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A two institution experience with 226 endoscopically placed jejunal feeding tubes in critically ill surgical patients
The American Journal of Surgery 186 (2003) 583–590
Scientific paper
A two institution experience with 226 endoscopically placed jejunal feeding tubes in critically ill surgical patients Jeffrey M. Nicholas, M.D.a,c,*, Mark W. Corneliusa, Kathryn M. Tchorz, M.D.a, Lorraine N. Tremblay, M.D., Ph.D.a, E. Ronald Spiegelman, Pharm.D.a, Kirk A. Easley, M.S.a, William Small, M.D.a, David V. Feliciano, M.D.a, Melissa A. Powell, M.D.b, Jerry Poklepovic, M.D.b a
Departments of Surgery and Radiology, Emory University/Grady Memorial Hospital/Rollins School of Public Health, Atlanta, GA, USA b Departments of Surgery and Radiology, University of South Florida/Tampa General Hospital, Tampa, FL, USA c Department of Surgery, Emory University/Grady Memorial Hospital, Room 308, Glenn Memorial Building, 69 Butler St. SE, Atlanta, GA 30303, USA Manuscript received August 30, 2003; revised manuscript September 3, 2003 Presented at the 55th Annual Meeting of the Southwestern Surgical Congress, Tucson, Arizona, April 27–30, 2003
Abstract Background: Early jejunal feeding after surgery or trauma reduces infectious complications. Although not ideal gastric and postpyloric feedings are often used, however, because of difficulty in placing feeding tubes distal to the ligament of Treitz (LOT). Our hypothesis was that feeding tube placement distal to the LOT can be accomplished using a bedside transendoscopic technique. Methods: Transendoscopic jejunal (TEJ) tube placement and TEJ tubes inserted simultaneously through percutaneous gastrostomy (PEG) tubes (PEG/TEJ) were attempted to be placed distal to the LOT. Results: In all, 226 feeding tubes (185 TEJ, 41 PEG/TEJ) were placed in 179 trauma and 47 nontrauma patients over 3 years (August 20, 1998 to July 15, 2001). Tube location was jejunal in 93.8% of trauma patients, 76.6% of nontrauma patients, and 90.3% of all patients. (Confidence intervals were 89.3% to 96.5%, 62.8% to 86.4%, and 85.7% to 93.5%). Days of total parenteral nutrition were reduced 71.3% in trauma patients, 22.8% in nontrauma patients, and 45% overall at one institution. Conclusions: Bedside TEJ and PEG/TEJ placement is safe and successful in placing feeding tubes distal to the LOT in more than 90% of critically ill surgical patients. © 2003 Excerpta Medica, Inc. All rights reserved. Keywords: Nutrition; Enteral; Endoscopy; Percutaneous endoscopic gastrostomy; Jejunum; Trauma
Enteral nutritional support has been shown to be efficacious when compared with total parenteral nutrition (TPN) in the critically ill [1–3]. In addition, both trauma and nontrauma patients have reduced morbidity when enteral feeding into the jejunum is begun in the early postoperative period [4 – 8]. It would seem advantageous to start early jejunal feeding in most surgical patients; however, placing a feeding device into the jejunum can be challenging in patients who have not undergone a laparotomy. Numerous techniques for nonoperative placement of feeding tubes have been described, but the majority of these fail to consistently
* Corresponding author. Tel.: ⫹1-404-616-5456, 404-616-7322; fax: ⫹1-404-616-7333. E-mail address: [email protected]
place feeding tubes distal to the ligament of Treitz (LOT) [9 –11]. Of interest, postpyloric feeding has not been demonstrated to reduce the rates of aspiration or pneumonia when compared with gastric feeding [12]. While select patients at risk for gastric feeding may tolerate postpyloric feeding better, little data exist comparing gastric or postpyloric feeding with true jejunal feeding in patients not requiring laparotomy [4,13,14]. This is in part due to the difficulty in timely placement of a feeding tube distal to the LOT using available bedside techniques. A safe bedside procedure that accurately places a feeding tube into the jejunum in patients without laparotomy would have obvious benefits [14,15]. In order to provide early and consistent feeding to trauma patients and to allow further study of whether there is a
0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.09.005
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difference between gastric or postpyloric and true jejunal feeding, the authors attempted to identify a technique that would allow early and accurate placement of a feeding tube beyond the LOT. Reed et al [16] reported success with postpyloric feeding tube placement using an endoscopic “push technique.” This technique had a 100% success rate in placing feeding tubes beyond the pylorus, but the authors did not break down the final postpyloric location of the feeding tubes. The hypothesis in this study was that use of the bedside “transendoscopic” technique would result in placement of feeding tubes distal to the LOT in critically ill patients.
Material and methods A retrospective analysis of endoscopic procedures to place feeding tubes over a 3-year period at two hospitals was performed. Transendoscopic jejunal (TEJ) feeding tubes and percutaneous endoscopic gastrostomy (PEG) tubes with TEJ tubes placed through them (PEG/TEJ tubes) were placed at Tampa General Hospital in Tampa, Florida, from August 20, 1998, to May 5, 2000, and at Grady Memorial Hospital in Atlanta, Georgia, from July 19, 2000 to July 25, 2001. All patients were cared for or consulted on by the trauma service at Tampa General Hospital, a level I trauma center for the University of South Florida, or the Emory University surgical services at Grady Memorial Hospital, an urban level I trauma center serving metropolitan Atlanta. Candidates for the study included critically ill trauma patients and a heterogeneous population of critically ill surgical patients being cared for in the intensive care unit. All procedures were performed at the bedside unless the patient was in the operating room having concomitant procedures performed. Endoscopic procedures were performed by clinical postgraduate year (PGY) 2, 3, 4, and 5 residents and PGY 6 and 7 fellows on the surgical services under the direction of faculty members or fellows trained in upper gastrointestinal (GI) endoscopy. Informed consent for upper GI endoscopy and feeding tube placement was obtained for all patients. Procedures were performed with the patient in a supine position or rolled slightly onto their left side using an Olympus GIF-100 or GIF-2T100 endoscope (Olympus, Melville, NY). Formal endoscopic evaluation of the esophagus, stomach and duodenum was performed during passage of the endoscope into the second portion of the duodenum. A 7F Wilson-Cook nasobiliary drainage catheter (Wilson-Cook Medical, Inc., Winston-Salem, NC) was passed through the biopsy channel of the endoscope. Occasionally, an 8F catheter was used necessitating the use of the GIF-2T100 endoscope. Transendoscopic placement was performed using the technique for postpyloric placement described by Reed et al [16]. In select patients who were likely to need prolonged feeding access, a PEG/TEJ was placed using a modified
technique originally described by Coates et al [17,18]. A TEJ was first placed as described by Reed et al [16]. Instead of transferring the tube from the mouth to the nares it was left in the oral cavity. Next a 24F PEG tube (Microvasive Boston Scientific, Atlanta, GA) was placed using a standard pull technique. The TEJ tube was inserted into the PEG and sutured to the PEG tube before pulling it through the abdominal wall. The PEG was then pulled through the abdominal wall simultaneously delivering the TEJ tube through the PEG. The PEG was then placed to dependent drainage, while the TEJ was used for enteric feeding into the small bowel. An abdominal radiograph was obtained after each procedure to confirm the location of the feeding tube. After this, tube feedings were initiated. All radiographs and their dictated reports were reviewed retrospectively to identify the precise location of the distal tip of the feeding tube. Tube location was classified as gastric, duodenal, at the LOT or jejunal. Duodenal tubes were classified as being in the first, second, third, or fourth portion of the duodenum (D1, D2, D3, or D4). Patients in whom radiographs could not be obtained were eliminated from the study. An attending radiologist familiar with the techniques and potential locations of feeding tubes placed fluoroscopically reviewed cases in which dictations were not available as well as those in which the tube location was not precisely specified in the dictation. A retrospective review of the surgeon’s dictated operative reports and medical records was used to identify complications of tube placement and use. In the later half of the study utilization of TPN was evaluated at Grady Memorial Hospital during three time periods: from January 1, 2000 to July 18, 2000 (time period 1), from July 19, 2001 to January 18, 2001 (time period 2), and from January 19, 2001, to July 25, 2001 (time period 3). Time period 1 was prior to utilization of the endoscopic techniques for feeding access, time period 2 correlated with the introduction of the technique, and time period 3 was when the endoscopic techniques were used routinely as a means of obtaining feeding access. Time periods 1 and 3 were compared to assess impact of the techniques on the use of TPN.
