390
into the right lung via the sixth intercostal space in the mid-axillary line. NGT insertion was attempted a second time under fluoroscopic guidance and was successful and uncomplicated on this occasion. Although there were no surgical complications following the initial procedure, the patient’s post-operative recovery was complicated by ongoing aspiration pneumonia, pneumothorax and haemothorax. After discussion with the patient’s family, the patient was deemed not for further resuscitation because of ongoing intensive respiratory support and overall decline. The patient passed away 38 days after initial admission into hospital. Incidence of thoracic complications following NGT insertion is reported between 1 and 3% with the majority of these being pneumothoraces and is more common in mechanically ventilated patients.1 NGTs are more likely to be malpositioned in the right rather than left tracheobronchial tree,2 which is unsurprising given that the right bronchial tree is more vertical and wider. Classically, NGT positions are assessed clinically via lung auscultation and pH testing, however, clinical assessment of NGT positioning is suboptimal as it is subject to performer bias and can be misleading.3 Use of follow-up chest X-ray, with assessment of position using two radiographs, has been reported as the gold standard;4 however, in our patient it did not prevent the observed pneumothorax. Recent literature points to alternatives in minimizing airway intubation and hence, associated complications. A 2011 study utilizing a dedicated NGT insertion team and realtime portable electromagnetic tube placement technology (Cortrak device available from Viasys, Conshohocken, PA, USA) reported nil incidence of malpositioning of NGT in the airways post-intervention, with a significant reduction in cases of associated pneumothoraces and all-cause mortality compared with historical controls.5 Using real-time bedside technology is an obvious advantage for clinicians, however, there are limitations as the device tracks NGT placement electromagnetically and so it is contraindicated in patients with susceptible implanted medical devices (e.g. pacemakers). Use of fluoroscopic and endoscopic-guided NGT placement may be of value in reducing initial NGT malposition; however, there is an issue of sustainability, given that it places a strain on resources.6 Other newer techniques that may be useful in preventing pneumothorax are the use of end-tidal carbon dioxide (ETCO2) detection devices that either change colour in the presence of high levels of CO2 (capnometry) or continuously measure CO2 levels via infrared technology (capnography). A recent meta-analysis found that capnometry and capnography had a 99% sensitivity and specificity
Images for surgeons
in detecting NGT malposition when compared with either radiography or direct observation.7 In summary, although iatrogenic pneumothorax caused by NGT insertion is a rare complication, there can be serious patient sequelae as presented in this case report. Use of guided techniques such as those described earlier may therefore be of value especially in high-risk groups such as the elderly and/or mechanically ventilated patients. It is important to note that routine use of image-guided techniques such as radiography has been shown to be resource intensive and so use of portable real-time placement technology or ETCO2 detection devices may be viable alternatives to reduce NGT misadventure.
References 1. Giantsou E, Gunning K. Blindly inserted nasogastric feeding tubes and thoracic complications in intensive care. Health (Irvine Calif) 2010; 2: 1135–41. 2. Bankier A, Wiesmayr M, Henk C et al. Radiographic detection of intrabronchial malpositions of nasogastric tubes and subsequent complications in intensive care unit patients. Intensive Care Med. 1997; 23: 406–10. 3. Weinberg L, Skewes D. Pneumothorax from intrapleural placement of a nasogastric tube. Anaesth. Intensive Care 2006; 34: 276–9. 4. Roubenoff R, Ravich W. Pneumothorax due to nasogastric feeding tubes. Report of four cases, review of the literature, and recommendations for prevention. Arch. Intern. Med. 1989; 149: 184–8. 5. Koopmann MC, Kudsk KA, Szotkowski MJ, Rees SM. A team-based protocol and electromagnetic technology eliminate feeding tube placement complications. Ann. Surg. 2011; 253: 287–302. 6. Sorokin R, Gottlieb J. Enhancing patient safety during feeding-tube insertion: a review of more than 2000 insertions. JPEN J. Parenter. Enteral Nutr. 2006; 30: 440–5. 7. Chau J, Lo S, Thompson D, Fernandez R, Griffiths R. Use of end-tidal carbon dioxide detection to determine correct placement of nasogastric tube: a meta-analysis. Int. J. Nurs. Stud. 2011; 48: 513–21.
