Efficacy and Complications of Enteral Feeding Tube Insertion After Liver Transplantation J.H. Chuna, J.Y. Ahna, H.-Y. Junga,*, H. Jung Parka, G.H. Kima, J.H. Leea, K.-S. Choia, K.W. Junga, D.H. Kima, K.D. Choia, H.J. Songa, G.H. Leea, J.H. Kimb, G.W. Songc, and J.-H. Kima a
Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea; bDepartment of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Asan Research Institute of Radiology, Seoul, Korea; and cDepartment of Liver Transplantation and Hepatobiliary Surgery, University of Ulsan College of Medicine, Asan Medical Center, Asan Research Institute of Surgery, Seoul, Korea
ABSTRACT Background. Adequate nutritional support for patients undergoing major surgery significantly affects postoperative recovery. Data on enteral feeding after liver transplantation (LT) are scarce. The aim of this work was to determine the efficacy and complications of feeding tubes inserted with the use of fluoroscopic assistance, endoscopic assistance, or transperitoneal jejunostomy in patients who underwent LT. Methods. From January 2008 to August 2013, 2,058 LTs were performed at Asan Medical Center, Seoul, Korea. Enteral feeding tubes were inserted in 155 patients (7.5%) after LT: with the use of fluoroscopic placement in 81 (52%), endoscopic placement in 49 (32%), and transperitoneal jejunostomy in 25 (16%). We retrospectively analyzed the efficacy and complications of enteral feeding tubes. Results. The median age was 55 years (interquartile range [IQR] 49e60). Enteral feeding indications were a high risk of gastric aspiration (n ¼ 90), gastric stasis (n ¼ 27), pneumonia (n ¼ 23), gastrointestinal bleeding (n ¼ 12), and bowel rest (n ¼ 3). Median enteral feeding durations were 14.5 days (IQR 8.0e30.7) for fluoroscopic placement, 20.0 days (IQR 8.0e40.0) for endoscopic placement, and 37.5 days (IQR 18.2e86.2) for transperitoneal jejunostomy. Times to establishment of oral feeding were 13.0 days (IQR 6.2e25.7) for fluoroscopic placement, 24.0 days (IQR 10.5e43.5) for endoscopic placement, and 37.0 days (IQR 17.0e64.2) for transperitoneal jejunostomy. After tube insertion, tube dislocation and blockage occurred in 34 patients (22%) and 16 patients (25%), respectively. Conclusions. Enteral feeding tube insertion in patients who can not maintain a nasogastric tube or start oral intake for a long time is important for nutritional support after LT. Proper feeding method selection according to patient condition can help patients by improving nutritional support after major operations such as LT.
A
DEQUATE nutritional support for patients undergoing major surgery significantly affects postoperative recovery. Enteral nutrition is superior to parenteral nutrition because it is safer and more physiologic. Therefore, early enteral feeding has been advocated in these patients because it may reduce postoperative morbidity [1e5]. Enteral access is usually obtained via a nasogastric feeding tube in patients who can not start oral feeding. However, adverse events, such as delayed gastric emptying, gastroesophageal reflux, and aspiration, can occur during nasogastric feeding [1e3]. ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
Transplantation Proceedings, 47, 451e456 (2015)
Nasojejunal feeding tube insertion or percutaneous transperitoneal jejunostomy can be performed when a nasogastric tube provides insufficient nutritional support in patients after surgery. Several complications, such as The first 2 authors contributed equally to this work. *Address correspondence to Hwoon-Yong Jung, MD, PhD, Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, No 388-1 Pungnap-2 dong, Songpa-gu, Seoul 138-736, Korea. E-mail: [email protected] 0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2014.11.035
451
452
CHUN, AHN, JUNG ET AL
Fig 1. (A) Fluoroscopic image after contrast injection showing that the tip of the feeding tube is in the proximal jejunum. (B) Nasojejunal feeding tube reaching to the third portion of duodenum under endoscopic guidance. (C) The position of the endoscopically inserted nasojejunal feeding tube was confirmed by abdominal radiography.
leakage, insertion site infection, and relaparotomy, have been reported with the use of the percutaneous transperitoneal jejunostomy approach [4e6], and a randomized clinical trial showed that the nasoenteral route is safer in patients undergoing esophagectomy [1]. An earlier study compared several methods for placement of nasojejunal feeding tubes in pancreatitis patients and postoperative gastrointestinal cancer patients [7]. However, few studies have examined the clinical outcomes of enteral feeding in liver transplantation (LT) patients. Therefore, we investigated the clinical outcomes and complications of enteral feeding provided by endoscopic assistance, fluoroscopic assistance, or transperitoneal jejunostomy in patients who require enteral nutrition after LT. MATERIALS AND METHODS Patients From January 2008 to August 2013, 2,058 patients (median age 55 years, interquartile range [IQR] 49e60 years; 1,687 men) underwent LT at Asan Medical Center, Seoul, Korea. Nasogastric tubes were inserted in all patients for bowel decompression and were removed when oral feeding was tolerated. For patients who had difficult starting early oral feeding, because of pneumonia, high risk of aspiration, gastrointestinal bleeding, acute pancreatitis, or gastric stasis, nasojejunal feeding tube insertion or transperitoneal jejunostomy was performed. We retrospectively reviewed the medical records of these patients. If the patient died before starting the diet or underwent another type of placement for secondary placement, they were excluded from the analysis. Given the retrospective nature of this study, the necessity for patient informed consent was waived. This study was approved by the Asan Medical Center Institutional Review Board.