Results Postprocedure radiographs were available in 226 patients (75% male). There were 179 trauma patients (79%) and a heterogeneous population of 47 critically ill surgical patients (21%). The injured patients sustained predominantly blunt trauma (n ⫽ 154, 86%), while penetrating trauma accounted for 5.6% of cases (n ⫽ 10) and 8.4% had burn injury (n ⫽ 15). Ninety-four percent of patients (n ⫽ 195) were on mechanical ventilation at the time of the procedures. Injury Severity Scores ranged from 5 to 51 with a mean of 25.5, and the average age was 47.5 years (range 15 to 88). Intensive care unit (ICU) length of stay (LOS)
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Table 1 Feeding tube location by mechanism of injury or pathologic diagnoses Mechanism of injury Trauma Blunt Penetrating Other Total trauma Nontrauma CNS injury Gastrointestinal surgery Vascular surgery Head and neck surgery Soft tissue infection Other Total nontrauma All patients
N
% Trauma
% Total
Feeding tube location
153 11 15 179
85.5 6.1 8.4 100
67.7 4.9 6.6 79.2
Jejunal Jejunal Jejunal Jejunal
(145), LOT (3), D4 (1), D3 (1), D2 (1), D1 (1), Gastric (1)** (10), D2 (1) (13), D2 (1), Gastric (1)* (168), LOT (3), D4 (1) D3 (1), D2 (3), D1 (1), Gastric (2)
18 16 4 3 2 4 47 226
38.3 34.0 8.5 6.4 4.3 8.5 100
8.0 7.1 1.8 1.3 0.9 1.8 20.8
Jejunal Jejunal Jejunal Jejunal Jejunal Jejunal Jejunal Jejunal
(15), LOT (1), D3 (1), D2 (1) (12), LOT (1) D4 (1), D3 (1), D2 (1) (2), D4 (1), Gastric (1) (2), D3 (1) (2) (3), D1 (1) (36), LOT (2), D4 (2), D3 (3), D2 (2), D1 (1), Gastric (1) (204), LOT (5), D4 (3), D3 (4), D2 (5), D1 (2), Gastric (3)
Blunt injury: motor vehicle crash (99), fall (19), pedestrian-motor vehicle crash (14), motorcycle crash (8), assault (5), crush injury (5), all terrain vehicle crash (1), bicycle-motor vehicle crash (1), diving accident (1). Penetrating injury: gunshot wound (10), stab wound (1). Other ⫽ burn wound (14), electrical injury (1). CNS (central nervous system) injury: (17), anoxic brain injury (1). Gastrointestinal surgery: colon carcinoma (3), cecal perforation (2), small bowel obstruction (2), ischemic bowel (2), perforated peptic ulcer (1), sigmoid volvulus (1), colonic dysmotility (1), gastrointestinal lymphoma (1), acute pancreatitis (2), pancreatic pseudocyst (1). Vascular surgery: acute aortic occlusion (2), ascending aortic aneurysm/aortic valve replacement (1), abdominal aortic aneurysm (1). Head and neck surgery: retropharyngeal abscess (1), base of tongue carcinoma (1), hemorrhage after septal rhinoplasty (1). Soft tissue infection: Fournier’s gangrene (1), necrotizing fasciitis (1). Other: septic pyelonephritis (1), pelvic abscess (1), bladder carcinoma (1), AIDS/Pneumocystis carini pneumonia (1). LOT ⫽ ligament of Treitz; D1 ⫽ first portion of duodenum; D2 ⫽ second portion of duodenum; D3 ⫽ third portion of duodenum; D4 ⫽ fourth portion of duodenum.
ranged from 3 to 98 days with a mean of 23.6 days, while hospital LOS ranged from 5 to 239 days with a mean of 41.2 days. The distribution of traumatic injuries, pathologic diagnoses in the nontrauma cases, and final tube location is shown in Table 1. More than 86% of cases (n ⫽ 195) were performed at the bedside, and 31 cases (13.7%) were performed in the operating room at the time of another procedure. The tip of the feeding tube was placed distal to the LOT in 90.3% of all patients. Tube location was identified as jejunal (n ⫽ 204, 90.3%; 95% confidence interval [CI] 85.7% to 93.5%), at the LOT (n ⫽ 5, 2.2%), D4 (n ⫽ 3, 1.3%), D3 (n ⫽ 4, 1.8%), D2 (n ⫽ 5, 2.2%), D1 (n ⫽ 2, 0.9%), or gastric (n ⫽ 3, 1.3%). The techniques were most accurate for jejunal placement in the trauma population (n ⫽ 168, 93.8%; 95% CI: 89.3% to 96.5%), while they were
slightly less accurate in the nontrauma population (n ⫽ 36, 76.6%; 95% CI: 62.8% to 86.4%; Table 2). When tubes placed at or beyond the LOT were considered, the overall accuracy of the techniques was 92.5% (n ⫽ 209, 95% CI: 88.3% to 95.3%). The success of placement at or beyond the LOT was highest in the trauma population achieving a 95.5% success rate (n ⫽ 171, 95% CI: 91.4% to 97.7%). The success in the nontrauma population for placement at or beyond the LOT was 80.8% (n ⫽ 47, 95% CI: 67.5% to 89.6%). Tubes were located from D1 to D4 (n ⫽ 14) in 6.2% overall, 3.4% (n ⫽ 6) in the trauma population, and 17.0% (n ⫽ 8) in the nontrauma population (Table 2). There was no statistical difference in location for isolated TEJ placements (n ⫽ 185) when compared with the combined PEG/TEJ procedures (n ⫽ 41; P ⫽ 0.09). A postpyloric location was attained in 223 of the 226 tubes (98.7%; Table
Table 2 Final feeding tube locations for trauma, nontrauma, and all patients Location
Jejunal
95% confidence interval
LOT
D4
D3
D2
D1
Trauma (n ⫽ 179) Nontrauma (n ⫽ 47) Total (n ⫽ 226)
168, 93.8% 36, 76.6% 204, 90.3%
89.3%–96.5% 62.8%–86.4% 85.7%–93.5%
3, 1.7% 2, 4.2% 5, 2.2%
1, 0.6% 2, 4.2% 3, 1.3%
1, 0.6% 3, 6.3% 4, 1.8%
3, 1.7% 2, 4.2% 5, 2.2%
1, 0.6% 1, 2.1% 2, 0.9%
Gastric 2, 1.1% 1, 2.1% 3, 1.3%
Location
Jejunal ⫹ LOT
95% confidence interval
D1–D4
Post pyloric
Trauma (n ⫽ 179) Nontrauma (n ⫽ 47) Total (n ⫽ 226)
171, 95.5% 38, 80.8% 209, 92.5%
91.4%–97.7% 67.5%–89.6% 88.3%–95.3%
6, 3.4% 8, 17.0% 14, 6.2%
177, 98.9% 46, 97.9% 223, 98.7%
LOT ⫽ ligament of Treitz; D4 ⫽ fourth portion of duodenum; D3 ⫽ third portion of duodenum; D2 ⫽ second portion of duodenum; D1 ⫽ first portion of duodenum.
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Table 3 Breakdown of nonjejunal feeding tubes and contributing factors Breakdown of nonjejunal tubes Tube #
Location
Diagnosis
Gastric tubes 1 G MVC 2 G Burn injury 3 G Aorto-occlusive disease s/p ABF bypass Duodenal tubes 1 D1 MVC 2 D1 Septic pyelonephritis 3 D2 Burn injury 4 D2 GSW face and head 5 D2 MVC 6 D2 Lymphoma 7 D2 CVA 8 D3 MVC 9 D3 Retropharyngeal abscess 10 D3 Anoxic brain injury 11 D3 Pancreatic pseudocyst 12 D4 Crush injury 13 D4 Abdominal aortic aneurysm 14 D4 Acute pancreatitis Ligament of Treitz tubes 1 LOT MVC 2 LOT MVC 3 LOT Fall 4 LOT Colon CA 5
LOT
CVA
Contributing factors PEG/TEJ; error in technique (did not hold TEJ while withdrawing endoscope) Previous gastric bypass preventing passage of endoscope into duodenum Unable to pass endoscope through the pylorus into duodenum PEG/TEJ with malrotation Recent right nephrectomy Difficulty passing scope into duodenum None None Retroperitoneal lymphadenopathy PEG/TEJ; error in technique, knotted catheter resulting in withdrawal of TEJ to untie None None None Recent resection of pseudocyst and tail of pancreas None Retroperitoneal hemorrhage and edema following AAA repair Duodenal narrowing from pancreatic edema None None None Hepatic flexure colon CA requiring partial duodenectomy. Patient developed postoperative gastric outlet obstruction None
G ⫽ gastric; D1 ⫽ first portion of duodenum; D2 ⫽ second portion of duodenum; D3 ⫽ third portion of duodenum; D4 ⫽ fourth portion of duodenum; LOT ⫽ ligament of Treitz; MVC motor vehicle crash; GSW ⫽ gunshot wound; CVA ⫽ cerebral vascular accident; CA ⫽ cancer; AAA ⫽ abdominal aortic aneurysm; PEG ⫽ percutaneous endoscopic gastrostomy; TEJ ⫽ transendoscopic jejunal feeding tube.
