endoscopic response (53%), and histologic response (71%).

CONCLUSIONS

Among EoE patients, only a small subset required a feeding tube and predominantly were young children with failure to thrive. Feeding tubes significantly improved growth and, when used in combination with other treatments, led to reduced esophageal eosinophilic inflammation.

Successful Medical Management of Bilateral Pneumothorax Due to Nasogastric Tube Misplacement in a Cat

A 7 yr old female spayed domestic shorthair was evaluated for suspected lily ingestion and acute vomiting. The cat had vomited suspected lily plant material before presentation, and a nasogastric tube (NGT) was placed to continue to administer activated charcoal. The NGT was passed with sedation and limited restraint. To confirm placement, a single lateral radiograph was taken, which showed that the tube was in the trachea, bronchus, through the pulmonary parenchyma, and extending into the region of the craniodorsal retroperitoneal space. The tube was subsequently removed, resulting in a tension pneumothorax. Bilateral thoracostomy tubes were placed and attached to continuous suction. The pneumothorax resolved after 2 days, the thoracostomy tubes were removed, and the cat was discharged on day 3 after admission. To the authors' knowledge, this is the first described pneumothorax complication with successful medical management secondary to routine nasogastric tube placement in a cat. This case report underscores the importance of preparedness for thoracostomy tube placement before removal of any NGT that has been confirmed to be placed through the pulmonary parenchyma.

Risk factors and natural history of bedside percutaneous endoscopic versus fluoroscopy-guided gastrostomy tubes in intensive care unit patients

INTRODUCTION

There is a paucity of literature comparing patients receiving bedside placed percutaneous endoscopic gastrostomy (PEG) versus fluoroscopic-guided percutaneous gastrostomy tubes (G-tube) in an intensive care unit (ICU) setting. This study aims to investigate and compare the natural history and complications associated with PEG versus fluoroscopic G-tube placement in ICU patients.

METHODS

All adult patients admitted in the ICU requiring feeding tube placement at our center from 1/1/2017 to 1/1/2022 with at least 12-month follow up were identified through retrospective chart review. Adjusting for patient comorbidities, hospital factors, and indications for enteral access, a 1-to-2 propensity score matched Cox proportional-hazards model was fitted to evaluate the treatment effect of bedside PEG tube placement versus G-tube placement on patient 1-year complication, readmission, and death rates. Major complications were defined as those requiring operative or procedural intervention.

RESULTS

This study included 740 patients, with 178 bedside PEG and 562 fluoroscopic G-tube placements. The overall rate of complication was 22.3% (13% PEG, 25.2% G-tube, P = 0.003). The major complication rate was 11.2% (8.5% PEG, 12.1% G-tube, P = 0.09). Most common complications were tube dysfunction (16.7% PEG; 39.4% G-tube; P = 0.04) and dislodgement (58.3% PEG; 40.8% G-tube). After propensity score matching, G-tube recipients had significantly increased risk for all-cause (HR 2.7, 95% CI 1.56-4.87, P < 0.001) and major complications (HR 2.11, 95% CI 1.05-4.23, P = 0.035). There were no significant differences in 1-year rates of readmission (HR 0.90, 95% CI 0.58-1.38, P = 0.62) or death (HR 1.00, 95% CI 0.70-1.44, P = 0.7).

CONCLUSIONS

The overall rate of complications for ICU patients requiring feeding tube in our cohort was 22.3%. ICU patients receiving fluoroscopic-guided percutaneous gastrostomy tube placement had significantly elevated risk of 1-year all-cause and major complications compared to those undergoing bedside PEG.

