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Techniques and Procedures |
Enteral Access in Mechanically Ventilated Patients
Andrew D. Guidroz, MD and
Ayaz J. Chaudhary, MD
Section of Gastroenterology/Hepatology, Medical College of Georgia,
Augusta, Georgia
Correspondence: Ayaz J. Chaudhary, MD, Medical College of Georgia,
Gastroenterology Department, 1120 15th Street, BBR2535, Augusta, GA 30912.
Electronic mail may be sent to
achaudha{at}mail.mcg.edu.
The early institution of enteral nutrition is now accepted as the preferred
route of feeding in critically ill patients with a functioning
gastrointestinal tract. It is particularly important to establish early
enteral nutrition in mechanically ventilated patients because of the metabolic
demands associated with mechanical ventilation. The options for enteral access
in mechanically ventilated patients are reviewed, with an emphasis on those
techniques that may be performed at the bedside. The advantages,
disadvantages, and complications of the different techniques will be
considered.
The establishment of early enteral nutrition is important in the care of
critically ill, mechanically ventilated patients. Before 1991, the use of
parenteral nutrition in critically ill patients was widespread. In 1991, the
first study showing an increased risk of infectious complications in patients
receiving parenteral nutrition was
published.1 Since
then, there has been an increasing body of evidence to support the use of
enteral nutrition in critically ill patients. Because of mechanical
ventilation and other comorbid conditions such as sepsis, critically ill
patients usually have metabolic requirements resulting in the need for early
enteral nutrition. Early gastric feeding can be associated with high gastric
residual volumes, resulting in an increased risk of aspiration pneumonia and
bacterial colonization of the
stomach.2 Despite
these disadvantages, enteral nutrition is associated with reduced infectious
and metabolic complications and is less costly than parenteral
nutrition.3,4
Enteral nutrition also promotes increased blood flow to the gut, resulting in
the maintenance of gut integrity and the promotion of gut
immunity.5 As a
result, enteral feeding is now considered the preferred route of feeding in
patients with a functioning gastrointestinal
tract.6
There are many potential gastrointestinal complications associated with
mechanical ventilation and critical
illness.7
Hypomotility has many causes and is seen in 39% to 50% of mechanically
ventilated
patients.8–10
Some of the methods used for the assessment of upper gastrointestinal motility
and the resulting rates of hypomotility are summarized in
Table 1. As a result of
hypomotility, mechanically ventilated patients frequently have feeding
intolerance, resulting in increased gastric residuals and risk of
gastroesophageal reflux. Endoscopic examination has shown that stress-related
mucosal damage is present in up to 75% of critically ill patients, with
clinically evident bleeding in 5% to
25%.7 Stress-related
mucosal damage may lead to the development of erosions and ulcers in the
stomach, and duodenum and gastroesophageal reflux may lead to erosive
esophagitis. If present, these complications should be taken into
consideration when determining which type of enteral access is most
appropriate for a given patient. The potential gastrointestinal complications
associated with critical illness are summarized in
Table 2.
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Table 2 Potential gastrointestinal complications in critically ill patients
that should be considered prior to enteral access
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Before initiation of nonvolitional nutrition support, it is necessary to
obtain enteral access. Obtaining enteral access in the mechanically ventilated
patient presents certain challenges not present in other patients
(Table 3). Because of the
severity of their illness, critically ill patients may not be able to be
safely transported out of the intensive care unit in order to obtain enteral
access. The expertise and facilities necessary for certain types of enteral
access are not available at all hospitals. Decreased gastric and small bowel
motility is present in most critically ill patients. The length of time
enteral access is anticipated is also important when choosing among options
for enteral access. Each of these considerations must be taken into account
when choosing which type of enteral access is appropriate in a given patient.
In this article, the options for enteral access in mechanically ventilated
patients will be reviewed, with an emphasis on the techniques that can be
performed at the bedside. In addition, the advantages and disadvantages and
potential complications of each will be considered. Although all of the
techniques and potential complications described may not pertain to critically
ill patients in the intensive care unit setting, they are important in
patients who fail to wean from mechanical ventilation.
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Nasogastric and Nasoenteric Tubes
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Because most clinicians would recommend permanent enteral access in
patients requiring nutrition support for longer than 4 to 6 weeks, nasoenteric
tubes are appropriate in those patients in which short-term enteral access is
anticipated. Nasoenteric tubes come in many sizes, and the distal end of the
tube may be placed in the stomach, duodenum, or jejunum. The tubes may be
placed directly or with the assistance of fluoroscopy or endoscopy.
Nasogastric Tubes
Nasoenteric feeding tubes first became commercially available for use in
the 1950s. Since then, they have been established as the most common mode of
short-term enteral access. Nasogastric tubes are the simplest and least
expensive means of providing short-term enteral access. The placement of
nasogastric tubes can be done at the bedside, and they are relatively easy to
place. The large diameter of the tube allows for gastric decompression and
fewer problems with occlusion when compared with their nasoenteric
counterparts. Their placement in the stomach allows for intermittent feeding
or for continuous feeding until adequate oral intake is achieved. However,
they are poorly tolerated for long-term use because of discomfort and the risk
of sinusitis and the development of gastroesophageal reflux, which can lead to
esophageal stricture. Blind passage entails a small but definite risk of
complications during placement.
Before insertion of the nasogastric tube, the appropriate length of
insertion should be determined. This can be accomplished by holding the end of
the tube to the nose and measuring to the ear, then from the ear to the
halfway point between the ear and the umbilicus. This should be the
approximate length of insertion into the stomach. With the neck flexed, the
tube is then inserted through the nasopharynx and into the esophagus until it
reaches the stomach. The correct placement of the nasogastric tube can be
confirmed by several methods. Instilling 50 mL of air into the nasogastric
tube and auscultating the epigastric region to confirm placement has been
widely used. However, reliability is dependent upon the practitioner's
experience. Measuring the pH of the nasogastric tube contents has been found
to be equivalent to x-ray verification of nasogastric tube
placement.11
However, confirmation of proper placement with an x-ray offers the advantage
of ensuring that the nasogastric tube is not looping back into the esophagus.
Monitoring for feeding intolerance, checking residuals, and elevation of the
head of the bed should be observed to protect against aspiration.
Nasoenteric Tubes
Nasoenteric tubes are placed with the end of the tube in the duodenum or
jejunum, resulting in the delivery of enteral nutrition beyond the pylorus.
These tubes come in varying diameter and lengths. Nasoenteric tubes are
indicated for patients who need short-term enteral access but cannot tolerate
gastric feedings because of gastroparesis or gastric outlet obstruction.
Nasoenteric tubes result in a shorter time interval to reaching the
nutritional goal rate and are associated with decreased gastric residuals when
compared with nasogastric tubes. Jejunal feedings have also been found to be
safe and more cost effective with fewer complications in the setting of acute
pancreatitis when compared with parenteral nutrition (PN). In 1997, McClave et
al reported no significant differences in pain scores, days to normalization
of amylase, or days to diet by mouth in a group of patients with mild
pancreatitis.12
However, the cost of TPN was 4 times greater than jejunal feeding. Abou-Assi
et al13 concluded
that although enteral nutrition was not as effective in meeting estimated
caloric requirements in patients with acute pancreatitis, it had fewer
metabolic and infectious complications while being significantly less
expensive.
