Transnasal Endoscopic Placement of Nasoenteric Feeding Tubes: Outcomes and Limitations in Non–Critically Ill PatientsFrom 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: sanjiv{at}ummc.edu.my.
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 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.
Key Words: transnasal endoscopy • nasoenteric tubes • nasojejunal tubes • enteral nutrition • postpyloric feeding • non–critically ill • outcomes Short-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)14 and, 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 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.
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 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.
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%).
The 3 cases in which NET placement was unsuccessful involved 2 patients with malignant duodenal obstruction and 1 patient with a nonhealing gastrocutaneous 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
There are limited data on the endoscopic placement of NET in non–critically ill patients and their outcomes. Our case series illustrates the benefits of NET feeding in patients with persistent gastrocutaneous fistulae, gastroparesis, acute pancreatitis, benign duodenal stenosis, and gastroesophageal reflux after upper GI surgery. It is doubtful whether NET feeding provided adequate palliation in our patients with malignant duodenal obstruction, and enteral (metallic) stenting might have been more appropriate. However, we were prohibited by cost constraints, and the extremely short life span of our patients raises doubt about the cost-effectiveness of enteral stenting in these situations. A possible limitation of this observational study was the variable endoscopic experience of physicians involved, which may have affected the placement times and tip positioning of NETs in some of the more difficult cases. In the 19 patients whom we have described, NET feeding succeeded in providing nutrition in patients in whom standard nasogastric feeding would have failed. As short-term feeding alone was required, the only alternative would have been parenteral nutrition (PN) in these patients. A few of our patients even required nutrition support for prolonged periods, between 55 and 95 days. Prolonged PN in these patients may have led to more complications and morbidity vs enteral nutrition alone.15 Various methods of endoscopic placement of NET currently exist.1,16 Fluoroscopy-guided placement of NETs remains the standard technique in many centers, as it has the advantage of not requiring trained endoscopists to perform the procedure. However, radiation exposure time is significantly longer with this technique,7,8 and it cannot be performed at the patient's bed-side, limiting its applicability in critically ill or unstable patients. Endoscopic NET placement with the transnasal route, on the other hand, has several advantages. It can be performed at the bedside and has been shown to be quicker to perform compared with transoral endoscopy (with a guidewire)13 and fluoroscopy-guided placement14 in critically ill patients. The fact that sedation is less often or not even required during the procedure enhances its appeal, especially in critically ill patients.13,14 However, as important as the duration and safety of endoscopic NET placement is, more so is the positioning of NETs into the jejunum. The benefits of postpyloric feeding are best observed when feeding is distal to the ligament of Treitz.17 The lower rates of jejunal placement (36.8%) probably reflect our early experience with the technique but remain comparable to previous published reports.12,13 However, the attainment of postpyloric placement in most cases appeared to be sufficient for enteral nutrition in our cases. Nevertheless, our experience with transnasal endoscopic NET placement suggests that it may not be suitable in situations of altered duodenal anatomy/pathology. The ultrathin endoscope does not appear sufficiently stiff to prevent looping or coiling in the gastric cavity. This then results in an unsatisfactory guidewire placement, which is not straight or deep enough into the duodenum. Our longer overall median duration of procedure, as compared with published data in critically ill patients,13,14 is directly attributed to the difficult cases of duodenal stenosis encountered (see Table 2). Diagnostic upper intestinal transnasal endoscopy has been shown to be as effective as diagnostic peroral endoscopy.18 However, there are no direct comparisons of the role of transnasal endoscopy in therapeutic applications, apart from the randomized study of NET placement in critically ill patients by Kulling et al.13 They reported that transnasal endoscopy was significantly inferior to transoral endoscopy with respect to passage through the pylorus and duodenum, but no differences in tube position were noted.13 In their initial experience with transnasal endoscopic placement of NET, Dranoff et al12 similarly reported difficulty with duodenal intubation using ultrathin endoscopes. In the clinical cases that we have described in a non–critical care setting, there was a significant difference in jejunal placement rates in patients with (0%) and without (36.8%) duodenal pathology. Peroral endoscopic placement techniques with standard, larger-diameter gastroscopes are probably more effective at NET placement than transnasal placement in cases with duodenal pathology because of the scope's increased stiffness and rigidity, although this has yet to be proven. A recently described peroral endoscopic placement technique, with the NET pushed through the nare, in non–critically ill patients was able to demonstrate a remarkable 97.6% jejunal placement rate.19 Clinical indications for NET placement in this series differed somewhat from our cohort, although their results remain impressive. Endoscopic placement of NET remains a technical challenge for most endoscopists. Transnasal endoscopy has various advantages with respect to NET placement, particularly in the critical care setting. Our experience demonstrates a role for transnasal endoscopic NET placement in non–critically ill patients, but limitations exist in patients with altered GI anatomy. A prospective comparison with other endoscopic methods is recommended to evaluate the most suitable technique in some of the more difficult cases that we have described.
Financial disclosure: none declared.
Nutrition in Clinical Practice, Vol. 23, No. 2,
176-181 (2008)
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