Inadvertent tracheobronchial placement of feeding tubes

Seventeen adult patients in whom small-diameter, flexible-tipped feeding tubes had been inadvertently placed in the lung were identified during a 22-month period. In nine patients pneumothorax developed, all cases due to transpleural passage of small-diameter (2.7-mm) feeding tubes. In one of these patients, hydropneumothorax and subsequent empyema developed. Placement of larger diameter (4.3-mm) feeding tubes did not lead to pneumothorax, but pneumonitis developed in one patient after intrapulmonary instillation of antacid solution. Of the 17 patients, 15 had impaired mental status or diminished gag, cough, or swallowing reflexes; the remaining two were pharmacologically sedated during the procedure. Radiographic confirmation of feeding tube placement is essential to avoid these complications, with particular attention paid to the course of the tube.     

Pneumothorax after removal of misplaced nasoenteric feeding tubes

We report three cases of pneumothorax secondary to inadvertent nasopulmonary intubation with feeding tubes. In all three cases, pneumothorax was not present on the initial radiograph that demonstrated the misplaced tube but developed only after removal of the feeding tube. We therefore recommend that clinicians and radiologists maintain a high index of suspicion for delayed pneumothorax after removal of misplaced feeding tubes.     

Iatrogenic bronchopleural fistula caused by feeding tube insertion

Nutritional supplements administered through flexible small caliber feeding tubes are an increasingly popular substitute for parenteral hyperalimentation. Small and large caliber nasogastric tubes can inadvertently pass into the tracheobronchial tree, even in the presence of an endotracheal tube with an inflated cuff. We report three patients who had small caliber feeding tubes passed through the tracheobronchial tree perforating into the pleural space. Potential complications include immediate or delayed pneumothorax, tension pneumothorax, hydropneumothorax, and empyema. Prompt post-insertion chest radiography is required to verify correct placement of small caliber feeding tubes.     

Fluoroscopically guided percutaneous gastrostomy and gastroenterostomy: analysis of 158 consecutive cases

We reviewed our experience with 158 consecutive patients who underwent either percutaneous gastrostomy or percutaneous gastroenterostomy during a 2-year period. The catheters used included Foley catheters (36), Cope-type gastric catheters (86), or Carey-Alzate-Coons gastrojejunostomy catheters (36). Gastrojejunostomy tubes were placed in patients with gastroesophageal reflux or aspiration, gastric atony, or partial gastric obstruction. Ninety percent of the tubes were placed for feeding purposes. The technical success rate was 100%. Thirty-day follow-up was obtained in 89%. Thirty-day mortality was 26%, reflecting the substantial number of debilitated patients. No deaths were directly related to tube placement. Major morbidity was 6% and included hemorrhage, peritonitis, tube migration, and sepsis. Minor morbidity was 12%. There was no difference in 30-day mortality or feeding tolerance between the tube types (p less than .05). Patients with Foley catheters had more complications necessitating surgical intervention and an increased incidence of tube changes required within 30 days. These were the only statistically significant differences between the tubes (p less than .05). Our results show that percutaneous gastrostomy is a safe and effective means of gastroenteric feeding or decompression. Because of the fewer complications and ease of insertion, the Cope type of gastrostomy tube has become our preferred catheter for percutaneous feeding or decompression.     

Enteral feeding tubes: placement by using fluoroscopy and endoscopy

Fluoroscopy and endoscopy are both effective for guiding placement of enteral feeding tubes, but the relative advantages and limitations of the two methods are less clear. Consequently, we studied 104 consecutive patients referred for primary fluoroscopic placement of a Frederick-Miller feeding catheter. Success rate, fluoroscopic and room times, and tube position were determined. Unsuccessful fluoroscopic placement was followed immediately by an endoscopic attempt. The success rate for fluoroscopic placement was 90% (94/104), with the tube placed into the jejunum in 53% and into the duodenum in 47%. The fluoroscopic and room times for successful fluoroscopic placements were 8.6 +/- 5.6 min (mean +/- SD) and 21.7 +/- 8.4 min, respectively. For the 10 unsuccessful placements, the fluoroscopic and room times were 16.2 +/- 5.4 min (mean +/- SD) and 45.6 +/- 18.4 min, respectively. Both time differences were significant statistically. Endoscopic placement was successful in all seven patients in whom it was attempted, with a mean time of 13.4 min. The tubes placed endoscopically were in the jejunum in 29% and in the duodenum in 71%. Our results show that fluoroscopic and endoscopic placement of enteral feeding tubes is highly effective. Fluoroscopic time in successful cases is usually less than 15 min. Endoscopic placement of feeding tubes is successful after fluoroscopic failure.     