There are several manual techniques to insert nasoenteric tubes at the
bedside. Though many methods have been reported in the literature, the passage
of the nasoenteric tube past the pylorus and into the jejunum is not always
successful and can be time consuming. If the patient requires laparotomy for a
reason other than enteral access, a nasoenteric tube can be guided into the
small intestine by the surgeon. The successful manual passage of nasoenteric
tubes into the small bowel seems to be related to experience, and placement
can be taught to members of the medical support team other than
physicians.14 The
use of prokinetic agents has been shown to assist with tube passage. The use
of erythromycin elixir has been shown to increase the passage of nasoenteric
tubes distal to the pylorus at 24 hours when compared with no drug
intervention.15
There are also trials showing the usefulness of metoclopramide to facilitate
the passage of feeding tubes into the small
intestine.16,17
As opposed to nasogastric tubes, some nasoenteric tubes have weighted tips.
However, the use of weighted tubes does not seem to facilitate passage of the
tube beyond the
pylorus.18
Salasidis et al19
have described the usefulness of gastric air insufflation to successfully
place nasoenteric tubes. Although the control group did not receive air
insufflation, 500 mL of air was used to inflate the stomach in the study
group. At 24 hours, the passage of the nasoenteric tube into the duodenum was
significantly higher in the group receiving air insufflation.
Fluoroscopy and endoscopy have both been used to increase the success rate
of nasoenteric tube placement. Fluoroscopy is used to visualize the feeding
tube intermittently within the stomach so that it may be repositioned.
Repositioning allows the tube to be placed near the pylorus to increase the
success of passage through the pylorus. The success rate of passage through
the pylorus has been noted to be >90% using fluoroscopic
techniques.20
There are multiple endoscopic techniques that have been described to
facilitate passage of nasoenteric tubes through the pylorus and into the small
bowel. The "guidewire" technique
(Fig. 1) consists of passing a
guidewire through the biopsy channel of an endoscope. After passage of the
guidewire into the small bowel, the endoscope is withdrawn while the
endoscopist attempts to keep the guidewire in place. Fluoroscopy can be used
to ensure that the guidewire is not withdrawn with the endoscope. The feeding
tube is then passed over the wire into the small bowel. The "drag"
technique (Fig. 2) involves the
passage of a feeding tube with a suture tied to the end of it into the
stomach. After passage of the endoscope, biopsy forceps are then used to guide
the feeding tube into the small intestine. Alternatively, Reid et
al19 described a
method by which a lubricated catheter containing a guidewire can be passed
through the biopsy channel after the endoscope has been advanced into the
small bowel.21
After removal of the endoscope while maintaining the position of the tube in
the small bowel, the guidewire is removed and the tube is ready for use.
However, the size of the nasoenteric tube that can be placed by this method is
limited. Even with a therapeutic gastroscope, it is not possible to place a
nasoenteric tube that is larger than 8 French (Fr) in diameter. After any of
the methods described above has been completed, the tube must be transferred
from the mouth to the nasal passage using a nasal transfer tube
(Fig. 1). Alternatively,
transnasal endoscopy may be done with an ultrathin endoscope for feeding tube
placement22
(Fig. 2). This method offers
the advantage of easy esophageal intubation and avoids the need for mouth to
nasal conversion.
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Figure 1. Guidewire technique for endoscopic nasoenteric tube placement. A, After
passage of the endoscope into the small bowel, a guidewire is inserted through
the biopsy channel and the endoscope is withdrawn leaving the guidewire in
place. A nasoenteric tube is then inserted over the guidewire. B, The
nasoenteric tube is transferred from the mouth to the nasal passage using a
nasal transfer tube. Reprinted from Techniques in Gastrointestinal Endoscopy,
Vol. 3, DeLegge M, Enteral Access—The Foundation of Feeding: Endoscopic
Nasoenteric Tube Feeding, page 26, © 2001, with permission from
Elsevier.
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Figure 2. The illustration on the left demonstrates the endoscopic placement of a
nasoenteric tube using the "drag" technique. The illustration on
the right demonstrates the transnasal endoscopic approach. Reprinted from
Techniques in Gastrointestinal Endoscopy, Vol. 3, DeLegge M, Enteral
Access—The Foundation of Feeding: Endoscopic Nasoenteric Tube Feeding,
pages 24 and 28, © 2001, with permission from Elsevier.
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Foote et al23
evaluated the time required for placement and success rate between endoscopic
and fluoroscopic placement of postpyloric feeding tubes and noted no
significant difference between the 2 methods. Although endoscopic placement
was more expensive, it also allowed direct visualization of the esophagus,
stomach, and portions of the small bowel, providing the opportunity to observe
incidental pathology. Endoscopic placement should also be considered in those
with a separate indication for esophagogastroduodenoscopy.
Complications Associated With Nasogastric and Nasoenteric Tubes
Regardless of the technique used for placement, there are many possible
complications associated with nasoenteric tube placement. Nasogastric tubes
predispose to gastroesophageal reflux that may lead to esophagitis and an
increased risk of epistaxis and sinusitis. When it occurs, epistaxis is most
commonly a result of trauma from nasogastric tube insertion and rarely
requires any intervention to stop the bleeding. Nasoenteric tubes are also
associated with the development of sinusitis in 13% to 25% of patients,
depending upon the method used for
diagnosis.24
Another frequent problem with nasoenteric tubes is occlusion. The diameter of
the tube, length of the tube, irrigation, and the use of the tube to give
medications all affect tube
occlusion.25
Though there is a risk of aspiration in patients with nasoenteric tubes, it
is difficult to determine the frequency upon review of the literature. There
is a risk of aspiration of up to 40% in patients who have nasoenteric access.
In patients with a decreased level of consciousness, this risk increases to
50% to 70%.26
Still, it is unknown how many of these aspiration events progress to
pneumonia. A meta-analysis by Lazarus et
al27 concluded that
there was no convincing evidence that jejunal feedings decreased the risk of
aspiration when compared with prepyloric feeding. Montecalvo et
al28 reported a
10.5% incidence of pneumonia in a group of ICU patients receiving nasogastric
tube feeds compared with 0% in patients receiving postpyloric feeds. However,
this difference was not statistically significant. Despite the conflicting
data in regard to the site of nasoenteric tube placement, it appears that
nursing care plays a large role in the risk of aspiration pneumonia.
Aspiration pneumonia is more common on the general medical and surgical floors
than it is in the intensive care unit. Marian et
al29 found a low
incidence of reflux and aspiration in patients who receive good nursing care
and monitoring in the intensive care unit.
