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Suzuki N. Nasogastric Tube Syndrome: A Case Report of Otalgia and Hoarseness in a Palliative Care Setting. J Pain Symptom Manage 2025; 69:e788-e792. [PMID: 40032034 DOI: 10.1016/j.jpainsymman.2025.02.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2025] [Revised: 02/22/2025] [Accepted: 02/24/2025] [Indexed: 03/05/2025]
Abstract
BACKGROUND Nasogastric tube syndrome (NGTS) is a rare but potentially life-threatening complication of nasogastric tube (NGT) placement. It is characterized by throat pain, hoarseness, and vocal cord paralysis. Awareness is essential for preventing severe airway compromise. CASE PRESENTATION A 57-year-old woman with pseudomyxoma peritonei developed NGTS while admitted to a palliative care unit with a prolonged NGT placement for intestinal obstruction. The patient presented with symptoms including throat pain, otalgia, and subsequent hoarseness. Fiberoptic laryngoscopy revealed restricted vocal cord abduction and posterior pharyngeal erythema. Despite the option of removing the NGT, it was retained due to ongoing drainage needs and the absence of respiratory distress. Conservative management, including corticosteroids, antibiotics, and proton pump inhibitors, led to symptom resolution. CONCLUSION This case emphasizes the importance of recognizing NGTS, particularly in palliative care settings, and highlights the need for vigilance for atypical symptoms like otalgia. Conservative management may be effective in selected cases, underscoring the importance of individualized care and increased awareness among clinicians.
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Affiliation(s)
- Naoki Suzuki
- Department of Palliative Medicine, Yamagata Prefectural Central Hospital, Yamagata 990-2292, Japan.
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2
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Vögelin C, Koch J, Marx G, Hill A. [Recommendations and Innovations in Nutritional Medicine in Critically Ill Patients]. Anasthesiol Intensivmed Notfallmed Schmerzther 2025; 60:169-184. [PMID: 40127648 DOI: 10.1055/a-2292-8916] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2025]
Abstract
Medical Nutrition Therapy (MNT) is a key component of treatment in intensive care units (ICU) and plays a crucial role in the prognosis of critically ill patients. An individualized nutrition strategy is essential to meet the specific needs of critically ill patients and to minimize potential complications.Recommendations for MNT differ between the guidelines of the German Society for Nutritional Medicine (DGEM), the European Society for Clinical Nutrition and Metabolism (ESPEN), and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), making its implementation in clinical practice challenging. Therefore, the first part of this article provides a pragmatic summary of the current recommendations for everyday clinical practice. The second part focuses on recent data and how these might influence current paradigms of MNT for critically ill patients, with particular emphasis on phase-appropriate macronutrient delivery and combinations of nutrition with other interventions.
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Ramai D, Heaton J, Fang J. Safety of Percutaneous Endoscopic Jejunostomy Placement Compared With Surgical and Radiologic Jejunostomy Placement: A Nationwide Inpatient Assessment. J Clin Gastroenterol 2024; 58:902-911. [PMID: 38019077 DOI: 10.1097/mcg.0000000000001948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/27/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND AND AIMS We compared the safety and outcomes of percutaneous jejunostomy tubes placed endoscopically (PEJ), fluoroscopically by interventional radiology (IR-jejunostomy), and open jejunostomy placed surgically (surgical jejunostomy). METHODS Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent a jejunostomy from 2016 to 2019. Selected patients were divided into 3 cohorts: PEJ, IR-jejunostomy, and surgical jejunostomy. Adjusted odds ratios (OR) for adverse events were calculated using multivariable logistic regression analysis. RESULTS A total of 6022 (65.2±9.8 y) surgical jejunostomy patients, 3715 (63.6±11.0 y) endoscopic jejunostomy patients, and 14,912 (64.8±11.6 y) IR-jejunostomy patients were identified. Compared with surgery, PEJ patients were 32% less likely to experience postprocedure complications (OR: 0.68; 95% CI: 0.58-0.79, P <0.001) while IR-jejunostomy patients were 17% less likely to experience complications (OR: 0.83; 95% CI: 0.73-0.94, P <0.001); test of proportion showed that endoscopy had significantly fewer total adverse events compared with IR ( P <0.001). For individual complications, compared with surgery, the odds of intestinal perforation using PEJ and IR, respectively, were 0.26 (95% CI: 0.14-0.49, P <0.001) and 0.31 (95% CI: 0.21-0.47, P <0.001), for postprocedure infection 0.32 (95% CI: 0.20-0.50; P <0.001) and 0.61 (95% CI: 0.45-0.83; P =0.001); and for hemorrhage requiring blood transfusion 0.71 (95% CI: 0.56-0.91; P =0.005) and 0.75 (95% CI: 0.61-0.91; P =0.003). CONCLUSIONS Endoscopic placement of percutaneous jejunostomy tubes (PEJ) in inpatients is associated with significantly lower risks of adverse events and mortality compared with IR and surgical jejunostomy.
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Affiliation(s)
- Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT
| | - Joseph Heaton
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, NJ
| | - John Fang
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT
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Zheng Z, Tang S, Shao Z, Cai H, Wang J, Lu L, Yang X, Liu J. Development and validation of a nomogram for predicting the placement of nasointestinal tubes in critically ill patients based on abdominal radiography: A single-center, retrospective study. Heliyon 2024; 10:e37498. [PMID: 39296028 PMCID: PMC11408785 DOI: 10.1016/j.heliyon.2024.e37498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 09/04/2024] [Accepted: 09/04/2024] [Indexed: 09/21/2024] Open
Abstract
Background Enteral nutrition administered via the nasointestinal tube (NET) is a prevalent nutritional modality among critically ill patients, and abdominal radiographs hold significant value in accurately ascertaining the precise positioning of the NET subsequent to its placement. Therefore, we propose an innovative approach to construct a clinical prediction model based on NET's configuration within the gastrointestinal tract in abdominal radiography. This model aims to enhance the accuracy of determining the position of NETs after their placement. Methods Patients admitted to the intensive care unit of Zhejiang Provincial People's Hospital between October 2017 and October 2021 were included to constitute the training cohort for retrospective analysis, and nomogram was constructed. Consecutively enrolled patients admitted to the same hospital from October 2021 to October 2023 were included as the validation cohort. The training cohort underwent a univariate analysis initially, followed by a multivariate logistic regression approach to analyze and identify the most appropriate model. Subsequently, nomogram was generated along with receiver operator characteristic curves, calibration curves, and decision curves for both the training and validation cohorts to evaluate the predictive performance of the model. Results The training and validation cohorts comprised 574 and 249 patients, respectively, with successful tube placement observed in 60.1 % and 76.3 % of patients, correspondingly. The predictors incorporated in the prediction maps encompass the "C-shape," the height of "inverse C-shape," showing the duodenojejunal flexure, and the location of the head end of the NET. The model demonstrated excellent predictive efficacy, achieving an AUC of 0.883 (95 % CI 0.855-0.911) and good calibration. Furthermore, when applied to the validation cohort, the nomogram exhibited strong discrimination with an AUC of 0.815 (95 % CI 0.750-0.880) and good calibration. Conclusion The combination of abdominal radiography and NET's configuration within the gastrointestinal tract enables accurate determination of NET placement in critically ill patients.
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Affiliation(s)
- Zihao Zheng
- Emergency and Critical Care Center, Intensive Care Unit, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310014, Zhejiang Province, China
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang Province, China
| | - Siyu Tang
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang Province, China
| | - Ziqiang Shao
- Emergency and Critical Care Center, Intensive Care Unit, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310014, Zhejiang Province, China
| | - Hanhui Cai
- Emergency and Critical Care Center, Intensive Care Unit, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310014, Zhejiang Province, China
| | - Jiangbo Wang
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang Province, China
| | - Lihai Lu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang Province, China
| | - Xianghong Yang
- Emergency and Critical Care Center, Intensive Care Unit, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310014, Zhejiang Province, China
| | - Jingquan Liu
- Emergency and Critical Care Center, Intensive Care Unit, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310014, Zhejiang Province, China
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Zheng YM, Wu HY, Ye MM, Cai JY, Yuan Y, Xie WR, Xu JT, Liu T, He XX, Wu LH. Comparison of the use of a spiral nasojejunal tube and transendoscopic enteral tubing in washed microbiota transplantation via the mid-gut route. Heliyon 2024; 10:e30310. [PMID: 38742080 PMCID: PMC11089310 DOI: 10.1016/j.heliyon.2024.e30310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/20/2024] [Accepted: 04/23/2024] [Indexed: 05/16/2024] Open
Abstract
Background Methods for washed microbiota transplantation (WMT) through the mid-gut include transendoscopic enteral tubing (TET) and manual spiral nasojejunal tube (SNT) placement have not been studied. Methods This prospective interventional study was performed at a single centre. Patients were divided into the SNT and mid-gut TET groups based on their conditions and wishes. In the SNT group, an SNT was passively inserted into the stomach, and abdominal X-rays were taken within 24 h to confirm tube placement in the small intestine. In the mid-gut TET group, mid-gut TET was placed in the small intestine for gastroscopy. Data on the clinical efficacy of WMT, intubation time, cost, overall comfort score, adverse reactions, etc., were collected from the two groups. Results Sixty-three patients were included in the study (SNT group (n = 40) and mid-gut TET group (n = 23)). The clinical efficacy of WMT in the SNT and mid-gut TET groups was 90 % and 95.7 %, respectively (P = 0.644). Compared with the mid-gut TET group, the SNT group showed a shorter operation time (120 s vs. 258 s, P = 0.001) and a lower average cost (641.7 yuan vs. 1702.1 yuan, P = 0.001). There was no significant difference in the overall comfort score or the incidence of common discomfort symptoms between the two groups. Conclusion The different implantation methods have different advantages; compared with mid-gut TET placement, manual SNT placement provides some benefits.
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Affiliation(s)
- Ya-Mei Zheng
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Hui-Yi Wu
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Meng-Meng Ye
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Jie-Yi Cai
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Yu Yuan
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Wen-Rui Xie
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Jia-Ting Xu
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Tao Liu
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Xing-Xiang He
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
| | - Li-Hao Wu
- Department of Gastroenterology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Research Center for Engineering Techniques of Microbiota-Targeted Therapies of Guangdong Province, Guangzhou, 510080, Guangdong Province, China
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Yamashita T, Otsuka K, Goto S, Ariyoshi T, Motegi K, Kohmoto M, Saito A, Sato Y, Kishimoto Y, Murakami M. Retrograde transgastric jejunostomy for nutritional management and aspiration prevention in cases with severe malignant esophageal strictures. DEN OPEN 2024; 4:e321. [PMID: 38023668 PMCID: PMC10661824 DOI: 10.1002/deo2.321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/31/2023] [Accepted: 11/09/2023] [Indexed: 12/01/2023]
Abstract
Locally advanced esophageal cancer often presents with dysphagia and can be complicated by aspiration pneumonia. Therefore, nutritional management is important to prevent pneumonia. Enteral nutrition via gastrostomies is common in esophageal cancer patients. Here, we describe the efficacy of nutritional management using a gastrojejunostomy tube retrogradely inserted in the esophagus through gastrostomy to simultaneously drain accumulated fluid on the proximal side of a malignant stricture. We performed this procedure for two cases with severe malignant strictures using two types of endoscope insertion. A 57-year-old male patient (Case 1) underwent a retrograde insertion of a gastrojejunostomy tube for severe esophageal malignant stricture with severe nausea and salivary reflux. After a narrow endoscope was inserted through the gastrostomy fistula, a gastrojejunostomy tube was inserted alongside a guidewire allowing the patient to undergo definitive chemoradiotherapy without symptoms. An 82-year-old male patient (Case 2) was scheduled for a minimally invasive esophagectomy following neoadjuvant chemotherapy after gastrostomy. However, the patient developed aspiration pneumonia due to salivary reflux; before surgery, a narrow nasal endoscope was inserted and passed through the strictures. The percutaneous endoscopic transgastric jejunostomy catheter was retrogradely inserted alongside the guidewire. In patients with malignant strictures and salivary reflux, retrograde insertion of gastrojejunostomy tubes can simultaneously provide enteral nutrition and saliva drainage.