A comparative, randomised MRI study of the physiological and appetitive responses to gelling (alginate) and non-gelling nasogastric tube feeds in healthy men

Inclusion in nasogastric tube feeds (NGTF) of acid-sensitive, seaweed-derived alginate, expected to form a reversible gel in the stomach, may create a more normal intragastric state and modified gastrointestinal responses. This may ameliorate NGTF-associated risk of diarrhoea, upper gastrointestinal symptoms and appetite suppression. In a randomised, crossover, comparison study, undertaken in twelve healthy males, an alginate-containing feed (F + ALG) or one that was alginate-free (F-ALG) (300 ml) was given over 1 h with a 7-14-d washout period between treatments. Baseline and for 4-h post-feed initiation, MRI measurements were made to establish small bowel water content (SBWC), gastric contents volume (GCV) and appearance, and superior mesenteric artery blood flux. Blood glucose and gut peptides were measured. Subjective appetite and upper gastrointestinal symptoms scores were obtained. Ad libitum pasta consumption 3-h post-feeding was measured. F + ALG exhibited a gastric appearance consistent with gelling surrounded by a freely mobile water halo. Significant main effects of feed were seen for SBWC (P = 0·03) and peptide YY (PYY) (P = 0·004) which were attributed to generally higher values for SBWC with F + ALG (max difference between adjusted means 72 ml at 210 min) and generally lower values for PYY with F + ALG. GCV showed a faster reduction with F + ALG, less between-participant variation and a feed-by-time interaction (P = 0·04). Feed-by-time interactions were also seen with glucagon-like-peptide 1 (GLP-1) (P = 0·02) and glucose-dependent insulinotropic polypeptide (GIP) (P = 0·002), both showing a blunted response with F + ALG. Apparent intragastric gelling with F + ALG and subsequent differences in gastrointestinal and endocrine responses have been demonstrated between an alginate-containing and alginate-free feed.

Impact of Mobile Apps in Conjunction With Percutaneous Endoscopic Gastrostomy on Patients' Complications, Quality of Life, and Health-Related Self-Care Behaviors: Randomized Clinical Trial

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is commonly chosen for long-term enteral nutrition support. However, common complications of PEG include wound infection, leakage, obstruction, bleeding, dislodgement, pneumonia, peritonitis, and more. The anticipation of these complications by both patients and their family caregivers underscores the essential requirement of ongoing technical guidance for the daily care of PEG and the adoption of preventative strategies.

OBJECTIVE

This study aimed to establish and compare a health education program utilizing a tracking system for PEG using a mobile app (PEG app) and instant messaging software versus a paper-based health education program with instant messaging software. Their effectiveness in preventing complications, avoiding hospital readmissions, improving self-care practices, and enhancing quality of life outcomes was assessed.

METHODS

A randomized controlled trial design was used, and the study sample consisted of patients from a medical center in central Taiwan who underwent thoracic surgery or gastroenterology procedures. Inclusion criteria were being a new case undergoing his or her first gastric tube insertion and having the ability to operate a smartphone. Exclusion criteria were cases requiring tube replacement or nasogastric tubes. A total of 74 participants were enrolled, with 37 participants in the experimental group and 37 participants in the control group. Data collection took place from hospitalization until 1 month after discharge. The experimental group received care using the gastric tube tracking system (PEG app) and the Line app that included phone, text, and photo capture capabilities, while the control group received routine nursing care and used the Line app.

RESULTS

The experimental group demonstrated a significant reduction in the occurrence of complications compared with the control group (χ21=12.087, P=.001). Specifically, the occurrence of leakage events was significantly lower in the experimental group than in the control group (χ21=12.906, P=.001). However, the experimental group exhibited superior self-care ability compared with the control group (t72=2.203, P=.03). There was no significant difference in overall quality of life scores between the experimental and control groups (t72=1.603, P=.11). However, the experimental group showed better social aspects of quality of life than the control group (t72=2.164, P=.03).

CONCLUSIONS

Integration of the PEG app with instant messaging can enhance self-care ability, improve social aspects of quality of life, and reduce complications. The study results suggest that the PEG app could be used as an adjunct tool to promote patients' self-directed management of their gastric tube at home, particularly for patients who have undergone their first PEG placement and are being discharged from the hospital.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300071271; https://tinyurl.com/4vvy584e.

