- Email: [email protected]
Transnasal endoscopic technique for feeding tube placement
CONCLUSION
This study evaluates a new double lumen, direct irrigation injection catheter which was created to allow both hemostatic injection therapy and irrigation of a bleeding lesion with the same device. The catheter provides approximately one-half the volume and three-quarters the force of irrigation provided by comparably sized bipolar probes, and it provides about 85 % of the force provided by a standard washing catheter. In addition, the double lumen catheter is at least as rigid as the thermal devices and allows a greater force of application than standard injection catheters. The importance of firmly tamponading a bleeding ulcer prior to hemostatic therapy has been demonstrated with thermal devices,9 but has not been assessed for injection therapy. A fairly rigid catheter should be desirable in order to allow placement of the needle into a firm-to-hard ulcer base. In addition, tamponade of the feeding vessel just prior to delivery of the injection solution conceivably could aid in hemostasis. No information is available on the force or volume of irrigation which is required to remove blood and clots from an ulcer base and our study does not address this question. Anecdotally, in clinical practice the double lumen irrigation catheter is able to clear an ulcer base of active oozing and mild to moderate spurting of blood as well as to wash away loosely adherent clots. The double lumen, direct irrigation injection catheter is a modification of existing injection catheters
Transnasal endoscopic technique for feeding tube placement Richard G. Mitchell, Robert M. Kerr, David J. Ott, Michael Chen,
MD MD MD MD
Endoscopic placement of feeding tubes has evolved over the last 15 years because of an increased demand for enteral feedings in hospitalized patients. Enteral feedings are safer and cheaper than parenteral nutrition, but proper positioning of the feeding tube can be problematic, especially in the critically ill patient. Early endoscopic methods such as tying sutures to feeding tubes to pull them into the duodenum or creating external "makeshift endoscopic channels" to
which should aid in the treatment of patients with gastrointestinal tract bleeding. ACKNOWLEDGMENT
The author is grateful for the assistance of Maria Trujillo. REFERENCES 1. Chung SCS, Leung JWC, Steele RJC, Crofts TJ, Li, AKC.
2. 3. 4.
5. 6.
7. 8. 9.
Endoscopic injection of adrenaline for actively bleeding ulcers: a randomized trial. Br Med J 1988;296:1631-3. Panes J, Viver J, Fome M, Garcia-Olivares E, Marw C, Garav J. Controlled trial of endoscopic sclerosis in bleeding peptic ulcers. Lancet 1987;2:1292. Laine L. Multipolar electrocoagulation vs. injection therapy in the treatment of bleeding peptic ulcers: a prospective, randomized trial. Gastroenterology 1990;99:1303-6. Waring JP, Sanowski RA, Sawyer RL, Woods CA, Foutch PG. A randomized comparison of multipolar electrocoagulation and injection sclerosis for the treatment of bleeding peptic ulcer. Gastrointest Endosc 1991;37:295-8. Chung SCS, Leung JWC, Sung JY, Lu KK, Li AKC. Injection or heat probe for bleeding ulcer. Gastroenterology 1991;100: 33-7. Paquet KJ, Feussner H. Endoscopic sclerosis and esophageal balloon tamponade in acute hemorrhage from esophagogastric varices: a prospective controlled randomized trial. Hepatology 1985;5:580-3. Westaby D, MacDougall BRD, Williams R. Improved survival following injection sclerotherapy for esophageal varices: final analysis of a controlled trial. Hepatology 1985;5:827-30. Laine L. Determination of the optimal technique for bipolar electrocoagulation treatment: an experimental evaluation of the BICAP and Gold probes. Gastroenterology 1991;100:107-12. Johnston JH, Jensen DM, Auth D. Experimental comparison of endoscopic YAG laser, electrosurgery, and heater probe for canine gut arterial coagulation: importance of compression and avoidance of erosion. Gastroenterology 1987;92:1101-8.
position the tube produced only limited success. 1- 3 More recent reports have used the Seldinger technique where a guidewire is endoscopically placed into the small intestine over which a tube is passed. 4 Although we have found the latter method an improvement from earlier techniques, tube placement remains particularly challenging in critically ill patients who are mechanically ventilated. Such patients are difficult to transport to fluoroscopic units and oral endotracheal tubes or oropharyngeal trauma can interfere with endoscopic intubation and mouth-to-nose tube transfer. Thus, we devised a simplified bedside approach using transnasal endoscopy better suited for the intensive care patient. We report our recent experience with this method and describe the technique. MATERIALS AND METHODS
Received March 2, 1992. For revision April 6, 1992. Accepted May 7, 1992. From the Departments of Gastroenterology and Radiology, Bowman Gray School of Medicine, Winston-Salem, North Carolina. Reprint requests: Richard Mitchell, MD, Section on Gastroenterology, Bowman Gray School of Medicine, Medical Center Boulevard, WinstonSalem, North Carolina 27157.