Menino Osbert Cotta,* BPharm (Hons) Shu Yi Tan,† MBBS Maria Virginia Pereira E. Cotta,† MBBS Kaye Bowers,† MBBS, FRACS *Intensive Care Unit, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia and †General Surgery, Monash Medical Centre, Clayton, Victoria, Australia doi: 10.1111/ans.12955
Stubborn nasojejunal feeding tube Temporary feeding tubes are commonly used in upper gastrointestinal (UGI) surgical departments for numerous reasons, for example enteral nutritional supplementation. A blocked feeding tube on the ward can be frustrating for the doctors and, in particular, for the nursing staff looking after them especially the repeatedly blocking tubes despite their valiant and persistent nursing care. There are numerous methods including simple bedside aspiration techniques or attempting to flush the tube with normal saline solu-
tion then immediately aspirating, which are the conventional methods1 to the more ‘advanced’ ward techniques, some of which are not ‘orthodox’, to manage the blocked tubes, for example, the use of solutions like Pancrease or even the soft drink Coca Cola2 with varying success. Nicholson3 studied the effect of an array of commonly used solutions and conclusively evaluated the success of commonly used solutions. Many of which provided no added benefit to the commonly use normal saline.3 Despite multiple attempts in © 2015 Royal Australasian College of Surgeons
Images for surgeons
391
methods to unblock the tube, even slightly withdrawing the NJ tube, the NJ tube could not be unblocked, thus unable to be used. The decision to remove the NJ tube was made and urgent reinsertion arranged. Upon withdrawal of the NJ tube, and with great shock, the reason for blockage was established (Fig. 1). The NJ tube tip was in a complex knot! The tip of the NJ tube managed to coil and knot itself in this complex arrangement, unseen by the surgical consultants of the UGI department. No method would have unblocked this tube. The ward management of blocked feeding tube is usually successful,3 and the nursing staff know the tricks in managing them; however, I make the suggestion of considering if the tube is nonresponsive to bedside unblocking techniques that there could be the possibility of the tube being in a ‘knot’ rendering the tube nonfunctional and forming an annoying, stubborn and blocked tube and just proceed to remove the tube. Fig. 1. Intraintestinal complex knot formed by the nasojejunal feeding tube tip.
unblocking tubes, occasionally it is unsuccessful and the regretful decision to removal and replace is required. We report a case of this blocked nasojejunal (NJ) feeding tube at the Royal Prince Albert Hospital. The NJ feeding tube was inserted intraoperatively post-gastroscopy and confirmed by intraoperative image intensifier radiography (tube at 135 cm) with use of contrast in a 37-year-old man who had significantly lost weight over 10 months after a Whipple’s procedure (pancreatoduodenectomy) and not tolerating sufficient oral nutrition. The intention of the feeding tube was to increase enteral nutritional supplementation,4,5 and to receive dietary/nutritional education while an inpatient. The feeding tube was initially functioning well and the nursing staff reported no functional issues. Flow issues did become problematically apparent and the tube was blocked 3 days after insertion. Despite conventional and non-conventional bedside
References 1. Pearce C, Duncan H. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad. Med. J. 2002; 78: 198–204. 2. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Ramirez-Perez C. Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit. J. Clin. Nurs. 2001; 10: 482–90. 3. Nicholson LJ. Declogging small-bore feeding tubes. JPEN J. Parenter. Enteral Nutr. 1987; 11: 594–7. 4. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ 1994; 308: 945–8. 5. Payne-James J, Silk D. Enteral nutrition: background, indications and management. Baillieres Clin. Gastroenterol. 1988; 2: 815–47.