Because there is an increase in circulatory requirements to the gut in
patients receiving enteral feedings, caution should be used in feeding
hemodynamically unstable patients such as those who are receiving
vasopressors. Though it is an extremely rare complication, small-bowel
ischemia has been reported in those receiving enteral
feedings.30 The
clinician should observe for abdominal distension, abdominal pain, increased
residuals, and dilated loops of bowel on abdominal films as these signs may
identify patients with feeding intolerance and risk of small bowel
ischemia.30
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Percutanous Endoscopic Gastrostomy and Jejunostomy
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When patients need enteral access for >4 to 6 weeks, long-term enteral
access is
indicated.31
Percutaneous enteral access is more reliable than nasoenteric access because
of the frequency of tube dysfunction associated with nasoenteric access.
Percutaneous enteral access also offers improved patient comfort and
eliminates the risk of sinusitis and nasal trauma associated with nasoenteric
access. Endoscopic procedures for enteral access placement include
percutaneous endoscopic gastrostomy (PEG), percutaneous gastrojejunostomy
(PEG-J), and direct percutaneous jejunostomy (DPEJ). All of these procedures
can be done at the bedside. The percutaneous endoscopic placement of feeding
tubes eliminates the need to transport the patient, which is advantageous in
mechanically ventilated patients when compared with radiographically and
surgically placed tubes, which frequently need transport of the patient in
order to be placed. Contraindications for PEG tubes are listed in
Table 4.
PEG
PEG was first described by Gauderer et
al32 in 1980. The
technique they described is now commonly referred to as the Ponsky pull
technique (Fig. 3), and it has
become the most common form of access used for long-term enteral nutrition.
Prophylactic antibiotics should be given before the procedure, as antibiotics
have been shown to reduce the risk of infection at the site of
insertion.33,34
In patients with no contraindication to PEG
(Table 4),
esophagogastroduodenoscopy is performed to ensure that gastric outlet
obstruction does not exist. The stomach is inflated with air bringing the
stomach close to the abdominal wall so that light from the endoscope may be
observed. It is also important to see good indentation of the gastric wall
with palpation of the abdominal wall. The area chosen for PEG insertion is
then prepped and draped. An incision approximately 1.5 times the diameter of
the tube is made, and a needle within a sheath is inserted through the
abdominal wall and into the
stomach.31 The
needle is removed and a guidewire is passed through the remaining outer
sheath, grasped by a snare inserted through the endoscope, and pulled through
the esophagus and out of the mouth. The guidewire is then tied to the end of
the PEG tube, which is then pulled through the esophagus and stomach until the
inner bolster secures against the gastric wall. The endoscope is then inserted
into the stomach to ensure proper position of the PEG tube. Alternatively,
Aisenberg et al35
have shown that if the external marking of the PEG tube is between 3 and 6 cm,
it is not necessary to confirm the position endoscopically.
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Figure 3. The major differences between PEG placement techniques are demonstrated.
The Ponsky pull technique is demonstrated in the series of illustrations on
the left. After insertion of a needle into the stomach, a guidewire is
inserted through the needle and grasped with a snare and the endoscope is
removed. The PEG tube is attached to the guidewire and is pulled until it is
secure against the abdominal wall. The Sachs-Vine technique is demonstrated in
the series of illustrations in the middle. Using this technique, the guidewire
remains in place throughout the procedure. The PEG tube is long, and the
endoscopist always has control of the PEG tube. The Russell technique is
demonstrated in the series of illustrations on the right. The main advantage
of this technique is that the PEG tube never has to pass through the mouth or
the esophagus. As a result, this technique is useful for people with bulky
oropharyngeal or esophageal tumors. Reprinted from Techniques in
Gastrointestinal Endoscopy, Vol. 3, Baskin WN, Percutaneous Endoscopic
Gastrostomy and Placement of a Jejunal Extension Tube, page 32, © 2001,
with permission from Elsevier.
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There are 2 techniques to place PEGs by the "push" method. The
Sachs-Vine technique was first introduced in 1983 as an alternative for the
endoscopic placement of gastrostomy
tubes.36 This
technique is similar to the Ponsky pull technique until the guidewire is
withdrawn from the mouth. The Sachs-Vine technique
(Fig. 3) uses a long semirigid
tube with a dilator on the proximal end and the PEG on the distal end. The
dilator end of the tube is inserted over the guidewire and advanced through
the esophagus and stomach until it is pushed through the abdominal wall. The
tube is grasped as it traverses the abdominal wall and is pulled until the
bolster on the distal end is secure against the gastric wall. The endoscope is
then passed a second time to ensure proper placement and to evaluate for any
complications. The advantage of this technique is that the guidewire remains
in place throughout the procedure. This results in better control for the
endoscopist as he always has control of the tube. In contrast, the endoscopist
no longer has control of the tube after it has been pulled through the mouth
and into the esophagus with the Ponsky technique. However, this technique may
be more difficult in those patients who have scarring of the abdominal wall
from previous surgery or those who have a thick abdominal wall because of
adipose tissue. Because of concern about the risk of infection when the PEG
tube is passed through the mouth during placement, Russell et
al37 introduced
another technique for PEG placement by the push method that does not need the
PEG tube to pass through the mouth (Fig.
3). After introduction of the guidewire into the stomach,
progressively larger dilators are passed over the guidewire until the diameter
is large enough for a balloon-tipped PEG to be introduced. The PEG tube is
introduced and the balloon is inflated and is secured against the gastric
wall. Because the PEG tube does not have to pass through the mouth when using
the Russell technique, this method of placement can be used in patients with
bulky oropharyngeal or esophageal tumors. However, the Russell technique does
have limitations. The diameter of the tube that can be placed by this method
is limited by the extent of dilation achieved. The larger the dilator, the
more likely it is that the stomach will be pushed away from the abdominal wall
as the dilator is passed. The Russell technique has been modified to include
the use of anchoring devices called T-fasteners to maintain the position of
the stomach as the dilators are
passed.38
The success rate for PEG placement is >95%, regardless of which
technique is used for
placement.39 In a
study by Barkmeier et
al,40 PEG placement
was less expensive than fluoroscopically placed gastrostomy tubes and surgical
endoscopic gastrostomy tubes with similar complication rates. Because of the
expense associated with the operating room, the authors recommended that
surgical endoscopic gastrostomy tubes be reserved for those patients already
undergoing a surgical procedure for another reason. Another trial compared PEG
to open surgical gastrostomy and concluded PEG was less costly, with a similar
rate of
complications.41
In the 1980s, the low-profile gastrostomy was developed as an alternative
to the standard PEG. After maturation of the stoma, a low-profile device can
be placed for long-term enteral access. These devices offer the patient a
better cosmetic appearance and are more convenient for ambulatory patients.