596
A Frederick-Miller tube (Cook Inc., Bloomington, Ind) was used in all patients. The weighted tip of this 5 F polyvinyl feeding tube was removed to allow introduction over a guidewire. The pediatric endoscope (Olympus PlO) with a diameter of 7.8 mm was used in all patients. Local anesthesia using xylocaine (Lidocaine" Viscous 2%) was GASTROINTESTINAL ENDOSCOPY
inserted into the nares followed by administration of parenteral midazolam hydrochloride (Versed"; Roche Laboratories) or diazepam (Valium('); Roche Laboratories, Nutley, N. J.) and meperidime (Demerolc,; Winthrop Laboratories, New York, N. Y.). The endoscope was positioned into the nasal passage and advanced under direct vision through the nasal cavity to the oropharynx. The vocal cords and hypopharynx are easily identified from this position. The endoscope is then maneuvered to the hypopharynx, advanced into the esophagus, and into the descending duodenum. A 0.035-inch guidewire (Wilson-Cook Medical Inc., WinstonSalem, N. C.), 400 em in length with a soft J-tip, is placed through the biopsy channel into the duodenum and jejunum. The endoscope is slowly removed while leaving the guidewire in place. The guidewire must be carefully advanced equal to that of endoscope withdrawal to avoid looping of the wire in the stomach. The 125-cm Frederick Miller tube is lubricated with water and advanced over the wire. The wire is then removed and tube placement is verified by abdominal radiograph. RESULTS
Over a 10-month period from August 1990 to May 1991, we performed 118 transnasal endoscopic feeding tube placements in 87 patients. The patient population was primarily from intensive care units at our institution. The feeding tube was successfully positioned in the duodenum (37%) or the jejunum (47%) in 100 of 118 attempts (85%). In 18 procedures (15%) the tube was coiled in the stomach. All attempts at transnasal intubation were successful. The procedure time was approximately 15 min. The only complication was minimal nasal bleeding in one patient. DISCUSSION
Over the past 15 years a variety of endoscopic procedures to place feeding tubes have evolved. The earlier methods, however, were often frustrating and time consuming. Endoscopists would attempt to grasp sutures attached to the feeding tube with biopsy forceps and advance the endoscope into the duodenum. Unfortunately, the endoscope became stiffer with biopsy forceps in its channel, making intubation of the descending duodenum difficult. Moreover, even if the duodenum was reached, the feeding tube was frequently pulled back into the stomach by friction against the endoscope during withdrawal. An alternate method, designed to improve upon endoscope maneuverability, employed a long thread passed through the biopsy channel which attached to the feeding tube. 1 • 2 The endoscope was guided into the duodenum, dragging the tube into the small intestine. However, after limited use, the technique was abandoned because of the danger of mucosal laceration as the thread slipped by the pylorus. 3 Finally a procedure termed the "makeshift endoscopic channel" created an external channel with surgical ties to allow passage of the feeding tube alongside the endoscope. 3 The procedure has not gained universal acceptance, probably because of the tedious nature of the technique. VOLUME 38, NO.5, 1992
The Seldinger technique, which uses an endoscopically placed guidewire to position the tube, overcomes many of the obstacles with these earlier methods. The problem of endoscope-feeding tube friction is avoided with use of the guidewire, and the endoscope is more maneuverable because biopsy forceps are not necessary. Lewis et al. 4 reported successful oral endoscopic placement of seven nasoenteral tubes using>the Seldinger technique, and Mathus-Vliegen and Tytgat5 reported success in 13 others. Although these methods worked in certain clinical settings, they are difficult to perform in intensive care patients, a group which accounts for the majority of our requests for endoscopic tube placement. Because the techniques of Lewis and Mathus-Vliegen depend on fluoroscopy, patients on mechanical ventilation require anesthesia and nursing teams for transportation, thereby increasing the cost and procedural time. Furthermore, these patients often have oral endo-tracheal tubes or traumatic facial injuries which can make oral endoscopic intubation tedious and interfere with the required transfer of guidewires and feeding tubes from the mouth to nose. Because of these difficulties with critically ill patients, we devised a simplified bedside approach using transnasal endoscopy that we believe is more useful and efficient in this population. The concept of transnasal endoscopy is not new and, in fact, is commonly employed in otolaryngologic procedures, including one report of naso-gastric tube placement. 6, 7 By passing the endoscope through the nose, obstruction from oral endo-tracheal tubes, oropharyngeal cancers, strictures, and surgical resections is avoided. Of particular importance, the guidewire is positioned from the start in the nose, thus eliminating the need for cumbersome guidewire transfer. Furthermore, we find that fluoroscopy is not necessary for correct tube placement in the majority of patients. Because this procedure overcomes previous pitfalls of endoscopic feeding tube placement, transnasal endoscopy is an ideal approach in the critically ill patient.