James Salinas, BSc, MBBS Charbel Sandroussi, MBBS (Hons), MMSc, FRACS General Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia doi: 10.1111/ans.12944
An unusual cause of bowel obstruction from a feeding jejunostomy A 54-year-old man underwent an Ivor–Lewis oesophagectomy with pyloromyotomy for a gastrointestinal stromal tumour in the lower third of the oesophagus. A 14 French MIC* gastrostomy feeding tube (Kimberley Clark, Ltd., NSW, Australia) was inserted by performing a serosal ‘Witzel’ tunnel. In this technique, an opening is created in the jejunum and the bowel is then plicated to cover the feeding tube with the external surface of the jejunum and attached to the undersurface of the anterior abdominal wall. Jejunostomy feeds were started on the first post-operative day and the caloric content was gradually increased without complication. A gastro graffin swallow study was performed on day 7 showing no leak from the oesophago-gastric anastomosis. Oral fluids were commenced. On the 12th post-operative day, jejonostomy feeds were stopped as the patient was tolerating a pureed diet. He was discharged the next day with a plan for removal of the jejonostomy tube after 4 weeks. © 2015 Royal Australasian College of Surgeons
The patient presented to the emergency department 11 days postdischarge (post-operative day 24) with pain over the jejunostomy site that was worse with movement. He was examined in the emergency department and no abnormality was found. He was sent home with advice to undertake 20-mL flushes of the jejunostomy tube, which he commenced on returning home. Three days later (2 weeks post-discharge), the patient was readmitted with severe cramping abdominal pain focussed around the feeding jejunostomy point of insertion. The patient had experienced some nausea and vomiting although the patient’s bowels had opened. On examination, there was no sign of peritonism. No further flushes of the jejunostomy tube were performed. A computed tomography (CT) scan found no abnormality and the patients symptoms resolved following fasting. The patient was discharged home, but re-presented within 12 h of resuming oral intake with similar symptoms. On re-review of the CT scan by the surgical team, attention was drawn to the large volume of the jejunostomy balloon. The balloon appeared to occupy a considerable if
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
into the right lung via the sixth intercostal space in the mid-axillary line. NGT insertion was attempted a second time under fluoroscopic guidance and was successful and uncomplicated on this occasion. Although there were no surgical complications following the initial procedure, the patient’s post-operative recovery was complicated by ongoing aspiration pneumonia, pneumothorax and haemothorax. After discussion with the patient’s family, the patient was deemed not for further resuscitation because of ongoing intensive respiratory support and overall decline. The patient passed away 38 days after initial admission into hospital. Incidence of thoracic complications following NGT insertion is reported between 1 and 3% with the majority of these being pneumothoraces and is more common in mechanically ventilated patients.1 NGTs are more likely to be malpositioned in the right rather than left tracheobronchial tree,2 which is unsurprising given that the right bronchial tree is more vertical and wider. Classically, NGT positions are assessed clinically via lung auscultation and pH testing, however, clinical assessment of NGT positioning is suboptimal as it is subject to performer bias and can be misleading.3 Use of follow-up chest X-ray, with assessment of position using two radiographs, has been reported as the gold standard;4 however, in our patient it did not prevent the observed pneumothorax. Recent literature points to alternatives in minimizing airway intubation and hence, associated complications. A 2011 study utilizing a dedicated NGT insertion team and realtime portable electromagnetic tube placement technology (Cortrak device available from Viasys, Conshohocken, PA, USA) reported nil incidence of malpositioning of NGT in the airways post-intervention, with a significant reduction in cases of associated pneumothoraces and all-cause mortality compared with historical controls.5 Using real-time bedside technology is an obvious advantage for clinicians, however, there are limitations as the device tracks NGT placement electromagnetically and so it is contraindicated in patients with susceptible implanted medical devices (e.g. pacemakers). Use of fluoroscopic and endoscopic-guided NGT placement may be of value in reducing initial NGT malposition; however, there is an issue of sustainability, given that it places a strain on resources.6 Other newer techniques that may be useful in preventing pneumothorax are the use of end-tidal carbon dioxide (ETCO2) detection devices that either change colour in the presence of high levels of CO2 (capnometry) or continuously measure CO2 levels via infrared technology (capnography). A recent meta-analysis found that capnometry and capnography had a 99% sensitivity and specificity
Images for surgeons
in detecting NGT malposition when compared with either radiography or direct observation.7 In summary, although iatrogenic pneumothorax caused by NGT insertion is a rare complication, there can be serious patient sequelae as presented in this case report. Use of guided techniques such as those described earlier may therefore be of value especially in high-risk groups such as the elderly and/or mechanically ventilated patients. It is important to note that routine use of image-guided techniques such as radiography has been shown to be resource intensive and so use of portable real-time placement technology or ETCO2 detection devices may be viable alternatives to reduce NGT misadventure.