Fluoroscopic Tube Insertion Fluoroscopic placement was performed in 81 patients (3.9%) who underwent LT. In patients who were receiving insufficient nutritional support by means of the nasogastric tube, owing to gastric stasis and gastrointestinal bleeding or pneumonia, and whose condition permitted transport to the fluoroscopy room, a nasojejunal
feeding tube was inserted with the use of fluoroscopic assistance (Fig 1). Patients were placed on the fluoroscopic table in the supine position. A 150-cm, 7.5-Fr multifunctional coil catheter and 0.035inch stiff hydrophilic guidewire were used to traverse the pylorus through the nose, and the guidewire was advanced into the proximal jejunum under fluoroscopic guidance. Thereafter, a 12-Fr enteral feeding tube was passed over the guidewire and into the proximal jejunum under fluoroscopic guidance. All fluoroscopic procedures were completed with identification of a good position for the tube tip in the proximal jejunum in a final fluoroscopic spot image with contrast injection. After the attending physicians confirmed placement of the feeding tube, enteral feeding was administered either continuously or intermittently. Nutritional support consisted of Encover solution (Otsuka, Tokyo, Japan).
Estimate patient’s condition (Hepatic encephalopathy, pulmonary edema, pneumonia, etc)
Good
Poor
Liver Transplantation
Consider Preoperative Transperitoneal Jejunostomy
Estimate patient’s condition (For oral feeding) Good
Poor
Estimate patient’s condition (Transport to radiology department or endoscopic room)
Good
Consider Fluoroscopic or Endoscopic feeding tube insertion
Oral Feeding
Poor
Consider Portable Endoscopic feeding tube insertion
Fig 2. Algorithm of enteral feeding in liver transplantation patients.
ENTERAL FEEDING TUBE INSERTION
453 Table 1. Baseline Characteristics of Included Patients
Fluoroscopic Placement (n ¼ 81)
Age, y, median (IQR) Sex, n Male Female Indication for liver transplantation, n (%) Hepatocellular carcinoma Liver cirrhosis Fulminant hepatitis MELD score, median (IQR) Type of operation, n (%) LDLT CDLT
Endoscopic Placement (n ¼ 49)
Transperitoneal Jejunostomy (n ¼ 25)
55.0 (48.5e62.0)
55.0 (48.5e58.0)
57.0 (49.5e61.0)
54 27
33 16
14 11
24 50 7 23.2
(30) (62) (8) (16.5e29.0)
46 (58) 35 (42)
10 31 8 23.7
(20) (63) (16) (17.5e29.5)
37 (76) 12 (24)
4 19 2 31.2
(16) (76) (8) (27.5e34.0)
9 (36) 16 (64)
Abbreviations: IQR, interquartile range; MELD, Model for End-Stage Liver Disease; LDLT, living-donor liver transplantation; CLDT, cadaveric-donor liver transplantation.
Feeding started at a rate of 22e33 mL per hour or per 6 hours and was increased to the required amount as advised by the consulting dietitian. Enteral feeding was stopped when patients were able to tolerate oral intake containing soft food.
started at a rate of 22e33 mL per hour or per 6 hours and was increased to the required amount as advised by the consulting dietitian. Enteral feeding was stopped when patients were able to tolerate oral intake containing soft food. Transperitoneal jejunostomies were removed in the outpatient department 2 months after discharge.
Endoscopic Tube Insertion Endoscopic placement was performed in 49 patients (2.4%) who underwent LT. In patients who were receiving insufficient nutritional support via the nasogastric tube, owing to gastric stasis and gastrointestinal bleeding or pneumonia, and who had too poor a condition to move to the fluoroscopy room, endoscopic placement of a nasojejunal tube was done. In patients who failed fluoroscopic placement or had biliary problems with endoscopic nasobiliary drainage and endoscopic nasopancreatic drainage, an enteral feeding tube was inserted with endoscopic assistance. For these patients, the procedure was performed with the use of portable endoscopy (GIF Q260; Olympus, Japan). The oropharynx was anesthetized with topical lidocaine, and midazolam was given for sedation. A lubricated 12-Fr nasojejunal feeding tube (Covidien, Mansfield, Ohio; usually 45e50 cm) was inserted into the stomach. Then, an experienced endoscopist inserted the endoscope in the stomach, grasped the feeding tube with biopsy forceps, and directed the tip of the feeding tube into the pylorus under endoscopic visualization. When the tip of the feeding tube reached the 3rd portion of the duodenum, the endoscope was carefully withdrawn (Fig 1). The tube was then taped in place around the nose. After the attending physician confirmed placement of the feeding tube in the 3rd portion of the duodenum, enteral feeding was administered either continuously or intermittently. Nutritional support consisted of Encover solution. Feeding started at a rate of 22e33 mL per hour or per 6 hours and was increased to the required amount as advised by the consulting dietitian. Enteral feeding was stopped when patients were able to tolerate oral intake containing soft food (Fig 2).