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Affiliation(s)
| | - Koji Otsuka
- Esophageal Cancer CenterShowa University HospitalTokyoJapan
| | - Satoru Goto
- Esophageal Cancer CenterShowa University HospitalTokyoJapan
| | | | - Kentaro Motegi
- Esophageal Cancer CenterShowa University HospitalTokyoJapan
| | | | - Akira Saito
- Esophageal Cancer CenterShowa University HospitalTokyoJapan
| | - Yoshihito Sato
- Esophageal Cancer CenterShowa University HospitalTokyoJapan
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Dadich A, Samaranayake P, Hurriyet H, Elliot C. Process improvement of a paediatric feeding clinic. Heliyon 2024; 10:e23150. [PMID: 38163113 PMCID: PMC10756986 DOI: 10.1016/j.heliyon.2023.e23150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 11/20/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
Purpose The purpose of this study is to identify opportunities to improve processes within a paediatric feeding clinic to enhance timely patient access to healthcare through effective and efficient resource use. Design/methodology/approach The study involved three interrelated methods. First, de-identified feeding clinic data, collected over seven years, were analysed to understand patient appointments. Second, clinician workshops and the swim lane method were used to map feeding clinic processes. Third, root cause analysis was conducted to identify bottlenecks and identify improvement opportunities. Findings The results revealed three, poorly connected sub-processes within the feeding clinic - namely: the patient triaging and appointment scheduling or allocation process; the clinic reporting process; and the cancellation and rescheduling process. These sub-processes were poorly connected because of inadequate resources, few standardised processes, and limited coordination between the different processes. Consequently, patient appointments were typically delayed, and patient reports were not always completed in a timely manner. Processes within the paediatric feeding clinic could therefore be improved by using digital tools, patient portals and telehealth, online interventions, an automated appointment confirmation system, and/or an automated transcription of each appointment. Originality/value This is the first published study to apply business process management to a paediatric feeding clinic. By using three methods to clarify opportunities to improve clinic processes, it highlights the potential value of health information technology in this context. This evidence will enable health service managers to ensure that children with feeding difficulties have timely access to appropriate care.
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Affiliation(s)
- Ann Dadich
- School of Business, Western Sydney University, Australia
| | | | - Hilal Hurriyet
- School of Business, Western Sydney University, Australia
| | - Chris Elliot
- Department of Paediatrics, St George Hospital, Australia
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Cha B, Lee J, Lee J, Park JS, Jeong S, Lee DH. Clinical correlation of cholelithiasis in patients undergoing percutaneous endoscopic gastrostomy. Sci Rep 2023; 13:22039. [PMID: 38086971 PMCID: PMC10716124 DOI: 10.1038/s41598-023-49417-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 12/07/2023] [Indexed: 12/18/2023] Open
Abstract
The risk factor for cholelithiasis include low physical activity. With an aging society, the number of bedridden patients who undergo percutaneous endoscopic gastrostomy (PEG) has increased, and cholelithiasis has often been found in these patients. This study aimed to evaluate the risk factors correlated with cholelithiasis in adults who underwent PEG. This retrospective single-center design study reviewed patients who underwent PEG and were confirmed to have cholelithiasis through imaging from March 1996 to December 2021. The investigated variables were age, sex, body mass index (BMI, kg/m2), cause of PEG insertion, initial physical activity status, laboratory findings on PEG insertion day, and incidence of acute cholecystitis. The differences between categorical and continuous variables were analyzed using Student's t test and chi-square test. We enrolled 576 eligible patients who underwent PEG insertion. A total of 161 patients were detected with cholelithiasis (28.0%). The overall independent risk factors for cholelithiasis in patients who underwent PEG insertion were increased C-reactive protein (CRP) levels and decreased physical activity status (bedridden state). The incidence of cholelithiasis was increased by up to 30.7%, especially in patients with bedridden status. However, the incidence of acute cholecystitis among cholelithiasis group was only 5.6%. BMI and total cholesterol were positively correlated with the size of gallbladder (GB) stones. One of the major risk factors for cholelithiasis is decreased physical activity, especially in patients who underwent PEG insertion. Abdominal imaging is recommended to confirm the presence of cholelithiasis and to consider prophylaxis for cholelithiasis, especially in bedridden patients with elevated initial CRP levels at the time of PEG insertion.
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Grants
- NRF-2022R1F1A1067621 the National Research Foundation of Korea (NRF) grant funded by the Korea government
- (Project Number: 9991006975, KMDF_PR_20200901_0155) the Korea Medical Device Development Fund grant funded by the Korean government (the Ministry of Science and ICT, Ministry of Trade, Industry and Energy, Ministry of Health & Welfare, and the Ministry of Food and Drug Safety)
- (NTIS, KMDF-RnD 202016B01) the Korea Medical Device Development Fund grant funded by the Korean government (the Ministry of Science and ICT, Ministry of Trade, Industry and Energy, Ministry of Health & Welfare, and the Ministry of Food and Drug Safety)
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Affiliation(s)
- Boram Cha
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jungnam Lee
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jaehyuk Lee
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jin-Seok Park
- Department of Internal Medicine, Shihwa medical center, Siheung, Republic of Korea.
| | - Seok Jeong
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Republic of Korea
| | - Don Haeng Lee
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Republic of Korea
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Chavan R, Gandhi C, Rawal KK, Shah C, Patel N, Rajput S. Nasojejunal tube-related duodenal perforations: a multicenter experience. Clin Endosc 2023; 56:817-822. [PMID: 37536747 PMCID: PMC10665622 DOI: 10.5946/ce.2023.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/20/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Radhika Chavan
- Department of Gastroenterology and Advanced Endoscopy, Ansh Clinic, Ahmedabad, Gujarat, India
| | - Chaiti Gandhi
- Department of Gastroenterology and Advanced Endoscopy, Ansh Clinic, Ahmedabad, Gujarat, India
| | - K K Rawal
- Department of Gastroenterology and Advanced Endoscopy, Prime Hospital, Rajkot, Gujarat, India
| | - Chirag Shah
- Department of Gastroenterology and Advanced Endoscopy, Mission Gastro Hospital, Ahmedabad, Gujarat, India
| | - Nisarg Patel
- Department of Gastroenterology and Endoscopy, Gujarat Gastro Hub, Mehsana, India
| | - Sanjay Rajput
- Department of Gastroenterology and Advanced Endoscopy, Ansh Clinic, Ahmedabad, Gujarat, India
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Wang Y, Zhang J, Zhu HM, Yu CP, Bao Y, Hou XF, Huang SC. The Therapeutic Effect of Swallow Training with a Xanthan Gum-Based Thickener in Addition to Classical Dysphagia Therapy in Chinese Patients with Post-Stroke Oropharyngeal Dysphagia: A Randomized Controlled Study. Ann Indian Acad Neurol 2023; 26:742-748. [PMID: 38022444 PMCID: PMC10666846 DOI: 10.4103/aian.aian_139_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/30/2023] [Accepted: 08/08/2023] [Indexed: 12/01/2023] Open
Abstract
Objective In patients with post-stroke oropharyngeal dysphagia (PSOD), classical dysphagia therapy (CDT) continues to provide unsatisfactory outcomes and makes it challenging for them to remove the nasal feeding tube. Increasing bolus viscosity helps prevent aspiration in PSOD. However, conventional starch thickeners enhance post-digestion residue. This study aims to evaluate the efficacy of swallow training with xanthan gum-based thickener (XGT) (Softia G, NUTRI Co., Ltd., Yokkaichi, Japan) additional to CDT in Chinese PSOD patients with a nasogastric tube when compared to CDT alone. Methods Patients with PSOD who had a nasogastric tube were randomly assigned to either the experimental group (E-group) or the control group (C-group) in this randomized controlled, single-blind, parallel-group study. Both groups received CDT for 4 weeks. The E-group cases received additional swallow training with a Softia G-prepared hydrogel training material. The Functional Oral Intake Scale (FOIS) and modified volume-viscosity swallow test (M-VVST) for swallowing safety and efficacy according to adjusted Chinese dietary habits were administered before and after treatment. Post-training, both groups' nasogastric tube removal rates were calculated. Results One hundred sixty-seven participants (E-group: 82 and C-group: 85) completed the study. The E-group's median score of FOIS improved significantly than the C-group after training (median = 5 vs. 3, P < 0.001). The incidence of coughing, voice changes, oxygen desaturation of 3% or more, pharyngeal residue and piecemeal deglutition in the E-group was significantly lower than that in the C-group (P < 0.05). The E-group had 100% nasogastric tube removal, while the C-group had 28.24% (P < 0.001). Conclusion Swallow training with XGT Softia G in addition to CDT can promote swallowing safety and efficacy in Chinese patients with PSOD more effectively than CDT alone.
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Affiliation(s)
- Yao Wang
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Jie Zhang
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Hui-Min Zhu
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Can-Ping Yu
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Yan Bao
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Xiao-Fang Hou
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
| | - Shao-Chun Huang
- Department of Rehabilitation Medicine, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, PR China
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11
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McCormack S, Patel K, Smith C. Blended diet for enteral tube feeding in young people: A systematic review of the benefits and complications. J Hum Nutr Diet 2023; 36:1390-1405. [PMID: 36692240 DOI: 10.1111/jhn.13143] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/16/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Interest and use of blended diets (BD) for young people who are tube fed has significantly increased in the last decade, driven primarily by the desires of motivated caregivers. This review identified, appraised and synthesised the available evidence on the benefits and complications of BD versus commercial feeds. METHODS A systematic review following PRISMA guidance and registered with PROSPERO was conducted across PubMed, Embase, CINAHL, Scopus and Cochrane up to August 2022. INCLUSION CRITERIA English language studies including (1) children, (2) original research (interventional and observational) and (3) examination of BD outcomes. Exclusion criteria were (1) unoriginal research or case reports, (2) focus on feeding management, preparations or attitudes and (3) comparing commercial blends only. Data were synthesised using an established narrative synthesis approach using the Mixed Methods Appraisal Tool. RESULTS Eight hundred and six database results were identified and 61 were sought for retrieval. A full-text article review revealed seven eligible studies, involving 267 participants (age range 9 months to 26 years). Studies reported differences in gastrointestinal symptoms (n = 222), medication use (n = 119), growth (n = 189) and complications or adverse events (n = 91). The results indicate positive outcomes, particularly in gastrointestinal symptom control, with few reports of mild adverse events in the included studies. CONCLUSIONS There is a paucity of data in this area and much heterogeneity in the included studies, but the available literature points towards positive outcomes. This is an important and highly relevant topic, and more primary research, ideally using standardised reporting, is required to answer the key questions.