REFERENCES 1. Keller RT. A technique of intestinal intubation with the fibreoptic endoscope. Gut 1973;14:143-4. 2. Guice KS, Thompson JC. Endoscopic placement of a weighted tip feeding tube in complex surgical patients. Surg Gynecol Obstet 1987;164:273-4. 3. Chung RSK, Denbesten L. Improved technique for placement of intestinal feeding with the fibreoptic endoscope. Gut 1976; 17:264-6. 4. Lewis BS, Mauer K, Bush A. The rapid placement of jejunal feeding tubes: the Seldinger technique applied to the gut. Gastrointest Endosc 1990;36:139-41. 5. Mathus-Vliegen EMH, Tytgat GNH. The role of endoscopy in the correct and rapid positioning of feeding tubes. Endoscopy 1983;15:78-84. 6. Leisser A, Delpre G, Kadish U. Through the nose with the gastroscope. Gastrointest Endosc 1990;35:77. 7. Govett GS, Amedee RG. Reliable insertion of nasogastric and enteral feeding tubes. Laryngoscope 1990;100:425-6.
597
This study evaluates a new double lumen, direct irrigation injection catheter which was created to allow both hemostatic injection therapy and irrigation of a bleeding lesion with the same device. The catheter provides approximately one-half the volume and three-quarters the force of irrigation provided by comparably sized bipolar probes, and it provides about 85 % of the force provided by a standard washing catheter. In addition, the double lumen catheter is at least as rigid as the thermal devices and allows a greater force of application than standard injection catheters. The importance of firmly tamponading a bleeding ulcer prior to hemostatic therapy has been demonstrated with thermal devices,9 but has not been assessed for injection therapy. A fairly rigid catheter should be desirable in order to allow placement of the needle into a firm-to-hard ulcer base. In addition, tamponade of the feeding vessel just prior to delivery of the injection solution conceivably could aid in hemostasis. No information is available on the force or volume of irrigation which is required to remove blood and clots from an ulcer base and our study does not address this question. Anecdotally, in clinical practice the double lumen irrigation catheter is able to clear an ulcer base of active oozing and mild to moderate spurting of blood as well as to wash away loosely adherent clots. The double lumen, direct irrigation injection catheter is a modification of existing injection catheters
Transnasal endoscopic technique for feeding tube placement Richard G. Mitchell, Robert M. Kerr, David J. Ott, Michael Chen,
MD MD MD MD
Endoscopic placement of feeding tubes has evolved over the last 15 years because of an increased demand for enteral feedings in hospitalized patients. Enteral feedings are safer and cheaper than parenteral nutrition, but proper positioning of the feeding tube can be problematic, especially in the critically ill patient. Early endoscopic methods such as tying sutures to feeding tubes to pull them into the duodenum or creating external "makeshift endoscopic channels" to
which should aid in the treatment of patients with gastrointestinal tract bleeding. ACKNOWLEDGMENT
The author is grateful for the assistance of Maria Trujillo. REFERENCES 1. Chung SCS, Leung JWC, Steele RJC, Crofts TJ, Li, AKC.
2. 3. 4.
5. 6.
7. 8. 9.
