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Post-Esophagectomy Tube Feeding: A Retrospective Comparison of Jejunostomy and a Novel Gastrostomy Feeding Approach  [PDF]
Kenan Huang, Bin Wu, Xinyu Ding, Zhifei Xu, Hua Tang
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0089190
Abstract: Background McKeown-type esophagectomy combined with retrosternal reconstruction is a common surgical treatment for esophageal cancer. Various enteral feeding options are available post-esophagectomy, but no definitive preference exists. Method “Retrosternal Route Gastrostomy Feeding (RGF)” was developed as an alternative enteral feeding approach that requires few additional surgical interventions. RGF is based on McKeown-type esophagectomy. We retrospectively compared RGF (n = 121) to jejunostomy feeding (JF) (n = 153) in 274 patients at the Department of Cardiothoracic Surgery in Changzheng Hospital (Shanghai, China) between June 2008 and Sept. 2012. Data pertaining to efficacy and procedural complications were compared among patients. Results RGF had a significantly shorter postoperative hospital stay (11 vs. 15 days, p<0.001) and time to removal of the feeding tube (9 vs. 14 days, p<0.001) compared to JF. Bowel obstruction (0.0% vs. 7.2% p = 0.003), abdominal distension (9.1% vs. 19% p = 0.022), and the occurrence of pneumonia (11.6% vs. 26.1% p = 0.003) were significantly lower in the RGF group. Feeding tube related complications and the associated morbidity rate were reduced in the RGF group. The two groups had similar tolerance to surgery. Conclusion Our data suggests that RGF is a safe post-esophagectomy enteral feeding alternative to JF.
Gastric versus post-pyloric feeding: a systematic review
Paul E Marik, Gary P Zaloga
Critical Care , 2003, DOI: 10.1186/cc2190
Abstract: Data sources were Medline, Embase, Healthstar, citation review of relevant primary and review articles, personal files, and contact with expert informants. From 122 articles screened, nine were identified as prospective randomized controlled trials (including a total of 522 patients) that compared gastric with post-pyloric feeding, and were included for data extraction. Descriptive and outcomes data were extracted from the papers by the two reviewers independently. Main outcome measures were the incidence of nosocomial pneumonia, average caloric goal achieved, average daily caloric intake, time to the initiation of tube feeds, time to goal, ICU LOS, and mortality. The meta-analysis was performed using the random effects model.Only medical, neurosurgical and trauma patents were enrolled in the studies analyzed. There were no significant differences in the incidence of pneumonia, percentage of caloric goal achieved, mean total caloric intake, ICU LOS, or mortality between gastric and post-pyloric feeding groups. The time to initiation of enteral nutrition was significantly less in those patients randomized to gastric feeding. However, time to reach caloric goal did not differ between groups.In this meta-analysis we were unable to demonstrate a clinical benefit from post-pyloric versus gastric tube feeding in a mixed group of critically ill patients, including medical, neurosurgical, and trauma ICU patients. The incidences of pneumonia, ICU LOS, and mortality were similar between groups. Because of the delay in achieving post-pyloric intubation, gastric feeding was initiated significantly sooner than was post-pyloric feeding. The present study, while providing the best current evidence regarding routes of enteral nutrition, is limited by the small total sample size.Enteral nutrition is increasingly being recognized as an integral component in the management of critically ill patients, having a major effect on morbidity and outcome. Early enteral nutrition has been demo
Management of gastro-bronchial fistula complicating a subtotal esophagectomy: a case report
James D Martin-Smith, John O Larkin, Finbar O'Connell, Narayanasamy Ravi, John Reynolds
BMC Surgery , 2009, DOI: 10.1186/1471-2482-9-20
Abstract: A 68 year old man underwent radical esophagectomy for esophageal adenocarcinoma. On postoperative day 14 the nasogastric drainage bag dramatically filled with air, without deterioration in respiratory function or progressive sepsis. A fiberoptic bronchoscopy was performed which demonstrated a gastro-bronchial fistula in the posterior aspect of the left main bronchus. He was managed conservatively with antibiotics, enteral nutrition via jejunostomy, and non-invasive respiratory support. A follow- up bronchoscopy 60 days after the diagnostic bronchoscopy, confirmed spontaneous closure of the fistulaThis is the first such case where a conservative approach with no surgery or endoprosthesis resulted in a successful outcome, with fistula closure confirmed at subsequent bronchoscopy. Our experience would suggest that in very carefully selected cases where bronchopulmonary contamination from the fistula is minimal or absent, there