Because of their small shaft, low profile gastrostomy devices are more
difficult to unintentionally remove than a standard PEG. More recently,
several authors have described methods by which a low-profile gastrostomy may
be placed when the initial procedure is
performed.42–44
PEG-J
PEG-J was first described in 1984 by Ponsky and
Aszodi.45 Today, 2
methods are commonly used for the placement of percutaneous endoscopic
gastrojejunostomy tubes. In both of the techniques, a PEG tube is placed by
one of the methods described above. In the first technique
(Fig. 4A), a jejunal extension
tube with a suture tied to the end is inserted through the gastrostomy. With
the endoscope in the stomach, the biopsy forceps are used to grasp the suture
and drag the tube through the pylorus and into the small bowel. Unfortunately,
the tube is frequently pulled back into the stomach as the endoscope is
withdrawn. In the second method (Fig.
4B), a guidewire is inserted through the gastrostomy, grasped by
biopsy forceps, and inserted through the pylorus and into the small bowel. A
jejunal extension tube is then passed over the guidewire and into the small
bowel. The guidewire is then withdrawn. More recently, Adler et
al46 have described
a method by which an ultrathin endoscope is passed through a mature
gastrostomy tract into the jejunum. A guidewire is then placed through the
endoscope into the jejunum and the endoscope is withdrawn. A tube can then be
placed over a guidewire under fluoroscopic guidance. Kimberly-Clarke (Draper,
UT) manufactures a long single-lumen large-bore gastrojejunal transpyloric
tube that may be placed by this method.
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Figure 4. Percutaneous endoscopic gastrojejunostomy. For both techniques, a
gastrostomy tube must already be in place. A, The drag and pull technique is
shown. A jejunal extension tube with a suture tied to the end is grasped by
forceps through the biopsy channel of the endoscope and is pulled into the
small bowel. B, Using the guidewire technique, a guidewire is inserted through
the gastrostomy, is grasped with biopsy forceps, and is inserted into the
small bowel. A jejunal extension tube is passed over the guidewire, which is
then withdrawn. Reprinted from Techniques in Gastrointestinal Endoscopy, Vol.
3, Baskin WN, Percutaneous Endoscopic Gastrostomy and Placement of a Jejunal
Extension Tube, page 36, © 2001, with permission from Elsivier.
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Jejunal extension tubes are advantageous because they allow enteral
feedings to be delivered into the small bowel while also allowing gastric
decompression. Adams et
al47 concluded that
enteral nutrition delivered by means of PEG-J was better tolerated than
enteral nutrition delivered by PEG in trauma patients. However, there are
disadvantages with these tubes as well. Because the jejunal extension tube
must fit through the PEG, it must have a small diameter. As a result, the tube
frequently occludes. The jejunal extension tubes can also migrate back into
the stomach after placement. Fan et
al48 concluded that
DPEJ provided more stable jejunal access with the need for fewer endoscopic
interventions when compared with percutaneous gastrostomy with jejunal
extension tube.
DPEJ
A jejunal feeding tube should be considered in those patients who have
gastroparesis, gastric outlet obstruction, severe gastroesophageal reflux, a
high risk of aspiration, or in those who have had a previous esophagectomy or
gastrectomy.49 The
first DPEJ was described in 1987 by Shike et
al.50 However, all
of the patients included in the study had prior gastrectomy or
gastrojejunostomy. It was the early 1990s before DPEJ was described in
patients who had no history of gastric
surgery.51 The
technique for placement is similar to the Ponsky pull technique for PEG
placement (Fig. 5). An
enteroscope or pediatric colonoscope is passed into the jejunum until
transillumination is seen through the abdominal wall. The abdominal wall is
palpated at the site of illumination to ensure good indentation inside of the
jejunum. A trochar is inserted through the abdominal wall and into the
jejunum. The needle is removed from the outer sheath, and a guidewire is
inserted through the sheath and into the jejunum, where it is grasped by
biopsy forceps and pulled through the duodenum, stomach, esophagus, and out of
the mouth. The feeding tube is then attached to the guidewire, and the
guidewire is pulled through the abdominal wall until the inner bolster is
positioned against the jejunal wall. The endoscope is used to confirm correct
position within the jejunum. Depending upon the study, DPEJ placement is
successful 72% to 86% of the time, with a complication rate similar to PEG
placement.52–54
An alternative method for DPEJ has been described which uses fluoroscopy to
assist with jejunostomy
placement.55 The
endoscope is passed into the jejunum and a snare is passed through the biopsy
channel and opened in the lumen of the jejunum. Fluoroscopy is used to guide
the trochar through the abdominal wall into the jejunum by visualizing the
open snare. Though the study was small, all 7 jejunal tubes attempted were
placed safely without any major complications.
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Figure 5. Direct percutaneous endoscopic jejunostomy. An enteroscope or pediatric
colonoscope is passed into the jejunum, and an appropriate site is chosen (B).
A needle within a cannula is inserted into the jejunum (C and D), and the
needle is removed. A guidewire is inserted through the cannula (E), and the
guidewire is grasped and withdrawn (F). The jejunal tube is tied to the
guidewire (G) and is pulled until the inner bolster is secure against the
jejunal wall (H). Reprinted from Techniques in Gastrointestinal Endoscopy,
Vol. 3, Ginsberg GG, Direct Percutaneous Endoscopic Jejunostomy, pages
46–47, © 2001, with permission from Elsevier.
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Complications of PEG, PEG-J, and DPEJ
Complications associated with PEG placement may occur at the time of the
placement or after placement. Aspiration occurs in approximately 1% to 2% of
procedures.39,56
Gastric contents should be thoroughly suctioned with the endoscope to reduce
the risk of aspiration. Infection at the PEG site is the most common
complication of PEG placement. Most infections at the PEG site are minor and
can be treated with good wound care and IV
antibiotics.57
Bleeding at the site of placement is relatively uncommon and usually resolves
after applying pressure at the insertion site. Rarely, hemorrhage may be
caused by puncturing a vessel in the abdominal wall during the
procedure.58
The more serious complications after PEG placement include buried bumper
syndrome, necrotizing fasciitis, and colocutaneous
fistula.57 Buried
bumper syndrome occurs when the internal bolster of the PEG tube erodes
through the stomach wall into the subcutaneous tissues. It is caused by
excessive tension on the internal bolster. Buried bumper syndrome may be
associated with gastric ulceration and resulting hemorrhage. When present, the
PEG should be removed to allow the stomach and abdominal wall to heal. Though
rare, necrotizing fasciitis of the abdominal wall has been reported and can be
fatal.59
Colocutaneous fistula is another uncommon complication after PEG
placement.58 The
colon can be punctured during initial placement of the PEG tube or the tube
may erode into the colon over time. It typically presents as diarrhea with
dehydration after replacement of a PEG. The tube should be removed and the
patient should be observed. Surgical intervention is rarely needed.
The complications with PEG-J tubes and DPEJ tubes are similar to those seen
with PEG tubes as described above. One complication that is unique to DPEJ
placement is small-bowel obstruction as a result of the internal bolster
blocking the lumen of the
jejunum.57 This
complication can be avoided by placing a tube with a small internal
bolster.