Lung ultrasound supports clinical evaluation of feeding competence development in preterm neonates

Introduction

The achievement of alimentary competencies is a milestone in the development of preterm neonates. Ten percent of neonates <37 weeks of gestational age and 25% of those VLBW experience swallowing disorders, with an increased risk of problems in the early phase of life (failure to thrive, growth retardation, inhalation, and consequent risk of pulmonary infection) and later in life due to delayed development of oromotor skills.The main diagnostic tools for swallowing disorders are endoscopic (fiber-optic endoscopic examination of swallowing, FEES) or radiographic (videofluoroscopic swallowing study, VFSS) exams. Given the invasiveness of these methods and the bias due to rheologic differences between bolus and contrast medium, FEES and VFSS are poorly reproducible. Moreover, neither of the technique is capable of detecting post-meal inhalations, especially microinhalations or those consequent to a whole meal rather than to a single swallowing.Lung ultrasound (LUS) is a widespread, repeatable, safe, fast point-of-care tool and we reported previous encouraging results in detecting silent and overt inhalation related to the meal in children with dysphagia/gastroesophageal reflux disease (GERD) risk factors.

Methods

We report a pilot study, that investigated LUS approach (performing imaging before and after meals) to assess feeding competence development in a cohort of n. 19 newborns <32 weeks of age.

Results

Meal monitoring by LUS did not show any significant difference in scoring before/after eating. The achievement of full enteral feeding correlates with GA at birth (p < 0.001) but not with LUS scoring. The introduction of the first meal by bottle correlates both with gestational age (p < 0.001) and ultrasound scores (p = 0.004). LUS score at 7 days of life resulted predictive for length of invasive/non-invasive respiratory support (p = 0.002) and length of oxygen supply (p = 0.001), while LUS score at 48 h of life did not (p n.s.).

Discussion

Our study suggests that the development of oral feeding skills is not strictly dependent on gestational age. Moreover, our research suggests the predominant role of LUS in predicting the time of readiness to oral feeding, as the LUS score can be a marker of respiratory and lung wellness, and consequently a predictor of neonate stability during deglutitory apnea.

Emergency nurse and physician perceptions of barriers and facilitators to optimal nutrition in the emergency department: A national cross-sectional survey

INTRODUCTION

Optimal nutritional support is becoming increasingly important in Emergency Departments (EDs) as over half of patients presenting to ED are reported to be malnourished or at risk of malnutrition. Few studies have examined the barriers and facilitators to nutritional support in ED.

AIM

To identify barriers and facilitators to providing optimal nutritional support in the ED from nurse and physician perspectives.

METHODS

A cross-sectional 31-item electronic survey was developed, validated, and distributed nationally in August 2021 in China.

RESULTS

A total of 1766 eligible respondents completed the survey, including 846 ED nurses and 920 ED physicians from 155 hospitals. Barriers to optimal nutrition were moderate (2.72/5 ± 0.88); the most common barrier was lack of multidisciplinary team-work support. Facilitators to support optimal nutrition were moderately high (3.58/5 ± 1.08); the most common facilitator was technical/professional support and organizational management. Respondents who received recent nutrition training and those with higher levels of nutrition knowledge (self-rated) perceived fewer barriers overall to optimal nutrition in ED (P < 0.01).

CONCLUSION

Context specific barriers and facilitators both hinder and support optimal nutrition in ED. Further research is required to develop tailored interventions to address specific barriers to optimal nutrition and enhance facilitators in the ED context.

Compliance With Percutaneous Endoscopic Gastrostomy Tube Insertion Guidelines and Associated Complications in a Tertiary Care Setting: A Clinical Audit

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) tube insertion is a widely utilized enteral access technique offering long-term nutritional support for patients unable to tolerate oral intake. While the PEG tube provides numerous advantages, adherence to evidence-based guidelines is crucial to minimize complications. This study aims to evaluate adherence to PEG tube insertion guidelines and analyze associated complication rates in a tertiary care setting.