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Affiliation(s)
- Siobhan McCormack
- Department of Paediatrics, Brighton and Sussex Medical School, Brighton, UK
- Department of Child Development and Neurodisability, Children's Health Ireland at Tallaght, Dublin, Ireland
| | - Kamal Patel
- Department of Paediatrics, Brighton and Sussex Medical School, Brighton, UK
- Department of Paediatrics, Royal Alexandra Children's Hospital, Brighton, UK
| | - Chris Smith
- Department of Paediatric Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
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12
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Ghosh Laskar S, Sinha S, Gupta M, Karmakar S, Nivedha J M, Kannan S, Budrukkar A, Swain M, Kumar A, Gupta T, Murthy V, Chaukar D, Pai P, Chaturvedi P, Pantvaidya G, Nair D, Nair S, Thiagarajan S, Deshmukh A, Noronha V, Patil V, Joshi A, Prabhash K, Agarwal JP. Prophylactic versus reactive feeding approach in patients undergoing adjuvant radiation therapy for oral cavity squamous cell carcinoma: A propensity score matched-pair analysis. Head Neck 2023; 45:1226-1236. [PMID: 36912016 DOI: 10.1002/hed.27336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/18/2023] [Accepted: 02/27/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND To assess the efficacy of prophylactic versus reactive feeding strategy in oral cavity squamous cell carcinoma (OCSCC) patients receiving adjuvant radiation therapy (RT). METHODS This was a post hoc analysis of patients of OCSCC enrolled in a randomized trial comparing three adjuvant strategies. In this trial, till 2010, a prophylactic feeding approach was followed for all patients. Since January 2011, a reactive feeding approach was followed. RESULTS Two hundred and sixty-eight in each cohort (total n = 526) were eligible for analysis after propensity score matching. At 6 weeks post-RT completion, the median weight loss in the prophylactic versus reactive cohort was 5 versus 3 kg, p = 0.002. At all other time points until 1 year, the median weight loss was lesser in reactive than in the prophylactic cohort. CONCLUSIONS A reactive feeding tube approach should be preferred for OCSCC receiving adjuvant RT.
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Affiliation(s)
- Sarbani Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shwetabh Sinha
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Meetakshi Gupta
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shreyasee Karmakar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Meenakshi Nivedha J
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sadhana Kannan
- Clinical Research Secretariat, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Ashwini Budrukkar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Monali Swain
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Anuj Kumar
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Tejpal Gupta
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Devendra Chaukar
- Department of Head and Neck Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prathamesh Pai
- Department of Head and Neck Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Pankaj Chaturvedi
- Department of Head and Neck Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Gouri Pantvaidya
- Department of Head and Neck Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Deepa Nair
- Department of Head and Neck Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sudhir Nair
- Department of Head and Neck Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shivakumar Thiagarajan
- Department of Head and Neck Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Anuja Deshmukh
- Department of Head and Neck Surgery, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vijay Patil
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jai Prakash Agarwal
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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13
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Strahm R, Weber M, Wiest R, Schmitt KU. Early Tube Feeding after Percutaneous Endoscopic Gastrostomy (PEG): An Observational Study. Nutrients 2023; 15:nu15051157. [PMID: 36904155 PMCID: PMC10005292 DOI: 10.3390/nu15051157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/23/2023] [Indexed: 03/02/2023] Open
Abstract
This study investigated whether enteral nutrition by early tube feeding led to changes in clinical parameters compared to tube feeding after 24 h. Starting on 1 January 2021, and following the latest update of the ESPEN guidelines on enteral nutrition, patients with percutaneous endoscopic gastrostomy (PEG) received tube feeding 4 h after tube insertion. An observational study was conducted to analyze whether the new scheme affected patient complaints, complications, or hospitalization duration compared to the previous procedure of tube feeding starting after 24 h. Clinical patient records from one year before and one year after the introduction of the new scheme were examined. A total of 98 patients were included, and of those 47 received tube feeding 24 h after tube insertion, and 51 received tube feeding 4 h after tube insertion. The new scheme did not influence the frequency or severity of patient complaints or complications related to tube feeding (all p-values > 0.05). However, the study showed that the length of stay in hospital was significantly shorter when following the new scheme (p = 0.030). In this observational cohort study an earlier start of tube feeding did not produce any negative consequences but did reduce the duration of hospitalization. Therefore, an early start, as suggested in the recent ESPEN guidelines, is supported and recommended.
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Affiliation(s)
- Rachel Strahm
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital Inselspital and University of Bern, 3010 Bern, Switzerland
- Academic-Practice-Partnership of Bern University of Applied Sciences and Insel Gruppe (Bern University Hospital Inselspital), 3008 Bern, Switzerland
| | - Manuel Weber
- Academic-Practice-Partnership of Bern University of Applied Sciences and Insel Gruppe (Bern University Hospital Inselspital), 3008 Bern, Switzerland
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, Bern University Hospital Inselspital, 3010 Bern, Switzerland
| | - Kai-Uwe Schmitt
- Academic-Practice-Partnership of Bern University of Applied Sciences and Insel Gruppe (Bern University Hospital Inselspital), 3008 Bern, Switzerland
- Correspondence:
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14
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Ascoli A, Missale F, Giordano GG, Vallin A, Gradaschi R, Guiddo E, Schenone G, Sukkar SG, Copello F, Parrinello G, Iandelli A, Peretti G, Marchi F. Immunonutrition in major oncologic head and neck surgery: Analysis of complications, plasmatic equilibrium, and costs. Head Neck 2023; 45:449-463. [PMID: 36490206 DOI: 10.1002/hed.27270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/27/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Malnutrition, in patients with solid tumors, is associated with a worse clinical outcome and about 40% of patients affected by head and neck cancers (HNC) are malnourished at the time of cancer diagnosis. We investigated the potential benefit of a standardized immunonutritional protocol (INP) to patients with HNC receiving major ablative surgery. METHODS An observational study was conducted enrolling 199 patients: 50 treated with the INP and 149 with standard enteral nutrition. Complication rates, need for medications, and costs were considered as outcomes. RESULTS INP played a protective role in development of major surgical complications (OR 0.23, p = 0.023), albumin administration (RR 0.38, p = 0.018), and antibiotic duration (p < 0.001) and is cost-effective in patients with moderate or severe malnutrition (-6083€ and -11 988€, p < 0.05). CONCLUSIONS Our study supports the utility of INP, and accurate nutritional screening can help to identify malnourished patients who would receive the most benefits from this protocol.
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Affiliation(s)
- Alessandro Ascoli
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
| | - Francesco Missale
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.,Department of Head & Neck Oncology & Surgery Otorhinolaryngology, Antoni Van Leeuwenhoek, Nederlands Kanker Instituut, Amsterdam, The Netherlands
| | - Giorgio-Gregory Giordano
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
| | - Alberto Vallin
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
| | - Raffaella Gradaschi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Dietetics and Clinical Nutrition Unit, University of Genova, Genoa, Italy
| | - Erica Guiddo
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Dietetics and Clinical Nutrition Unit, University of Genova, Genoa, Italy
| | | | - Samir Giuseppe Sukkar
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Dietetics and Clinical Nutrition Unit, University of Genova, Genoa, Italy
| | - Francesco Copello
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Occupational Medicine Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | - Giorgio Peretti
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
| | - Filippo Marchi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Genoa, Italy
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15
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Kundal A, Singh S, Sharma J, S D, Karn S. Spontaneous Enteral Migration of a Feeding Jejunostomy Tube: An Unusual Complication. Cureus 2023; 15:e34861. [PMID: 36923197 PMCID: PMC10010317 DOI: 10.7759/cureus.34861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/13/2023] Open
Abstract
Established consensus suggests that enteral nutrition is more beneficial in patients with a functioning gut than parenteral nutrition. It helps in early physical rehabilitation from a disease or surgical stress and is associated with fewer complications compared to parenteral nutrition. Jejunal feeding is one of the routine modes of enteral nutrition in patients with gastric dysfunction, either due to surgery or critical illness. Various complications have been reported when using feeding tubes, grouped as mechanical, infectious, gastrointestinal, and metabolic. Here, we report an unusual case of a 47-year male with a history of prepyloric perforation repair leak who presented to us on postoperative day 14 with an enterocutaneous fistula and a feeding jejunostomy tube in situ. He was evaluated and managed conservatively and discharged on enteral feeds, both orally and via a jejunostomy tube. One month after discharge, he presented with features of intestinal obstruction with a missing jejunostomy tube. Radiological investigations suggested enteral migration of the jejunostomy tube, which was managed non-operatively, and the patient was discharged on day three post-admission after per rectal expulsion of the tube.
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Affiliation(s)
- Ashikesh Kundal
- Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Sudhir Singh
- Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Jyoti Sharma
- Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Dhivakar S
- Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Summi Karn
- Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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16
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Dadich A, Kaplun S, Kaplun C, Hopwood N, Elliot C. 'it was that … specialist … that finally listened to us … that's probably a weird answer to what you were expecting': Clinician and carer perspectives on brilliant feeding care. Health Expect 2022; 26:488-497. [PMID: 36482799 PMCID: PMC9854327 DOI: 10.1111/hex.13683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/19/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION To extend research on positive aspects of health care, this article focusses on health care for children who tube-feed-this is because knowledge about tube-feeding for children is limited and fragmented. This is achieved by consulting with clinicians and carers who supported children who tube-feed to clarify their understandings of and experiences with brilliant feeding care. METHODS Nine clinicians and nine carers who supported children who tube-fed were interviewed. The interview transcripts were analysed thematically. RESULTS Findings highlighted several features of brilliant feeding care-namely: practices that go above and beyond; attentiveness; empowerment; being 'on the same page'; hopefulness and normalcy. CONCLUSIONS These findings show that seemingly trivial or small acts of care can make a significant meaningful difference to carers of children who tube-feed. Such accounts elucidate brilliant care as grounded in feasible, everyday actions, within clinicians' reach. The implications associated with these findings are threefold. First, the findings highlight the need for clinicians to listen, be attuned and committed to the well-being of children who tube-feed and their carers, share decision-making, source resources, and instil hope. Second, the findings suggest that carers should seek out and acknowledge clinicians who listen, involve them in decision-making processes, and continue to source the resources required to optimize child and carer well-being. Third, the findings point to the need for research to clarify the models of care that foster brilliant feeding care, and the conditions required to introduce and sustain these models. PATIENT OR PUBLIC CONTRIBUTION All of the carers and clinicians who contributed to this study were invited to participate in a workshop to discuss, critique, and sense-check the findings. Three carers and one clinician accepted this invitation. Collectively, they indicated that the findings resonated with them, and they agreed with the themes, which they indicated were well-substantiated by the data.