Transperitoneal Jejunostomy Transperitoneal jejunostomy was performed in 25 patients (1.2%) who underwent LT. In patients showing a poor condition, such as hepatic encephalopathy, hepatorenal syndrome with pulmonary edema, or pneumonia, or in patients who were not easily weaned from a ventilator, a jejunostomy was placed at the same time as the LT. A 9-Fr jejunostomy tube (Fresenius Kabi) was advanced through the abdominal wall. For patients who received a surgical jejunostomy tube, enteral feeding was administered either continuously or intermittently. Nutritional support consisted of Encover solution. Feeding
Definitions Time to establishment of oral feeding was defined as the period from the day of feeding tube insertion to the initiation of soft diet. If the patient died before starting the diet, it was considered to be a missing value. Time to reach target nutrition rate was defined as the period from the day of feeding tube insertion to the day of reaching the feeding rate or amount advised by the consulting dietitian.
Statistics Data are presented as the median with IQR, and outcome measures were analyzed and compared among the 3 groups. Differences between categoric variables were tested with the use of Pearson chisquare test or Fisher exact test. Continuous variables were tested with the use of Mann-Whitney U test. For comparisons among 3 groups of >2 unpaired values that were not normally distributed, a Kruskal-Wallis H test and 1-way analysis of variance were used. A P value of 92% success rate and no complications [16e18]. A randomized clinical trial found that fluoroscopic placement takes less time, that placement can be confirmed immediately, and that feeding can be initiated as soon as patients return to the ward [16]. In the present study, we successfully placed feeding tubes with the use of fluoroscopy in 98% of patients (79/81); endoscopic tube insertion was subsequently performed in the other 2 patients. In those 2 patients, an antral deformity created after the LT was found, and insertion of a feeding tube by means of fluoroscopic guidance was difficult. Following fluoroscopic tube placement, the durations from tube insertion to initiation of enteral feeding and from tube insertion to the target nutrition rate were 4.0 hours (IQR 2.0e12.0) and 7.0 days (IQR 3.0e10.0), respectively, and the median duration of enteral feeding was 14.5 days (IQR 8.0e30.7). Among the 79 patients in whom the tube was successfully inserted, tube dislocation occurred in 19 patients (24%) at a median of 7.0 days (IQR 3.7e17.0) after insertion. Spontaneous tube removal occurred in 7 of these 79 patients (9%), and self-removal by patients occurred in 12 (15%). Reinsertion was performed immediately by means of fluoroscopy in 15 patients (79%) and by means of endoscopy in 4 patients (21%). No patients failed enteral tube feeding owing to feeding tubeerelated complications. With our results, we think that fluoroscopic placement can be safely and effectively performed in LT patients who need enteral feeding. However, when a patient is critically ill and transport of a patient to the radiology department is unsafe, or when there is an antral deformity, endoscopic placement can be a good alternative. An earlier study reported that endoscopic guidance in the placement of feeding tubes showed a >96% success rate, although aggravated abdominal distension and epistaxis can occur during tube placement [16]. A randomized trial comparing nasojejunal feeding and percutaneous jejunal feeding following esophageal surgery reported a 30% complication rate in the nasojejunal feeding tube group, with tube dislocation being the most common complication [1]. In the present study, we successfully placed feeding tubes by endoscopy in all patients (49/49) and there were no clinically important complications during the procedure. Following endoscopic tube placement, the durations from tube insertion to initiation of enteral feeding and from tube
456
insertion to the target nutrition rate were 4.0 hours (IQR 2.0e8.5) and 4.5 days (2.0e10.5), respectively, and the median duration of enteral feeding was 20.9 days (IQR 8.0e40.0). Among the 49 patients in whom the tube was successfully inserted, tube dislocation occurred in 15 patients (30%) at a median of 13.5 days (IQR 3.7e26.7) after insertion. Spontaneous tube removal occurred in 6 of these 49 patients (12%), and self-removal by patients occurred in 9 (18%). Reinsertion was performed immediately by means of fluoroscopy in 1 patient (7%) and by means of endoscopy in 14 patients (93%). No patients failed enteral tube feeding owing to feeding tubeerelated complications. The present study showed that endoscopic placement can be safely performed and can be tried in patients whose condition limits movement or who require mechanical ventilation. Moreover, endoscopic tube insertion can be considered to be the first choice of enteral feeding when additional patient information is needed by endoscopy, the patient has a history of previous stomach surgery, bleeding of the upper gastrointestinal tract is suspected, or a severe deformity is predicted after surgery. An earlier study reported a transperitoneal jejunostomye related relaparotomy rate of 1% in a large series of 2,022 patients [5]. The most common complications were obstruction or dislocation in 0.7% of patients, and the most serious complication was bowel necrosis in 0.2% of patients. In the present study, leakage at the jejunostomy necessitating relaparotomy occurred in 1 patient (4%). When long-term postoperative enteral feeding is expected owing to poor preoperative conditions, such as hepatic encephalopathy, hepatorenal syndrome with pulmonary edema, or pneumonia, a jejunostomy during an operation can be considered to be a method of proper enteral feeding. STUDY LIMITATIONS