References 1. Giantsou E, Gunning K. Blindly inserted nasogastric feeding tubes and thoracic complications in intensive care. Health (Irvine Calif) 2010; 2: 1135–41. 2. Bankier A, Wiesmayr M, Henk C et al. Radiographic detection of intrabronchial malpositions of nasogastric tubes and subsequent complications in intensive care unit patients. Intensive Care Med. 1997; 23: 406–10. 3. Weinberg L, Skewes D. Pneumothorax from intrapleural placement of a nasogastric tube. Anaesth. Intensive Care 2006; 34: 276–9. 4. Roubenoff R, Ravich W. Pneumothorax due to nasogastric feeding tubes. Report of four cases, review of the literature, and recommendations for prevention. Arch. Intern. Med. 1989; 149: 184–8. 5. Koopmann MC, Kudsk KA, Szotkowski MJ, Rees SM. A team-based protocol and electromagnetic technology eliminate feeding tube placement complications. Ann. Surg. 2011; 253: 287–302. 6. Sorokin R, Gottlieb J. Enhancing patient safety during feeding-tube insertion: a review of more than 2000 insertions. JPEN J. Parenter. Enteral Nutr. 2006; 30: 440–5. 7. Chau J, Lo S, Thompson D, Fernandez R, Griffiths R. Use of end-tidal carbon dioxide detection to determine correct placement of nasogastric tube: a meta-analysis. Int. J. Nurs. Stud. 2011; 48: 513–21.
Menino Osbert Cotta,* BPharm (Hons) Shu Yi Tan,† MBBS Maria Virginia Pereira E. Cotta,† MBBS Kaye Bowers,† MBBS, FRACS *Intensive Care Unit, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia and †General Surgery, Monash Medical Centre, Clayton, Victoria, Australia doi: 10.1111/ans.12955
Stubborn nasojejunal feeding tube Temporary feeding tubes are commonly used in upper gastrointestinal (UGI) surgical departments for numerous reasons, for example enteral nutritional supplementation. A blocked feeding tube on the ward can be frustrating for the doctors and, in particular, for the nursing staff looking after them especially the repeatedly blocking tubes despite their valiant and persistent nursing care. There are numerous methods including simple bedside aspiration techniques or attempting to flush the tube with normal saline solu-
tion then immediately aspirating, which are the conventional methods1 to the more ‘advanced’ ward techniques, some of which are not ‘orthodox’, to manage the blocked tubes, for example, the use of solutions like Pancrease or even the soft drink Coca Cola2 with varying success. Nicholson3 studied the effect of an array of commonly used solutions and conclusively evaluated the success of commonly used solutions. Many of which provided no added benefit to the commonly use normal saline.3 Despite multiple attempts in © 2015 Royal Australasian College of Surgeons
Images for surgeons
391
methods to unblock the tube, even slightly withdrawing the NJ tube, the NJ tube could not be unblocked, thus unable to be used. The decision to remove the NJ tube was made and urgent reinsertion arranged. Upon withdrawal of the NJ tube, and with great shock, the reason for blockage was established (Fig. 1). The NJ tube tip was in a complex knot! The tip of the NJ tube managed to coil and knot itself in this complex arrangement, unseen by the surgical consultants of the UGI department. No method would have unblocked this tube. The ward management of blocked feeding tube is usually successful,3 and the nursing staff know the tricks in managing them; however, I make the suggestion of considering if the tube is nonresponsive to bedside unblocking techniques that there could be the possibility of the tube being in a ‘knot’ rendering the tube nonfunctional and forming an annoying, stubborn and blocked tube and just proceed to remove the tube. Fig. 1. Intraintestinal complex knot formed by the nasojejunal feeding tube tip.