METHODS

A retrospective clinical audit was conducted at Quaid-e-Azam International Hospital, Islamabad. Data were collected over three years from patients undergoing PEG tube insertion by a single consultant gastrointestinal surgeon. Adherence to guidelines was evaluated using a 10-item checklist developed based on European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Complication rates and patient characteristics were analyzed.

RESULTS

The study included 70 participants (mean age = 72.21 ± 13.17). The PEG tube insertion rate was 100%. The mean checklist score was 8.34 ± 1.2. Laboratory investigations were performed for 98.6% of patients. 91.4% of patients had a life expectancy exceeding 30 days. 60% of patients received an anticoagulation hold. Prophylactic antibiotics were administered to 90% of patients. Psychological counseling and dietician consultation were offered to 38.6% and 64.2% of patients, respectively. Caregivers received specialized training in 98.5% of cases. 12.8% of patients experienced early complications post-procedure, and 14.2% experienced late complications. PEG tube removal occurred in 27% of patients, with only one patient experiencing complications after removal.

CONCLUSION

Adherence to PEG tube insertion guidelines was observed in various aspects of patient care, resulting in a low incidence of complications. Comprehensive auditing and guideline adherence are essential to ensure optimal patient safety and procedural outcomes.

Nutritional status and growth of children and adolescents with and without cerebral palsy in eastern Uganda: A longitudinal comparative analysis

There is a need to understand the growth and burden of malnutrition in children with cerebral palsy (CP) in order to design appropriate inclusive nutrition strategies. We compared the nutritional status and four-year longitudinal growth of a population-based cohort of children and adolescents (C&A) with CP (n = 97; 2-17 years; 55/42 M/F), and an age and sex matched group without CP (n = 91; 2-17y; 50/41 M/F) in rural Uganda. The cohorts were assessed in 2015 and 2019 for weight, height, social demographic characteristics, and feeding related factors. Nutritional status was determined using the World Health Organization (WHO) Z-scores. Wilcoxon sign rank and Mann-Whitney tests were used to test within and between group differences. Multivariable linear regression was used to determine predictors of the change in growth. Approximately two thirds (62/97 (64%)) of C&A with CP were malnourished (with <-2SD in any of the WHO Z-scores), especially those with feeding difficulties (OR = 2.65; P = 0.032), and those who needed to be fed (OR = 3.8; P = 0.019). Both the CP and non-CP groups deviated negatively from the WHO reference growth curve for height, with a significantly slower growth in the CP group (median change score of height-for-age Z score (HAZ) between assessments = -0.80(-1.56, 0.31), p<0.01), than the non-CP group (median HAZ change score = -0.27(-0.92,0.34, p = 0.034). There was a statistically significant group difference in the median HAZ change score between the CP and non-CP groups (z = -2.21, p = 0.026). Severity of motor impairment measured by the Gross Motor Function Classification System (GMFCS-level) correlated negatively (r = -1.37,95%CI -2.67, -0.08) with the change in HAZ scores among the CP group. Children and adolescents with severe motor impairments exhibit an increased risk of malnutrition and growth retardation compared to their age matched peers without CP, which underscores the need to develop inclusive community-based nutrition strategies for children with cerebral palsy.

How far is the endoscopist to blame for a percutaneous endoscopic gastrostomy complication?

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a well-established, minimally invasive, and easy to perform procedure for nutrition delivery, applied to individuals unable to swallow for various reasons. PEG has a high technical success rate of insertion between 95% and 100% in experienced hands, but varying complication rates ranging from 0.4% to 22.5% of cases.

AIM

To discuss the existing evidence of major procedural complications in PEG, mainly focusing on those that could probably have been avoided, had the endoscopist been more experienced, or less self-confident in relation to the basic safety rules for PEG performance.

METHODS

After a thorough research of the international literature of a period of more than 30 years of published “case reports” concerning such complications, we critically analyzed only those complications which were considered - after assessment by two experts in PEG performance working separately - to be directly related to a form of malpractice by the endoscopist.