Endoscopic injection of adrenaline for actively bleeding ulcers: a randomized trial. Br Med J 1988;296:1631-3. Panes J, Viver J, Fome M, Garcia-Olivares E, Marw C, Garav J. Controlled trial of endoscopic sclerosis in bleeding peptic ulcers. Lancet 1987;2:1292. Laine L. Multipolar electrocoagulation vs. injection therapy in the treatment of bleeding peptic ulcers: a prospective, randomized trial. Gastroenterology 1990;99:1303-6. Waring JP, Sanowski RA, Sawyer RL, Woods CA, Foutch PG. A randomized comparison of multipolar electrocoagulation and injection sclerosis for the treatment of bleeding peptic ulcer. Gastrointest Endosc 1991;37:295-8. Chung SCS, Leung JWC, Sung JY, Lu KK, Li AKC. Injection or heat probe for bleeding ulcer. Gastroenterology 1991;100: 33-7. Paquet KJ, Feussner H. Endoscopic sclerosis and esophageal balloon tamponade in acute hemorrhage from esophagogastric varices: a prospective controlled randomized trial. Hepatology 1985;5:580-3. Westaby D, MacDougall BRD, Williams R. Improved survival following injection sclerotherapy for esophageal varices: final analysis of a controlled trial. Hepatology 1985;5:827-30. Laine L. Determination of the optimal technique for bipolar electrocoagulation treatment: an experimental evaluation of the BICAP and Gold probes. Gastroenterology 1991;100:107-12. Johnston JH, Jensen DM, Auth D. Experimental comparison of endoscopic YAG laser, electrosurgery, and heater probe for canine gut arterial coagulation: importance of compression and avoidance of erosion. Gastroenterology 1987;92:1101-8.
position the tube produced only limited success. 1- 3 More recent reports have used the Seldinger technique where a guidewire is endoscopically placed into the small intestine over which a tube is passed. 4 Although we have found the latter method an improvement from earlier techniques, tube placement remains particularly challenging in critically ill patients who are mechanically ventilated. Such patients are difficult to transport to fluoroscopic units and oral endotracheal tubes or oropharyngeal trauma can interfere with endoscopic intubation and mouth-to-nose tube transfer. Thus, we devised a simplified bedside approach using transnasal endoscopy better suited for the intensive care patient. We report our recent experience with this method and describe the technique. MATERIALS AND METHODS
Received March 2, 1992. For revision April 6, 1992. Accepted May 7, 1992. From the Departments of Gastroenterology and Radiology, Bowman Gray School of Medicine, Winston-Salem, North Carolina. Reprint requests: Richard Mitchell, MD, Section on Gastroenterology, Bowman Gray School of Medicine, Medical Center Boulevard, WinstonSalem, North Carolina 27157.
596
A Frederick-Miller tube (Cook Inc., Bloomington, Ind) was used in all patients. The weighted tip of this 5 F polyvinyl feeding tube was removed to allow introduction over a guidewire. The pediatric endoscope (Olympus PlO) with a diameter of 7.8 mm was used in all patients. Local anesthesia using xylocaine (Lidocaine" Viscous 2%) was GASTROINTESTINAL ENDOSCOPY
inserted into the nares followed by administration of parenteral midazolam hydrochloride (Versed"; Roche Laboratories) or diazepam (Valium('); Roche Laboratories, Nutley, N. J.) and meperidime (Demerolc,; Winthrop Laboratories, New York, N. Y.). The endoscope was positioned into the nasal passage and advanced under direct vision through the nasal cavity to the oropharynx. The vocal cords and hypopharynx are easily identified from this position. The endoscope is then maneuvered to the hypopharynx, advanced into the esophagus, and into the descending duodenum. A 0.035-inch guidewire (Wilson-Cook Medical Inc., WinstonSalem, N. C.), 400 em in length with a soft J-tip, is placed through the biopsy channel into the duodenum and jejunum. The endoscope is slowly removed while leaving the guidewire in place. The guidewire must be carefully advanced equal to that of endoscope withdrawal to avoid looping of the wire in the stomach. The 125-cm Frederick Miller tube is lubricated with water and advanced over the wire. The wire is then removed and tube placement is verified by abdominal radiograph. RESULTS
Over a 10-month period from August 1990 to May 1991, we performed 118 transnasal endoscopic feeding tube placements in 87 patients. The patient population was primarily from intensive care units at our institution. The feeding tube was successfully positioned in the duodenum (37%) or the jejunum (47%) in 100 of 118 attempts (85%). In 18 procedures (15%) the tube was coiled in the stomach. All attempts at transnasal intubation were successful. The procedure time was approximately 15 min. The only complication was minimal nasal bleeding in one patient. DISCUSSION