unblocking tubes, occasionally it is unsuccessful and the regretful decision to removal and replace is required. We report a case of this blocked nasojejunal (NJ) feeding tube at the Royal Prince Albert Hospital. The NJ feeding tube was inserted intraoperatively post-gastroscopy and confirmed by intraoperative image intensifier radiography (tube at 135 cm) with use of contrast in a 37-year-old man who had significantly lost weight over 10 months after a Whipple’s procedure (pancreatoduodenectomy) and not tolerating sufficient oral nutrition. The intention of the feeding tube was to increase enteral nutritional supplementation,4,5 and to receive dietary/nutritional education while an inpatient. The feeding tube was initially functioning well and the nursing staff reported no functional issues. Flow issues did become problematically apparent and the tube was blocked 3 days after insertion. Despite conventional and non-conventional bedside
References 1. Pearce C, Duncan H. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad. Med. J. 2002; 78: 198–204. 2. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Ramirez-Perez C. Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit. J. Clin. Nurs. 2001; 10: 482–90. 3. Nicholson LJ. Declogging small-bore feeding tubes. JPEN J. Parenter. Enteral Nutr. 1987; 11: 594–7. 4. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ 1994; 308: 945–8. 5. Payne-James J, Silk D. Enteral nutrition: background, indications and management. Baillieres Clin. Gastroenterol. 1988; 2: 815–47.
James Salinas, BSc, MBBS Charbel Sandroussi, MBBS (Hons), MMSc, FRACS General Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia doi: 10.1111/ans.12944
An unusual cause of bowel obstruction from a feeding jejunostomy A 54-year-old man underwent an Ivor–Lewis oesophagectomy with pyloromyotomy for a gastrointestinal stromal tumour in the lower third of the oesophagus. A 14 French MIC* gastrostomy feeding tube (Kimberley Clark, Ltd., NSW, Australia) was inserted by performing a serosal ‘Witzel’ tunnel. In this technique, an opening is created in the jejunum and the bowel is then plicated to cover the feeding tube with the external surface of the jejunum and attached to the undersurface of the anterior abdominal wall. Jejunostomy feeds were started on the first post-operative day and the caloric content was gradually increased without complication. A gastro graffin swallow study was performed on day 7 showing no leak from the oesophago-gastric anastomosis. Oral fluids were commenced. On the 12th post-operative day, jejonostomy feeds were stopped as the patient was tolerating a pureed diet. He was discharged the next day with a plan for removal of the jejonostomy tube after 4 weeks. © 2015 Royal Australasian College of Surgeons
The patient presented to the emergency department 11 days postdischarge (post-operative day 24) with pain over the jejunostomy site that was worse with movement. He was examined in the emergency department and no abnormality was found. He was sent home with advice to undertake 20-mL flushes of the jejunostomy tube, which he commenced on returning home. Three days later (2 weeks post-discharge), the patient was readmitted with severe cramping abdominal pain focussed around the feeding jejunostomy point of insertion. The patient had experienced some nausea and vomiting although the patient’s bowels had opened. On examination, there was no sign of peritonism. No further flushes of the jejunostomy tube were performed. A computed tomography (CT) scan found no abnormality and the patients symptoms resolved following fasting. The patient was discharged home, but re-presented within 12 h of resuming oral intake with similar symptoms. On re-review of the CT scan by the surgical team, attention was drawn to the large volume of the jejunostomy balloon. The balloon appeared to occupy a considerable if
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