RESULTS

Malpractice by the endoscopist were considered cases of: Gastrostomy tubes passed through the colon or though the left lateral liver lobe, bleeding after puncture injury of large vessels of the stomach or the peritoneum, peritonitis after viscera damage, and injuries of the esophagus, spleen, and pancreas.

CONCLUSION

For a safe PEG insertion, the overfilling of the stomach and small bowel with air should be avoided, the clinician should check thoroughly for the proper trans-illumination of the light source of the endoscope through the abdominal wall and ensure endoscopically visible imprint of finger palpation on the skin at the center of the site of maximum illumination, and finally, the physician should be more alert with obese patients and those with previous abdominal surgery.

Incidence and time until the first traction or obstruction of the nasoenteral tube in hospitalized adults

OBJECTIVE

To determine incidence and time until first traction or obstruction of nasoenteral tube in hospitalized adults.

METHODS

Prospective double cohort study that included 494 adults who were users of nasoenteral tubes as inpatients in two clinical units and two surgical units in a teaching hospital. The occurrence of tube tractions and obstructions was monitored daily between 2017 and 2019. The Kaplan-Meier method was used to estimate time until the first event.

RESULTS

Tube traction occurred in 33% of the sample, and the incidence of the event was higher on the first five days of tube use. Tube obstruction incidence was 3.4% and grew as tube use time increased.

CONCLUSION

Traction incidence was higher at the beginning of the period of use, whereas obstruction incidence grew as tube use time increased.

Complications of Gastrostomy and Gastrojejunostomy: The Prevalence in Children

Purpose

This study aimed to provide an overview of the prevalence of the complications of a gastrostomy or a gastrojejunostomy with a low-profile gastric tube in children. The study also examined the effect of presence of the gastrostomy tube on the prevalence of complications.

Methods

In this cross-sectional study, parents were invited to complete an online questionnaire. Children aged 0-16 years with a low-profile gastrostomy or gastrojejunostomy tube were included in the study.

Results

A total of 67 complete surveys were conducted. The mean age of the included children was seven years. The most common complications during the past week, were skin irritation (35.8%), abdominal pain (34.3%), and the formation of granulation tissue (29.9%). The most common complications during the past six months were skin irritation (47.8%), vomiting (43.4%), and abdominal pain (38.8%). Most complications occurred within the first year after gastrojejunostomy placement and gradually decreased as the duration since the placement of the gastrojejunostomy tube increased. The prevalence of severe complications was rare. Parental confidence in caring for the gastrostomy positively correlated with increases in the duration of the gastrostomy tube. Even so, parental confidence in the care of the gastrostomy tube was reduced in some parents more than a year after its placement.

Conclusion

The prevalence of gastrojejunostomy complications in children is relatively high. The incidences of severe complications after the placement of a gastrojejunostomy tube were rare in this study. A lack of confidence in the care of the gastrostomy tube was noted in some parents more than a year after its placement.

Outcomes and Complications of Radiological Gastrostomy vs. Percutaneous Endoscopic Gastrostomy for Enteral Feeding: An Updated Systematic Review and Meta-Analysis

Background

Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiological gastrostomy (PRG) are commonly utilized to establish access to enteral nutrition. However, data comparing the outcomes of PEG vs. PRG are conflicting. Therefore, we aimed to conduct an updated systemic review and meta-analysis comparing PRG and PEG outcomes.

Methods

Medline, Embase, and Cochrane library databases were searched until February 24, 2023. Primary outcomes included 30-day mortality, tube leakage, tube dislodgement, perforation, and peritonitis. Secondary outcomes included bleeding, infectious complications, and aspiration pneumonia. All analyses were conducted using Comprehensive Meta-Analysis Software.