is no associated inflammation of the tracheobronchial tree and the patient is stable from a respiratory point of view without evidence of sepsis, there may be a role for a trial of conservative management.The development of a fistula between the tracheobronchial tree and the gastric conduit post esophagectomy is a rare and often fatal complication. Most fistulae occur from direct communication between a dehisced anastomosis and adjacent bronchus. Anastomotic leaks are responsible for approximately 40% of post-esophagectomy deaths [1]. Clinically apparent thoracic anastomotic leaks and fistulae are associated with a high rate of mortality despite advances in critical care and endoprostheses [2]. We present herein a particularly rare case, a fistula from the left main bronchus into a cervical esophagogastric anastomosis, and discuss the presentation and the approach to successful conservative management.A 68 year old man presented with a five month history of progressive dysphagia and weight loss of 5 kg. An adenocarcinoma arising in Barrett's epit
Endoscopic placement of enteral feeding tubes  [cached]
Gerard P Rafferty,Tony CK Tham
World Journal of Gastrointestinal Endoscopy , 2010,
Abstract: Malnutrition is common in patients with acute and chronic illness. Nutritional management of these malnourished patients is an essential part of healthcare. Enteral feeding is one component of nutritional support. It is the preferred method of nutritional support in patients that are not receiving adequate oral nutrition and have a functioning gastrointestinal tract (GIT). This method of nutritional support has undergone progression over recent times. The method of placement of enteral feeding tubes has evolved due to development of new feeding tubes and endoscopic technology. Enteral feeding can be divided into methods that provide short-term and long-term access to the GIT. This review article focuses on the current range of methods of gaining access to the GIT to provide enteral feed.
A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients
Hayden White, Kellie Sosnowski, Khoa Tran, Annelli Reeves, Mark Jones
Critical Care , 2009, DOI: 10.1186/cc8181
Abstract: Prospective randomized study. Ventilated patients were randomly assigned to receive enteral feed via a nasogastric or a post-pyloric tube. Post-pyloric tubes were inserted by the bedside nurse and placement was confirmed radiographically.A total of 104 patients were enrolled, 54 in the gastric group and 50 in the post-pyloric group. Bedside post-pyloric tube insertion was successful in 80% of patients. Patients who failed post-pyloric insertion were fed via the nasogastric route, but were analysed on an intent-to treat basis. A per protocol analysis was also performed. Baseline characteristics were similar for all except Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was higher in the post-pyloric group. There was no difference in length of stay or ventilator days. The gastric group was quicker to initiate feed 4.3 hours (2.9 - 6.5 hours) as compared to post-pyloric group 6.6 hours (4.5 - 13.0 hours) (P = 0.0002). The time to reach target feeds from admission was also faster in gastric group: 8.7 hours (7.6 - 13.0 hours) compared to 12.3 hours (8.9 - 17.5 hours). The average daily energy and protein deficit were lower in gastric group 73 Kcal (2 - 288 Kcal) and 3.5 g (0 - 15 g) compared to 167 Kcal (70 - 411 Kcal) and 6.5 g (2.8 - 17.3 g) respectively but was only statistically significant for the average energy deficit (P = 0.035). This difference disappeared in the per protocol analysis. Complication rates were similar.Early post-pyloric feeding offers no advantage over early gastric feeding in terms of overall nutrition received and complicationsClinical Trial: anzctr.org.au:ACTRN12606000367549Adequate nutritional support plays a significant role in the outcome of critically ill patients [1]. Furthermore, it is generally accepted that enteral feeding is preferable to parenteral feeding [2-4]. Benefits of enteral feeding may include improvements in intestinal structure and function, prevention of bacterial translocation and infective co
促胃肠动力药提高鼻肠管幽门后置管成功率的网状meta分析
Prokinetic agent for promoting post-pyloric placement of naso-enteral feeding tubes: a network meta-analysis
 [PDF]

董慧君△,董小方,,,董洄羽
- , 2017, DOI: 10.13705/j.issn.1671-6825.2017.01.016
Abstract: 目的:采用网状meta分析的方法比较甲氧氯普胺、红霉素和多潘立酮3种促胃肠动力药提高鼻肠管幽门后置管成功率的有效性。方法:计算机检索Cochrane Central Register of Controlled Trials、PubMed、EMBASE、OVID、Web of Science、中国知网和万方数据库,检索时限为从各数据库建库至2015年10月。按纳入和排除标准进行文献筛选、资料提取及meta分析。结果:共纳入11篇文献,共计802例患者。直接meta分析结果显示,甲氧氯普胺(OR=2.37, 95%CI=1.64~3.42, P<0.001)、红霉素(OR=3.45, 95%CI=2.05~5.81, P<0.001)、多潘立酮(OR=3.62,95%CI=2.00~6.56, P<0.001)在提高幽门后置管成功率方面疗效均优于安慰剂。排序概率图显示,红霉素效果最佳,其次是甲氧氯普胺和多潘立酮。结论:在提高鼻肠管幽门后置管成功率的促胃肠动力药中,红霉素的效果优于甲氧氯普胺和多潘立酮。