2), and there were only 2 gastric tubes in the trauma population. One was attributable to an error in technique described in the operative report, and the other occurred in a burn patient with a previous gastric bypass procedure that prevented passage of the endoscope into the duodenum. There was one tube in the gastric location in the nontrauma population in a patient who had undergone an aortobifemoral bypass. In this patient the endoscope could not be passed through the pylorus. A breakdown of all nonjejunal tubes can be seen in Table 3 along with contributing factors for nonjejunal location. Final tube location was independent of the level of the resident or fellow performing the endoscopy. Tube placement and tube use complications are illustrated in Table 4. Three major procedural complications occurred (1.3% of cases). Tube use complications occurred in the majority of patients over time (Table 4). The use of TPN at Grady Memorial Hospital was assessed by comparing time periods 1 and 3 (Table 5). Between the two periods the overall use of TPN decreased with both the number of patients receiving TPN and the total number of TPN days being reduced. The overall number of patients receiving TPN decreased from 42 to 17 (59.5% decrease) and the overall number of TPN days was reduced from 429 to 236 (45% decrease). In the nontrauma
population the number of TPN patients decreased from 20 to 17 (15% decrease) and the number of TPN days decreased from 171 to 132 (22.8% decrease). The effects were most pronounced in the trauma population where the number of trauma ICU admissions increased from 233 to 300 (28.8% increase) from one time period to another. Despite this increase, the number of TPN patients decreased from 22 to 7 (68% decrease) and the number of TPN days decreased
Table 4 Tube placement and tube use complications Tube placement complications (N)
Tube use complications
Met-hemoglobinemia (1) Reperforation of Graham patch closure (1) Transverse colon injury (1) Knotted tube, untied but prolonged PEG/TEJ procedure (2) Transient hypertension Transient hypotension Transient decrease in O2 saturations Transient increase in intracranial pressure
Inadvertent partial removal Inadvertent complete removal Kinking Leaking Occlusion Migration Tube passed per rectum
PEG ⫽ percutaneous gastrostomy tubes; TEJ ⫽ transendoscopic jejunal feeding tube.
J.M. Nicholas et al. / The American Journal of Surgery 186 (2003) 583–590 Table 5 Total parenteral nutrition (TPN) use in trauma patients at Grady Memorial Hospital Trauma data (Grady data only) Time Period
1/01/00– 7/18/00
7/19/00– 1/18/01
1/19/01– 7/25/01
# ICU admits # TPN patients # TPN days # Tubes placed % TPN use in ICU admits # Days of TPN/ICU admit Mean TPN days/patient Mean days with FT Mean days without FT % Change in # TPN patients % Change in # TPN days % Change in ICU admits
233 22 258 0 9.4%
275 31 374 23 11.3%
300 7 74 51 2.3%
1.1
1.36
0.25
11.7 NA 11.7 NA
12.1 10.3 12.8 41% increase
10.5*(3.6)† 19.7*(3.5)† 3.8 68% decrease
NA
45% increase
71.3% decrease
NA
18% increase
28.8% increase
* One patient on TPN for 52 days. † Mean after exclusion of patient with 52 days. ICU ⫽ intensive care unit; TPN ⫽ total parenteral nutrition; FT ⫽ feeding tube; NA ⫽ not available.
from 258 to 74 (71.3% decrease). As the daily cost of TPN at our institution is approximately $40, potential cost savings in TPN expense per year were calculated to be $14,706 in the trauma population, $3119 in the nontrauma population with an overall potential savings of $15,444 in TPN expenditures per year.
Comments The route of enteral feeding remains controversial. There is significant evidence that certain patient populations have physiologic abnormalities of the proximal gastrointestinal tract placing them at high risk for intolerance of gastric feeding [4,14,15,19 –21]. Decreased gastric emptying, gastroesophageal reflux, and decreased lower esophageal sphincter tone have all been demonstrated in the critically ill [4,21]. In addition, patients with diabetes mellitus have gastroparesis, patients with a known history of aspiration have the highest risk of aspiration events with enteral feeding, and several papers have documented the risk of gastric feedings in patients with injuries to the brain [19 –22]. Finally, the presence of a nasogastric tube alone has been show to increase gastroesophageal reflux [23]. Transendoscopic placement of a feeding catheter was first described by Coates and MacFadyen [17,18]. Reed et al [16] later described his technique for placement of a post pyloric feeding tube in 1998. While there were excellent results in achieving postpyloric placement of a feeding tube
587
in this report, a distinction between duodenal and jejunal location of the tip of the feeding tube was not made. In this study, the same technique was used to place feeding tubes (7F Wilson-Cook nasobiliary drainage catheter) distal to the LOT. The results confirm the success of this technique for postpyloric feeding tube placement as this was accomplished in 98.7% of the cases. Further breakdown of the exact location of the tube in the GI tract was performed by analysis of post placement abdominal radiographs. An overall success rate of 90.3% for placing a feeding tube into the jejunum (95% CI: 85.7% to 93.5%) was obtained. To our knowledge this is the highest reported success rate in the literature for jejunal placement using a nonoperative bedside technique. The technique had the greatest accuracy in the trauma population with a 93.8% success rate (95% CI: 89.3% to 96.5%), but was slightly less accurate in a diverse population of critically ill patients with a 76.6% accuracy rate (95% CI: 62.8% to 86.4%). There are several limitations to endoscopic passage of a feeding tube beyond the LOT. For example, timing of placement may play a role. Almost all trauma patients had their feeding tubes placed within 48 hours of admission. The majority of nontrauma patients were hospitalized for a significant length of time prior to the procedure. There was a subjective clinical impression by the endoscopists that the greater the length of time until tube placement the greater the mucosal edema noted in the stomach and duodenum at the time of the procedure. This edema might limit passage of the feeding catheter through the distal portion of the duodenum and beyond the LOT. Another explanation may be that tube placement is less successful in patients with primary diagnoses that anatomically affect the duodenum or proximal jejunum (Table 3). A final explanation may be that there is a learning curve to obtain optimal results with the techniques, as was suggested by the first 100 cases performed, all performed under supervision of a single faculty person. In the first 100 cases, 4 of the 5 trauma patients that had unsuccessful jejunal placement were among the first 20 cases performed. Seven of 10 patients overall in which the tube was not successfully advanced beyond the ligament of Treitz were within the first third of the cases performed. In contrast, in the last third of these 100 cases there was a 100% success rate for passage into the jejunum in the trauma patients (30 of 30), and a 75% success rate in nontrauma patients (3 of 4) for an overall accuracy of 97% (33 of 34). Only in one case was the tube not advanced into the jejunum. There are several subtleties to the procedure that the authors noted with experience. First, it is extremely important to see the tube pass from the second portion of the duodenum into the third portion. The tube may not always negotiate this curve, and more than one attempt may be required to pass this area successfully. This can be assured by directly observing this portion of the procedure with the endoscope. Second, once the tube is into the third portion of the duodenum passage usually occurs without difficulty,
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however, an occasional tube may double back on itself. If the scope is maintained in the second portion of the duodenum while 10 to 20 cc of tube are advanced, tubes that are doubling back in the duodenum will be detected. Withdrawing and readvancing the tube will generally allow successful passage. With experience a tactile sensation is developed for tubes that are passing easily and tubes that are coiling. Major complications are infrequent with TEJ and PEG/ TEJ placement and occurred in only 3 cases (1.3%) in this study. One case of methemoglobinemia was precipitated by excessive use of benzocaine spray as a topical anesthetic, a known complication of this agent [24]. Its use should be limited, or an alternative topical anesthetic may be preferable. One patient developed free air in the abdomen 24 hours after an uneventful placement of a TEJ 2 weeks after Graham patch closure of a perforated duodenal ulcer. Caution should be exercised in selecting such patients for endoscopy. An alternate technique for introducing a feeding tube may be desirable in these patients. One final complication was an injury to the transverse colon during placement of a PEG/TEJ tube, a recognized complication of PEG placement [25]. In general, this can be avoided by ensuring that a good light reflex is seen on the abdominal wall at the time of PEG placement, ie, avoidance of blind PEG placement. No other major complications of the procedure were identified. Transient decreases in systolic blood pressure after administration of analgesic and sedative agents did occur but no major hypotensive episodes or hypoxic episodes were identified. No inadvertent extubations or loss of airway occurred during any of the procedures. In addition, many patients with injuries to the brain and intracranial pressure monitors in place underwent the procedure safely; however, the majority of these procedures were performed after stabilization of intracranial pressures. The patient with a severe injury to the brain and an elevated intracranial pressure may not be an ideal candidate for this procedure. Finally, many patients in cervical collars who had not had clearance of the cervical spine and patients with documented injuries to the cervical spine underwent the procedure safely without adverse neurological events. Tube use complications were frequent and included tube kinking, occlusion, leakage, displacement, migration, malpositioning, and inadvertent removal. Tube occlusion, however, was surprisingly infrequent given the diameter of the tube. This is probably due to the Teflon coating on the tube and the recommendation to flush the tube with water every two to four hours while in use. No gastrointestinal perforations, erosions, nor bleeding episodes could be attributed to the tube itself. Complications not previously noted with other nasoenteric feeding devices or PEGs were not encountered. Limitations of the techniques described are that they are invasive and require skill in endoscopy. While placement of a feeding tube beyond the pylorus was accomplished in 98.6% of cases, there did seem to be a learning curve for
successful placement beyond the LOT. Hemodynamically labile patients and patients with injuries to the brain with an elevated intracranial pressure may not be appropriate candidates for these procedures. The techniques were associated with a reduction in the use of TPN in this study, but a precise cause and effect relationship cannot be established from this retrospective study. In conclusion, transendoscopic placement of TEJ or PEG/TEJ tubes is useful for the surgeon skilled in endoscopy. These techniques allow early and accurate bedside placement of feeding tubes beyond the LOT and can be used to compare true jejunal feeding in patients who have not received laparotomy with other forms of enteral feeding.
