Endoscopic enteral access for enteral nutrition

Clinical Update

American Society for Gastrointestinal Endoscopy

Editor: Ronnie Fass, MD

Vol. 15, No. 2 October 2007

Commentary: Endoscopic enteral access for enteral nutrition in patients who are unable to maintain an oral intake is an important palliative procedure that is within the gastroenterologist’s armamentarium. Many new developments and improvements in this area have been introduced in the last decade. In this review, Dr DeLegge provides a detailed description of several bedside techniques of nasogastric-tube placements. In addition, different percutaneous endoscopic procedures for establishing enteral access are described. Importantly, proper usage of these modalities and potential complications are also presented. In the end, Dr DeLegge recognizes that endoscopists should be well trained in these endoscopic techniques, understand their advantages and disadvantages, and use proper clinical judgment when offering them to patients. – Ronnie Fass, MD, Editor

ENDOSCOPIC ENTERAL ACCESS FOR ENTERAL NUTRITION Mark H. DeLegge, MD, FASGE Professor of Medicine, Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina, USA utritional support of the hospitalized patient is important in improving patient outcomes. In a patient who can eat and drink, the provision of enteral nutrition (EN) support is focused on the use of nutritional supplements, dietary counseling, and appetite stimulation. However, in those patients who will not eat or cannot eat secondary to some dysfunction of the GI tract, an enteral route, or feeding tube, to provide EN is necessary. Thus, obtaining enteral access becomes the foundation for any attempt at providing EN. The science of enteral access and EN support has evolved dramatically over the recent years.

N

second bedside device uses electromagnetism to track movement of an NJ tube, which contains a specialized tip, throughout the stomach, around the duodenal C-loop, and into the jejunum. The movement of the tube is displayed on a bedside monitor designed specifically for the system.5

ENDOSCOPIC NASOENTERIC ACCESS

Failure to pass an NJ tube at the bedside requires the use of fluoroscopic or endoscopic methods of passage. The preference of either technique is center dependent. In those institutions without bedside fluoroscopic capabilities, transport of patients to the radiology suite, especially patients who are critically ill, can be time consuming, expensive, and hazardous. In these instances, bedside endoscopic passage of an NJ tube is preferred.

A number of techniques have been promoted for blind, bedside placement of an nasojejunal (NJ) tube.1 There are studies that evaluated the blind positioning of an NJ tube beyond the pylorus with the use of pharmacologic agents.2,3 The results were mixed. More recently, bedside devices have become available to assist the clinician in passing an NJ tube. A magnet device (the Gabriel device; Syncro Medical Innovations, Pittsburgh, PA) is used in combination with a metal-tipped NJ tube. The magnet is slowly traced over the configuration of the stomach, duodenum, and jejunum on the abdominal wall. This pulls the NJ tube into proper position.4 A

Endoscopic placement of an NJ feeding tube can be done at the bedside with the patient under conscious sedation. The techniques for bedside, endoscopic, nasoenteric tube passage are listed in Table 1. The drag-andpull method is the method with the most history. In this technique, a suture or other material is attached to the end of an NJ tube. This suture is used to drag the NJ tube into position in the small intestine with a grasping forceps. Difficulty usually occurs in releasing the suture from the grasping forceps, which results in inadvertent displacement of the NJ tube back into the stomach. A second common technique, the over-the-

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guidewire technique, requires the initial placement of a guidewire into the small intestine. An endoscope is placed into the distal duodenum or the proximal jejunum, and a guidewire is passed through the biopsy channel beyond the tip of the endoscope and well into the proximal jejunum. The endoscope is removed, and the guidewire is left in place. A feeding tube is subsequently passed blindly or with fluoroscopic assistance into position in the small intestine. Patrick et al6 reported a 94% success rate when using this technique. Kulling et al7 describe the use of an ultrathin endoscope to perform nasal endoscopy for NJ-tube passage. The ultrathin endoscope is passed beyond the pylorus. A guidewire is placed into the small bowel through the biopsy channel of the endoscope. The ultrathin endoscope is subsequently removed. An NJ tube is passed over the guidewire into position.

TABLE 1. ENDOSCOPIC METHODS OF NASOENTERIC TUBE PLACEMENT Methods

Technique

Drag and pull

Suture on end of a tube pulled with forceps into position

Over the guidewire

Tube pushed into position over a guidewire

Through the scope

Tube pushed through biopsy channel of endoscope into small bowel

Nasal endoscopy

Tube passed over guidewire placed through a nasal endoscope

Push positioning

Tube stiffened with guidewires and pushed into position

PERCUTANEOUS ENDOSCOPIC ENTERAL ACCESS If a patient requires enteral access for more than 4 weeks, then endoscopic percutaneous procedures are preferred (Table 2). These procedures include PEG, percutaneous endoscopic gastrojejunostomy (PEG/J), and direct percutaneous endoscopic jejunostomy (DPEJ). All of these procedures require the use of an endoscope and, usually, conscious sedation.