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Affiliation(s)
- Ann Dadich
- School of BusinessWestern Sydney UniversityParramattaNSWAustralia
| | - Simone Kaplun
- School of BusinessWestern Sydney UniversityParramattaNSWAustralia
| | - Cathy Kaplun
- Transforming early Education and Child Health (TeEACH) Strategic Research InitiativeWestern Sydney UniversityWestmeadNew South WalesAustralia
| | - Nick Hopwood
- Faculty of Arts and Social ScienceUniversity of Technology SydneyBroadwayNew South WalesAustralia
| | - Christopher Elliot
- Department of PaediatricsSt George HospitalKogarahNew South WalesAustralia
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17
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Buoite Stella A, Manganotti P. Enteral Nutrition and Hydration in Patients with Acute Stroke: Efficacy of an Automatic Pump System for Water Administration and Flushes-A Pilot Study. SENSORS (BASEL, SWITZERLAND) 2022; 22:8029. [PMID: 36298380 PMCID: PMC9609995 DOI: 10.3390/s22208029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/04/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Enteral nutrition is often prescribed in acute stroke to meet energy and fluid needs in patients with dysphagia. Tubes clogging represent a common complication of enteral formula delivery, requiring substitution and influencing nutrition administration. Frequent water flushes are recommended as one of the most effective procedures to prevent tube occlusion, but it might be time demanding and not consistently performed by the healthcare staff. This study aimed to assess the efficacy of an automatic flush pump, compared to a manual flush system, to prevent tubes' occlusions in acute-stroke patients, as this might affect nutrition and hydration. METHODS Gastrointestinal symptoms, nutrition and hydration biomarkers were also monitored to determine the different devices' safety. Sixty-two patients were included in the study and allocated to the "manual" or "automatic" flushes device. RESULTS The mean duration of data collection was 7 ± 2 days. Tube occlusions occurred in 22.6% of the patients in the "manual" group, whereas only one tube clogging was reported in the "automatic" group (p = 0.023). No significant differences between groups were reported for constipation and diarrhea frequency nor nutrition and hydration status. When the nurses were asked to simulate manual flush administration at the same frequency of the automatic device, they were able to meet the recommendations only 10% of the time. CONCLUSION This preliminary study suggests the efficacy of automatic flush systems to prevent enteral tube clogging, without affecting health status compared to standard manual flush systems.
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18
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Hadera T, Worku T, Tuli W. Nurses' Knowledge, Practice, and Associated Factors with Enteral Nutrition in Adult Intensive Care Units of Public Hospitals. Ethiop J Health Sci 2022; 32:423-432. [PMID: 35693571 PMCID: PMC9175211 DOI: 10.4314/ejhs.v32i2.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 10/25/2021] [Indexed: 11/25/2022] Open
Abstract
Background In critically ill patients, enteral nutrition is recommended as a route for nutrient delivery. Nurses' knowledge and practice of enteral nutrition influence patients' clinical outcomes. Therefore, this study sought to assess nurses' knowledge, practice, and associated factors regarding enteral nutrition in adult intensive care unit patients in public hospitals in Addis Ababa, Ethiopia. Methods A cross-sectional study design was used to collect data from 196 nurses working in public hospitals in Addis Ababa from April 11 to April 30, 2020. The data were entered into Epi Data version 3.1 and analyzed with SPSS version 21. The correlation between independent variables and dependent variables was estimated using bivariate and multivariate logistic regression at a 95% confidence level. Results The level of inadequate knowledge and poor practice of nurses relating to enteral nutrition was 67.7% and 53.8%, respectively. Bachelor's degree holders were less likely to be knowledgeable (AOR= 0.24, 95% CI: (0.61, 0.93)). Nurses' practice about enteral nutrition was significantly associated with nurses' age (AOR = 0.023, 95 % CI: (0.001,0.52), nurses receiving training on enteral nutrition (AOR = 1.951, 95 % CI: (0.06, 0.60)), and nurses from ICUs having a guideline and protocol on enteral feeding practice (AOR = 3.401, 95 % CI: (1.186, 9.789). Conclusions In the study, it was revealed that a substantial proportion of nurses had inadequate knowledge of enteral nutrition and practiced poor enteral nutrition.
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Affiliation(s)
- Tsige Hadera
- Department of Nursing, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Tigist Worku
- Department of Emergency Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wagari Tuli
- Department of Emergency Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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19
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Karkossa F, Lehmann N, Klein S. A systematic approach for assessing the suitability of enteral feeding tubes for the administration of controlled-release pellet formulations. Int J Pharm 2022; 612:121286. [PMID: 34775043 DOI: 10.1016/j.ijpharm.2021.121286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 10/19/2022]
Abstract
Enteral nutrition plays an important role for patients who are unable to properly swallow food. In such patients, enteral feeding tubes are often used, through which food, but often also oral medications, are administered. However, this can pose the risk of tube clogging. Compared to the administration of crushed tablets, multiparticulate dosage forms are often considered easier to administer and furthermore have the advantage of enabling the administration of even controlled-release preparations. The objective of this systematic study was to identify tube- and formulation-related factors that contribute to successful administration of coated pellet formulations via a variety of commercially available feeding tube devices. The suitability of enteral feeding tubes for the administration of controlled-release pellet formulations that differed in size and type of starter core and functional coating was investigated in a stepwise approach using a novel in vitro setup. Results of the study indicate that pellet diameter and inner diameter of the feeding tube are by no means reliable parameters for estimating the tube's suitability for pellet administration, but that many other tube and formulation-related factors and combinations thereof must be considered to ensure safe and effective drug administration via enteral feeding tubes.
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Affiliation(s)
- Frank Karkossa
- University of Greifswald, Department of Pharmacy, Institute of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, 3 Felix Hausdorff Street, Greifswald 17489, Germany
| | - Nicole Lehmann
- University of Greifswald, Department of Pharmacy, Institute of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, 3 Felix Hausdorff Street, Greifswald 17489, Germany
| | - Sandra Klein
- University of Greifswald, Department of Pharmacy, Institute of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, 3 Felix Hausdorff Street, Greifswald 17489, Germany.
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20
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Santos DCD, Ataide CDG, Mota da Costa N, Oliveira Junior VPD, Egea MB. Blenderized formulations in home enteral nutrition: a narrative review about challenges in nutritional security and food safety. Nutr Rev 2022; 80:1580-1598. [PMID: 35026011 DOI: 10.1093/nutrit/nuab121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Blenderized formulations (BFs) are prepared by homogenization of food that is normally used in oral nutrition. BFs are mainly used in home enteral nutrition (HEN), although their use has also been reported by hospitals when commercial enteral formulas are not available. HEN is applied when the patient has been discharged from the hospital. This nutritional therapy promotes the patient's reintegration into the family nucleus and promotes humanized care, and decreases treatment costs. However, the patient should continue to receive health and nutritional care, ranging from periodic nutritional re-evaluation to adaptation of the dietary plan. HEN provides the patient a greater contact with the family, whereas BFs promote the adaptation of the diet with food, respecting the food diversity and culture, lower cost, and easier access to food. Disadvantages of BFs include more time spent by the professional to calculate the dietary plan, greater difficulty in adjusting daily needs, and less microbiological and chemical stability. In this review, the nutritional, food security, and safety aspects of BF used in HEN are discussed. Technological quality aspects that are essential knowledge in the preparation of the patient's dietary plan also are presented.
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Affiliation(s)
- Daiane Costa Dos Santos
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Carla Daniela Gomes Ataide
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Nair Mota da Costa
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Valtemir Paula de Oliveira Junior
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
| | - Mariana Buranelo Egea
- D.C.d. Santos is with the Goiás Federal University (UFG), Institute of Tropical Pathology and Public Health, IPTSP-UFG, Goiânia, Goiás, Brazil. C.D.G. Ataide is with the Hospital DF Star, Asa Sul, Brasília, Brazil. N.M. da Costa, V.P. de Oliveira Junior, and M.B. Egea are with the Federal Institute of Education, Science, and Technology Goiano, Rio Verde, Goiás, Brazil
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21
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Chamely EA, Hoang B, Jafri NS, Felinski MM, Bajwa KS, Walker PA, Barge J, Wilson EB, Cen P, Shah SK. Palliative Endoscopic Salvage of a Functionally Obstructed Gastrojejunostomy - Report of Technique. CRSLS : MIS CASE REPORTS FROM SLS 2022; 9:e2021.00094. [PMID: 36016812 PMCID: PMC9387390 DOI: 10.4293/crsls.2021.00094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Gastric outlet obstruction secondary to foregut gastrointestinal malignancies can be managed with a variety of medical, endoscopic, and surgical options. Laparoscopic gastrojejunostomy is an option for those patients who are able to tolerate an operation as a long-term palliative option. This operation may be associated with some significant postoperative technical and nontechnical complications, including delayed gastric emptying. This paper describes an incision-less, endoscopic option that we propose can be used to salvage a functionally obstructed gastrojejunostomy. CASE DESCRIPTION A 57-year old male patient had a history of pancreatic adenocarcinoma causing gastric outlet obstruction and underwent a previously created surgical gastrojejunostomy at an outside hospital. His procedure was complicated by anastomotic leak and essentially persistent obstructive symptoms secondary to delayed gastric emptying. Though his anastomosis was demonstrably patent, these symptoms were thought to be secondary to a functional obstruction at the gastrojejunostomy. After repeated workups and many failed attempts to treat these symptoms, he ultimately underwent endoscopic placement of an uncovered colonic stent into the efferent limb of his gastrojejunostomy. This allowed for preferential drainage of gastric contents down the efferent limb, and improvement of his delayed gastric emptying. CONCLUSIONS In a select group of patients with advanced foregut malignancy, and with high re-operative risks, salvage endoscopic stenting may be useful in the palliation of symptoms from a functionally obstructed gastrojejunostomy.
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Affiliation(s)
- Elias A Chamely
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Bryan Hoang
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Nadim S Jafri
- Michael E DeBakey Institute of Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, TX
| | - Melissa M Felinski
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Kulvinder S Bajwa
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Peter A Walker
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | | | - Erik B Wilson
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Putao Cen
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX
| | - Shinil K Shah
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
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22
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Bowman CA, Hutchins E, Burgermaster M, Sant V, Seres DS. Nasal Feeding Tubes Are Associated with Fewer Adverse Events than Feeding via Ostomy in Hospitalized Patients Receiving Enteral Nutrition. Am J Med 2022; 135:97-102.e1. [PMID: 34543647 PMCID: PMC8688227 DOI: 10.1016/j.amjmed.2021.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 07/29/2021] [Accepted: 08/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical feeding ostomies (eg, gastrostomy) have become required by many nursing facilities for all patients receiving enteral nutrition, whether for short- or long-term use. These policies lack supportive evidence. Comparisons of adverse event rates between surgical and natural orifice tubes are few and lacking in the inpatient setting. Additionally, we hypothesize that adverse events related to feeding tubes are underreported. We sought to quantify adverse events to test the relative safety of surgical feeding ostomies and natural orifice (eg. nasogastric or orogastric) feeding tubes in hospitalized patients. METHODS This was a prospective observational cohort study of enterally fed inpatients using semiweekly focused physical examination, scripted survey, and chart review. RESULTS All tube-fed patients admitted to a large, urban, academic hospital received semiweekly bedside evaluation and chart review over a 9-week period (n = 226 unique patients, mean 6.25 visits each, total 1118 observations). Demographics were comparable between 148 subjects with natural orifice and 113 subjects with surgical feeding tubes. A higher incidence of adverse events was observed with surgical tubes (3.34 vs 1.25 events per 100 subject days, P < .001). Only 50% of all adverse events were documented in the medical record. More patients with surgical tubes were discharged to skilled nursing facilities (58% vs 24%). CONCLUSIONS Surgical feeding tubes are associated with significantly higher in-hospital adverse event rates when compared with natural orifice (nasal or oral) feeding tubes. Policies requiring surgical feeding ostomies should be reevaluated.