Discussion R. Albrecht (Oklahoma City, OK): The authors have chosen to examine the success of the endoscopic “push technique” in placing feeding tubes beyond the ligament of Treitz in trauma and critically ill surgical patients. They retrospectively reviewed the results of this procedure in 226 patients, revealing a 90.3% success rate in placing the feeding tube tip beyond the ligament of Treitz, and 98.7% beyond the pylorus. They showed that by instituting this technique that the use of total parenteral nutrition decreased significantly in their hospital, thus providing potential cost savings. There is cumulative evidence that early institution of enteral feeding can be beneficial to critically ill patients and avoiding TPN may decrease complications and costs associated with the parenteral route. This study provides us with a successful technique for placing feeding tubes into the small bowel. However, the manuscript left me with several unanswered questions. Because the key to decreasing complications may be the early institution of feedings, what is the mean time from admission to when the tubes were in place and feedings were begun? Did patients receive nutrition before the tubes were placed and what route was utilized prior to successful feeding tube placement? You stated in the manuscript that tube use complications were frequent—such as kinking, occlusion, leakage, displacement, and inadvertent removal. How often did these complications occur? How many tubes needed replacement? And how long were patients left without feedings due to these complications? One of the reasons for utilizing distal feedings is to decrease aspiration and potential pneumonia rates. Did you have any patients aspirate and did the patients with distal feedings have a lesser incidence of pneumonia? Finally, you reported length of stay of 5 to 239 days, with a mean of 23 days. Did the patient who stayed 5 days benefit from an endoscopic feeding tube? Given the cost of the nasobiliary tube, radiographs, the use of the endoscopy equipment, surgeons charges, and OR time in some cases, do you think this is a cost-effective way to place all feeding tubes or would it be better to use this technique, as Reed et al did, in patients
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who were intolerant of tube feedings in a more proximal location? F. Moore (Houston, TX): What tube are you using? Do you do anything special? We take it out early because we have found that the commercially available nasobiliary stents that we use become quite stiff over time. We have had one case of delayed perforation and two cases of intussusception. Have you had these complications? The second observation is, when you place these tubes they sometimes go well beyond the ligament of Treitz. You start jejunal feeding, signs of intolerance really are minimal, and you can push people into developing nonocclusive bowel necrosis. Do you have an enteral feeding protocol, and when do you stop enteral feeding? Have you seen any cases of pneumatosis intestinalis or nonocclusive bowel necrosis? D. Margulies (Los Angeles, CA): What is the complication rate in terms of pneumonia and aspiration? The tube I have been placing has a port in the stomach so that it can empty the stomach at the same time, but I am not really sure that is important and would be interested to see whether you have a proximal port in the tube you use, in order to empty the stomach at the same time, that is, whether it’s a dual lumen or not. And, if there is no port proximally, have you had problems with aspiration? Jeffrey M. Nicholas: Our mean time to placement is difficult to quantify because this was a retrospective study. We didn’t really go back to look at how long it took from the patient’s admission until the tube was placed, but I can tell you that these have ranged in time, predominantly based on the availability of endoscopy equipment. In the best-case scenarios, we have these in within 12 hours of admission; worst-case scenarios, the gastroscope was broken or out, and we have had to delay these by as many as several days, 5 days or so. In the interim, we try to provide some other form of nutritional support. We will attempt gastric feeds and see if the patients tolerate them. We will also try blind passage of postpyloric feeding tubes at the bedside to try to institute something in between and when all else fails, if we feel the patient warrants it, we will place them on TPN. Again, this puts the tubes beyond the ligament of Treitz, and we would feel that this important in distinguishing them from gastric versus any other form of postpyloric tube feeding, the majority of which are really duodenal in nature if you break down many of the papers. Tube use complications, inadvertent removal—when is the cost of placing these worth the hassle? We have attempted to bridle as many of these as possible at the time of placement which can actually be done with the length of the tube that is cut off to measure it so that it is in at the appropriate length, and we will use the remaining portion of the blue tube to bridle these tubes in place, reducing the amount of them that come out; but despite the bridle, we have had miraculous removals of these tubes. When they come out, we attempt to replace them and will again go through the same type of things to try to provide nutrition in the interim. Some of these patients will just not tolerate
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gastric feeds. Many of them are NPO going back and forth for orthopedic procedures and other surgical procedures, and so again, having these past Treitz we feel provides a benefit to these patients. I cannot really comment as to whether we have reduced aspiration or pneumonia. This was not a prospective study, and the hope would be that the next step with this would be to truly compare a nonoperative jejunally placed tube to gastric or postpyloric, ie, duodenal feeding, to see whether there truly is a difference in nonoperative patients of gastric versus true jejunal feeding comparing aspiration and pneumonia rates. There was a question as to whether the placement was effective in the 5-day stay patient. If these patients are intubated in our ICU at 24 hours, we try to get a tube in them to feed them, recognizing that the benefits of early enteral nutrition are when they are provided early, and the studies that did this looked at feeding coming off the operating room table. It is very difficult to predict who is going to remain intubated, who is going to stay on the ventilator for 1 or 2 days and whose head injury is going to rapidly improve and come off the ventilator and extubate, so it may not have been worth it in this particular individual; I am not sure how we quantify that up front to know who’s coming off and who is staying on. With respect to Dr. Moore’s questions about complications, we have not noted any perforations from these tubes. I have had anecdotal reports from some residents and a couple of radiologists that CT scans have suggested an intussusception. We have not had any clinical intussusception that have required treatment. I am not aware of any major GI bleeds that have occurred from these tubes, although we share your concerns that when they have been in for a long time, they become somewhat rigid. We have had these in patients for as long as 3 months. In terms of nonocclusive bowel necrosis, and how do we prevent this, and have we seen it? I don’t think we have had nonocclusive bowel necrosis occur from this form of feeding. Our policy would be to not feed anyone until they are fully resuscitated from shock and their base deficits have cleared. We will then institute slow enteral feeds and try to ramp these up over a period of 24 to 48 hours to goal. If the patient becomes septic or goes on some form of vasopressor support for any reason, we will stop tube feeds or back them down to a trophic level with concerns for bowel necrosis. Regarding Dr. Margulies’ comments on pneumonia and aspiration, I think this will need to be dealt with prospectively. We hope that this may provide a method to further prospective work, comparing gastric versus true jejunal feeding.
Acknowledgments The authors thank the endoscopy nurses in the gastrointestinal laboratory at Tampa General Hospital for their bed-
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side assistance and dedication to the trauma service. Without their help this project would not have been possible.
References [1] King BK, Kudsk KA, Li J, et al. Route and type of nutrition influence mucosal immunity to bacterial pneumonia. Ann Surg 1999;229: 272– 8. [2] Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg 1992;216:172– 83. [3] Moore EE, Moore FA. Immediate enteral nutrition following multisystem trauma: a decade perspective. J Am Coll Nutr 1991;10:633– 48. [4] Nicholas JM, Cornelius MW, Tchorz KM, Tremblay LN, Spiegelman ER, Easley KA, et al. A two institution experience with 226 endoscopically placed jejunal feeding tubes in critically ill surgical patients. J Parent Ent Nutr 1993;17(suppl):1–9. [5] Moore EE, Jones TN. Benefits of immediate jejunostomy feeding after major abdominal trauma—a prospective, randomized study. J Trauma 1986;26:874 – 81. [6] Kudsk KA, Croce MA, Fabian TC, et al. Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg 1992;215:503–13. [7] Zaloga GP. Early enteral nutritional support improves outcome: hypothesis or fact [editorial]? Crit Care Med 1999;27:259 – 61. [8] Singh G, Ram RP, Khanna SK. Early postoperative enteral feeding in patients with nontraumatic intestinal perforation and peritonitis. J Am Coll Surg 1998;187:142– 6. [9] Zaloga GP. Bedside method for placing small bowel feeding tubes in critically ill patients. A prospective study. Chest 1991;100:1643– 6. [10] Gutierrez ED, Balfe DM. Fluoroscopically guided nasoenteric feeding tube placement: results of a 1-year study. Radiology 1991;178: 759 – 62. [11] Minard G. Enteral access. NCP 1994;9:172– 82.
[12] Kearns PJ, Chin D, Mueller L, et al. The incidence of ventilatorassociated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Crit Care Med 2000;28:1742– 6. [13] Ott L, Annis K, Hatton J, et al. Postpyloric enteral feeding costs for patients with severe head injury: blind placement, endoscopy, and PEG/J versus TPN. J Neurotrauma 1999;16:233– 42. [14] Lewis BS. Perform PEJ, not PED. Gastrointest Endosc 1990;36:311– 13. [15] Romand JA, Suter PM. Enteral nutrition: the right stuff at the right time in the right place. Crit Care Med 2000;28:2671–2. [16] Reed RL, Eachempati SR, Russell MK, et al. Endoscopic placement of jejunal feeding catheters in critically ill patients by a “push” technique. J Trauma 1998;45:388 –93. [17] Coates NE, MacFadyen BV. Endoscopic jejunal access for enteral feeding. Am J Surg 1995;169:627– 8. [18] MacFadyen BV, Catalano MF, Raijman I, et al. Percutaneous endoscopic gastrostomy with jejunal extension: a new technique. Am J Gastroenterol 1992;87:725– 8. [19] Metheny NA, Eisenberg P, Spies M. Aspiration pneumonia in patients fed through nasoenteral tubes. Heart Lung 1986;15:256 – 61. [20] Olivares L, Segovia A, Revuelta R. Tube feeding and lethal aspiration in neurological patients: a review of 720 autopsy cases. Stroke 1974; 5:654 –7. [21] Saxe JM, Ledgerwood AM, Lucas CE, et al. Lower esophageal sphincter dysfunction precludes safe gastric feeding after head injury. J Trauma 1994;37:581– 6. [22] Kirby DF, Clifton GL, Turner H, et al. Early enteral nutrition after brain injury by percutaneous endoscopic gastrojejunostomy. J Parent Ent Nutr 1991;15:298 –302. [23] Ibanez J, Penafiel A, Raurich JM, et al. Gastroesophageal reflux in intubated patients receiving enteral nutrition: effect of supine and semirecumbent positions. J Parent Ent Nutr 1992;16:419 –22. [24] Lee E, Boorse R, Marcinczyk M. Methemoglobinemia secondary to benzocaine topical anesthetic. Surg Laparosc Endosc 1996;6:492–3. [25] Roozrokh HC, Ripepi A, Stahlfeld K, et al. Gastrocolocutaneous fistula as a complication of peg tube placement. Surg Endosc 2002; 16:538 –9.