PERCUTANEOUS ENDOSCOPIC GASTRIC ENTERAL ACCESS PEG was developed by Gauderer and Ponsky8 in the early 1980s. This procedure involves the placement of a PEG tube after endoscopic transillumination of the stomach for an appropriate PEG-access position. The use of prophylactic antibiotics before the procedure is important in the prevention of postprocedure infections.9 After appropriate patient selection and consent, the patient receives standard upper endoscopy. These patients are at risk of aspiration, by the nature of their dysphagia and require PEG placement and the presence of other comorbid disease states. The patient should be maintained at a head-elevated position of 30° during PEG placement, with aggressive pharyngeal suctioning in an attempt to reduce the occurrence of aspiration. A point of appropriate PEG access is determined by a combination of abdominal-wall transillumination with the endoscope and abdominalwall palpation that can be visualized during endoscopy. Intradermal anesthesia should raise a skin wheal at the proposed insertion site. After cleansing of the abdominal wall, a 7- to 1-cm incision is made. The incision may be vertical or horizontal on the abdominal wall. This incision site will allow the PEG tube to exit the gastric cavity through the abdominal wall by the use of an attached PEG-tube dilator. Placement of the PEG tube may be by either the Sachs-Vine (push) or Ponsky (pull) techniques. A cannula is passed through the abdominal-wall incision site into the gastric lumen under direct endoscopic visualization. A guidewire is passed through this cannula into the gastric lumen. The guidewire is snared and pulled out through the oral cavity with the endoscope. In the push technique, a PEG tube is pushed over the guidewire, into the gastric lumen, and out the abdominal incision until the internal PEG-tube bolster rests against the gastric mucosa. In the pull technique, the PEG tube is tied to the end of the guidewire and the PEG tube is pulled down into the gastric lumen and out the abdominal incision. A decision to use either technique is simply a matter of physician prefer2

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TABLE 2. ENTERAL ACCESS METHODS Type of access

Used for

Length of need, mo

Nasal/oral access Gastric tube

Gastric feeding, gastric decompression

<1

Gastrojejunal tube

Gastric feeding, jejunal feeding, gastric decompression

<1

Jejunal tube

Jejunal feeding

<1

Gastric feeding, gastric decompression

>1

Percutaneous access Gastrostomy

Gastrojejunostomy

Gastric feeding, jejunal feeding, gastric decompression

Jejunostomy

Jejunal feeding

>1 but <6

>1

ence.10 A prospective outcome evaluation of PEG placement found this procedure to be associated with few procedure-related complications (Table 3).11 Once the PEG tube is in proper position, the external skin bolster is pushed down over the PEG toward the exterior abdominal wall. Excessive tightening of the bolster can cause abdominal-wall tissue ischemia, wound leakage, and, potentially, necrotizing fasciitis.12 The external skin bolster should be maintained 1 to 2 cm away from the abdominal wall. Sponges should be placed over the external bolster, not underneath, to prevent placing excessive pressure on the abdominal-wall tissue. Tube feedings may begin within 3 to 6 hours after PEG-tube placement.13 Vol. 15, No. 2 October 2007

SMALL-BOWEL PERCUTANEOUS ENDOSCOPIC ENTERAL ACCESS

TABLE 3. PEG-RELATED COMPLICATIONS

In those patients in whom small-bowel feedings are desired, endoscopic, percutaneous small-bowel access may be obtained by 2 methods. The first method, PEG/J, places a jejunal feeding tube through an existing PEG into the small bowel by using a variety of methods. Early literature described poor outcomes with the use of the PEG/J systems.14 Previous J-tube–placement techniques often required dragging a jejunal (J) tube, by using a grasping forceps, into the small intestine via an attached string. Attempts at removing the endoscope from the small bowel or the grasping forceps from the attached string often resulted in displacement of the Jtube back into the stomach. J-tube failures were often secondary to migration of the J-tube from the small bowel to the stomach or tube clogging.