Results

The initial search revealed 872 studies. Of these, 43 of these studies met our inclusion criteria and were included in the final meta-analysis. Of 471,208 total patients, 194,399 received PRG and 276,809 received PEG. PRG was associated with higher odds of 30-day mortality when compared to PEG (odds ratio (OR): 1.205, 95% confidence interval (CI): 1.015 - 1.430, I² = 55%). In addition, tube leakage and tube dislodgement were higher in the PRG group than in PEG (OR: 2.231, 95% CI: 1.184 - 4.2 and OR: 2.602, 95% CI: 1.911 - 3.541, respectively). Perforation, peritonitis, bleeding, and infectious complications were higher with PRG than PEG.

Conclusion

PEG is associated with lower 30-day mortality, tube leakage, and tube dislodgement rates than PRG.

I see, I learn, I do: Development and evaluation of a video-enhanced nasogastric tube feeding training programme for caregivers

AIM

We examined the effectiveness of a video-enhanced education package in improving caregiver outcomes (number of steps at first feeding attempt, time to achieve competency and knowledge) compared to the current institutional training approach.

DESIGN

Quasi-experiment.

METHODS

From August 2016-June 2017, we recruited 112 caregivers in a Singaporean tertiary hospital. We allocated 72 and 40 caregivers to video-enhanced and standard education, respectively. Median values are reported with interquartile ranges (IQR), and analysed using Mann-Whitney U test.

RESULTS

Caregivers taught with our video-enhanced package performed a median of 7.0 (IQR = 3.5-7.5) out of eight steps correctly at their first attempt, a 40% increase. There was no change in the median number of training sessions but the 75th percentile dropped to 9.3 from 6.0, a 35% reduction. Post-training knowledge improved from a median of 0.5 (IQR = 0-2.0) to 1.0 (IQR = 0-3.0). The video-enhanced package can improve caregivers' knowledge and accelerate their skill competency.

Development of a nomogram for predicting nosocomial infections among patients after cardiac valve replacement surgery

AIMS AND OBJECTIVES

To construct a predictive nomogram of the risk of nosocomial infections among patients after cardiac valve replacement surgery.

BACKGROUND

Nosocomial infections are a standout challenge that worsens the prognosis of patients after valve replacement surgery. However, studies on the nomogram of nosocomial infections in these patients have remained scarce.

DESIGN

A retrospective cohort study.

METHODS

Patients (n = 720) following valve replacement surgery from 2018 to 2019 were selected. LASSO regression and multivariate logistic regression were utilised to ascertain predictors of nosocomial infections. The predictive performance of the nomogram was appraised by calibration and discrimination. Decision and impact curves were used to assess the clinical utility. Internal validation was implemented via 1000 bootstrap samples to mitigate overfitting. TRIPOD guidelines were used in this study.

RESULTS

One hundred and fifty one patients (20.97%) experienced nosocomial infections following valve replacement surgery. Heart failure, preoperative anaemia, valve material, American Society of Anesthesiologists score ≥ IV, prolonged duration of surgery, duration of mechanical ventilation ≥ 24 h and indwelling nasogastric tube were predictors of nosocomial infections. Using these variables, we developed a predictive nomogram of the occurrence of nosocomial infections and the internal validation results demonstrated good discrimination and calibration of the nomogram. The clinical decision and impact curve revealed significant clinical utility.

CONCLUSIONS

The present study constructed a nomogram for predicting the risk of nosocomial infections in patients following cardiac valve replacement surgery. This nomogram may strengthen the effective screening of patients at high risk of nosocomial infections.

RELEVANCE TO CLINICAL PRACTICE

This risk warning tool can assist clinical staff in making decisions and providing individualised infection control measures for patients, which has a significant reference value for clinical practice.

NO PATIENT OR PUBLIC CONTRIBUTION

The data for this study were obtained from the hospital database, and the entire process of the study did not involve patient participation.