The present study has limitations associated with the small number of cases and its retrospective design. Insertion techniques were selected depending on patient’s condition during and after LT, and random allocation of patients to different insertion techniques was not available. Therefore, direct comparison of the 3 different techniques in the same situations was not possible. Furthermore, patients who died before diet initiation or who underwent another type of placement for secondary placement were excluded from the analysis. Nevertheless, we expect our present findings to provide an impetus for future prospective randomized studies with proper methodologic designs for studying enteral feeding tube insertion after LT. CONCLUSION
Enteral feeding tube insertion in patients who can not maintain nasogastric tubes or begin oral intake or a long time is important for nutritional support after LT. Each method of tube insertiondfluoroscopy, endoscopy, or surgerydshows its own advantages and disadvantages. Although a prospectively designed randomized control study is needed in the future, the present results show that
CHUN, AHN, JUNG ET AL
proper selection of feeding methods according to patient condition can help patients by improving nutritional support after major operations such as LT. REFERENCES [1] Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg 1992;216:172e83. [2] Daly JM, Weintraub FN, Shou J, Rosato EF, Lucia M. Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients. Ann Surg 1995;221:327e38. [3] Bozzetti F, Braga M, Gianotti L, Gavazzi C, Mariani L. Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial. Lancet 2001;358(9292):1487e92. [4] Jeejeebhoy KN. Enteral nutrition versus parenteral nutritiondthe risks and benefits. Nat Clin Pract Gastroenterol Hepatol 2007;4:260e5. [5] Mazaki T, Ebisawa K. Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature. J Gastrointest Surg 2008;12:739e55. [6] Han-Geurts IJ, Hop WC, Verhoef C, Tran KT, Tilanus HW. Randomized clinical trial comparing feeding jejunostomy with nasoduodenal tube placement in patients undergoing oesophagectomy. Br J Surg 2007;94:31e5. [7] Silk DB. The evolving role of post-ligament of Trietz nasojejunal feeding in enteral nutrition and the need for improved feeding tube design and placement methods. JPEN J Parenter Enteral Nutr 2011;35:303e7. [8] Davies AR, Bellomo R. Establishment of enteral nutrition: prokinetic agents and small bowel feeding tubes. Curr Opin Crit Care 2004;10:156e61. [9] Holmes JH, Brundage SI, Yuen P, Hall RA, Maier RV, Jurkovich GJ. Complications of surgical feeding jejunostomy in trauma patients. J Trauma 1999;47:1009e12. [10] Myers JG, Page CP, Stewart RM, Schwesinger WH, Sirinek KR, Aust JB. Complications of needle catheter jejunostomy in 2,022 consecutive applications. Am J Surg 1995;170:547e50. discussion 550e1. [11] Abhyankar A, Corkery JJ, Lander AD. Postoperative pneumatosis intestinalis in infants does not automatically preclude enteral feeding. J Pediatr Surg 2001;36:1820e3. [12] Qin H, Lu XY, Zhao Q, Li DM, Li PY, Liu M, et al. Evaluation of a new method for placing nasojejunal feeding tubes. World J Gastroenterol 2012;18:5295e9. [13] Edington J, Kon P, Martyn CN. Prevalence of malnutrition in patients in general practice. Clin Nutr 1996;15:60e3. [14] Abu-Hilal M, Hemandas AK, McPhail M, Jain G, Panagiotopoulou I, Schibelli T, et al. A comparative analysis of safety and efficacy of different methods of tube placement for enteral feeding following major pancreatic resection. A nonrandomized study. JOP 2010;11:8e13. [15] Gerritsen A, Besselink MG, Cieslak KP, Vriens MR, Steenhagen E, van Hillegersberg R, et al. Efficacy and complications of nasojejunal, jejunostomy and parenteral feeding after pancreaticoduodenectomy. J Gastrointest Surg 2012;16:1144e51. [16] Zhihui T, Wenkui Y, Weiqin L, Zhiming W, Xianghong Y, Ning L, et al. A randomised clinical trial of transnasal endoscopy versus fluoroscopy for the placement of nasojejunal feeding tubes in patients with severe acute pancreatitis. Postgrad Med J 2009;85(1000):59e63. [17] Fan AC, Baron TH, Rumalla A, Harewood GC. Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension. Gastrointest Endosc 2002;56:890e4. [18] O’Keefe SJ, Foody W, Gill S. Transnasal endoscopic placement of feeding tubes in the intensive care unit. JPEN J Parenter Enteral Nutr 2003;27:349e54.
Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea; bDepartment of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Asan Research Institute of Radiology, Seoul, Korea; and cDepartment of Liver Transplantation and Hepatobiliary Surgery, University of Ulsan College of Medicine, Asan Medical Center, Asan Research Institute of Surgery, Seoul, Korea
ABSTRACT Background. Adequate nutritional support for patients undergoing major surgery significantly affects postoperative recovery. Data on enteral feeding after liver transplantation (LT) are scarce. The aim of this work was to determine the efficacy and complications of feeding tubes inserted with the use of fluoroscopic assistance, endoscopic assistance, or transperitoneal jejunostomy in patients who underwent LT. Methods. From January 2008 to August 2013, 2,058 LTs were performed at Asan Medical Center, Seoul, Korea. Enteral feeding tubes were inserted in 155 patients (7.5%) after LT: with the use of fluoroscopic placement in 81 (52%), endoscopic placement in 49 (32%), and transperitoneal jejunostomy in 25 (16%). We retrospectively analyzed the efficacy and complications of enteral feeding tubes. Results. The median age was 55 years (interquartile range [IQR] 49e60). Enteral feeding indications were a high risk of gastric aspiration (n ¼ 90), gastric stasis (n ¼ 27), pneumonia (n ¼ 23), gastrointestinal bleeding (n ¼ 12), and bowel rest (n ¼ 3). Median enteral feeding durations were 14.5 days (IQR 8.0e30.7) for fluoroscopic placement, 20.0 days (IQR 8.0e40.0) for endoscopic placement, and 37.5 days (IQR 18.2e86.2) for transperitoneal jejunostomy. Times to establishment of oral feeding were 13.0 days (IQR 6.2e25.7) for fluoroscopic placement, 24.0 days (IQR 10.5e43.5) for endoscopic placement, and 37.0 days (IQR 17.0e64.2) for transperitoneal jejunostomy. After tube insertion, tube dislocation and blockage occurred in 34 patients (22%) and 16 patients (25%), respectively. Conclusions. Enteral feeding tube insertion in patients who can not maintain a nasogastric tube or start oral intake for a long time is important for nutritional support after LT. Proper feeding method selection according to patient condition can help patients by improving nutritional support after major operations such as LT.
A
DEQUATE nutritional support for patients undergoing major surgery significantly affects postoperative recovery. Enteral nutrition is superior to parenteral nutrition because it is safer and more physiologic. Therefore, early enteral feeding has been advocated in these patients because it may reduce postoperative morbidity [1e5]. Enteral access is usually obtained via a nasogastric feeding tube in patients who can not start oral feeding. However, adverse events, such as delayed gastric emptying, gastroesophageal reflux, and aspiration, can occur during nasogastric feeding [1e3]. ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
Transplantation Proceedings, 47, 451e456 (2015)
Nasojejunal feeding tube insertion or percutaneous transperitoneal jejunostomy can be performed when a nasogastric tube provides insufficient nutritional support in patients after surgery. Several complications, such as The first 2 authors contributed equally to this work. *Address correspondence to Hwoon-Yong Jung, MD, PhD, Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, No 388-1 Pungnap-2 dong, Songpa-gu, Seoul 138-736, Korea. E-mail: [email protected] 0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2014.11.035
451
452
CHUN, AHN, JUNG ET AL
Fig 1. (A) Fluoroscopic image after contrast injection showing that the tip of the feeding tube is in the proximal jejunum. (B) Nasojejunal feeding tube reaching to the third portion of duodenum under endoscopic guidance. (C) The position of the endoscopically inserted nasojejunal feeding tube was confirmed by abdominal radiography.
leakage, insertion site infection, and relaparotomy, have been reported with the use of the percutaneous transperitoneal jejunostomy approach [4e6], and a randomized clinical trial showed that the nasoenteral route is safer in patients undergoing esophagectomy [1]. An earlier study compared several methods for placement of nasojejunal feeding tubes in pancreatitis patients and postoperative gastrointestinal cancer patients [7]. However, few studies have examined the clinical outcomes of enteral feeding in liver transplantation (LT) patients. Therefore, we investigated the clinical outcomes and complications of enteral feeding provided by endoscopic assistance, fluoroscopic assistance, or transperitoneal jejunostomy in patients who require enteral nutrition after LT. MATERIALS AND METHODS Patients From January 2008 to August 2013, 2,058 patients (median age 55 years, interquartile range [IQR] 49e60 years; 1,687 men) underwent LT at Asan Medical Center, Seoul, Korea. Nasogastric tubes were inserted in all patients for bowel decompression and were removed when oral feeding was tolerated. For patients who had difficult starting early oral feeding, because of pneumonia, high risk of aspiration, gastrointestinal bleeding, acute pancreatitis, or gastric stasis, nasojejunal feeding tube insertion or transperitoneal jejunostomy was performed. We retrospectively reviewed the medical records of these patients. If the patient died before starting the diet or underwent another type of placement for secondary placement, they were excluded from the analysis. Given the retrospective nature of this study, the necessity for patient informed consent was waived. This study was approved by the Asan Medical Center Institutional Review Board.