Colocutaneous fistula (PEG placed through colon during placement)

Proper J-tube placement through a PEG requires a modification of earlier techniques. Success can often be obtained by using an over-the-guide wire method. After the PEG is placed, the endoscope is reinserted in the patient and an alligator or grasping forceps is passed through the PEG to the outside of the patient. A guidewire is grasped by the forceps and pulled into the stomach. An air-plug device is passed over the guidewire and secured into position on the external end of the PEG, which allows insufflation of the stomach and adequate visualization. The endoscope, forceps, and guidewire are pushed down to the third or fourth portion of the duodenum. The grasping forceps is pushed 8 to 10 cm beyond the endoscope under direct visualization. The air plug is removed, and tension is applied on the guidewire, which still remains in the grasping forceps. The J-tube is lubricated and passed over the guidewire into position and locked into the distal end of the PEG. The endoscope is pulled back into the stomach while pushing the grasping forceps forward to maintain its position in the jejunum. Once the endoscope is back in the stomach, the guidewire is released and removed. The grasping forceps is removed, and the endoscope confirms proper passage of the J-tube through the PEG without looping. DeLegge et al15 reported a 100% success rate when using this technique for PEG/J placement, with a procedure time of approximately 26 minutes. There were no major complications. This PEG/J system allowed for both gastric decompression and small-bowel feeding concurrently. With the development of smaller, 5-mm endoscopes and 3.6-mm pediatric bronchoscopes, alternative PEG/J placement techniques have been developed. The mini-endoscopes are passed directly through the lumen of the PEG into the small bowel. A guidewire is passed through the biopsy channel of endoscope into the small bowel. The endoscope is removed, and a J-tube is passed over the guidewire into position blindly or under fluoroscopic visualization.16 Another PEG/J-placement technique describes the use of a rat-tooth biliary stent removal forceps to drag the J-tube through the PEG tube into the small bowel. Other PEG/J-placement techniques have been described.17,18 An alternative method of obtaining small-bowel enteral access, DPEJ, directly places a J-tube into the small bowel by using an endoscope. This procedure requires the use of an enteroscope or a pediatric colonoscope to reach a puncture position beyond the ligament of Treitz. Once the abdominal-wall site is appropriately transilluminated with the endoscope, a standard pull PEG technique is used to place the DPEJ. It is often necwww.asge.org

Aspiration pneumonia (during PEG placement or with tube feeding)

Gastric or esophageal perforation Gastric hemorrhage Leakage around PEG tube Liver hemorrhage (PEG placed through liver) Necrotizing fasciitis (slough of abdominal wall secondary to infection) Pain at PEG site Peritonitis Pneumoperitoneum (symptomatic) Tube displacement (by patient or health care personnel) Tube obstruction (tube feeding or medications) Wound infection (at PEG-tube site) DPEJ, direct percutaneous endoscopic jejunostomy EN, enteral nutrition NJ, nasojejunal PEG/J, PEG jejunostomy

essary to use intravenous glucagon or an anticholinergic agent during the procedure to paralyze the small bowel so that appropriate transillumination can be obtained. A standard 20F or 24F PEG tube may be placed and used as the J-tube. Good success with this procedure was reported by Mellert et al,19 Shike et al,20 Bueno et al,21 Barrera et al,22 and Shetzline et al.23 Reported success rates ranged from 72% to 100%. In these series, the most common cause of DPEJ failure was inadequate abdominal-wall transillumination (50%) and gastric outlet or proximal small-bowel obstruction (30%). The major complication rate was approximately 2% and included colonic perforation, severe gastric bleed, and an abdominal-wall abscess. Minor complication rates were approximately 6% to 11% and included skin-site infection, persistent pain at the jejunal-access site, pressure-induced jejunal mucosal ulcerations, and persistent enterocutaneous fistulas.

COMPARATIVE STUDIES OF DPEJ VS PEG/J DPEJ, as opposed to PEG/J, should be performed in patients who will require long-term jejunal feedings (>6 months) or in whom gastric access for decompression or medication instillation is not necessary. A retrospective study by Fan et al24 compared physician reinterventions for J-tube complications, such as J-tube migration, in a group of patients who received PEG/J compared with another group of patients who received DPEJ. The patients who received DPEJ had significantly fewer endoscopic reinterventions. This lower endoscopic reintervention rate was again confirmed by DeLegge et al25 in a prospective series of 44 patients randomized to PEG/J vs DPEJ. The importance of EN in the at-risk population is reported throughout the medical literature. However, EN cannot be delivered without enteral access. The endoscopist should be familiar with the placement of gastric and small-bowel enteral access devices. Vol. 15, No. 2 October 2007