Aim: To evaluate the effectiveness and safety of 3 prokinetic agents(metoclopramide,erythromycin, and domperidone)for post-pyloric placement of naso-enteral feeding tubes.Methods: Cochrane Central Register of Controlled Trials, PubMed, EMBASE, OVID, Web of Science, CNKI and Wanfang Data were searched from their inception to October 2015. Literature selection, data extraction and meta-analysis were conducted according to inclusion criteria and exclusion criteria.Results: Eleven trials involving 802 patients fed via naso-enteral feeding tubes were identified. The direct meta-analysis showed that compared with placebo or no intervention, metoclopramide(OR=2.37, 95%CI=1.64-3.42, P<0.001), erythromycin(OR=3.45, 95%CI=2.05-5.81, P<0.001)and domperidone(OR=3.62, 95%CI=2.00-6.56, P<0.001)could increase successful rate of post-pyloric placement of naso-enteral feeding tubes. The rank probability plot showed that the success rate of erythromycin was the highest and then metoclopramide and domperidone in a descending order.Conclusion: Among 3 prokinetic agents, erythromycin is superior to the other 2 in success rate of post-pyloric placement of naso-enteral feeding tubes
A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes
Athos J Rassias, Perry A Ball, Howard L Corwin
Critical Care , 1998, DOI: 10.1186/cc120
Abstract: Seven hundred and forty feeding tubes were inserted during the study period. In 14 cases (2%), the feeding tube was inserted into the tracheopulmonary system. Five patients (0.7%) suffered a major complication, including two (0.3%) who died from complications directly related to the feeding tube placement. All patients had altered consciousness and 13 of the 14 had endotracheal tubes in place. Malposition of the feeding tube was not predictable from clinical signs and auscultation, but was detectable by chest roentgenogram.Inadvertent insertion of enteral feeding tubes into the tracheopulmonary system during placement is associated with significant morbidity and mortality. Clinical signs at the time of insertion are not useful in identifying feeding tubes which are malpositioned. In the ICU patient, a chest roentgenogram is required after all feeding tube insertions prior to the initiation of enteral feeding. In the high-risk patient, alternatives to blind feeding tube insertion should be considered.Enteral feeding is now generally recognized as the preferred method for providing nutritional support to critically ill patients. When compared to parenteral nutrition, enteral feeding is considered to be both safer and associated with improved outcome [1]. Over the last two decades narrow-bore enteral feeding tubes have gained widespread acceptance as the preferred device for providing enteral nutrition. They were introduced in response to problems associated with the stiffer larger-bore tubes [2, 3]. The narrow-bore tubes are softer, made from silastic, and generally provide for greater patient comfort and fewer erosive complications than occur with the larger type. Most tubes of this type have a removable steel stylet, which makes them stiffer and allows for easier passage. A particular advantage of enteral feeding is the avoidance of the risk associated with placement of a central venous catheter [4, 5]. However, the use of feeding tubes is not without its own compli
Daily enteral feeding practice on the ICU: attainment of goals and interfering factors
JM Binnekade, R Tepaske, P Bruynzeel, EMH Mathus-Vliegen, RJ de Haan
Critical Care , 2005, DOI: 10.1186/cc3504
Abstract: The feeding practice of all ICU patients receiving enteral nutrition for at least 48 hours was recorded during a 1-year period. Actual intake was expressed as the percentage of the prescribed volume of formula (a success is defined as 90% or more). Prescribed volume (optimal intake) was guided by protocol but adjusted to individual patient conditions by the intensivist. The potential barriers to the success of feeding were assessed by multivariate analysis.Four-hundred-and-three eligible patients had a total of 3,526 records of feeding days. The desired intake was successful in 52% (1,842 of 3,526) of feeding days. The percentage of successful feeding days increased from 39% (124 of 316) on day 1 to 51% (112 of 218) on day 5. Average ideal protein intake was 54% (95% confidence interval (CI) 52 to 55), energy intake was 66% (95% CI 65 to 68) and volume 75% (95% CI 74 to 76). Factors impeding successful nutrition were the use of the feeding tube to deliver contrast, the need for prokinetic drugs, a high Therapeutic Intervention Score System category and elective admissions.The records revealed an unsatisfactory feeding process. A better use of relative successful volume intake, namely increasing the energy and protein density, could enhance the nutritional yield. Factors such as an improper use of tubes and feeding intolerance were related to failure. Meticulous recording of intake and interfering factors helps to uncover inadequacies in ICU feeding practice.Protein energy malnutrition is a major problem in severely ill hypercatabolic patients in the intensive care unit (ICU) [1]. Early initiation of enteral nutrition has proved to be beneficial, with significant positive effects on septic complications, and has been shown to improve the outcome when compared with parenteral nutrition. Enteral nutrition guarantees the preservation of gut mass and prevents increased gut permeability to bacteria and toxins [2-5]. In addition, the gut-associated lymphoid tissue is bette