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Affiliation(s)
| | | | - Marissa Burgermaster
- Department of Nutritional Sciences, Dell Medical School, University of Texas at Austin, Austin
| | - Vivek Sant
- Department of Surgery, NYU School of Medicine, New York, NY
| | - David S Seres
- Institute of Human Nutrition and Department of Medicine, Columbia Univeristy Irving Medical Center, New York, NY.
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23
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Dadich A, Hockey K, Kaplun C, Fleming C, Hopwood N, Moraby K, Elliot C. Clinician and carer moral concerns when caring for children who tube-feed. J Child Health Care 2021:13674935211052842. [PMID: 34696607 DOI: 10.1177/13674935211052842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Child healthcare can be vexed by moral concerns - this extends to the care of children who tube-feed. Children who tube-feed often receive care from family members and clinicians of various disciplines. Each brings expertise, experiences, values, and views to a situation, prioritising the child's needs while attending to those they deem important in potentially disparate ways. Their understanding of a situation is shaped by beliefs, feelings, and perceptions. How then are key decisions made about the care of a child who tube-feeds? This article explores clinicians' and carers' moral concerns when caring for children who tube-feed. Interviews with clinicians (n = 9) and carers (n = 9) clarified three findings: first, there are often disparate beliefs about the need for tube-feeding; second, tube-feeding can evoke strong emotions; and third, it can be difficult to normalise tube-feeding. This article demonstrates how challenges can emerge when relationships between clinicians and carers diverge. Furthermore, it establishes how an ethic of care can bring different interests together to bolster the relationships required to optimise feeding care and promote health outcomes among children who tube-feed and their carers. This requires improved dialogue between and among clinicians and carers to create shared understandings of what is, what should be, and how to benefit children who tube-feed.
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Affiliation(s)
- Ann Dadich
- School of Business, 6489Western Sydney University, Penrith South, NSW, Australia
| | - Kaitlyn Hockey
- School of Business, 6489Western Sydney University, Penrith South, NSW, Australia
| | - Cathy Kaplun
- School of Nursing and Midwifery, 6489Western Sydney University, Penrith South, NSW, Australia
| | - Catharine Fleming
- School of Science and Health, 6489Western Sydney University, Penrith South, NSW, Australia
| | - Nick Hopwood
- Faculty of Arts and Social Science, 1994University of Technology Sydney, Sydney, NSW, Australia
| | - Khadeejah Moraby
- SA Health, 1050Central Early Childhood and Families Service, Women's and Children's Health Network, Adelaide, SA, Australia
| | - Chris Elliot
- Department of Paediatrics, 90135Saint George Private Hospital, Kogarah, NSW, Australia
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24
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Simpson K. Clinical Case Reports on the acceptability and tolerance of a High-Energy whey peptide-based Pediatric oral nutritional supplement in children aged over 12 months. Clin Case Rep 2021; 9:e04887. [PMID: 34631071 PMCID: PMC8491306 DOI: 10.1002/ccr3.4887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 08/27/2021] [Accepted: 09/09/2021] [Indexed: 11/10/2022] Open
Abstract
The nutritional management of the complex needs of children with impaired gastrointestinal function can be challenging, using a high-energy pediatric whey-based peptide formula in clinical practice demonstrates its role in managing symptoms.
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Affiliation(s)
- Kathryn Simpson
- CCICP - Central Cheshire Integrated Care Partnership Crewe UK
- Mid Cheshire Hospital's NHS Trust Crewe UK
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25
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Ye X, Chang YC, Findlay M, Brown T, Bauer J. The effect of timing of enteral nutrition support on feeding outcomes and dysphagia in patients with head and neck cancer undergoing radiotherapy or chemoradiotherapy: A systematic review. Clin Nutr ESPEN 2021; 44:96-104. [PMID: 34330518 DOI: 10.1016/j.clnesp.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/11/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND & AIMS Patients with head and neck cancer (HNC) often require enteral nutrition (EN). This systematic review reports the effect of EN timing in patients with HNC undergoing curative-intent and definitive or adjuvant radiotherapy or chemoradiotherapy on tube feeding duration, tube-related complications and dysphagia. METHODS Randomised controlled trials (RCTs) published between January 2015-April 2020 were obtained from Medline, CINAHL and Embase. Study quality and certainty of evidence were assessed with Cochrane Risk-of-Bias and Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS Two RCTs (n = 265) in five manuscripts were included. The risk of bias was moderate in one RCT and low in the other RCT. Timing of EN (prophylactic vs. reactive) may have little or no effect on tube feeding duration or complications, however, the effect on dysphagia was uncertain. Certainty of evidence was low for short-term and moderate for long-term tube feeding duration, low for tube-related complications and very low for dysphagia. There was imprecision due to small sample sizes, heterogeneity in the definitions and protocols for prophylactic and reactive EN, variations in time points for outcome assessment and indirect dysphagia measures. CONCLUSION Larger well-designed trials are warranted to increase certainty of evidence regarding EN timing in patients with HNC.
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Affiliation(s)
- Xiaodan Ye
- School of Human Movement and Nutrition Sciences, University of Queensland, Queensland, Australia.
| | - Yuan-Chin Chang
- School of Human Movement and Nutrition Sciences, University of Queensland, Queensland, Australia.
| | - Merran Findlay
- Cancer Services, Royal Prince Alfred Hospital, New South Wales, Australia; Chris O'Brien Lifehouse, New South Wales, Australia.
| | - Teresa Brown
- School of Human Movement and Nutrition Sciences, University of Queensland, Queensland, Australia; Nutrition & Dietetics, Royal Brisbane & Women's Hospital, Queensland, Australia.
| | - Judy Bauer
- School of Human Movement and Nutrition Sciences, University of Queensland, Queensland, Australia.
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26
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Curtis JS, Kennedy SE, Attarha B, Edwards L, Jacob R. Upper Gastrointestinal Disorders in Adult Patients with Intellectual and Developmental Disabilities. Cureus 2021; 13:e15384. [PMID: 34094790 PMCID: PMC8170855 DOI: 10.7759/cureus.15384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The purpose of this literature review is to address the diagnosis and treatment of upper gastrointestinal (GI) disorders in patients with intellectual and developmental disabilities (IDD). Manifestations of upper GI dysmotility and disorders include dysphagia, pulmonary aspiration, malnutrition, gastroesophageal reflux, and gastritis, all of which can impact a person’s quality of life and lead to chronic, life-threatening conditions. This article will explore the existing diagnostic methods and treatments for gastrointestinal disorders as they relate to patients with IDD.
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Affiliation(s)
- Jack S Curtis
- Internal Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Sara E Kennedy
- Internal Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Barrett Attarha
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Linda Edwards
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Rafik Jacob
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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27
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Lisiecka D, Kearns A, Bourke F, Lawson I, Muir C. A qualitative meta-synthesis of evidence (meta-ethnography) exploring the personal experiences of gastrostomy tube in neurodegenerative diseases: a case of motor neurone disease. Disabil Rehabil 2021; 44:4949-4965. [PMID: 34033736 DOI: 10.1080/09638288.2021.1922518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE The lived experiences of a gastrostomy tube (GT) in adults with neurodegenerative diseases (NDDs) are not well understood. The aim of this qualitative meta-synthesis was to review and synthesise the available evidence to inform clinical practice and identify research gaps. METHODS Meta-ethnographic synthesis of qualitative studies was conducted with systematic searching of eight databases from inception to March 2021. Qualitative studies reporting personal experiences of GTs in adults with NDDs were identified. New theories were developed during translation of concepts from each study and combined as a "line-of-argument" synthesis. Patient and public involvement was incorporated as two of the authors are living with an NDD and a GT. RESULTS AND CONCLUSIONS Of 2863 unique records identified, only nine fulfilled the review criteria. All studies recruited participants with motor neurone disease (MND); no other NDDs were represented. Two main themes emerged: decision making and living with GT. Decision making was the predominant theme and data regarding living with GT were sparse. There is limited research on the lived experience of a GT in adults with NDDs. The lived experience of GT in MND is complex and individualised. Future research is indicated to inform clinical practice.Implications for rehabilitationEvidence related to the lived experiences of gastrostomy tube (GT) in neurodegenerative diseases (NDDs) is lacking especially in relation to the time after GT insertion.Decision making in relation to GT is a complex and individualised psychological process for some people, while others perceive no decisional conflict.Support from healthcare professionals is crucial during the decision-making time and should not cease after GT insertion.Support from healthcare professionals can help resolve any clinical complications and also incorporate GT into everyday routines.Healthcare professionals should be aware that their views on the benefits and problems related to GT may differ to those of individuals with a NDD.
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Affiliation(s)
- Dominika Lisiecka
- Department of Nursing and Healthcare Sciences, School of Health and Social Sciences, Munster Technological University, Kerry Campus, Tralee, Ireland
| | - Aine Kearns
- Department of Speech & Language Therapy, School of Allied Health, University of Limerick, Limerick, Ireland
| | - Fiona Bourke
- Department of Speech & Language Therapy, School of Allied Health, University of Limerick, Limerick, Ireland
| | - Ian Lawson
- North Yorkshire Disability Forum, Whitby, UK
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28
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Akashi T, Hashimoto R, Funakoshi A. Effect of a Novel, Energy-Dense, Low-Volume Nutritional Food in the Treatment of Superior Mesenteric Artery Syndrome. Cureus 2021; 13:e15243. [PMID: 34178549 PMCID: PMC8225409 DOI: 10.7759/cureus.15243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Superior mesenteric artery syndrome (SMAS) is an intermittent or persistent passage obstruction that occurs in the third portion of the duodenum between the aorta and the superior mesenteric artery. After symptoms stabilize, the nutritional intake is started by ingesting a small amount. Recently, an energy-dense, low-volume nutritional food, Terumeal uplead® (Terumo Corporation, Tokyo, Japan) with an energy density of 4.0 kcal/mL, was launched. We report a case of a postoperative SMAS patient who was successfully treated using Terumeal uplead® through gastrostomy. An 83-year-old man who developed adhesive intestinal obstruction underwent right hemicolectomy, lysis of adhesion, and partial small bowel resection. Gastric distension persisted after surgery; thus, gastrostomy was performed for decompression and enteral nutrition on the 21st postoperative day, and enteral feeding was started on the 23rd postoperative day. However, fluoroscopy showed obstruction in the third portion of the duodenum, which was considered to be SMAS. To reduce the administration volume, enteral nutrition was replaced with Terumeal uplead® from the 28th postoperative day (intermittent administration thrice a day, 300 mL, 1,200 kcal per day). From the 34th postoperative day, the gastrostomy tube was clamped for two hours after administration, and no drainage was observed. Oral intake was resumed from the 36th postoperative day, and it was used in combination with enteral nutrition. Three months later, the patient was discharged home and continued oral ingestion with occasional decompression from the gastrostomy tube. Thus, Terumeal uplead® may be useful during the conservative treatment of SMAS by initiation with small amounts.