Acute Buried Bumper Syndrome: A Case Report

Buried bumper syndrome (BBS) is a rare but severe complication of percutaneous endoscopic gastrostomy (PEG) tube feeding. Patients with BBS lose PEG tube patency and may experience peristomal pain, content leaks, or peritonitis. An early diagnosis can avert further complications. BBS is a clinical diagnosis, but an abdominal computerized tomography scan or upper endoscopy is needed to confirm the diagnosis. BBS is a long-term complication of PEG tube feeding, and cases of acute onset are scant in the literature. We report a unique case of a 65-year-old female with a history of stroke who developed BBS five weeks after PEG tube placement.

Evolving Therapeutic Roles of Nasogastric Tubes: Current Concepts in Clinical Practice

Nasogastric tubes (NGT) have been in use for over 100 years and are still considered as essential and resuscitative tools in multiple medical specialties for acute and chronic care. They are vital for decompression of the stomach in the presence of bowel obstruction in the critically ill and useful as a conduit for the administration of medications and sometimes for short term parenteral nutrition. The placement of nasogastric tubes is relatively routine. However, they must be inserted and maintained safely and effectively to avoid serious and possibly even fatal associated complications. This review focuses on recent updates in research regarding nasogastric tubes. Cognizance of the recent advances in indications, contraindications, techniques of insertion, confirmation of correct positioning, securement, complications, management of complications, and state of the art research about the nasogastric tube is crucial for practitioners of all medical and surgical specialties.

Buried bumper syndrome: A critical analysis of endoscopic release techniques

Buried bumper syndrome (BBS) is the situation in which the internal bumper of the gastrostomy tube, due to prolonged compression of the tissues between the external and the internal bumper, migrates from the gastric lumen into the gastric wall or further, into the tract outside the gastric lumen, ending up anywhere between the stomach mucosa and the surface of the skin. This restricts liquid food from entering the stomach, since the internal opening is obstructed by gastric mucosal overgrowth. We performed a comprehensive search of the PubMed literature to retrieve all the case-reports and case-series referring to BBS and its management, after which we focused on the endoscopic techniques for releasing the internal bumper to re-establish the functionality of the tube. From the “push” and the “push and pull T” techniques to the most sophisticated-using high tech instruments, all 10 published techniques have been critically analysed and the pros and cons presented, in an effort to optimize the criteria of choice based on maximum efficacy and safety.

‘Cut and push’ as an alternative to endoscopic retrieval of PEG type gastrostomy tubes

PURPOSE

Percutaneous Endoscopically placed Gastrostomy (PEG) tubes are frequently used in children. The traditional endoscopic method to remove/change the PEG device requires general anaesthesia in children. A minimally invasive alternative is the 'Cut and Push' method (C&P): avoiding the risks/wait times of general anaesthesia and reducing resource burden. Data regarding the safety/effectiveness of C&P in children are lacking with concerns raised about the possibility of gastrointestinal obstruction.

METHODS

We retrospectively reviewed all cases of PEG removal / change to button in children (< 18 years) between December 2020 and January 2022. Cases were identified from a prospectively maintained database and all cases of C&P included. Parents/carers were asked if the child had suffered any complications following C&P and if flange was visualised in stools.

RESULTS

During the time period, 27 PEGs were either removed or changed to button via C&P. The average waiting time for C&P was 14.29 days, significantly shorter than the minimum 6-month waiting time for elective endoscopy. Our evaluation revealed no complications of C&P at median 70 days (range 25-301). In three cases the flange was visualised in the stool, at 2 days, 3 days and 5 weeks following C&P respectively.

DISCUSSION

These data support the available literature suggesting C&P is an effective means to facilitate minimally invasive and prompt PEG removal/change to button in children. We recommend minimum weight and age parameters for this procedure and further evaluation of the safety and resource implications of this technique.

