Transnasal Endoscopic Placement of Nasoenteric Feeding Tubes

Nutrition in Clinical Practice http://ncp.sagepub.com

Transnasal Endoscopic Placement of Nasoenteric Feeding Tubes: Outcomes and Limitations in NonCritically Ill Patients Sanjiv Mahadeva, Abdul Malik, Ida Hilmi, Choon-Seng Qua, Choon-Heng Wong and Khean-Lee Goh Nutr Clin Pract 2008; 23; 176 DOI: 10.1177/0884533608314535 The online version of this article can be found at: http://ncp.sagepub.com/cgi/content/abstract/23/2/176

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Clinical Observations

Transnasal Endoscopic Placement of Nasoenteric Feeding Tubes: Outcomes and Limitations in Non–Critically Ill Patients

Nutrition in Clinical Practice Volume 23 Number 2 April/May 2008 176-181 © 2008 American Society for Parenteral and Enteral Nutrition 10.1177/0884533608314535 http://ncp.sagepub.com hosted at http://online.sagepub.com

Sanjiv Mahadeva, MRCP; Abdul Malik, MMed; Ida Hilmi, MRCP; Choon-Seng Qua, MRCP; Choon-Heng Wong, MRCP; and Khean-Lee Goh, MD, FRCP Financial disclosure: none declared. second part of the duodenum. NET placement was least successful in cases with duodenal stenosis. NETs remained in situ for a median of 24 days (range, 2-94), with tube dislodgement (n = 3) and clogging (n = 5) as the main complications. NET feeding resulted in complete healing of gastrocutaneous fistulae in 5 of 6 patients and provision of total enteral nutrition in 3 of 4 cases of acute pancreatitis and 9 of 11 cases of gastroparesis or proximal duodenal obstruction. Transnasal endoscopy has a role in the placement of NET in non–critically ill patients requiring postpyloric feeding. However, there are some limitations, particularly in cases with altered duodenal anatomy. (Nutr Clin Pract. 2008;23:176-181)

Transnasal endoscopic placement of nasoenteric tubes (NETs) has been demonstrated to be useful in the critical care setting, with limited data on its role in non–critically ill patients. The authors collected data on consecutive patients from a non–critical care setting undergoing transnasal endoscopic NET placement. All NETs were endoscopically placed using a standard over-the-guidewire technique, and positions were confirmed with fluoroscopy. Patients were monitored until the removal of NETs or death. Twenty-two patients (median age = 62.5 years, 36.4% female) were referred for postpyloric feeding, with main indications of persistent gastrocutaneous fistula (n = 6), gastroparesis or gastric outlet obstruction (n = 5), duodenal stenosis (n = 6), acute pancreatitis (n = 4), and gastroesophageal reflux after surgery (n = 1). Postpyloric placement of NET was achieved in 19 of 22 (86.3%) patients, with 36.8% tube positions in the jejunum, 47.4% in the distal duodenum, and 15.8% in the

Keywords: transnasal endoscopy; nasoenteric tubes; nasojejunal tubes; enteral nutrition; postpyloric feeding; non–critically ill; outcomes

more recently, in patients with acute pancreatitis.5 There are limited data, otherwise, on its role in adult patients who are not critically ill. The placement of nasoenteric feeding tubes (NETs) remains a major obstacle to successful short-term postpyloric feeding.6 Available insertion techniques consist of a bedside blind method, fluoroscopy-guided placement, and endoscopy-assisted placement, with the latter 2 techniques achieving the best placement rates.7-9 Most peroral endoscopic techniques require an oronasal transfer step, which is cumbersome and time-consuming.10 The development of ultrathin endoscopes in the past decade has allowed examination of the upper GI tract using a transnasal route.11 With this approach, direct transnasal endoscopic placement of NETs was recently described, eliminating the need for oronasal transfer.12 This technique has subsequently been shown to be comparable to

S

hort-term postpyloric feeding in critically ill patients has been shown to have clear advantages. Reduction of pulmonary aspiration from gastroesophageal reflux, decreased septic morbidity rates, early attainment of caloric requirements, and maintenance of nutrition in the presence of gastric feed intolerance have all been demonstrated in these patients.1-3 In the non–critical care setting, short-term postpyloric enteral feeding has traditionally been instituted following abdominal surgery (usually via a surgical jejunostomy)4 and, From the Division of Gastroenterology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Address correspondence to: Sanjiv Mahadeva, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia; e-mail: [email protected].

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Transnasal Endoscopic Placement of Nasoenteric Feeding Tubes / Mahadeva et al

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Figure 1. Sequential images demonstrating the technique of transnasal endoscopy into the duodenum, followed by the passage of guidewire and eventual placement of the nasoenteric tube.

per-oral endoscopic13 and radiological14 placement techniques of NETs, with the advantage of a shorter procedure duration. However, all of these studies have been conducted in only critically ill patients, with many patients having nondiseased upper GI tracts. There are limited data on transnasal endoscopic placement of NETs in non– critically ill patients requiring postpyloric feeding. We describe a single-center experience of transnasal NET placement in consecutive non–critically ill patients.

position, and a 10 French polyurethane NET (Ross Feeding Tube; Abbott Laboratories, Columbus, OH) was passed over the guidewire as deeply as possible (Figure 1). Following removal of the wire, the external component of the NET was secured to the patient’s nares by tape and the tube position checked by fluoroscopy, which is available in our endoscopy unit. If the NET position was not satisfactory, the whole procedure was repeated. All patients were followed up prospectively until the time of removal of NET or death. Data on tube function, any complications, and final outcome were obtained.