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Affiliation(s)
- Tetsuro Akashi
- Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, JPN
| | - Risa Hashimoto
- Department of Internal Medicine, Saiseikai Fukuoka General Hospital, Fukuoka, JPN
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29
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Lee JH, Kwon HY, Kwon KS, Park SH, Suh YJ, Kim JS, Kim H, Shin YW. Percutaneous endoscopic gastrostomy feeding effects in patients with neurogenic dysphagia and recurrent pneumonia. Ther Adv Respir Dis 2021; 15:1753466621992735. [PMID: 33764224 PMCID: PMC8010805 DOI: 10.1177/1753466621992735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: Percutaneous endoscopic gastrostomy (PEG) feeding provides enteral nutrition to patients with neurological dysphagia. However, the conditions in which PEG should be applied to prevent pneumonia remain unclear. We aimed to evaluate the effect of PEG for patients with neurological dysphagia in preventing pneumonia. Methods: We undertook a retrospective data review of 232 patients with neurological dysphagia who had undergone PEG from January 2008 to December 2018 at Inha University Hospital, in Incheon, Korea. We excluded patients who had not been followed up 6 months pre- and post-PEG feeding. In total, our study comprised 42 patients. We compared pneumonia episodes and incidence pre- and post-PEG. Results: During the median post-PEG follow-up period, the 6-month pneumonia incidence among patients who had undergone PEG had decreased [median 0.3 (interquartile range (IQR) 0.0–0.7) versus 0.1 (IQR 0.1–0.3) episodes, p = 0.04]. In a multiple mixed model, PEG did not decrease the incidence of pneumonia (p = 0.76). However, the association between PEG and the incidence of pneumonia differed significantly depending on the presence or absence of recurrent pneumonia (p < 0.001). Conclusions: PEG could effectively reduce the incidence of pneumonia in patients with neurogenic dysphagia, especially in those who had experienced recurrent pneumonia. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Jung Hwan Lee
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea.,Department of Hospital Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Hea Yoon Kwon
- Division of Infectious Disease, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Kye Sook Kwon
- Division of Gastroenterology, Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon 22332, Republic of Korea
| | - Soo-Hyun Park
- Department of Hospital Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Young Ju Suh
- Department of Biomedical Sciences, Inha University School of Medicine, Incheon, South Korea
| | - Jung-Soo Kim
- Department of Hospital Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Hyungkil Kim
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Yong Woon Shin
- Division of Gastroenterology, Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
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30
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Park JH, Cho YC, Shin JH, Nouri Y, Kim JW, Kim JH, Ko HK. Temporary percutaneous radiologic gastrojejunostomy with single gastropexy. Acta Radiol 2021; 62:329-333. [PMID: 32517532 DOI: 10.1177/0284185120929707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although the effectiveness of percutaneous radiologic gastrojejunostomy (PRGJ) has been reported, a detailed description of the indications and clinical effectiveness of temporary PRGJ is still limited. PURPOSE To evaluate the clinical effectiveness and technical feasibility of temporary PRGJ using the modified Chiba-needle technique with single gastropexy. MATERIAL AND METHODS Temporary PRGJ using the modified Chiba-needle technique with single gastropexy was performed in 27 consecutive patients (19 men, 8 women; mean age = 61 years; age range = 32-77 years) for esophageal perforation (n = 18) or postoperative gastroparesis (n = 9). Outcomes analyzed included the technical and clinical success, procedure-related complications, and the tube indwelling period. RESULTS Technical and clinical success was achieved in all 27 patients. All the tubes were electively removed 19-364 days (mean indwelling period = 104 days) after confirmation of the possibility of oral intake. Asymptomatic pneumoperitoneum occurred in 2/27 (7.4%) patients as minor complications and was resolved spontaneously by the time of the one-week follow-up. There were no major complications. During the follow-up period, a total of 11 tube changes were performed in seven patients for an elective tube change within a six-month interval (n = 5) or because of tube occlusion (n = 6). CONCLUSION Temporary PRGJ using the modified Chiba-needle technique with a single gastropexy was clinically effective and technically feasible in patients with esophageal perforation or gastroparesis. It can provide adequate enteral nutrition during its temporary placement.
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Affiliation(s)
- Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, Republic of Korea
| | - Young Chul Cho
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yasir Nouri
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin-Hyoung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Heung-Kyu Ko
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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31
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Abstract
Enteral feeding in community settings is becoming increasingly common, and this article aims to help nurses and other healthcare professionals to refresh their knowledge of the important concepts in the community-based care of patients receiving enteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. The article provides an overview on the management and care of the patient, the basic principles surrounding the equipment used, identifying the wider team and essential communication to bear in mind, as well as the importance of tailoring a care plan to the individual's needs, taking into consideration cognition, mental health, social needs and other factors. The article also covers red flags that may be seen in the community after tube insertion that require immediate medical attention.
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Affiliation(s)
- Sarah Jane Palmer
- Registered nurse and freelance writer, based at the Department of Work and Pensions as a disability analyst
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32
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Chen MC, Chao HC, Yeh PJ, Lai MW, Chen CC. Therapeutic Efficacy of Nasoenteric Tube Feeding in Children Needing Enteral Nutrition. Front Pediatr 2021; 9:646395. [PMID: 33816405 PMCID: PMC8012528 DOI: 10.3389/fped.2021.646395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 02/08/2021] [Indexed: 11/24/2022] Open
Abstract
Background: There is limited information on therapeutic benefits and tube-related complications of pediatric nasoenteric (NE) tube feeding. We viewed, from different clinical aspects, NE tube feeding in children who are under intolerable conditions. Methods: A 10-years retrospective study enrolled 77 pediatric patients who underwent an endoscopic-guided placement of the NE tube for enteral nutrition. The evaluated data, including growth parameters, feeding volume, parenteral nutrition (PN) dependence, and nutritional markers [serum hemoglobin (Hb) and albumin] before and after NE tube feeding were compared. Tube-related complications and major adverse events were also recorded. Results: A total of 77 patients (including 50 males) underwent 176 endoscopic-guided placements of the NE tube with an average duration of 133.7 (6.0-1,847.3) days. The gastroesophageal reflux disease-related symptoms (vomiting, desaturations, and aspiration pneumonia) improved in 71.4% of patients. Feeding volume increased significantly after intervention, especially in patients with delayed gastric emptying, from 144.8 ± 28.5 to 1,103.1 ± 524.7 ml/days (p < 0.001). Weaning from PN was successfully achieved in 84.3% of patients with an average of 9.33 ± 7.30 days. About 16 patients (20.8%) were subsequently highly compatible with oral feeding after NE tube placement for an average of 24.7 ± 14.1 days. Patients either without neurologic dysfunction or with no ventilator-dependent status had a higher chance of shifting to oral feeding. Weight-for-age z-scores increased by 0.15 ± 1.33 after NE tube intervention. One NE tube-related adverse event, which caused bowel perforation at 6 days post-insertion, was recorded. No direct tube-related mortality was observed. Conclusions: Endoscopic-guided NE tube placement is a relatively safe, non-invasive procedure for pediatric patients who require enteral nutrition. Feeding via NE tube showed beneficial effects such as improvement in symptoms, PN weaning, and maintenance of body growth without major tube-related complications.
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Affiliation(s)
- Mi-Chi Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Hsun-Chin Chao
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,Chang Gung University College of Medicine, Taoyuan City, Taiwan
| | - Pai-Jui Yeh
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Ming-Wei Lai
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,Chang Gung University College of Medicine, Taoyuan City, Taiwan
| | - Chien-Chang Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,Chang Gung University College of Medicine, Taoyuan City, Taiwan
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33
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Ketsuwan S, Tanpowpong P, Ruangwattanapaisarn N, Phaopant S, Suppalarkbunlue N, Kooanantkul C, Anantasit N, Vaewpanich J. Intravenous Metoclopramide to Improve the Success Rate of Blind Bedside Post-pyloric Placement of Feeding Tube in Critically Ill Children: A Randomized, Double-Blind, Placebo-Controlled Study. Front Pediatr 2021; 9:739247. [PMID: 35004534 PMCID: PMC8727866 DOI: 10.3389/fped.2021.739247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/15/2021] [Indexed: 11/14/2022] Open
Abstract
Objective: Impaired gastric emptying is a common cause of delayed feeding in critically ill children. Post-pyloric feeding may help improve feeding intolerance and nutritional status and, hence, contribute to a better outcome. However, post-pyloric feeding tube insertion is usually delayed due to a technical difficulty. Therefore, prokinetic agents have been used to facilitate blind bedside post-pyloric feeding tube insertion. Metoclopramide is a potent prokinetic agent that has also been used to improve motility in adults and children admitted to intensive care units. The objective of this study was to determine the efficacy of intravenous metoclopramide in promoting the success rate of blind bedside post-pyloric feeding tube placement in critically ill children. Design: The design of this study is randomized, double blind, placebo controlled. Setting: The setting of the study is a single-center pediatric intensive care unit. Patients: Children aged 1 month-18 years admitted to the pediatric intensive care unit with severe illness or feeding intolerance were enrolled in this study. Intervention: Patients were randomly selected to receive intravenous metoclopramide or 0.9% normal saline solution (the placebo) prior to the tube insertion. The study outcome was the success rate of post-pyloric feeding tube placement confirmed by an abdominal radiography 6-8 h after the insertion. Measurements and Main Results: We found that patients receiving metoclopramide had a higher success rate (37/42, 88%) of post-pyloric feeding tube placement than the placebo (28/40, 70%) (p = 0.04). Patients who received sedative drug or narcotic agent showed a tendency of higher success rate (p = 0.08). Conclusion: Intravenous metoclopramide improves the success rate of blind bedside post-pyloric placement of feeding tube in critically ill children. Trial Registration: Thai Clinical Trial Registry TCTR20190821002. Registered 15th August 2019.
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Affiliation(s)
- Sirima Ketsuwan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pornthep Tanpowpong
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nichanan Ruangwattanapaisarn
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Supatra Phaopant
- Department of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nattanicha Suppalarkbunlue
- Clinical Pharmacy Department, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Nattachai Anantasit
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jarin Vaewpanich
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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34
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Gogna S, Samson D, Choi J, Con J, Prabhakaran K, Rhee P, Latifi R. The Role of Nutritional Access in Malnourished Elderly Undergoing Major Surgery for Acute Abdomen: A Propensity Score-Matched Analysis. Am Surg 2020; 87:1252-1258. [PMID: 33345560 DOI: 10.1177/0003134820973719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND About 50% of the elderly undergoing emergency abdominal surgery are malnourished. The role of timely surgical nutritional access in this group of patients is unknown. METHODS We analyzed the National Inpatient Sample database from 2009 through the first three-quarters of 2015 of patients aged ≥65 years who were malnourished and underwent major abdominal surgery for the acute abdomen within the first 2 days of hospital admission. RESULTS Of 3 246 721 patients analyzed, 4311 patients met inclusion criteria. Of these, only 507 (11.8%) patients had surgical nutritional access (gastrostomy or jejunostomy) (group I), while 3804 patients (88.2%) did not (group II). In the propensity score-matched population, there were 482 patients in each group. The patients in group I had lower odds of mortality and postoperative gastrointestinal complications (paralytic ileus, anastomotic dehiscence, and intestinal fistulae) (P-value <.01, respectively). DISCUSSION Elderly who receive surgical nutritional access have lower rates of gastrointestinal complications and mortality.