Scientific paper
A two institution experience with 226 endoscopically placed jejunal feeding tubes in critically ill surgical patients Jeffrey M. Nicholas, M.D.a,c,*, Mark W. Corneliusa, Kathryn M. Tchorz, M.D.a, Lorraine N. Tremblay, M.D., Ph.D.a, E. Ronald Spiegelman, Pharm.D.a, Kirk A. Easley, M.S.a, William Small, M.D.a, David V. Feliciano, M.D.a, Melissa A. Powell, M.D.b, Jerry Poklepovic, M.D.b a
Departments of Surgery and Radiology, Emory University/Grady Memorial Hospital/Rollins School of Public Health, Atlanta, GA, USA b Departments of Surgery and Radiology, University of South Florida/Tampa General Hospital, Tampa, FL, USA c Department of Surgery, Emory University/Grady Memorial Hospital, Room 308, Glenn Memorial Building, 69 Butler St. SE, Atlanta, GA 30303, USA Manuscript received August 30, 2003; revised manuscript September 3, 2003 Presented at the 55th Annual Meeting of the Southwestern Surgical Congress, Tucson, Arizona, April 27–30, 2003
Abstract Background: Early jejunal feeding after surgery or trauma reduces infectious complications. Although not ideal gastric and postpyloric feedings are often used, however, because of difficulty in placing feeding tubes distal to the ligament of Treitz (LOT). Our hypothesis was that feeding tube placement distal to the LOT can be accomplished using a bedside transendoscopic technique. Methods: Transendoscopic jejunal (TEJ) tube placement and TEJ tubes inserted simultaneously through percutaneous gastrostomy (PEG) tubes (PEG/TEJ) were attempted to be placed distal to the LOT. Results: In all, 226 feeding tubes (185 TEJ, 41 PEG/TEJ) were placed in 179 trauma and 47 nontrauma patients over 3 years (August 20, 1998 to July 15, 2001). Tube location was jejunal in 93.8% of trauma patients, 76.6% of nontrauma patients, and 90.3% of all patients. (Confidence intervals were 89.3% to 96.5%, 62.8% to 86.4%, and 85.7% to 93.5%). Days of total parenteral nutrition were reduced 71.3% in trauma patients, 22.8% in nontrauma patients, and 45% overall at one institution. Conclusions: Bedside TEJ and PEG/TEJ placement is safe and successful in placing feeding tubes distal to the LOT in more than 90% of critically ill surgical patients. © 2003 Excerpta Medica, Inc. All rights reserved. Keywords: Nutrition; Enteral; Endoscopy; Percutaneous endoscopic gastrostomy; Jejunum; Trauma
Enteral nutritional support has been shown to be efficacious when compared with total parenteral nutrition (TPN) in the critically ill [1–3]. In addition, both trauma and nontrauma patients have reduced morbidity when enteral feeding into the jejunum is begun in the early postoperative period [4 – 8]. It would seem advantageous to start early jejunal feeding in most surgical patients; however, placing a feeding device into the jejunum can be challenging in patients who have not undergone a laparotomy. Numerous techniques for nonoperative placement of feeding tubes have been described, but the majority of these fail to consistently
* Corresponding author. Tel.: ⫹1-404-616-5456, 404-616-7322; fax: ⫹1-404-616-7333. E-mail address: [email protected]
place feeding tubes distal to the ligament of Treitz (LOT) [9 –11]. Of interest, postpyloric feeding has not been demonstrated to reduce the rates of aspiration or pneumonia when compared with gastric feeding [12]. While select patients at risk for gastric feeding may tolerate postpyloric feeding better, little data exist comparing gastric or postpyloric feeding with true jejunal feeding in patients not requiring laparotomy [4,13,14]. This is in part due to the difficulty in timely placement of a feeding tube distal to the LOT using available bedside techniques. A safe bedside procedure that accurately places a feeding tube into the jejunum in patients without laparotomy would have obvious benefits [14,15]. In order to provide early and consistent feeding to trauma patients and to allow further study of whether there is a
0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.09.005
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difference between gastric or postpyloric and true jejunal feeding, the authors attempted to identify a technique that would allow early and accurate placement of a feeding tube beyond the LOT. Reed et al [16] reported success with postpyloric feeding tube placement using an endoscopic “push technique.” This technique had a 100% success rate in placing feeding tubes beyond the pylorus, but the authors did not break down the final postpyloric location of the feeding tubes. The hypothesis in this study was that use of the bedside “transendoscopic” technique would result in placement of feeding tubes distal to the LOT in critically ill patients.
Material and methods A retrospective analysis of endoscopic procedures to place feeding tubes over a 3-year period at two hospitals was performed. Transendoscopic jejunal (TEJ) feeding tubes and percutaneous endoscopic gastrostomy (PEG) tubes with TEJ tubes placed through them (PEG/TEJ tubes) were placed at Tampa General Hospital in Tampa, Florida, from August 20, 1998, to May 5, 2000, and at Grady Memorial Hospital in Atlanta, Georgia, from July 19, 2000 to July 25, 2001. All patients were cared for or consulted on by the trauma service at Tampa General Hospital, a level I trauma center for the University of South Florida, or the Emory University surgical services at Grady Memorial Hospital, an urban level I trauma center serving metropolitan Atlanta. Candidates for the study included critically ill trauma patients and a heterogeneous population of critically ill surgical patients being cared for in the intensive care unit. All procedures were performed at the bedside unless the patient was in the operating room having concomitant procedures performed. Endoscopic procedures were performed by clinical postgraduate year (PGY) 2, 3, 4, and 5 residents and PGY 6 and 7 fellows on the surgical services under the direction of faculty members or fellows trained in upper gastrointestinal (GI) endoscopy. Informed consent for upper GI endoscopy and feeding tube placement was obtained for all patients. Procedures were performed with the patient in a supine position or rolled slightly onto their left side using an Olympus GIF-100 or GIF-2T100 endoscope (Olympus, Melville, NY). Formal endoscopic evaluation of the esophagus, stomach and duodenum was performed during passage of the endoscope into the second portion of the duodenum. A 7F Wilson-Cook nasobiliary drainage catheter (Wilson-Cook Medical, Inc., Winston-Salem, NC) was passed through the biopsy channel of the endoscope. Occasionally, an 8F catheter was used necessitating the use of the GIF-2T100 endoscope. Transendoscopic placement was performed using the technique for postpyloric placement described by Reed et al [16]. In select patients who were likely to need prolonged feeding access, a PEG/TEJ was placed using a modified
technique originally described by Coates et al [17,18]. A TEJ was first placed as described by Reed et al [16]. Instead of transferring the tube from the mouth to the nares it was left in the oral cavity. Next a 24F PEG tube (Microvasive Boston Scientific, Atlanta, GA) was placed using a standard pull technique. The TEJ tube was inserted into the PEG and sutured to the PEG tube before pulling it through the abdominal wall. The PEG was then pulled through the abdominal wall simultaneously delivering the TEJ tube through the PEG. The PEG was then placed to dependent drainage, while the TEJ was used for enteric feeding into the small bowel. An abdominal radiograph was obtained after each procedure to confirm the location of the feeding tube. After this, tube feedings were initiated. All radiographs and their dictated reports were reviewed retrospectively to identify the precise location of the distal tip of the feeding tube. Tube location was classified as gastric, duodenal, at the LOT or jejunal. Duodenal tubes were classified as being in the first, second, third, or fourth portion of the duodenum (D1, D2, D3, or D4). Patients in whom radiographs could not be obtained were eliminated from the study. An attending radiologist familiar with the techniques and potential locations of feeding tubes placed fluoroscopically reviewed cases in which dictations were not available as well as those in which the tube location was not precisely specified in the dictation. A retrospective review of the surgeon’s dictated operative reports and medical records was used to identify complications of tube placement and use. In the later half of the study utilization of TPN was evaluated at Grady Memorial Hospital during three time periods: from January 1, 2000 to July 18, 2000 (time period 1), from July 19, 2001 to January 18, 2001 (time period 2), and from January 19, 2001, to July 25, 2001 (time period 3). Time period 1 was prior to utilization of the endoscopic techniques for feeding access, time period 2 correlated with the introduction of the technique, and time period 3 was when the endoscopic techniques were used routinely as a means of obtaining feeding access. Time periods 1 and 3 were compared to assess impact of the techniques on the use of TPN.