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Radiographic Gastrostomy and Jejunostomy
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Radiographic gastrostomy and jejunostomy offer an alternative for enteral
access without proceeding to surgery. This route of access is particularly
useful in patients who are not candidates for percutaneous endoscopic enteral
access because of obstruction resulting from head and neck cancer or
esophageal cancer. Radiographic techniques using ultrasound can be done at
bedside, whereas techniques using fluoroscopy and computed tomography usually
necessitate transport of the patient. Use of these techniques requires that
the hospital have a radiologist on staff familiar with enteral access
placement.
Radiographic Gastrostomy
The first technique describing radiographic gastrostomy was introduced in
1981 and used fluoroscopy for the percutaneous placement of a gastrostomy
tube.60 Since then,
multiple techniques have been described using fluoroscopy, ultrasound,
computed tomography, or a combination of fluoroscopy and ultrasound. Air is
used to distend the stomach; then fluoroscopy or computed tomography is used
to place the gastrostomy tube. One of the techniques for radiographic
gastrostomy is shown in Figure
6. After the stomach in insufflated with air, a needle is placed
through the abdominal wall and into the stomach. A guidewire is inserted
through the needle, and progressively larger dilators are used to dilate the
tract until it is large enough for the gastrostomy tube. Some techniques use
anchoring devices similar to those used with the Russell push technique to
maintain the stomach against the abdominal wall. Computed tomography offers
the advantage of being able to see adjacent organs at the time of gastrostomy
placement.
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Figure 6A. Radiographic gastrostomy. T-fasteners are used to secure the stomach to the
abdominal wall. Reprinted from Vascular and Interventional Radiology: The
Requisites (Kaufman JA, Lee MJ, eds.), Lee MJ, GI Tract Intervention, page
524, Philadelphia, PA: Mosby © 2004, with permission from Elsevier. 6B
After installation of air into the stomach (A), a needle is inserted through
the abdominal wall and a guidewire is fed through the needle (B). After
dilation with progressively larger dilators (C), the tube is inserted and the
balloon is inflated to secure the tube against the gastric wall (D). Reprinted
from Alimentary Tract Radiology (Margulis AR, Burhenne HJ, eds.), Bilbao MK,
Gastrointestinal Tract, page 2297, St. Louis, MO: Mosby © 1983, with
permission from Elsevier.
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Bleck et al61
have described a technique in which ultrasound was used to localize the
stomach after it was filled with saline. In some instances, a nasogastric tube
could not be passed because of near complete obstruction of the esophagus as a
result of malignancy. In these instances, the stomach was filled with saline
after passage of a needle under ultrasonic guidance. A needle is then inserted
into the gastric lumen for placement of a guidewire, and serial dilations are
performed before gastrostomy placement. Gastrostomy placement was successful
in all 38 patients, although 3 did need a second attempt. Like computed
tomography, ultrasound offers the advantage of being able to see adjacent
organs such as liver and colon at the time of gastrostomy placement.
The success of placement of gastrostomy tubes by fluoroscopy is similar to
that of PEG placement and open gastrostomy placement, with similar or lower
rates of
complications.41,62
In one study, all of the unsuccessful gastrostomy placements by endoscopic
techniques were placed successfully by the fluoroscopic
technique.41 After
review of 34 articles reporting on complication rates of radiologically placed
gastrostomy tubes,
Vanek63 noted that
the major complication rate (2.1%) and total complication rate (13.8%) was
lower than PEG or open gastrostomy. Advantages of radiologically placed
gastrostomy tubes include the ability to place a percutaneous feeding tube in
those patients with hypopharyngeal or esophageal obstruction caused by
malignancy and the high rate of successful placement. In addition, the
gastrostomy tube may be placed with local anesthesia only rather than
conscious sedation required for PEG placement. Disadvantages include the need
to use smaller-caliber tubes that are prone to occlusion, the need to
transport the patient in order for the procedure to be performed, and the need
for a radiologist familiar with enteral access
placement.31,63
Radiographic Gastrojejunostomy
After successful gastrostomy placement, a jejunal catheter can be inserted
through the previous gastrostomy site and into the jejunum. Gray et
al64 first
described the technique by which a guidewire was inserted through the previous
gastrostomy site and passed into the jejunum under fluoroscopy. The jejunal
tube was then inserted over the guidewire and the guidewire was removed.
However, the jejunal tube had a small diameter and occlusion of some tubes did
occur. Just as a PEG-J may be placed endoscopically, a jejunal extension tube
may be placed though a gastrostomy tube radiologically. Once again, this
technique requires a small diameter jejunal tube that is prone to
occlusion.
Radiographic Jejunostomy
Many techniques have been described for the radiographic placement of
direct jejunal access. Gray et
al65 were the first
to describe a technique using ultrasound and fluoroscopy to place a jejunal
feeding tube. In this technique, a nasoenteric tube is used to inflate the
jejunum, which is then localized with a combination of ultrasound and
fluoroscopy to determine placement of the jejunal tube. Rosenblum et
al66 described a
technique by which a catheter with a balloon at the distal end was inserted
into the jejunum. After insertion, the balloon is filled with contrast so that
it can be viewed in the jejunum under fluoroscopy. After localization of the
jejunum, the techniques are similar. A needle is inserted into the jejunum,
and a small amount of contrast is injected through the needle so that it may
be viewed under fluoroscopy to confirm the location within the jejunum. A
guidewire is inserted through the needle and the needle is removed.
T-fasteners are frequently used to secure the jejunum to the abdominal wall
before dilation. Progressively larger dilators are passed over the guidewire
until the tract is large enough for the catheter to fit through. The catheter
is then secured with an anchoring device within the jejunum or with sutures to
the outer abdominal wall.
The technical success rate of radiographic jejunostomy placement is
approximately
87%.49,67
Advantages of radiographic jejunostomy include the ability to place the
feeding tube with local anesthesia rather than conscious sedation, the high
success rate of placement, and it is the minimally invasive approach for
jejunostomy
placement.49
Disadvantages include the small diameter of the jejunal tube that makes it
prone to occlusion and that an interventional radiologist is required for
placement.
Complications of Radiographic Gastrostomy and Jejunostomy
The complications that can be associated with radiographic gastrostomy and
jejunostomy are similar to endoscopically placed tubes and include tube site
infections, ulceration, bleeding, and small bowel obstruction for jejunostomy.
In general, the complication rate for radiographic gastrostomy and jejunostomy
placement is small. However, the rates of leaking at the placement site and
dislodgement of the tube are higher for radiographically placed
tubes.67
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Surgical Gastrostomy and Jejunostomy
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|---|
Before the introduction of the technique for PEG placement by Gauderer et
al,32 open surgical
gastrostomy had been used to provide a means of enteral access for almost a
century. Since then, many techniques have been described for the placement of
open and laparoscopic gastrostomy and jejunostomy tubes. Because this article
focuses on options for enteral access in mechanically ventilated patients,
these techniques will not be reviewed in detail. However, indications,
advantages and disadvantages, and complications will be reviewed.
Vanek49,63
offers a thorough explanation of the surgical techniques available for
gastrostomy and jejunostomy in articles published in prior issues of
Nutrition in Clinical Practice.