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REFERENCES 1. Thurlow PM. Bedside enteral feeding tube placement into duodenum and jejunum. JPEN J Parenter Enteral Nutr 1986;10:104-5. 2. Kittinger JM, Sandler RS, Heizer WD. Efficacy of metoclopramide as an adjunct to duodenal placement of small-bore feeding tubes: a randomized, placebo controlled, double-blind study. JPEN J Parenter Enteral Nutr 1987;11:33-7. 3. Whatley K, Turner WW Jr, Dey M, et al. When does metoclopramide facilitate transpyloric intubation. JPEN J Parenter Enteral Nutr 1984;8:679-81. 4. Gabriel SA, Ackermann RJ, Castresana MR, et al. A new technique for placement of nasoenteral feeding tubes using external metal guidance. Crit Care Med 1997;25:641-5. 5. Gray R, Reed L, Handal P, et al. Enhanced access for delivery of enteral feeding in the intensive care unit utilizing a team approach and an electromagnetic tube placement device. Presented at Clinical Nutrition Week, Nashville, TN, 2006. 6. Patrick PG, Marulendra S, Kirby DF, et al. Endoscopic naso-gastric-jejunal feeding tube placement in critically ill patients. Gastrointest Endosc 1997;45:72-6.

13. Choudry U, Barde CJ, Market R, et al. Percutaneous endoscopic gastrostomy: a randomized prospective comparison of early and delayed feeding. Gastrointest Endosc 1996;44:164-7. 14. Disario JA, Foutch PG, Sanowski RA. Poor results with percutaneous endoscopic jejunostomy. Gastrointest Endosc 1990;36:257-60. 15. DeLegge MH, Patrick PG, Gibbs R. Percutaneous endoscopic gastrojejunostomy with a tapered tip, unweighted jejunal feeding tube: improved placement success. Am J Gastroenterol 1996;91:1130-4. 16. Baskin WN, Johnson JF. Trans-PEG endoscopy for rapid PEJ placement. Am J Gastroenterol 1994;89:1701-4. 17. Sabol DA, Varadarajula V. Use of stent retrieval rat tooth forceps for percutaneous endoscopic gastrostomy/jejunostomy. J Clin Gastroenterol 2003;36:80. 18. Sibille A, Glorieux D, Fauville J-P, et al. An easier method for percutaneous endoscopic gastrojejunostomy tube placement. Gastrointest Endosc 1998;48:514-7. 19. Mellert J, Naruhn MB, Grand KE, et al. Direct percutaneous jejunostomy (EPJ). Clinical results. Surg Endosc 1994;8:867-9. 20. Shike M, Latkany L, Gerdes H, et al. Direct percutaneous endoscopic jejunostomies for Enteral feeding. Gastrointest Endosc 1996;44:536-40.

7. Kulling D, Bauerfeind P, Fried M. Transnasal versus transoral endoscopy for the placement of nasoenteral feeding tubes in critically ill patients. Gastrointest Endosc 2000;52:506-10.

21. Beuno JT, Schatner MA, Barrera R, et al. Endoscopic placement of direct percutaneous tubes in patients with complications after esophagectomy. Gastrointest Endosc 2003;57:536-40.

8. Gauderer MWL, Ponsky J, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5.

22. Barrera R, Scattner M, Nygaard S, et al. Outcome of direct percutaneous endoscopic jejunostomy tube placement for nutritional support in critically ill, mechanically ventilated patients. J Crit Care 2001;16:178-81.

9. Jain NK, Larson DE, Schroeder KW , et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy: a prospective, randomized double blind clinical trial. Ann Intern Med 1987;107:824-8. 10. Hogan RB, DeMarco DC, Hamilton JK, et al. Percutaneous endoscopic gastrostomy—to push or pull: a prospective randomized trial. Gastrointest Endosc 1986;32:253-8. 11. Larson De, Burton DD, Schroeder KW , et al. Percutaneous endoscopic gastrostomy: indications, success, complications and mortality in 314 consecutive patients. Gastroenterology 1987;93:48-52. 12. DeLegge MH, Lantz G, Kazacos E, et al. Effect of external bolster tension on PEG tube tract formation. Gastrointest Endosc 1996;43:A349.

23. Shetzline MA, Suhocki PV, Workman MJ. Direct percutaneous endoscopic jejunostomy with small bowel enteroscopy and fluoroscopy. Gastrointest Endosc 2001;58:633-8. 24. Fan AC, Baron TH, Rumalla A, et al. Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension. Gastrointest Endosc 2002;56:890-4. 25. DeLegge MH, Ginsberg G, McClave S, et al. Randomized prospective comparison of direct percutaneous endoscopic jejunostomy (DPEJ) vs. percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) feeding tube placement for enteral feeding. Gastrointest Endosc 2004;59:158(A).

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