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Affiliation(s)
- Shekhar Gogna
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - David Samson
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - James Choi
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - Jorge Con
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - Kartik Prabhakaran
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - Peter Rhee
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
| | - Rifat Latifi
- Department of Surgery, New York Medical College Valhalla, 8138Westchester Medical Center, NY, USA
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Hopwood N, Elliot C, Moraby K, Dadich A. Parenting children who are enterally fed: How families go from surviving to thriving. Child Care Health Dev 2020; 46:741-748. [PMID: 32901970 DOI: 10.1111/cch.12808] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/30/2020] [Accepted: 09/02/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Complex feeding difficulties requiring enteral (tube) feeding affect everyone around the child. Parents experience additional stress and are at risk of social isolation. This study investigated the strategies families develop and use to adjust and adapt to enteral feeding so they were not just surviving but thriving as a family. METHODS Twenty parents whose children had been or continued to be enterally fed were interviewed, four of them twice as their experience of enteral feeding progressed. Learning theory was used to conceptualize findings in terms of changing use of tools that mediated parents' response to feeding-related challenges. RESULTS Parents encountered dilemmas relating to enteral feeding: maintaining participation in everyday activities, managing responses to the use of tubes for feeding, and doing what feels right for their child. They used four kinds of mediating tools to overcome these: memory aids and readiness tools, metaphors and narratives, repurposed everyday objects and personalized routines and materialities. CONCLUSIONS This novel account of tool used to resolve dilemmas provides an empirically and theoretically grounded basis for supporting parents to thrive despite the challenges of enteral feeding. Specifically, it can guide information given to help parents anticipate and cope with dilemmas arising from enteral feeding.
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Affiliation(s)
- Nick Hopwood
- School of International Studies and Education, University of Technology Sydney, Broadway, New South Wales, Australia.,Department of Curriculum Studies, Stellenbosch University, Matieland, South Africa
| | - Chris Elliot
- Department of Pediatrics, St George Hospital, Kogarah, New South Wales, Australia.,School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Community Child Health, Sydney Children's Hospitals Randwick, Sydney, New South Wales, Australia
| | - Khadeejah Moraby
- Central Early Childhood and Families Service, Allied Health, Women's and Children's Health Network, North Adelaide, South Australia, Australia.,Speech Pathology Department, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Ann Dadich
- School of Business, Western Sydney University, Penrith, New South Wales, Australia
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Sayadi Shahraki M, Berjis N, Bighamian A, Mahmoudieh M, Shahabi Shahmiri S, Sheikhbahaei E. Minimally invasive technique for gastrostomy tube insertion: A novel laparoscopic approach. Asian J Endosc Surg 2020; 13:610-613. [PMID: 31930718 DOI: 10.1111/ases.12780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 10/31/2019] [Accepted: 12/01/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Percutaneous endoscopic gastrostomy (PEG) is the most common way of inserting a gastrostomy tube. If PEG is not appropriate for a patient, then the laparoscopic or open technique should be used. Here, we introduce a new laparoscopic technique for inserting a gastrostomy tube. MATERIAL AND SURGICAL TECHNIQUE We used this new laparoscopic approach in 21 patients for whom PEG was not suitable. After marking on the abdominal skin and inserting the trocars, two 2-0 silk sutures were passed. Two stitches were placed 2 cm apart in the stomach with one hand. Each suture was pulled out with the fascia closure, the stomach was pulled out with a Babcock, and a purse-string suture using a round 2-0 silk suture was placed outside the stomach, creating a mushroom-retained gastrostomy. CONCLUSION This new laparoscopic technique is minimally invasive. It provides full control through only two trocars and required smaller incisions than common laparoscopic approaches. This method can be used to insert a gastrostomy tube in indicated patients when PEG placement is not suitable.
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Affiliation(s)
- Masoud Sayadi Shahraki
- Laparoscopic Surgery Fellowship, Isfahan Minimally Invasive Surgery and Obesity Research Center, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nezamoddin Berjis
- Otorhinolaryngology Department, Kashani University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Afshin Bighamian
- Department of Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Mahmoudieh
- Laparoscopic Surgery Fellowship, Isfahan Minimally Invasive Surgery and Obesity Research Center, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shahab Shahabi Shahmiri
- Laparoscopic Surgery Fellowship, Isfahan Minimally Invasive Surgery and Obesity Research Center, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Erfan Sheikhbahaei
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Balekuduru AB, Bongu SS, Mandalapu NB, Ramachandraiah G, Khemka VK, Subbaraj SB. Fluoroscopy-Assisted Percutaneous Endoscopic Gastrostomy (F-PEG)—Single-Center Experience and Outcome. JOURNAL OF DIGESTIVE ENDOSCOPY 2020. [DOI: 10.1055/s-0040-1716580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractBackground Gastrointestinal route is considered for feeding in subjects who are unable to swallow, either as a temporary or permanent option. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode for long-term enteral nutrition. The aim was to study the outcome of protocol-based PEG placement in a tertiary medical center.Materials and Methods All the patients who underwent PEG placement between January 2017 and December 2019 were included in the retrospective study. Study variables were entered into a uniform structured proforma. The procedure was done by two people using Ponsky-Gauderer pull-technique. Fluoroscopy guidance was considered for placement in special situations. Post-procedure, all the patients were regularly followed as per protocol to evaluate for adverse events.Results One hundred and eighteen patients with placement of PEG were included in the study. The mean age of the patients was 49.6 ± 7 years with 67.8% males. The most common indication of PEG was inability to swallow associated with head injury (43, 36.4%), followed by carcinoma esophagus (35, 29.8%) and stroke (24, 20.3%). Fluoroscopy was useful in 38 (32%) for PEG site identification. Tube dislodgement (16, 13.5%) and aspiration pneumonia (20, 16.9%) were the common adverse events. Age more than 60 years and dysphagia in neurologic disorders accounted for more than 60% of adverse events. Forty-nine (42%) of the PEG patients expired due to either primary illness or due to sepsis after a median time of 139 days (range: 32–288 days). There was no difference in the survival in patients with or without PEG-related complications (p = 0. 74).Conclusions Fluoroscopy assistance helps in accurate PEG placement in one third. Age > 60 years and dysphagia in neurologic disorders were independent risk factors associated with PEG tube complications.
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Affiliation(s)
| | - Shruti Sagar Bongu
- Department of Gastroenterology, M.S. Ramaiah Hospitals, Bangalore, Karnataka, India
| | | | | | - Vinit Kumar Khemka
- Department of Gastroenterology, M.S. Ramaiah Hospitals, Bangalore, Karnataka, India
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Parsi MA, Jirapinyo P, Abu Dayyeh BK, Bhutani MS, Chandrasekhara V, Krishnan K, Kumta NA, Melson J, Pannala R, Trikudanathan G, Trindade AJ, Sethi A, Watson RR, Maple JT, Lichtenstein DR. Techniques and devices for the endoscopic treatment of gastroparesis (with video). Gastrointest Endosc 2020; 92:483-491. [PMID: 32684298 DOI: 10.1016/j.gie.2020.03.3857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Gastroparesis is a symptomatic chronic disorder of the stomach characterized by delayed gastric emptying in the absence of mechanical obstruction. Several endoscopic treatment modalities have been described that aim to improve gastric emptying and/or symptoms associated with gastroparesis refractory to dietary and pharmacologic management. METHODS In this report we review devices and techniques for endoscopic treatment of gastroparesis, the evidence regarding their efficacy and safety, and the financial considerations for their use. RESULTS Endoscopic modalities for treatment of gastroparesis can be broadly categorized into pyloric, nonpyloric, and nutritional therapies. Pyloric therapies such as botulinum toxin injection, stent placement, pyloroplasty, and pyloromyotomy specifically focus on pylorospasm as a therapeutic target. These interventions aim to reduce the pressure gradient across the pyloric sphincter, with a resultant improvement in gastric emptying. Nonpyloric therapies, such as venting gastrostomy and gastric electrical stimulation, are intended to improve symptoms. Nutritional therapies, such as feeding tube placement, aim to provide nutritional support. CONCLUSIONS Several endoscopic interventions have shown utility in improving the quality of life and symptoms of select patients with refractory gastroparesis. Methods to identify which patients are best suited for a specific treatment are not well established. Endoscopic pyloromyotomy is a relatively recent development that may prove to be the preferred pyloric-directed intervention, although additional and longer-term outcomes are needed.
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Affiliation(s)
- Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Joshua Melson
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Rahul Pannala
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Guru Trikudanathan
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Amrita Sethi
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Rabindra R Watson
- New York-Presbyterian Medical Center/Columbia University Medical Center, New York, New York, USA
| | - John T Maple
- Department of Gastroenterology, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - David R Lichtenstein
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Abstract
Gastroparesis is characterized by delayed gastric emptying, with symptoms such as nausea, vomiting and abdominal pain, in the absence of mechanical obstruction. In most cases, it is idiopathic although diabetes mellitus is another leading cause. The physiology of gastric emptying is a complex process which is influenced by various inputs including the central nervous system, enteric nervous system and gut hormones. Developments in our understanding of gastroparesis have now demonstrated dysfunction in these systems, thus disrupting normal gastric emptying. Once mechanical obstruction is excluded, gastric scintigraphy remains the gold standard for diagnosis although wireless motility capsule and breath testing are alternative methods for diagnosis. Treatment for gastroparesis is challenging, and widely available therapies are often limited either by their poor evidence for efficacy or concerns over their long-term safety profile. Novel prokinetic agents have shown initial promise in clinical trials, and new endoscopic techniques such as gastric per-oral endoscopic myotomy are emerging. These new treatment modalities may provide an option in refractory gastroparesis with the adage of reduced morbidity compared to surgical treatments.
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Affiliation(s)
- A Sullivan
- Homerton University Hospital, London, UK
| | | | - A Ruban
- Department of Surgery and Cancer, Imperial College, London, UK.
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Abstract
Nutrition support involves the use of oral supplements, enteral tube feeding or parenteral nutrition. These interventions are considered when oral intake alone fails to meet nutritional requirements. Special diets and oral supplements are usually the first approach to managing malnutrition; however, their role becomes limited when oral intake is restricted or if swallowing is unsafe. Enteral tube feeding or parenteral nutrition are alternative means of providing nutrition support for this select group of patients. Percutaneous endoscopic gastrostomy (PEG) feeding was introduced into clinical practice in 1980. It describes a feeding tube placed directly into the stomach under endoscopic guidance. It is an established means of providing enteral nutrition to those who have functionally normal gastrointestinal tracts, but who cannot meet their nutritional requirements due to inadequate oral intake. The intervention is usually reserved when nutritional intake is likely to be inadequate for more than 4-6 weeks. Although the benefits of PEG have been shown for a select group of patients, there currently exists concerns about the increasing frequency of this intervention, and also uncertainty about the long-term benefits for certain patients. The 2004 UK National Confidential Enquiry into Patient Outcome and Death report emphasised this concern, with almost a fifth of PEG being undertaken for futile indications that negatively influenced morbidity and mortality. The present review paper discusses the indications for, controversies surrounding and complications of gastrostomy feeding and provides practical advice on optimising patient selection for this intervention.