Laparoscopic and Open Surgical Gastrostomy and Jejunostomy
Techniques for open surgical gastrostomy first described in the
1890s.68 were It
was almost 100 years later before laparoscopic gastrostomy was
described.69 PEG is
usually preferred over surgical gastrostomy because of a lower cost and
shorter time for placement, with similar rates of
complications.70,71
In the mechanically ventilated patient, PEG also offers the advantage of being
done at the bedside. Laparoscopic gastrostomy should be considered in those
with interposition of the liver or colon between the abdominal wall and
stomach or in those with oral or esophageal obstruction making PEG placement
impossible.70 Open
surgical gastrostomy should be considered in those patients having open
abdominal surgery for an alternative reason and in those with extensive
abdominal adhesions. One type of surgical gastrostomy, the Stamm technique, is
shown in Figure 7.
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Figure 7. Stamm gastrostomy. An incision is made in the gastric wall. The tube is
placed through the incision and is secured with a pursestring suture. The
catheter is inserted farther, and a second pursestring suture is used to
secure the tube. To prevent leakage of gastric contents into the peritoneum,
the stomach is secured to the abdominal wall. Reprinted from Vanek VW, Ins and
Outs of Enteral Access: Part 2-Long Term Access—Esophagostomy and
Gastrostomy. Nutr Clin Pract. 2003;18:51, with permission from the American
Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. does not
endorse the use of this material in any form other than its entirety.
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There are several laparoscopic and open surgical methods available for
jejunostomy placement. Needle jejunostomy
(Fig. 8), in which a catheter
is passed over a needle into the jejunum, is well tolerated in those patients
who need short-term jejunal
access.72 However,
the small caliber of the tube increases the risk of occlusion. Alternatively,
surgical jejunostomy may be used in patients requiring long-term jejunal
access. One such technique, the Witzel Jejunostomy, is shown in
Figure 9. Surgical jejunostomy
should be considered in those patients with previous gastrectomy,
gastroparesis, and those with severe gastroesophageal reflux.
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Figure 8. Needle jejunostomy. A needle is inserted into the jejunum (A) and a
catheter is fed through the needle (B). The needle is withdrawn. The catheter
is sutured into place (C). A second needle is inserted through the abdominal
wall, and the catheter is brought through the needle (D). The jejunum is
attached to the abdominal wall (E), and the catheter is secured to the skin
(F). Reprinted from Vanek VW, Ins and Outs of Enteral Access. Part 3:
Long-Term Access—Jejunostomy. Nutr Clin Pract. 2003; 18:205, with
permission from the American Society for Parenteral and Enteral Nutrition
(A.S.P.E.N.). A.S.P.E.N. does not endorse the use of this material in any form
other than its entirety.
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Figure 9. Witzel jejunostomy. An incision is made in the jejunum (A), and the tube is
inserted through the opening and secured with a pursestring suture (B). A
separate suture is used to wrap the jejunum around the tube (C) to secure the
tube. The jejunum is attached to the abdominal wall (D). The tube is secured
to the skin (E) after being pulled through the abdominal wall. Reprinted from
Vanek VW, Ins and Outs of Enteral Access. Part 3: Long-Term
Access—Jejunostomy. Nutr Clin Pract. 2003;18:202, with permission from
the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
A.S.P.E.N. does not endorse the use of this material in any form other than
its entirety.
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Advantages of surgical gastrostomy and jejunostomy include the ability to
place large-diameter feeding tubes, direct evaluation of intraabdominal organs
so that perforation and laceration can be avoided, and high rates of
successful
placement.63
Disadvantages include the need for general anesthesia, longer recovery, and
expense. Complications include wound infections, gastrointestinal bleeding,
and tube dislodgement with peritoneal
contamination.31
|
Summary
|
|---|
The early institution of enteral nutrition is now accepted as the preferred
route of feeding in critically ill patients with a functioning
gastrointestinal tract. Although obtaining enteral access in mechanically
ventilated patients presents certain challenges, there are many options
currently available. The length of time that enteral access is anticipated is
an important consideration. Gastrointestinal complications including bleeding
and hypomotility are relatively common in critically ill patients. As such,
the functioning of the gastrointestinal tract should be considered when
determining which type of enteral access is most appropriate for any given
patient. PEG is the most commonly used method for long-term enteral access, as
it is more widely available than radiographic gastrostomy and less costly than
surgical gastrostomy, while having similar complication rates associated with
placement. Endoscopically placed tubes also offer the advantage of being able
to be placed at the bedside, precluding the need for transport of a
mechanically ventilated patient. In patients who need long-term enteral access
and have a high risk of aspiration, gastroesophageal reflux, or gastroparesis,
jejunostomy offers an attractive alternative to gastrostomy.
- The Veterans Affairs Total Parenteral Nutrition Cooperative Study
Group. Perioperative TPN in surgical patients. N Engl J
Med. 1991;325:525
–532.[Abstract]
- Mentec H, Dupont H, Bocchetti M, Cani P, Ponche F, Bleichner G.
Upper digestive intolerance during enteral nutrition in critically ill
patients: frequency, risk factors, and complications. Crit Care
Med. 2001;29:1955
–1961.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Kudsk KA, Croce MA, Fabian TC, et al. Enteral versus parenteral
feeding: effects on septic morbidity following blunt and penetrating abdominal
trauma. Ann Surg.1992; 215:503
–513.[Web of Science][Medline]
[Order article via Infotrieve]
- Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding,
compared with parenteral, reduces septic complications: the results of a
meta-analysis. Ann Surg.1992; 216:172
–183.[Web of Science][Medline]
[Order article via Infotrieve]
- DeWitt RC, Kudsk KA. The gut's role in metabolism, mucosal barrier
function, and gut immunology. Infect Dis Clin North
Am. 1999;13:465
–481.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Marik PE, Zaloga GP. Early enteral nutrition in acutely ill
patients: a systematic review. Crit Care Med.2001; 29:2264
–2270.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Mutlu GM, Mutlu EA, Factor P. GI complications in patients
receiving mechanical ventilation. Chest.2001; 119:1222
–1241.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Montejo JC. Enteral nutrition-related gastrointestinal
complications in critically ill patients: a multicenter study: the Nutritional
and Metabolic Working Group of the Spanish Society of Intensive Care Medicine
and Coronary Units. Crit Care Med.1999; 27:1447
–1453.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Dark DS, Pingleton SK. Nonhemorrhagic gastrointestinal
complications in acute respiratory failure. Crit Care
Med. 1989;17:755
–758.[Web of Science][Medline]
[Order article via Infotrieve]
- Ritz MA, Fraser R, Edwards N, et al. Delayed gastric emptying in
ventilated critically ill patients: measurement by 13 C-octanoic acid breath
test. Crit Care Med.2001; 29:1744
–1749.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Metheny N, Reed L, Wiersema L, McSweeney M, Wehrle MA, Clark J.
Effectiveness of pH measurements in predicting feeding tube placement: an
update. Nursing Res.1993; 42:324
–331.