Over the past 15 years a variety of endoscopic procedures to place feeding tubes have evolved. The earlier methods, however, were often frustrating and time consuming. Endoscopists would attempt to grasp sutures attached to the feeding tube with biopsy forceps and advance the endoscope into the duodenum. Unfortunately, the endoscope became stiffer with biopsy forceps in its channel, making intubation of the descending duodenum difficult. Moreover, even if the duodenum was reached, the feeding tube was frequently pulled back into the stomach by friction against the endoscope during withdrawal. An alternate method, designed to improve upon endoscope maneuverability, employed a long thread passed through the biopsy channel which attached to the feeding tube. 1 • 2 The endoscope was guided into the duodenum, dragging the tube into the small intestine. However, after limited use, the technique was abandoned because of the danger of mucosal laceration as the thread slipped by the pylorus. 3 Finally a procedure termed the "makeshift endoscopic channel" created an external channel with surgical ties to allow passage of the feeding tube alongside the endoscope. 3 The procedure has not gained universal acceptance, probably because of the tedious nature of the technique. VOLUME 38, NO.5, 1992
The Seldinger technique, which uses an endoscopically placed guidewire to position the tube, overcomes many of the obstacles with these earlier methods. The problem of endoscope-feeding tube friction is avoided with use of the guidewire, and the endoscope is more maneuverable because biopsy forceps are not necessary. Lewis et al. 4 reported successful oral endoscopic placement of seven nasoenteral tubes using>the Seldinger technique, and Mathus-Vliegen and Tytgat5 reported success in 13 others. Although these methods worked in certain clinical settings, they are difficult to perform in intensive care patients, a group which accounts for the majority of our requests for endoscopic tube placement. Because the techniques of Lewis and Mathus-Vliegen depend on fluoroscopy, patients on mechanical ventilation require anesthesia and nursing teams for transportation, thereby increasing the cost and procedural time. Furthermore, these patients often have oral endo-tracheal tubes or traumatic facial injuries which can make oral endoscopic intubation tedious and interfere with the required transfer of guidewires and feeding tubes from the mouth to nose. Because of these difficulties with critically ill patients, we devised a simplified bedside approach using transnasal endoscopy that we believe is more useful and efficient in this population. The concept of transnasal endoscopy is not new and, in fact, is commonly employed in otolaryngologic procedures, including one report of naso-gastric tube placement. 6, 7 By passing the endoscope through the nose, obstruction from oral endo-tracheal tubes, oropharyngeal cancers, strictures, and surgical resections is avoided. Of particular importance, the guidewire is positioned from the start in the nose, thus eliminating the need for cumbersome guidewire transfer. Furthermore, we find that fluoroscopy is not necessary for correct tube placement in the majority of patients. Because this procedure overcomes previous pitfalls of endoscopic feeding tube placement, transnasal endoscopy is an ideal approach in the critically ill patient.
REFERENCES 1. Keller RT. A technique of intestinal intubation with the fibreoptic endoscope. Gut 1973;14:143-4. 2. Guice KS, Thompson JC. Endoscopic placement of a weighted tip feeding tube in complex surgical patients. Surg Gynecol Obstet 1987;164:273-4. 3. Chung RSK, Denbesten L. Improved technique for placement of intestinal feeding with the fibreoptic endoscope. Gut 1976; 17:264-6. 4. Lewis BS, Mauer K, Bush A. The rapid placement of jejunal feeding tubes: the Seldinger technique applied to the gut. Gastrointest Endosc 1990;36:139-41. 5. Mathus-Vliegen EMH, Tytgat GNH. The role of endoscopy in the correct and rapid positioning of feeding tubes. Endoscopy 1983;15:78-84. 6. Leisser A, Delpre G, Kadish U. Through the nose with the gastroscope. Gastrointest Endosc 1990;35:77. 7. Govett GS, Amedee RG. Reliable insertion of nasogastric and enteral feeding tubes. Laryngoscope 1990;100:425-6.
597