Results Postprocedure radiographs were available in 226 patients (75% male). There were 179 trauma patients (79%) and a heterogeneous population of 47 critically ill surgical patients (21%). The injured patients sustained predominantly blunt trauma (n ⫽ 154, 86%), while penetrating trauma accounted for 5.6% of cases (n ⫽ 10) and 8.4% had burn injury (n ⫽ 15). Ninety-four percent of patients (n ⫽ 195) were on mechanical ventilation at the time of the procedures. Injury Severity Scores ranged from 5 to 51 with a mean of 25.5, and the average age was 47.5 years (range 15 to 88). Intensive care unit (ICU) length of stay (LOS)
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585
Table 1 Feeding tube location by mechanism of injury or pathologic diagnoses Mechanism of injury Trauma Blunt Penetrating Other Total trauma Nontrauma CNS injury Gastrointestinal surgery Vascular surgery Head and neck surgery Soft tissue infection Other Total nontrauma All patients
N
% Trauma
% Total
Feeding tube location
153 11 15 179
85.5 6.1 8.4 100
67.7 4.9 6.6 79.2
Jejunal Jejunal Jejunal Jejunal
(145), LOT (3), D4 (1), D3 (1), D2 (1), D1 (1), Gastric (1)** (10), D2 (1) (13), D2 (1), Gastric (1)* (168), LOT (3), D4 (1) D3 (1), D2 (3), D1 (1), Gastric (2)
18 16 4 3 2 4 47 226
38.3 34.0 8.5 6.4 4.3 8.5 100
8.0 7.1 1.8 1.3 0.9 1.8 20.8
Jejunal Jejunal Jejunal Jejunal Jejunal Jejunal Jejunal Jejunal
(15), LOT (1), D3 (1), D2 (1) (12), LOT (1) D4 (1), D3 (1), D2 (1) (2), D4 (1), Gastric (1) (2), D3 (1) (2) (3), D1 (1) (36), LOT (2), D4 (2), D3 (3), D2 (2), D1 (1), Gastric (1) (204), LOT (5), D4 (3), D3 (4), D2 (5), D1 (2), Gastric (3)
Blunt injury: motor vehicle crash (99), fall (19), pedestrian-motor vehicle crash (14), motorcycle crash (8), assault (5), crush injury (5), all terrain vehicle crash (1), bicycle-motor vehicle crash (1), diving accident (1). Penetrating injury: gunshot wound (10), stab wound (1). Other ⫽ burn wound (14), electrical injury (1). CNS (central nervous system) injury: (17), anoxic brain injury (1). Gastrointestinal surgery: colon carcinoma (3), cecal perforation (2), small bowel obstruction (2), ischemic bowel (2), perforated peptic ulcer (1), sigmoid volvulus (1), colonic dysmotility (1), gastrointestinal lymphoma (1), acute pancreatitis (2), pancreatic pseudocyst (1). Vascular surgery: acute aortic occlusion (2), ascending aortic aneurysm/aortic valve replacement (1), abdominal aortic aneurysm (1). Head and neck surgery: retropharyngeal abscess (1), base of tongue carcinoma (1), hemorrhage after septal rhinoplasty (1). Soft tissue infection: Fournier’s gangrene (1), necrotizing fasciitis (1). Other: septic pyelonephritis (1), pelvic abscess (1), bladder carcinoma (1), AIDS/Pneumocystis carini pneumonia (1). LOT ⫽ ligament of Treitz; D1 ⫽ first portion of duodenum; D2 ⫽ second portion of duodenum; D3 ⫽ third portion of duodenum; D4 ⫽ fourth portion of duodenum.
ranged from 3 to 98 days with a mean of 23.6 days, while hospital LOS ranged from 5 to 239 days with a mean of 41.2 days. The distribution of traumatic injuries, pathologic diagnoses in the nontrauma cases, and final tube location is shown in Table 1. More than 86% of cases (n ⫽ 195) were performed at the bedside, and 31 cases (13.7%) were performed in the operating room at the time of another procedure. The tip of the feeding tube was placed distal to the LOT in 90.3% of all patients. Tube location was identified as jejunal (n ⫽ 204, 90.3%; 95% confidence interval [CI] 85.7% to 93.5%), at the LOT (n ⫽ 5, 2.2%), D4 (n ⫽ 3, 1.3%), D3 (n ⫽ 4, 1.8%), D2 (n ⫽ 5, 2.2%), D1 (n ⫽ 2, 0.9%), or gastric (n ⫽ 3, 1.3%). The techniques were most accurate for jejunal placement in the trauma population (n ⫽ 168, 93.8%; 95% CI: 89.3% to 96.5%), while they were
slightly less accurate in the nontrauma population (n ⫽ 36, 76.6%; 95% CI: 62.8% to 86.4%; Table 2). When tubes placed at or beyond the LOT were considered, the overall accuracy of the techniques was 92.5% (n ⫽ 209, 95% CI: 88.3% to 95.3%). The success of placement at or beyond the LOT was highest in the trauma population achieving a 95.5% success rate (n ⫽ 171, 95% CI: 91.4% to 97.7%). The success in the nontrauma population for placement at or beyond the LOT was 80.8% (n ⫽ 47, 95% CI: 67.5% to 89.6%). Tubes were located from D1 to D4 (n ⫽ 14) in 6.2% overall, 3.4% (n ⫽ 6) in the trauma population, and 17.0% (n ⫽ 8) in the nontrauma population (Table 2). There was no statistical difference in location for isolated TEJ placements (n ⫽ 185) when compared with the combined PEG/TEJ procedures (n ⫽ 41; P ⫽ 0.09). A postpyloric location was attained in 223 of the 226 tubes (98.7%; Table
Table 2 Final feeding tube locations for trauma, nontrauma, and all patients Location
Jejunal
95% confidence interval
LOT
D4
D3
D2
D1
Trauma (n ⫽ 179) Nontrauma (n ⫽ 47) Total (n ⫽ 226)
168, 93.8% 36, 76.6% 204, 90.3%
89.3%–96.5% 62.8%–86.4% 85.7%–93.5%
3, 1.7% 2, 4.2% 5, 2.2%
1, 0.6% 2, 4.2% 3, 1.3%
1, 0.6% 3, 6.3% 4, 1.8%
3, 1.7% 2, 4.2% 5, 2.2%
1, 0.6% 1, 2.1% 2, 0.9%
Gastric 2, 1.1% 1, 2.1% 3, 1.3%
Location
Jejunal ⫹ LOT
95% confidence interval
D1–D4
Post pyloric
Trauma (n ⫽ 179) Nontrauma (n ⫽ 47) Total (n ⫽ 226)
171, 95.5% 38, 80.8% 209, 92.5%
91.4%–97.7% 67.5%–89.6% 88.3%–95.3%
6, 3.4% 8, 17.0% 14, 6.2%
177, 98.9% 46, 97.9% 223, 98.7%
LOT ⫽ ligament of Treitz; D4 ⫽ fourth portion of duodenum; D3 ⫽ third portion of duodenum; D2 ⫽ second portion of duodenum; D1 ⫽ first portion of duodenum.
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Table 3 Breakdown of nonjejunal feeding tubes and contributing factors Breakdown of nonjejunal tubes Tube #
Location
Diagnosis
Gastric tubes 1 G MVC 2 G Burn injury 3 G Aorto-occlusive disease s/p ABF bypass Duodenal tubes 1 D1 MVC 2 D1 Septic pyelonephritis 3 D2 Burn injury 4 D2 GSW face and head 5 D2 MVC 6 D2 Lymphoma 7 D2 CVA 8 D3 MVC 9 D3 Retropharyngeal abscess 10 D3 Anoxic brain injury 11 D3 Pancreatic pseudocyst 12 D4 Crush injury 13 D4 Abdominal aortic aneurysm 14 D4 Acute pancreatitis Ligament of Treitz tubes 1 LOT MVC 2 LOT MVC 3 LOT Fall 4 LOT Colon CA 5
LOT
CVA
Contributing factors PEG/TEJ; error in technique (did not hold TEJ while withdrawing endoscope) Previous gastric bypass preventing passage of endoscope into duodenum Unable to pass endoscope through the pylorus into duodenum PEG/TEJ with malrotation Recent right nephrectomy Difficulty passing scope into duodenum None None Retroperitoneal lymphadenopathy PEG/TEJ; error in technique, knotted catheter resulting in withdrawal of TEJ to untie None None None Recent resection of pseudocyst and tail of pancreas None Retroperitoneal hemorrhage and edema following AAA repair Duodenal narrowing from pancreatic edema None None None Hepatic flexure colon CA requiring partial duodenectomy. Patient developed postoperative gastric outlet obstruction None
G ⫽ gastric; D1 ⫽ first portion of duodenum; D2 ⫽ second portion of duodenum; D3 ⫽ third portion of duodenum; D4 ⫽ fourth portion of duodenum; LOT ⫽ ligament of Treitz; MVC motor vehicle crash; GSW ⫽ gunshot wound; CVA ⫽ cerebral vascular accident; CA ⫽ cancer; AAA ⫽ abdominal aortic aneurysm; PEG ⫽ percutaneous endoscopic gastrostomy; TEJ ⫽ transendoscopic jejunal feeding tube.