- McClave SA, Greene LM, Snider HL, et al. Comparison of the safety
of early enteral versus parenteral nutrition in mild acute pancreatitis.
JPEN J Parenter Enteral Nutr.1997; 21:14
–20.[Abstract/Free Full Text]
- Abou-Assi S, Craig K, O'Keefe SJ. Hypocaloric jejunal feeding is
better than TPN in acute pancreatitis: results of a randomized comparative
study. Am J Gastroenterol.2002; 97:2255
–2262.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Cresci G, Martindale R. Bedside placement of small bowel feeding
tubes in hospitalized patients: a new role for the dietitian.
Nutrition.2003; 19:843
–846.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Stern MA, Wolf DC. Erythromycin as a prokinetic agent: a
prospective, randomized, controlled study of efficacy in nasoenteric tube
placement. Am J Gastroenterol.1994; 89:2011
–2013.[Web of Science][Medline]
[Order article via Infotrieve]
- Whatley K, Turner WW, Dey M, Leonard J, Guthrie M. When does
metoclopramide facilitate transpyloric intubation? JPEN J Parenter
Enteral Nutr. 1984;8:679
–681.[Abstract/Free Full Text]
- Kittinger JW, Sandler RS, Heizer WD. Efficacy of metoclopramide as
an adjunct to duodenal placement of small bore feeding tubes: a randomized,
placebo-controlled, double-blind study. JPEN J Parenter Enteral
Nutr. 1987;11:33
–37.[Abstract]
- Levenson R, Turner WW, Dyson A, Zike L, Reisch J. Do weighted
nasoenteric feeding tubes facilitate duodenal intubations? JPEN J
Parenter Enteral Nutr.1988; 12:135
–137.[Abstract/Free Full Text]
- Salasidis R, Fleiszer T, Johnston R. Air insufflation technique of
enteral tube insertion: a randomized, controlled trial. Crit Care
Med. 1998;26:1036
–1039.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Gutierrez ED, Balfe DM. Fluoroscopically guided nasoenteric feeding
tube placement: results of a 1-year study. Radiology.1991; 178:759
–762.[Abstract/Free Full Text]
- Reed LR, Eachempati SR, Russel MK, Fahkry C. Endoscopic placement
of jejunal feeding catheters in critically ill patients by a
"push" technique. J Trauma Injury Infect Crit
Care. 1998;45:388
–393.[CrossRef]
- Dranoff JA, Angood PJ, Topazian M. Transnasal endoscopy for enteral
feeding tube placement in critically ill patients. Am J
Gastroenterol. 1999;94:2902
–2904.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Foote JA, Kemmeter PR, Prichard PA. A randomized trial of
endoscopic and fluoroscopic placement of postpyloric feeding tubes in
critically ill patients. JPEN J Parenter Enteral Nutr.2004; 28:154
–157.[Abstract/Free Full Text]
- George DL, Falk PS, Umberto Meduri G, et al. Nosocomial sinusitis
in patients in the medical intensive care unit: a prospective epidemiological
study. Clin Infect Dis.1998; 27:463
–470.[Web of Science][Medline]
[Order article via Infotrieve]
- Vanek VW. Ins and outs of enteral access: part 1: long term access,
short-term enteral access. Nutr Clin Pract.2002; 17:275
–283.[Abstract/Free Full Text]
- McClave SA, DeMeo MT, DeLegge MH, et al. North American Summit on
Aspiration in the Critically Ill Patient: consensus statement. JPEN
J Parenter Enteral Nutr.2002; 26(Suppl):S80
–S85.[Medline]
[Order article via Infotrieve]
- Lazarus BA, Murphy JB, Culpepper L. Aspiration associated with
long-term gastric versus jejunal feeding: a critical analysis of the
literature. Arch Phys Med Rehabil.1990; 71:46
–53.[Web of Science][Medline]
[Order article via Infotrieve]
- Montecalvo MA, Steger KA, Farber HW, et al. Nutritional outcome and
pneumonia in critical care patients randomized to gastric versus jejunal tube
feedings: the Critical Care Research Team. Crit Care
Med. 1992;20:1377
–1387.[Web of Science][Medline]
[Order article via Infotrieve]
- Marian M, Rappaport W, Cunningham D, et al. The failure of
conventional methods to promote spontaneous transpyloric feeding tube passage
and the safety of intragastric feeding in the critically ill ventilated
patient. Surg Gynecol Obstet.1993; 176:475
–479.[Web of Science][Medline]
[Order article via Infotrieve]
- McClave SA, Chang WK. Feeding the hypotensive patient: does enteral
feeding precipitate or protect against ischemic bowel? Nutr Clin
Pract. 2003;18:279
–284.[Abstract/Free Full Text]
- Minard G. Enteral access. Nutr Clin Pract.1994; 9:172
–182.[Abstract/Free Full Text]
- Gauderer MW, Ponsky JL, Izant RZ Jr. Gastrostomy without
laparotomy: a percutaneous endoscopic technique. J Pediatr
Surg. 1980;15:872
–875.[Web of Science][Medline]
[Order article via Infotrieve]
- Jain NK, Larson DE, Schroeder KW, et al. Antibiotic prophylaxis for
percutaneous endoscopic gastrostomy: a prospective, randomized, double-blind
clinical trial. Ann Intern Med.1987; 107:824
–828.[Abstract/Free Full Text]
- Gossner L, Keymling J, Hahn EG, Ell C. Antibiotic prophylaxis in
percutaneous endoscopic gastrostomy (PEG): a prospective randomized clinical
trial. Endoscopy.1999; 31:119
–124.[Medline]
[Order article via Infotrieve]
- Aisenberg J, Cohen L, Lewis BS. Marked endoscopic gastrostomy tubes
permit one-pass Ponsky technique. Gastrointest Endosc.1991; 37:552
–553.[Web of Science][Medline]
[Order article via Infotrieve]
- Sachs BA, Vine HS, Palestrant AM. A nonoperative technique for the
establishment of gastrostomy in the dog. Invest
Radiol. 1983;18:485
–487.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Russell TR, Brotman M, Norris F. Percutaneous gastrostomy.
Am J Surg.1984; 148:132
–137.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Wu TK, Pietrocola D, Welch HF. New method of percutaneous
endoscopic gastrostomy using anchoring devices. Am J
Surg. 1987;153:230
–232.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percutaneous
endoscopic gastrostomy: indications, success, complications, and mortality in
314 consecutive patients. Gastroenterology.1987; 93:48
–51.[Web of Science][Medline]
[Order article via Infotrieve]
- Barkmeier JM, Trerotola SO, Wiebke EA, et al. Percutaneous
radiological, surgical endoscopic, and percutaneous endoscopic
gastrostomy/gastrojejunostomy: comparative study and cost analysis.
Cardiovasc Intervent Radiol.1998; 21:324
–328.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Stiegmann GV, Goff JS, Silas D, Pearlman N, Sun J, Norton L.