Fluoroscopic Tube Insertion Fluoroscopic placement was performed in 81 patients (3.9%) who underwent LT. In patients who were receiving insufficient nutritional support by means of the nasogastric tube, owing to gastric stasis and gastrointestinal bleeding or pneumonia, and whose condition permitted transport to the fluoroscopy room, a nasojejunal
feeding tube was inserted with the use of fluoroscopic assistance (Fig 1). Patients were placed on the fluoroscopic table in the supine position. A 150-cm, 7.5-Fr multifunctional coil catheter and 0.035inch stiff hydrophilic guidewire were used to traverse the pylorus through the nose, and the guidewire was advanced into the proximal jejunum under fluoroscopic guidance. Thereafter, a 12-Fr enteral feeding tube was passed over the guidewire and into the proximal jejunum under fluoroscopic guidance. All fluoroscopic procedures were completed with identification of a good position for the tube tip in the proximal jejunum in a final fluoroscopic spot image with contrast injection. After the attending physicians confirmed placement of the feeding tube, enteral feeding was administered either continuously or intermittently. Nutritional support consisted of Encover solution (Otsuka, Tokyo, Japan).
Estimate patient’s condition (Hepatic encephalopathy, pulmonary edema, pneumonia, etc)
Good
Poor
Liver Transplantation
Consider Preoperative Transperitoneal Jejunostomy
Estimate patient’s condition (For oral feeding) Good
Poor
Estimate patient’s condition (Transport to radiology department or endoscopic room)
Good
Consider Fluoroscopic or Endoscopic feeding tube insertion
Oral Feeding
Poor
Consider Portable Endoscopic feeding tube insertion
Fig 2. Algorithm of enteral feeding in liver transplantation patients.
ENTERAL FEEDING TUBE INSERTION
453 Table 1. Baseline Characteristics of Included Patients
Fluoroscopic Placement (n ¼ 81)
Age, y, median (IQR) Sex, n Male Female Indication for liver transplantation, n (%) Hepatocellular carcinoma Liver cirrhosis Fulminant hepatitis MELD score, median (IQR) Type of operation, n (%) LDLT CDLT
Endoscopic Placement (n ¼ 49)
Transperitoneal Jejunostomy (n ¼ 25)
55.0 (48.5e62.0)
55.0 (48.5e58.0)
57.0 (49.5e61.0)
54 27
33 16
14 11
24 50 7 23.2
(30) (62) (8) (16.5e29.0)
46 (58) 35 (42)
10 31 8 23.7
(20) (63) (16) (17.5e29.5)
37 (76) 12 (24)
4 19 2 31.2
(16) (76) (8) (27.5e34.0)
9 (36) 16 (64)
Abbreviations: IQR, interquartile range; MELD, Model for End-Stage Liver Disease; LDLT, living-donor liver transplantation; CLDT, cadaveric-donor liver transplantation.
Feeding started at a rate of 22e33 mL per hour or per 6 hours and was increased to the required amount as advised by the consulting dietitian. Enteral feeding was stopped when patients were able to tolerate oral intake containing soft food.
started at a rate of 22e33 mL per hour or per 6 hours and was increased to the required amount as advised by the consulting dietitian. Enteral feeding was stopped when patients were able to tolerate oral intake containing soft food. Transperitoneal jejunostomies were removed in the outpatient department 2 months after discharge.
Endoscopic Tube Insertion Endoscopic placement was performed in 49 patients (2.4%) who underwent LT. In patients who were receiving insufficient nutritional support via the nasogastric tube, owing to gastric stasis and gastrointestinal bleeding or pneumonia, and who had too poor a condition to move to the fluoroscopy room, endoscopic placement of a nasojejunal tube was done. In patients who failed fluoroscopic placement or had biliary problems with endoscopic nasobiliary drainage and endoscopic nasopancreatic drainage, an enteral feeding tube was inserted with endoscopic assistance. For these patients, the procedure was performed with the use of portable endoscopy (GIF Q260; Olympus, Japan). The oropharynx was anesthetized with topical lidocaine, and midazolam was given for sedation. A lubricated 12-Fr nasojejunal feeding tube (Covidien, Mansfield, Ohio; usually 45e50 cm) was inserted into the stomach. Then, an experienced endoscopist inserted the endoscope in the stomach, grasped the feeding tube with biopsy forceps, and directed the tip of the feeding tube into the pylorus under endoscopic visualization. When the tip of the feeding tube reached the 3rd portion of the duodenum, the endoscope was carefully withdrawn (Fig 1). The tube was then taped in place around the nose. After the attending physician confirmed placement of the feeding tube in the 3rd portion of the duodenum, enteral feeding was administered either continuously or intermittently. Nutritional support consisted of Encover solution. Feeding started at a rate of 22e33 mL per hour or per 6 hours and was increased to the required amount as advised by the consulting dietitian. Enteral feeding was stopped when patients were able to tolerate oral intake containing soft food (Fig 2).