Methods Data on consecutive patients referred for NET placement were prospectively collected. All patients had initially been referred to this institution’s clinical nutrition team for parenteral feeding and subsequently offered enteral feeding via NET. The study was approved by a local institutional review committee. Procedures were performed by senior and trainee endoscopists, all of whom had similar levels of experience in transnasal endoscopy. In accordance with this unit’s usual practice, all patients received sedation with 1.25 to 2.5 mg of midazolam, with the exception of patients with respiratory disease. Topical analgesia (1% lignocaine) to the nasopharynx was applied in all cases. A 5.9-mm outer diameter ultrathin endoscope (GIF XP-160; Olympus, Tokyo, Japan) was passed transnasally into the upper GI tract, and a diagnostic examination was performed. The endoscope was then advanced as far as possible into the duodenum, followed by the insertion of a Teflon-coated, soft-tipped guidewire through the working channel of the endoscope. Once visible endoscopically, the guidewire was then advanced further down the lumen beyond the endoscopic view until resistance was felt. The endoscope was then withdrawn while maintaining a wire

Results NET Placement Twenty-two patients (median age = 62.5 years; range, 20-83 years; 8 [36.4%] female) in a non–critically ill setting were referred for NET placement between June 2005 and October 2006. Indications for postpyloric feeding are highlighted in Table 1. Successful placement of NET beyond the pylorus was achieved in 19 of 22 (86.3%) patients. The median time for transnasal endoscopy and NET placement was 18 minutes, with a range from 12 to 45 minutes. The procedure duration for cases with duodenal stenosis (benign and malignant) was the longest because of looping and coiling of the ultrathin endoscope within the stomach. This usually resulted in a looped wire within the stomach and subsequent coiling of the NET within the stomach (Figure 2). In 3 cases with duodenal stenosis, the procedure had to be repeated, adding to the procedure duration (Table 2). Among the 19 cases, NET placement achieved was as follows: jejunum, 7 (36.8%) (Figure 3); distal duodenum, 9 (47.4%); and second part duodenum, 3 (15.8%).


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Table 1.

Indications for Nasoenteric Tube Feeding in 22 Non–Critically Ill Patients

Indication Persistent gastrocutaneous fistula Gastroparesis/gastric outlet obstruction

Duodenal stenosis

Postduodenal feeding Gastroesophageal reflux

Primary Diagnosis

n

Infected percutaneous endoscopic gastrostomy Linitis plastica (gastric cancer) Pancreatic cancer with gastric infiltration Gastric cancer (preoperative)a Pancreatic cancer (preoperative)a Ampullary carcinoma Primary duodenal carcinoma Chronic pancreatitis Metastases from cervical cancer Duodenal malrotation Acute severe pancreatitis Post–Whipple procedure

6 3 1 1 1 1 1 1 1 1 4 1

a

Short-term enteral feeding prior to elective surgery date.

Table 2.

Details of Transnasal Nasoenteric Tube Placement Procedure in 22 Non–Critically Ill Patients

Indication

Range of Procedure Duration, min

Successful, n

Persistent gastrocutaneous fistula

12-18

5/6

Gastroparesis/gastric outlet obstruction

18-22

5/5

Duodenal stenosis

35-45

4/6

Postduodenal feeding

14-19

4/4

Gastroesophageal reflux

14

1/1

Placement Distal duodenum = 2 Jejunum = 3 Distal duodenum = 3 Jejunum = 2 Second part duodenum = 3 Distal duodenum = 1 Distal duodenum = 2 Jejunum = 2 Distal duodenum = 1

fistula who appeared to have a fixed duodenum, possibly from fibrosis. In these 3 patients, the endoscope looped in the stomach as attempts were made to pass it into the duodenum. Subsequent guidewire passage also resulted in gastric looping of the guidewire and the inability to bypass the duodenum. The ultimate passage of the NET into the proper position was unsuccessful. No immediate or delayed complications occurred following transnasal endoscopic NET placement.

Clinical Outcomes

Figure 2. Radiographic image demonstrating the coiling of the nasoenteric tube within the gastric cavity in a patient with duodenal stenosis and the tip of the tube in the proximal duodenum only.

The 3 cases in which NET placement was unsuccessful involved 2 patients with malignant duodenal obstruction and 1 patient with a nonhealing gastrocutaneous

Standard enteral feeds were administered through infusion pumps for inpatients, while a few terminally ill patients were discharged home with slow bolus feeding. The median duration that NETs remained in place was 24 days (range, 2-94 days). Tube dislodgement occurred in 3 (13.6%) cases. NETs were successfully reinserted in 2 of the cases, whereas a third patient declined further intervention. Clogging disrupted feeding in 5 (26.3%) cases, all of which resolved with repeated flushing. The eventual outcomes of postpyloric feeding are summarized in Table 3. NET feeding allowed for complete healing of 5 of 6 cases


Transnasal Endoscopic Placement of Nasoenteric Feeding Tubes / Mahadeva et al

Table 3.

179

Clinical Outcomes of Non–Critically Ill Patients With Nasoenteric Tube Feeding (n = 19) Duration of Enteral Feeding, d

Indication Persistent gastrocutaneous fistula (n = 5)

24-94

Gastroparesis/gastric outlet obstruction (n = 5)

2-34

Duodenal stenosis (n = 4)

14-56

Postduodenal feeding (n = 4)

14-16

Gastroesophageal reflux (n = 1)

14

Figure 3. Plain radiograph demonstrating the successful placement of the nasoenteric tube beyond the ligament of Treitz in the jejunum.

Outcome Complete healing of fistulae in all percutaneous endoscopic gastrostomy reinserted into 4 patients 1 mortality due to pneumonia 3 patients died in