2), and there were only 2 gastric tubes in the trauma population. One was attributable to an error in technique described in the operative report, and the other occurred in a burn patient with a previous gastric bypass procedure that prevented passage of the endoscope into the duodenum. There was one tube in the gastric location in the nontrauma population in a patient who had undergone an aortobifemoral bypass. In this patient the endoscope could not be passed through the pylorus. A breakdown of all nonjejunal tubes can be seen in Table 3 along with contributing factors for nonjejunal location. Final tube location was independent of the level of the resident or fellow performing the endoscopy. Tube placement and tube use complications are illustrated in Table 4. Three major procedural complications occurred (1.3% of cases). Tube use complications occurred in the majority of patients over time (Table 4). The use of TPN at Grady Memorial Hospital was assessed by comparing time periods 1 and 3 (Table 5). Between the two periods the overall use of TPN decreased with both the number of patients receiving TPN and the total number of TPN days being reduced. The overall number of patients receiving TPN decreased from 42 to 17 (59.5% decrease) and the overall number of TPN days was reduced from 429 to 236 (45% decrease). In the nontrauma
population the number of TPN patients decreased from 20 to 17 (15% decrease) and the number of TPN days decreased from 171 to 132 (22.8% decrease). The effects were most pronounced in the trauma population where the number of trauma ICU admissions increased from 233 to 300 (28.8% increase) from one time period to another. Despite this increase, the number of TPN patients decreased from 22 to 7 (68% decrease) and the number of TPN days decreased
Table 4 Tube placement and tube use complications Tube placement complications (N)
Tube use complications
Met-hemoglobinemia (1) Reperforation of Graham patch closure (1) Transverse colon injury (1) Knotted tube, untied but prolonged PEG/TEJ procedure (2) Transient hypertension Transient hypotension Transient decrease in O2 saturations Transient increase in intracranial pressure
Inadvertent partial removal Inadvertent complete removal Kinking Leaking Occlusion Migration Tube passed per rectum
PEG ⫽ percutaneous gastrostomy tubes; TEJ ⫽ transendoscopic jejunal feeding tube.
J.M. Nicholas et al. / The American Journal of Surgery 186 (2003) 583–590 Table 5 Total parenteral nutrition (TPN) use in trauma patients at Grady Memorial Hospital Trauma data (Grady data only) Time Period
1/01/00– 7/18/00
7/19/00– 1/18/01
1/19/01– 7/25/01
# ICU admits # TPN patients # TPN days # Tubes placed % TPN use in ICU admits # Days of TPN/ICU admit Mean TPN days/patient Mean days with FT Mean days without FT % Change in # TPN patients % Change in # TPN days % Change in ICU admits
233 22 258 0 9.4%
275 31 374 23 11.3%
300 7 74 51 2.3%
1.1
1.36
0.25
11.7 NA 11.7 NA
12.1 10.3 12.8 41% increase
10.5*(3.6)† 19.7*(3.5)† 3.8 68% decrease
NA
45% increase
71.3% decrease
NA
18% increase
28.8% increase
* One patient on TPN for 52 days. † Mean after exclusion of patient with 52 days. ICU ⫽ intensive care unit; TPN ⫽ total parenteral nutrition; FT ⫽ feeding tube; NA ⫽ not available.
from 258 to 74 (71.3% decrease). As the daily cost of TPN at our institution is approximately $40, potential cost savings in TPN expense per year were calculated to be $14,706 in the trauma population, $3119 in the nontrauma population with an overall potential savings of $15,444 in TPN expenditures per year.
Comments The route of enteral feeding remains controversial. There is significant evidence that certain patient populations have physiologic abnormalities of the proximal gastrointestinal tract placing them at high risk for intolerance of gastric feeding [4,14,15,19 –21]. Decreased gastric emptying, gastroesophageal reflux, and decreased lower esophageal sphincter tone have all been demonstrated in the critically ill [4,21]. In addition, patients with diabetes mellitus have gastroparesis, patients with a known history of aspiration have the highest risk of aspiration events with enteral feeding, and several papers have documented the risk of gastric feedings in patients with injuries to the brain [19 –22]. Finally, the presence of a nasogastric tube alone has been show to increase gastroesophageal reflux [23]. Transendoscopic placement of a feeding catheter was first described by Coates and MacFadyen [17,18]. Reed et al [16] later described his technique for placement of a post pyloric feeding tube in 1998. While there were excellent results in achieving postpyloric placement of a feeding tube
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in this report, a distinction between duodenal and jejunal location of the tip of the feeding tube was not made. In this study, the same technique was used to place feeding tubes (7F Wilson-Cook nasobiliary drainage catheter) distal to the LOT. The results confirm the success of this technique for postpyloric feeding tube placement as this was accomplished in 98.7% of the cases. Further breakdown of the exact location of the tube in the GI tract was performed by analysis of post placement abdominal radiographs. An overall success rate of 90.3% for placing a feeding tube into the jejunum (95% CI: 85.7% to 93.5%) was obtained. To our knowledge this is the highest reported success rate in the literature for jejunal placement using a nonoperative bedside technique. The technique had the greatest accuracy in the trauma population with a 93.8% success rate (95% CI: 89.3% to 96.5%), but was slightly less accurate in a diverse population of critically ill patients with a 76.6% accuracy rate (95% CI: 62.8% to 86.4%). There are several limitations to endoscopic passage of a feeding tube beyond the LOT. For example, timing of placement may play a role. Almost all trauma patients had their feeding tubes placed within 48 hours of admission. The majority of nontrauma patients were hospitalized for a significant length of time prior to the procedure. There was a subjective clinical impression by the endoscopists that the greater the length of time until tube placement the greater the mucosal edema noted in the stomach and duodenum at the time of the procedure. This edema might limit passage of the feeding catheter through the distal portion of the duodenum and beyond the LOT. Another explanation may be that tube placement is less successful in patients with primary diagnoses that anatomically affect the duodenum or proximal jejunum (Table 3). A final explanation may be that there is a learning curve to obtain optimal results with the techniques, as was suggested by the first 100 cases performed, all performed under supervision of a single faculty person. In the first 100 cases, 4 of the 5 trauma patients that had unsuccessful jejunal placement were among the first 20 cases performed. Seven of 10 patients overall in which the tube was not successfully advanced beyond the ligament of Treitz were within the first third of the cases performed. In contrast, in the last third of these 100 cases there was a 100% success rate for passage into the jejunum in the trauma patients (30 of 30), and a 75% success rate in nontrauma patients (3 of 4) for an overall accuracy of 97% (33 of 34). Only in one case was the tube not advanced into the jejunum. There are several subtleties to the procedure that the authors noted with experience. First, it is extremely important to see the tube pass from the second portion of the duodenum into the third portion. The tube may not always negotiate this curve, and more than one attempt may be required to pass this area successfully. This can be assured by directly observing this portion of the procedure with the endoscope. Second, once the tube is into the third portion of the duodenum passage usually occurs without difficulty,
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however, an occasional tube may double back on itself. If the scope is maintained in the second portion of the duodenum while 10 to 20 cc of tube are advanced, tubes that are doubling back in the duodenum will be detected. Withdrawing and readvancing the tube will generally allow successful passage. With experience a tactile sensation is developed for tubes that are passing easily and tubes that are coiling. Major complications are infrequent with TEJ and PEG/ TEJ placement and occurred in only 3 cases (1.3%) in this study. One case of methemoglobinemia was precipitated by excessive use of benzocaine spray as a topical anesthetic, a known complication of this agent [24]. Its use should be limited, or an alternative topical anesthetic may be preferable. One patient developed free air in the abdomen 24 hours after an uneventful placement of a TEJ 2 weeks after Graham patch closure of a perforated duodenal ulcer. Caution should be exercised in selecting such patients for endoscopy. An alternate technique for introducing a feeding tube may be desirable in these patients. One final complication was an injury to the transverse colon during placement of a PEG/TEJ tube, a recognized complication of PEG placement [25]. In general, this can be avoided by ensuring that a good light reflex is seen on the abdominal wall at the time of PEG placement, ie, avoidance of blind PEG placement. No other major complications of the procedure were identified. Transient decreases in systolic blood pressure after administration of analgesic and sedative agents did occur but no major hypotensive episodes or hypoxic episodes were identified. No inadvertent extubations or loss of airway occurred during any of the procedures. In addition, many patients with injuries to the brain and intracranial pressure monitors in place underwent the procedure safely; however, the majority of these procedures were performed after stabilization of intracranial pressures. The patient with a severe injury to the brain and an elevated intracranial pressure may not be an ideal candidate for this procedure. Finally, many patients in cervical collars who had not had clearance of the cervical spine and patients with documented injuries to the cervical spine underwent the procedure safely without adverse neurological events. Tube use complications were frequent and included tube kinking, occlusion, leakage, displacement, migration, malpositioning, and inadvertent removal. Tube occlusion, however, was surprisingly infrequent given the diameter of the tube. This is probably due to the Teflon coating on the tube and the recommendation to flush the tube with water every two to four hours while in use. No gastrointestinal perforations, erosions, nor bleeding episodes could be attributed to the tube itself. Complications not previously noted with other nasoenteric feeding devices or PEGs were not encountered. Limitations of the techniques described are that they are invasive and require skill in endoscopy. While placement of a feeding tube beyond the pylorus was accomplished in 98.6% of cases, there did seem to be a learning curve for
successful placement beyond the LOT. Hemodynamically labile patients and patients with injuries to the brain with an elevated intracranial pressure may not be appropriate candidates for these procedures. The techniques were associated with a reduction in the use of TPN in this study, but a precise cause and effect relationship cannot be established from this retrospective study. In conclusion, transendoscopic placement of TEJ or PEG/TEJ tubes is useful for the surgeon skilled in endoscopy. These techniques allow early and accurate bedside placement of feeding tubes beyond the LOT and can be used to compare true jejunal feeding in patients who have not received laparotomy with other forms of enteral feeding.