Transperitoneal Jejunostomy Transperitoneal jejunostomy was performed in 25 patients (1.2%) who underwent LT. In patients showing a poor condition, such as hepatic encephalopathy, hepatorenal syndrome with pulmonary edema, or pneumonia, or in patients who were not easily weaned from a ventilator, a jejunostomy was placed at the same time as the LT. A 9-Fr jejunostomy tube (Fresenius Kabi) was advanced through the abdominal wall. For patients who received a surgical jejunostomy tube, enteral feeding was administered either continuously or intermittently. Nutritional support consisted of Encover solution. Feeding
Definitions Time to establishment of oral feeding was defined as the period from the day of feeding tube insertion to the initiation of soft diet. If the patient died before starting the diet, it was considered to be a missing value. Time to reach target nutrition rate was defined as the period from the day of feeding tube insertion to the day of reaching the feeding rate or amount advised by the consulting dietitian.
Statistics Data are presented as the median with IQR, and outcome measures were analyzed and compared among the 3 groups. Differences between categoric variables were tested with the use of Pearson chisquare test or Fisher exact test. Continuous variables were tested with the use of Mann-Whitney U test. For comparisons among 3 groups of >2 unpaired values that were not normally distributed, a Kruskal-Wallis H test and 1-way analysis of variance were used. A P value of 92% success rate and no complications [16e18]. A randomized clinical trial found that fluoroscopic placement takes less time, that placement can be confirmed immediately, and that feeding can be initiated as soon as patients return to the ward [16]. In the present study, we successfully placed feeding tubes with the use of fluoroscopy in 98% of patients (79/81); endoscopic tube insertion was subsequently performed in the other 2 patients. In those 2 patients, an antral deformity created after the LT was found, and insertion of a feeding tube by means of fluoroscopic guidance was difficult. Following fluoroscopic tube placement, the durations from tube insertion to initiation of enteral feeding and from tube insertion to the target nutrition rate were 4.0 hours (IQR 2.0e12.0) and 7.0 days (IQR 3.0e10.0), respectively, and the median duration of enteral feeding was 14.5 days (IQR 8.0e30.7). Among the 79 patients in whom the tube was successfully inserted, tube dislocation occurred in 19 patients (24%) at a median of 7.0 days (IQR 3.7e17.0) after insertion. Spontaneous tube removal occurred in 7 of these 79 patients (9%), and self-removal by patients occurred in 12 (15%). Reinsertion was performed immediately by means of fluoroscopy in 15 patients (79%) and by means of endoscopy in 4 patients (21%). No patients failed enteral tube feeding owing to feeding tubeerelated complications. With our results, we think that fluoroscopic placement can be safely and effectively performed in LT patients who need enteral feeding. However, when a patient is critically ill and transport of a patient to the radiology department is unsafe, or when there is an antral deformity, endoscopic placement can be a good alternative. An earlier study reported that endoscopic guidance in the placement of feeding tubes showed a >96% success rate, although aggravated abdominal distension and epistaxis can occur during tube placement [16]. A randomized trial comparing nasojejunal feeding and percutaneous jejunal feeding following esophageal surgery reported a 30% complication rate in the nasojejunal feeding tube group, with tube dislocation being the most common complication [1]. In the present study, we successfully placed feeding tubes by endoscopy in all patients (49/49) and there were no clinically important complications during the procedure. Following endoscopic tube placement, the durations from tube insertion to initiation of enteral feeding and from tube
456
insertion to the target nutrition rate were 4.0 hours (IQR 2.0e8.5) and 4.5 days (2.0e10.5), respectively, and the median duration of enteral feeding was 20.9 days (IQR 8.0e40.0). Among the 49 patients in whom the tube was successfully inserted, tube dislocation occurred in 15 patients (30%) at a median of 13.5 days (IQR 3.7e26.7) after insertion. Spontaneous tube removal occurred in 6 of these 49 patients (12%), and self-removal by patients occurred in 9 (18%). Reinsertion was performed immediately by means of fluoroscopy in 1 patient (7%) and by means of endoscopy in 14 patients (93%). No patients failed enteral tube feeding owing to feeding tubeerelated complications. The present study showed that endoscopic placement can be safely performed and can be tried in patients whose condition limits movement or who require mechanical ventilation. Moreover, endoscopic tube insertion can be considered to be the first choice of enteral feeding when additional patient information is needed by endoscopy, the patient has a history of previous stomach surgery, bleeding of the upper gastrointestinal tract is suspected, or a severe deformity is predicted after surgery. An earlier study reported a transperitoneal jejunostomye related relaparotomy rate of 1% in a large series of 2,022 patients [5]. The most common complications were obstruction or dislocation in 0.7% of patients, and the most serious complication was bowel necrosis in 0.2% of patients. In the present study, leakage at the jejunostomy necessitating relaparotomy occurred in 1 patient (4%). When long-term postoperative enteral feeding is expected owing to poor preoperative conditions, such as hepatic encephalopathy, hepatorenal syndrome with pulmonary edema, or pneumonia, a jejunostomy during an operation can be considered to be a method of proper enteral feeding. STUDY LIMITATIONS