Nutrition management by a multidisciplinary team for prevention of nutritional deficits and morbidity following esophagectomy

This study evaluated the effects of perioperative nutrition management by a multidisciplinary team on nutrition and postoperative complications of patients with esophageal cancer. A total of 239 patients with esophageal cancer who underwent esophagectomy and gastric conduit reconstruction for esophageal or esophagogastric junction cancer between February 2019 and February 2020 were included in the study. They were divided into the experimental group (120 patients) and the control group (119 patients) using the random number table method. Control group patients received routine diet management and experimental group patients received perioperative nutrition management by a multidisciplinary team. The differences of nutriture and postoperative complications between the two groups were compared. At 3 and 7 days after surgery, the experimental group patients had higher total protein and albumin levels (P<0.05), shorter postoperative anal exhaust time (P<0.05), lower incidence of postoperative gastrointestinal adverse reactions, pneumonia, anastomotic fistula, hypoproteinemia (P<0.05), and lower hospitalization costs (P<0.05) than the control group. Nutrition management by a multidisciplinary team effectively improved the nutriture of patients, promoted the rapid recovery of postoperative gastrointestinal function, reduced postoperative complications, and reduced hospitalization costs.

Gut dysmotility in children with neurological impairment: the nutritional management

Intestinal motility disorders represent a frequent problem in children with neurological impairment. These conditions are characterized by abnormal movements of the gut, which can result in symptoms such as constipation, diarrhea, reflux, and vomiting. The underlying mechanisms leading to dysmotility are various, and the clinical manifestations are often nonspecific. Nutritional management is an important aspect of care for children with gut dysmotility, as it can help to improve their quality of life. Oral feeding, when safe and in the absence of risk of ingestion or severe dysphagia, should always be encouraged. When oral nutrition is insufficient or potentially harmful, it is necessary to switch to an enteral by tube or parenteral nutrition before the onset of malnutrition. In most cases, children with severe gut dysmotility may require feeding via a permanent gastrostomy tube to ensure adequate nutrition and hydration. Drugs may be necessary to help manage gut dysmotility, such as laxatives, anticholinergics and prokinetic agents. Nutritional management of patients with neurological impairment often requires an individualized care plan to optimize growth and nutrition and to improve overall health outcomes. This review tries to sum up most significant neurogenetic and neurometabolic disorders associated with gut dysmotility that may require a specific multidisciplinary care, identifying a proposal of nutritional and medical management.

Edaravone Administered Orally and Via Nasogastric Tube in Healthy Adults: A Comparative Bioavailability Phase 1 Study

Intravenous edaravone is used to treat patients with amyotrophic lateral sclerosis. This randomized, open-label, two-way crossover, single-dose phase 1 study compared the relative bioavailability of a newly developed edaravone oral suspension when administered orally and via a nasogastric tube (NGT) as a model of percutaneous endoscopic gastrostomy tube administration in healthy adult subjects. Thirty-six subjects were randomly assigned to one of two groups, with 18 per group. Blood was collected pre- and post-dose for pharmacokinetic assessments; safety was evaluated. Plasma concentration-time profiles of unchanged edaravone were similar between administration routes. Comparative bioavailability analysis revealed that geometric least squares mean ratios (NGT/oral) for maximum plasma concentration and area under the plasma concentration-time curve from time zero to infinity of unchanged edaravone were 1.052 and 0.981, respectively. No serious adverse events or adverse drug reactions were reported. These results suggest that oral edaravone suspension can be administered directly to the stomach without dose adjustment via feeding tubes; both oral and NGT administration are well tolerated.

Nurses' Knowledge and Practice of Nasogastric Tube Placement: A Descriptive Research Study

The aim of this study is to examine nurses' knowledge and behaviors about nasogastric tube placement according to current standards. This descriptive study was conducted in a private hospital in Turkey with the participation of 184 nurses. Data were collected through a questionnaire consisting of two parts: "Personal Information Form" and "NGT Placement Information Form." About half of the nurses (45.6%) did not read current information about nasogastric tubes, though 36.5% were aware of the auscultation method as the best method for nasogastric tube placement confirmation and approximately half (48.9%) of them used this method. Nurses who participated in our study did not use a pH test, capnography, or radiography methods to confirm nasogastric tube placement. As a result, it is recommended that nurses follow current evidence about nasogastric tube placement and maintain or improve their education on this topic.