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Complications of percutaneous gastrostomy and gastrojejunostomy tubes in children. Pediatr Radiol 2020; 50:404-414. [PMID: 31848639 DOI: 10.1007/s00247-019-04576-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/21/2019] [Accepted: 11/12/2019] [Indexed: 12/31/2022]
Abstract
Percutaneous feeding tubes are generally considered a safe option for enteral feeding and are widely used in children who require long-term nutritional support. However, complications are not infrequent and can range from bothersome to life-threatening. Radiologists should be familiar with the imaging appearances of potential complications for optimal patient care. In this review, we discuss radiologic appearances of common complications and less frequent but serious complications related to percutaneous feeding tubes. Additionally, as fluoroscopic feeding tube evaluation is often requested as the initial imaging study, we also discuss the fluoroscopic appearances of some uncommon complications.
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Mahmoud ME, Aldaraan KZ, Hassab MH, Aljabr SF. Schistosoma ova found in gastrostomy site granulation tissue. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2019.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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A Novel Method of Nasojejunal Feeding and Gastric Decompression Using a Double Lumen Silicone Tube for Upper Gastrointestinal Obstruction. Surg Laparosc Endosc Percutan Tech 2020; 30:106-110. [PMID: 31923160 DOI: 10.1097/sle.0000000000000754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Kvasnovsky CL, Rich BS, Denning NL, Kallis MP, Lipskar AM. Modified open technique for laparoscopic gastrostomy tube placement results in more leakage post operatively than Seldinger technique. Am J Surg 2019; 218:722-725. [DOI: 10.1016/j.amjsurg.2019.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/17/2019] [Accepted: 07/17/2019] [Indexed: 10/26/2022]
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Al-Obaid LN, Bazarbashi AN, Cohen ME, Kim J, Lei Y, Axelrad JE, Fox A, Chandra S, Gordon FD. Enteric tube placement in patients with esophageal varices: Risks and predictors of postinsertion gastrointestinal bleeding. JGH OPEN 2019; 4:256-259. [PMID: 32280774 PMCID: PMC7144797 DOI: 10.1002/jgh3.12255] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 08/16/2019] [Indexed: 12/12/2022]
Abstract
Background and Aim Enteric tube (ET) placement is approached with caution in patients with esophageal varices (EV) due to concern of causing variceal bleeding. Data are limited on rates and predictors of gastrointestinal bleeding (GIB) in these patients. This study aims to assess the rate and predictors of bleeding from EV after ET placement. Methods We performed a retrospective chart review on patients requiring ET access with known EV. Inclusion criteria were age >18 with endoscopically proven EV who required ET placement. Patients who were admitted with, or developed a GIB prior to placement of ET were excluded, as were patients admitted for liver transplantation. Primary outcome was incidence of GIB within 48 h of tube placement. Secondary outcome was a >2 g/dL drop in hemoglobin within 48 h of placement without evidence of bleed. Statistical analysis was performed using Fischer's exact test, Mann-Whitney U test, and univariate logistic regression model. Results A total of 75 patients were included in the analysis. The most common etiology of cirrhosis was alcohol (44%). The most common location of EV was in the lower third of the esophagus (61%). The primary outcome was observed in 11 (14.6%) patients. The secondary outcome was found in eight (10.6%) patients. On univariate analysis, GIB was associated with higher MELD-Na (P = 0.026) and EV located in the lower third of the esophagus (P = 0.048). Conclusion ET placement in patients with EV is associated with low risk of bleeding. Elevated MELD-Na and lower EV location conferred a higher risk of bleeding after ET placement.
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Affiliation(s)
- Lolwa N Al-Obaid
- Department of Internal Medicine Lahey Hospital and Medical Center Burlington Massachusetts USA
| | - Ahmad Najdat Bazarbashi
- Department of Medicine New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Margot E Cohen
- Department of Medicine New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Judith Kim
- Department of Medicine New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Yuxiu Lei
- Division of Pulmonary and Critical Care Medicine Lahey Hospital and Medical Center Burlington Massachusetts USA
| | - Jordan E Axelrad
- Department of Medicine New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Alyson Fox
- Division of Gastroenterology and Hepatology New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Subani Chandra
- Division of Pulmonary and Critical Care Medicine New York-Presbyterian/Columbia University Medical Center New York City New York USA
| | - Fredric D Gordon
- Division of Transplantation and Hepatobiliary Diseases Lahey Hospital and Medical Center Burlington Massachusetts USA
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Cano JJ, Thrift AP, El-Serag HB. Prospective implementation of algorithmic patient selection for gastrostomy tube placement consultations: a pre- and post-intervention analysis. Clin Exp Gastroenterol 2019; 12:231-237. [PMID: 31213872 PMCID: PMC6549408 DOI: 10.2147/ceg.s197122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/13/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Studies have shown high but variable mortality following gastrostomy tube (GT) placement. There are no standard practice guidelines for GT placement. Aim: To evaluate if implementation of patient selection and prognosis algorithms for GT insertion has favorable effects on patient outcomes. Methods: This was a pre-, post-cohort analysis in a Veterans Affairs hospital. We implemented a patient selection algorithm aided by the Sheffield Gastrostomy Scoring System (SGSS) in July 2015. We reviewed all referrals to the inpatient service for a GT between July 2014 and June 2016 (pre-, post- implementation), and collected albumin and SGSS at time of consultation, date of GT insertion, and outcomes including vital status and albumin 30 days post-consultation. Patients were followed until 30 October 2016. We compared outcomes pre- and post-implementation. Results: A total of 126 referrals were reviewed, 68 pre- and 58 post-algorithm implementation. Seventy-seven GTs were placed; 58 (75.3%) fulfilled the algorithm-appropriate indications. The mean SGSS was significantly lower among patients in whom GT was placed for algorithm-appropriate indications 2.03 (SD =0.86) vs inappropriate indications (2.59, SD =0.63; p<0.001). Sixty-five (51.6%) patients died by conclusion of study. Thirty day mortality after GT placement was 26.2% (post- (22.4%) vs pre- (29.4%)). Changes in serum albumin at day 30 was non-significant. Conclusion The use of algorithm guidance by the prospective use of the SGSS was associated with a higher likelihood of GT placement both overall and for algorithm-appropriate indications.
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Affiliation(s)
- Joseph J Cano
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Department of Medicine, Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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de Vasconcellos Santos FA, Torres Júnior LG, Wainstein AJA, Drummond-Lage AP. Jejunostomy or nasojejunal tube after esophagectomy: a review of the literature. J Thorac Dis 2019; 11:S812-S818. [PMID: 31080663 DOI: 10.21037/jtd.2018.12.62] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Patients undergoing esophagectomy for cancer are a difficult to treat group of patients. At diagnosis they will present some degree of malnutrition in up to 80% and the causes are from multifactorial origin: the inability of food ingestion, advanced age, taste disturbances, and morbidity related to neoadjuvant treatment. In order to restaure the nutritional status, enteral nutritional support is preferable to parenteral support because of the risks of septic complications associated with venous catheters. During the postoperative period, the oral route is often inaccessible in these patients due to swallowing disorders and eventually mechanical ventilation, and if possible, often it does not provide sufficient caloric amounts for postoperative energy balance. For these reasons, it is usually recommended additional nutritional support. There are few studies in the literature that specifically address which is the most adequate route for enteral nutrition in patients undergoing esophagectomy. Nasojejunal catheters present a higher incidence of local complications, such as displacement and occlusion, whereas jejunostomy is more associated with reinterventions for the treatment of complications secondary to extravasation. Although there is weak evidence in the literature and a lack of randomized, prospective and multicenter studies evaluating the best enteral nutrition route in the postoperative period of esophagectomy, the use of the nasoenteric catheter seems to be adequate due to its simplicity of positioning and low rates of severe complications. In this paper a review is performed of the evidence about this subject.
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Affiliation(s)
- Fernando Augusto de Vasconcellos Santos
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG, Brazil.,Departmet of Surgery, Hospital Governador Israel Pinheiro, Belo Horizonte, MG, Brazil
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Abstract
BACKGROUND AND OBJECTIVES Children who become tube-dependent need specialized treatment in order to make the transition to oral feeding. Little is known about long-term effects of tube weaning programs. This study analyzes long-term effects (outcome, growth, and nutrition data) in a large sample of formerly tube-dependent children 1 to 6 years after participation in tube weaning programs, based on the "Graz model of tube weaning." METHODS Parents of children who completed a tube weaning program between 2009 and 2014 (N = 564) were asked to complete a questionnaire on their child's growth and nutrition. Data was analyzed using SPSS V22.0 for Windows (SPSS, Chicago, IL). RESULTS Response rate was 47.16% (N = 266). Seven children had died between completion of the program and the long-term follow-up. Two hundred and thirty-nine children (92.3%) were still exclusively orally fed 1 to 6 years after completion of the weaning program, 17 children (6.6%) were partially tube-fed. Three children were completely tube-fed (1.1%). Growth data showed no significant changes in zBMI (World Health Organization standards z values for body mass index) between completion of weaning and long-term follow-up. Provided data on nutrition of fully orally fed patients showed that most children (N = 162, 68%) were eating an age-appropriate diet, whereas a small percentage (N = 10, 4%) were fed with a high-caloric formula, a selective diet (N = 12, 5%), or a liquid/pureed diet (N = 55, 23%). CONCLUSIONS Many children who undergo a tube weaning program based on the "Graz model of tube weaning" are able to stay on full oral feeds in the years after completion of the wean without deterioration of growth.
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Farrag K, Shastri YM, Beilenhoff U, Aksan A, Stein J. Percutaneous endoscopic gastrostomy (PEG): a practical approach for long term management. BMJ 2019; 364:k5311. [PMID: 30670385 DOI: 10.1136/bmj.k5311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Karima Farrag
- Department of Gastroenterology and Clinical Nutrition, DGD Clinics Sachsenhausen, Frankfurt am Main, 60594 Frankfurt am Main, Germany
- Interdisciplinary Crohn Colitis Centre Rhein-Main, 60594 Frankfurt am Main, Germany
| | | | - Ulrike Beilenhoff
- Scientific Secretariat, European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA), 89075 Ulm, Germany
| | - Ayşegül Aksan
- Interdisciplinary Crohn Colitis Centre Rhein-Main, 60594 Frankfurt am Main, Germany
- Faculty of Health Sciences, Hacettepe University, 06532 Ankara, Turkey
| | - Jürgen Stein
- Department of Gastroenterology and Clinical Nutrition, DGD Clinics Sachsenhausen, Frankfurt am Main, 60594 Frankfurt am Main, Germany
- Interdisciplinary Crohn Colitis Centre Rhein-Main, 60594 Frankfurt am Main, Germany
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Mason CA, Skarda DE, Bucher BT. Outcomes After Laparoscopic Gastrostomy Suture Techniques in Children. J Surg Res 2018; 232:26-32. [DOI: 10.1016/j.jss.2018.05.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/05/2018] [Accepted: 05/17/2018] [Indexed: 12/19/2022]
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