The present study has limitations associated with the small number of cases and its retrospective design. Insertion techniques were selected depending on patient’s condition during and after LT, and random allocation of patients to different insertion techniques was not available. Therefore, direct comparison of the 3 different techniques in the same situations was not possible. Furthermore, patients who died before diet initiation or who underwent another type of placement for secondary placement were excluded from the analysis. Nevertheless, we expect our present findings to provide an impetus for future prospective randomized studies with proper methodologic designs for studying enteral feeding tube insertion after LT. CONCLUSION
Enteral feeding tube insertion in patients who can not maintain nasogastric tubes or begin oral intake or a long time is important for nutritional support after LT. Each method of tube insertiondfluoroscopy, endoscopy, or surgerydshows its own advantages and disadvantages. Although a prospectively designed randomized control study is needed in the future, the present results show that
CHUN, AHN, JUNG ET AL
proper selection of feeding methods according to patient condition can help patients by improving nutritional support after major operations such as LT. REFERENCES [1] Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg 1992;216:172e83. [2] Daly JM, Weintraub FN, Shou J, Rosato EF, Lucia M. Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients. Ann Surg 1995;221:327e38. [3] Bozzetti F, Braga M, Gianotti L, Gavazzi C, Mariani L. Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial. Lancet 2001;358(9292):1487e92. [4] Jeejeebhoy KN. Enteral nutrition versus parenteral nutritiondthe risks and benefits. Nat Clin Pract Gastroenterol Hepatol 2007;4:260e5. [5] Mazaki T, Ebisawa K. Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature. J Gastrointest Surg 2008;12:739e55. [6] Han-Geurts IJ, Hop WC, Verhoef C, Tran KT, Tilanus HW. Randomized clinical trial comparing feeding jejunostomy with nasoduodenal tube placement in patients undergoing oesophagectomy. Br J Surg 2007;94:31e5. [7] Silk DB. The evolving role of post-ligament of Trietz nasojejunal feeding in enteral nutrition and the need for improved feeding tube design and placement methods. JPEN J Parenter Enteral Nutr 2011;35:303e7. [8] Davies AR, Bellomo R. Establishment of enteral nutrition: prokinetic agents and small bowel feeding tubes. Curr Opin Crit Care 2004;10:156e61. [9] Holmes JH, Brundage SI, Yuen P, Hall RA, Maier RV, Jurkovich GJ. Complications of surgical feeding jejunostomy in trauma patients. J Trauma 1999;47:1009e12. [10] Myers JG, Page CP, Stewart RM, Schwesinger WH, Sirinek KR, Aust JB. Complications of needle catheter jejunostomy in 2,022 consecutive applications. Am J Surg 1995;170:547e50. discussion 550e1. [11] Abhyankar A, Corkery JJ, Lander AD. Postoperative pneumatosis intestinalis in infants does not automatically preclude enteral feeding. J Pediatr Surg 2001;36:1820e3. [12] Qin H, Lu XY, Zhao Q, Li DM, Li PY, Liu M, et al. Evaluation of a new method for placing nasojejunal feeding tubes. World J Gastroenterol 2012;18:5295e9. [13] Edington J, Kon P, Martyn CN. Prevalence of malnutrition in patients in general practice. Clin Nutr 1996;15:60e3. [14] Abu-Hilal M, Hemandas AK, McPhail M, Jain G, Panagiotopoulou I, Schibelli T, et al. A comparative analysis of safety and efficacy of different methods of tube placement for enteral feeding following major pancreatic resection. A nonrandomized study. JOP 2010;11:8e13. [15] Gerritsen A, Besselink MG, Cieslak KP, Vriens MR, Steenhagen E, van Hillegersberg R, et al. Efficacy and complications of nasojejunal, jejunostomy and parenteral feeding after pancreaticoduodenectomy. J Gastrointest Surg 2012;16:1144e51. [16] Zhihui T, Wenkui Y, Weiqin L, Zhiming W, Xianghong Y, Ning L, et al. A randomised clinical trial of transnasal endoscopy versus fluoroscopy for the placement of nasojejunal feeding tubes in patients with severe acute pancreatitis. Postgrad Med J 2009;85(1000):59e63. [17] Fan AC, Baron TH, Rumalla A, Harewood GC. Comparison of direct percutaneous endoscopic jejunostomy and PEG with jejunal extension. Gastrointest Endosc 2002;56:890e4. [18] O’Keefe SJ, Foody W, Gill S. Transnasal endoscopic placement of feeding tubes in the intensive care unit. JPEN J Parenter Enteral Nutr 2003;27:349e54.