Metabolic assessment and enteral tube feeding usage in children with acute neurological diseases
Leite, Heitor Pons;Fantozzi, Gina;
Sao Paulo Medical Journal , 1998, DOI: 10.1590/S1516-31801998000600006
Abstract: objective: to report on acquired experience of metabolic support for children with acute neurological diseases, emphasizing enteral tube feeding usage and metabolic assessment, and also to recommend policies aimed towards improving its implementation. design: retrospective analysis. setting: pediatric intensive care unit of hospital do servidor público estadual de s?o paulo. subjects: 44 patients consecutively admitted to the pediatric icu over a period of 3 years who were given nutrition and metabolic support for at least 72 hours. head trauma, cns infections and craniotomy post-operative period following tumor exeresis were the main diagnoses. measurements: records of protein-energy intake, nutrient supply route, nitrogen balance and length of therapy. results: from a total of 527 days of therapy, single parenteral nutrition was utilized for 34.3% and single enteral tube feeding for 79.1% of that period. 61.4% of the children were fed exclusively via enteral tube feeding, 9.1% via parenteral and 39.5 % by both routes. the enteral tube feeding was introduced upon admission and transpyloric placement was successful in 90% of the cases. feeding was started 48 hours after icu admission. the caloric goal was achieved on the 7th day after admission, and thereafter parenteral nutrition was interrupted. the maximum energy supply was 104.2 ± 23.15 kcal/kg. the median length of therapy was 11 days (range 4-38). none of the patients on tube feeding developed gi tract bleeding, pneumonia or bronchoaspiration episodes and, of the 4 patients who were given exclusive tpn, 2 developed peptic ulcer. the initial urinary urea nitrogen was 7.11 g/m2 and at discharge 6.44 g/m2. the protein supply increased from 1.49 g/kg to 3.65 g/kg (p< 0.01). the nitrogen balance increased from -7.05 to 2.2 g (p< 0.01). conclusions: children with acute neurological diseases are hypercatabolic and have high urinary nitrogen losses. the initial negative nitrogen balance can be increased by more aggres
A new technique for bedside placement of enteral feeding tubes: a prospective cohort study
Günther Zick, Alexander Frerichs, Markus Ahrens, Bodo Schniewind, Gunnar Elke, Dirk Sch?dler, Inéz Frerichs, Markus Steinfath, Norbert Weiler
Critical Care , 2011, DOI: 10.1186/cc9407
Abstract: This was a prospective cohort study in 27 critically ill patients subjected to transnasal endoscopy and intubation of the pylorus. Attending intensive care physicians were trained in the handling of the new endoscope for transnasal gastroenteroscopy for two days. A jejunal feeding tube was advanced via the instrument channel and the correct position assessed by contrast radiography. The primary outcome measure was successful postpyloric placement of the tube. Secondary outcome measures were time needed for the placement, complications such as bleeding and formation of loops, and the score of the placement difficulty graded from 1 (easy) to 4 (difficult). Data are given as mean values and standard deviation.Out of 34 attempted jejunal tube placements, 28 tubes (82%) were placed correctly in the jejunum. The duration of the procedure was 28 ± 12 minutes. The difficulty of the tube placement was judged as follows: grade 1: 17 patients, grade 2: 8 patients, grade 3: 7 patients, grade 4: 2 patients. In three cases, the tube position was incorrect, and in another three cases, the procedure had to be aborted. In one patient bleeding occurred that required no further treatment.Fast and reliable transnasal insertion of postpyloric feeding tubes can be accomplished by trained intensive care physicians at the bedside using the presented procedure. This new technique may facilitate early initiation of enteral feeding in intensive care patients.Feeding the critically ill patient should be preferentially accomplished via the enteral route [1,2]. A recent meta-analysis revealed that mortality and the incidence of pneumonia were significantly reduced in patients with enteral nutrition within 24 hours [3]. Parenteral nutrition may be associated with higher mortality [4].Intolerance of gastric feeding and high gastric volumes are the main obstacles for enteral nutrition [5]. If intragastric feeding fails despite prokinetic therapy with erythromycin and metoclopramide it is recommende
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