Discussion R. Albrecht (Oklahoma City, OK): The authors have chosen to examine the success of the endoscopic “push technique” in placing feeding tubes beyond the ligament of Treitz in trauma and critically ill surgical patients. They retrospectively reviewed the results of this procedure in 226 patients, revealing a 90.3% success rate in placing the feeding tube tip beyond the ligament of Treitz, and 98.7% beyond the pylorus. They showed that by instituting this technique that the use of total parenteral nutrition decreased significantly in their hospital, thus providing potential cost savings. There is cumulative evidence that early institution of enteral feeding can be beneficial to critically ill patients and avoiding TPN may decrease complications and costs associated with the parenteral route. This study provides us with a successful technique for placing feeding tubes into the small bowel. However, the manuscript left me with several unanswered questions. Because the key to decreasing complications may be the early institution of feedings, what is the mean time from admission to when the tubes were in place and feedings were begun? Did patients receive nutrition before the tubes were placed and what route was utilized prior to successful feeding tube placement? You stated in the manuscript that tube use complications were frequent—such as kinking, occlusion, leakage, displacement, and inadvertent removal. How often did these complications occur? How many tubes needed replacement? And how long were patients left without feedings due to these complications? One of the reasons for utilizing distal feedings is to decrease aspiration and potential pneumonia rates. Did you have any patients aspirate and did the patients with distal feedings have a lesser incidence of pneumonia? Finally, you reported length of stay of 5 to 239 days, with a mean of 23 days. Did the patient who stayed 5 days benefit from an endoscopic feeding tube? Given the cost of the nasobiliary tube, radiographs, the use of the endoscopy equipment, surgeons charges, and OR time in some cases, do you think this is a cost-effective way to place all feeding tubes or would it be better to use this technique, as Reed et al did, in patients
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who were intolerant of tube feedings in a more proximal location? F. Moore (Houston, TX): What tube are you using? Do you do anything special? We take it out early because we have found that the commercially available nasobiliary stents that we use become quite stiff over time. We have had one case of delayed perforation and two cases of intussusception. Have you had these complications? The second observation is, when you place these tubes they sometimes go well beyond the ligament of Treitz. You start jejunal feeding, signs of intolerance really are minimal, and you can push people into developing nonocclusive bowel necrosis. Do you have an enteral feeding protocol, and when do you stop enteral feeding? Have you seen any cases of pneumatosis intestinalis or nonocclusive bowel necrosis? D. Margulies (Los Angeles, CA): What is the complication rate in terms of pneumonia and aspiration? The tube I have been placing has a port in the stomach so that it can empty the stomach at the same time, but I am not really sure that is important and would be interested to see whether you have a proximal port in the tube you use, in order to empty the stomach at the same time, that is, whether it’s a dual lumen or not. And, if there is no port proximally, have you had problems with aspiration? Jeffrey M. Nicholas: Our mean time to placement is difficult to quantify because this was a retrospective study. We didn’t really go back to look at how long it took from the patient’s admission until the tube was placed, but I can tell you that these have ranged in time, predominantly based on the availability of endoscopy equipment. In the best-case scenarios, we have these in within 12 hours of admission; worst-case scenarios, the gastroscope was broken or out, and we have had to delay these by as many as several days, 5 days or so. In the interim, we try to provide some other form of nutritional support. We will attempt gastric feeds and see if the patients tolerate them. We will also try blind passage of postpyloric feeding tubes at the bedside to try to institute something in between and when all else fails, if we feel the patient warrants it, we will place them on TPN. Again, this puts the tubes beyond the ligament of Treitz, and we would feel that this important in distinguishing them from gastric versus any other form of postpyloric tube feeding, the majority of which are really duodenal in nature if you break down many of the papers. Tube use complications, inadvertent removal—when is the cost of placing these worth the hassle? We have attempted to bridle as many of these as possible at the time of placement which can actually be done with the length of the tube that is cut off to measure it so that it is in at the appropriate length, and we will use the remaining portion of the blue tube to bridle these tubes in place, reducing the amount of them that come out; but despite the bridle, we have had miraculous removals of these tubes. When they come out, we attempt to replace them and will again go through the same type of things to try to provide nutrition in the interim. Some of these patients will just not tolerate
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gastric feeds. Many of them are NPO going back and forth for orthopedic procedures and other surgical procedures, and so again, having these past Treitz we feel provides a benefit to these patients. I cannot really comment as to whether we have reduced aspiration or pneumonia. This was not a prospective study, and the hope would be that the next step with this would be to truly compare a nonoperative jejunally placed tube to gastric or postpyloric, ie, duodenal feeding, to see whether there truly is a difference in nonoperative patients of gastric versus true jejunal feeding comparing aspiration and pneumonia rates. There was a question as to whether the placement was effective in the 5-day stay patient. If these patients are intubated in our ICU at 24 hours, we try to get a tube in them to feed them, recognizing that the benefits of early enteral nutrition are when they are provided early, and the studies that did this looked at feeding coming off the operating room table. It is very difficult to predict who is going to remain intubated, who is going to stay on the ventilator for 1 or 2 days and whose head injury is going to rapidly improve and come off the ventilator and extubate, so it may not have been worth it in this particular individual; I am not sure how we quantify that up front to know who’s coming off and who is staying on. With respect to Dr. Moore’s questions about complications, we have not noted any perforations from these tubes. I have had anecdotal reports from some residents and a couple of radiologists that CT scans have suggested an intussusception. We have not had any clinical intussusception that have required treatment. I am not aware of any major GI bleeds that have occurred from these tubes, although we share your concerns that when they have been in for a long time, they become somewhat rigid. We have had these in patients for as long as 3 months. In terms of nonocclusive bowel necrosis, and how do we prevent this, and have we seen it? I don’t think we have had nonocclusive bowel necrosis occur from this form of feeding. Our policy would be to not feed anyone until they are fully resuscitated from shock and their base deficits have cleared. We will then institute slow enteral feeds and try to ramp these up over a period of 24 to 48 hours to goal. If the patient becomes septic or goes on some form of vasopressor support for any reason, we will stop tube feeds or back them down to a trophic level with concerns for bowel necrosis. Regarding Dr. Margulies’ comments on pneumonia and aspiration, I think this will need to be dealt with prospectively. We hope that this may provide a method to further prospective work, comparing gastric versus true jejunal feeding.
Acknowledgments The authors thank the endoscopy nurses in the gastrointestinal laboratory at Tampa General Hospital for their bed-
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side assistance and dedication to the trauma service. Without their help this project would not have been possible.
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[12] Kearns PJ, Chin D, Mueller L, et al. The incidence of ventilatorassociated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Crit Care Med 2000;28:1742– 6. [13] Ott L, Annis K, Hatton J, et al. Postpyloric enteral feeding costs for patients with severe head injury: blind placement, endoscopy, and PEG/J versus TPN. J Neurotrauma 1999;16:233– 42. [14] Lewis BS. Perform PEJ, not PED. Gastrointest Endosc 1990;36:311– 13. [15] Romand JA, Suter PM. Enteral nutrition: the right stuff at the right time in the right place. Crit Care Med 2000;28:2671–2. [16] Reed RL, Eachempati SR, Russell MK, et al. Endoscopic placement of jejunal feeding catheters in critically ill patients by a “push” technique. J Trauma 1998;45:388 –93. [17] Coates NE, MacFadyen BV. Endoscopic jejunal access for enteral feeding. Am J Surg 1995;169:627– 8. [18] MacFadyen BV, Catalano MF, Raijman I, et al. Percutaneous endoscopic gastrostomy with jejunal extension: a new technique. Am J Gastroenterol 1992;87:725– 8. [19] Metheny NA, Eisenberg P, Spies M. Aspiration pneumonia in patients fed through nasoenteral tubes. Heart Lung 1986;15:256 – 61. [20] Olivares L, Segovia A, Revuelta R. Tube feeding and lethal aspiration in neurological patients: a review of 720 autopsy cases. Stroke 1974; 5:654 –7. [21] Saxe JM, Ledgerwood AM, Lucas CE, et al. Lower esophageal sphincter dysfunction precludes safe gastric feeding after head injury. J Trauma 1994;37:581– 6. [22] Kirby DF, Clifton GL, Turner H, et al. Early enteral nutrition after brain injury by percutaneous endoscopic gastrojejunostomy. J Parent Ent Nutr 1991;15:298 –302. [23] Ibanez J, Penafiel A, Raurich JM, et al. Gastroesophageal reflux in intubated patients receiving enteral nutrition: effect of supine and semirecumbent positions. J Parent Ent Nutr 1992;16:419 –22. [24] Lee E, Boorse R, Marcinczyk M. Methemoglobinemia secondary to benzocaine topical anesthetic. Surg Laparosc Endosc 1996;6:492–3. [25] Roozrokh HC, Ripepi A, Stahlfeld K, et al. Gastrocolocutaneous fistula as a complication of peg tube placement. Surg Endosc 2002; 16:538 –9.