Endoscopic versus operative gastrostomy: final results of a prospective
randomized trial. Gastrointest Endosc.1990; 36:1
–5.[Web of Science][Medline]
[Order article via Infotrieve]
- Ferguson DR, Harig JM, Kozarek RA, Kelsey PB, Picha GJ. Placement
of a feeding button ("One-Step Button") as the initial procedure.
Am J Gastroenterol.1993; 88:501
–504.[Web of Science][Medline]
[Order article via Infotrieve]
- Marion MT, Zweng TN, Strodel WE. One-stage gastrostomy button: an
assessment. Endoscopy.1994; 26:666
–670.[Medline]
[Order article via Infotrieve]
- Kozarek RA, Payne M, Barkin J, Goff J, Gostout C. Prospective
multicenter evaluation of an initially placed button gastrostomy.
Gastrointest Endosc.1995; 41:105
–108.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Ponsky JL, Aszodi A. Percutaneous endoscopic jejunostomy.
Am J Gastroenterol.1984; 79:113
–116.[Web of Science][Medline]
[Order article via Infotrieve]
- Adler DG, Gostout CJ, Baron TH. Percutaneous transgastric placement
of jejunal feeding tubes with an ultrathin scope. Gastrointest
Endosc. 2003;55:106
–110.[CrossRef][Web of Science]
- Adams GF, Guest DP, Ciraulo DL, Lewis PL, Hill RC, Barker DE.
Maximizing tolerance of enteral nutrition in severely injured trauma patients:
a comparison of enteral feedings by means of percutaneous endoscopic
gastrostomy versus percutaneous endoscopic gastrojejunostomy. J
Trauma. 2000;48:459
–465.[Web of Science][Medline]
[Order article via Infotrieve]
- Fan AC, Baron TH, Rumalla A, Harewood GC. Comparison of direct
percutaneous endoscopic jejunostomy and PEG with jejunal extension.
Gastrointest Endosc.2002; 56:890
–894.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Vanek VW. Ins and outs of enteral access: part 3: long-term access:
jejunostomy. Nutr Clin Pract.2003; 18:201
–220.[Abstract/Free Full Text]
- Shike M, Schroy P, Ritchie MA, Lightdale CJ, Morse R. Percutaneous
endoscopic jejunostomy in cancer patients with previous gastric resection.
Gastrointest Endosc.1987; 33:372
–374.[Web of Science][Medline]
[Order article via Infotrieve]
- Shike M, Wallach C, Likier H. Direct percutaneous endoscopic
jejunostomies. Gastrointest Endosc.1991; 37:62
–65.[Web of Science][Medline]
[Order article via Infotrieve]
- Shike M, Latkany L, Gerdes H, Bloch AS. Direct percutaneous
endoscopic jejunostomies for enteral feeding. Gastrointest
Endosc. 1996;44:536
–540.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Shike M, Latkany L. Direct percutaneous endoscopic jejunostomy.
Gastrointest Endosc Clin North Am.1998; 8:569
–580.[Medline]
[Order article via Infotrieve]
- Rumalla A, Baron TH. Results of direct percutaneous endoscopic
jejunostomy, an alternative method for providing jejunal feeding.
Mayo Clin Proc.2000; 75:807
–810.[Abstract]
- Shetzline MA, Suhocki PV, Workman MJ. Direct percutaneous
endoscopic jejunostomy with small bowel enteroscopy and fluoroscopy.
Gastrointest Endosc.2001; 53:633
–638.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Kobayashi K, Cooper GS, Chak A, Sivak MV Jr, Wong RC. A prospective
evaluation of outcomes in patients referred for PEG placement.
Gastrointest Endosc.2002; 55:500
–506.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- McClave SA, Chang WK. Complications of enteral access.
Gastrointest Endosc.2003; 58:739
–751.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Amann W, Mischinger HJ, Berger A, et al. Percutaneous endoscopic
gastrostomy (PEG): 8 years of clinical experience in 232 patients.
Surg Endosc.1997; 11:741
–744.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Martindale R, Witte M, Hodges G, Kelley J, Harris S, Andersen C.
Necrotizing fasciitis as a complication of percutaneous endoscopic
gastrostomy. JPEN J Parenter Enteral Nutr.1987; 11:583
–585.[Abstract/Free Full Text]
- Preshaw RM. A percutaneous method for inserting a feeding
gastrostomy tube. Surg Gynecol Obstet.1981; 152:658
–660.[Medline]
[Order article via Infotrieve]
- Bleck JS, Reiss B, Gebel M, et al. Percutaneous sonographic
gastrostomy: method, indications, and problems. Am J
Gastroenterol. 1998;93:941
–945.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Cosentini EP, Sautner T, Gnant M, Winkelbauer F, Teleky B, Jakesz
R. Outcomes of surgical, percutaneous endoscopic, and percutaneous radiologic
gastrostomies. Arch Surg. 1998;1076
–1083.
- Vanek VW. Ins and outs of enteral access: part 2: long term access:
esophagostomy and gastrostomy. Nutr Clin Pract.2003; 18:50
–74.[Abstract/Free Full Text]
- Gray RR, St. Louis EL, Grosman H. Modified catheter for
percutaneous gastrojejunostomy. Radiology.1989; 173:276
–278.[Abstract/Free Full Text]
- Gray RR, Ho CS, Yee A, Montanera W, Jones DP. Direct percutaneous
jejunostomy. Am J Roentgenol.1987; 149:931
–932.[Free Full Text]
- Rosenblum J, Taylor FC, Lu CT, Martich V. A new technique for
direct percutaneous jejunostomy tube placement. Am J
Gastroenterol. 1990;85:1165
–1167.[Web of Science][Medline]
[Order article via Infotrieve]
- Van Overhagen H, Ludviksson MA, Laméris JS, et al. US and
fluoroscopic-guided percutaneous jejunostomy: experience in 49 patients.
J Vasc Interv Radiol.2000; 11:101
–106.[CrossRef][Web of Science][Medline]
[Order article via Infotrieve]
- Stamm M. Gastrostomy: a new method. Med
News. 1894;54:324
–326.
- Haggie JA. Laparoscopic tube gastrostomy. Ann Royal Coll
Surg Engl. 1992;74:258
–259.
- Ho HS, Ngo H. Gastrostomy for enteral access: a comparison among
placement by laparotomy, laparoscopy, and endoscopy. Surg
Endosc. 1999;13:941
–944.
- Bergstrom LR, Larson DE, Zinsmeister AR. Utilization and outcomes
of surgical gastrostomies and jejunostomies in a era of percutaneous
endoscopic gastrostomy: a population-based study. Mayo Clin
Proc. 1995;70:829
–836.[Abstract]
- Delaney HM, Carnevale NJ, Garvey JW. Jejunostomy by needle catheter
technique. Surgery.1973; 73:786
–790.[Web of Science][Medline]
[Order article via Infotrieve]
Nutrition in Clinical Practice, Vol. 19, No. 6,
610-621 (2004)
DOI: 10.1177/0115426504019006610
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