Fluoroscopic insertion of post-pyloric feeding tubes: success rates and complications

AIM: To examine the success and complication rates of radiological placement of post-pyloric feeding tubes, including those inserted with the assistance of a guide-wire. MATERIALS AND METHODS: Two hundred referrals (156 patients), between the dates of 5 April 2002 and 10 September 2004, were identified retrospectively from computerized records. Subsequently, the radiology reports and patients' notes were reviewed to evaluate the indications for post-pyloric feeding, success of placement, use of a guide-wire, and any complications. RESULTS: A post-pyloric tube was placed in the distal duodenum/jejunum in 183 (91.5%) patients and in the proximal duodenum or distal stomach in six (3%). A tube could not be inserted in 11 (5.5%) patients, and 51 (25.5%) of the insertions required the use of a guide-wire. Immediate complications were recorded in seven patients (3.5%): vomiting (n=5); hypotension and apnoea requiring naloxone (n=1) and hypoxia requiring endotracheal intubation (n=1). CONCLUSION: Radiological placement of post-pyloric feeding tubes has a success rate comparable with endoscopically placed tubes, and it rarely involves significant technique-related complications.     

烧伤病人多条体内插管的护理观察

目的：烧伤病人接受单一留置插管的机会较多，但严重烧伤病人同时接受多条留置插管的机会并非少见。为进一步了解烧伤病人同时接受多条留置插管的护理经验，我们对严重烧伤病人同时留置两条或两条以上的病历资料进行了复习。方法：归纳、分析2001年以来，同时接受两条或两条以上留置插管烧伤病人的护理资料，主要统计指标为：留置插管种类，分布比例，留置时间，并发症。结果：经鼻吸氧导管占83．3％，留置尿管占70．8％，静脉插管占33．3％，胃肠减压管占16．7％，鼻饲导管和气管插管各占4．2％；留置时间最长者为静脉置管，未并发感染等并发症。结论：烧伤病人同时接受两条或两条以上留置插管的机会较多，应引起医护人员的重视。     

Fluoroscopically Guided Three-Tube Insertion for the Treatment of Postoperative Gastroesophageal Anastomotic Leakage

Objective

To retrospectively evaluate the feasibility and effectiveness of three-tube insertion for the treatment of postoperative gastroesophageal anastomotic leakage (GEAL).

Materials and Methods

From January 2007 to January 2011, 28 cases of postoperative GEAL after an esophagectomy with intrathoracic esophagogastric anastomotic procedures for esophageal and cardiac carcinoma were treated by the insertion of three tubes under fluoroscopic guidance. The three tubes consisted of a drainage tube through the leak, a nasogastric decompression tube, and a nasojejunum feeding tube. The study population consisted of 28 patients (18 males, 10 females) ranging in their ages from 36 to 72 years (mean: 59 years). We evaluated the feasibility of three-tube insertion to facilitate leakage site closure, and the patients'' nutritional benefit by checking their serum albumin levels between pre- and post-enteral feeding via the feeding tube.

Results

The three tubes were successfully placed under fluoroscopic guidance in all twenty-eight patients (100%). The procedure times for the three tube insertion ranged from 30 to 70 minutes (mean time: 45 minutes). In 27 of 28 patients (96%), leakage site closure after three-tube insertion was achieved, while it was not attained in one patient who received stent implantation as a substitute. All patients showed good tolerance of the three-tube insertion in the nasal cavity. The mean time needed for leakage treatment was 21 ± 3.5 days. The serum albumin level change was significant, increasing from pre-enteral feeding (2.5 ± 0.40 g/dL) to post-enteral feeding (3.7 ± 0.51 g/dL) via the feeding tube (p < 0.001). The duration of follow-up ranged from 7 to 60 months (mean: 28 months).

Conclusion

Based on the results of this study, the insertion of three tubes under fluoroscopic guidance is safe, and also provides effective relief from postesophagectomy GEAL. Moreover, our findings suggest that three-tube insertion may be used as the primary procedure to treat postoperative GEAL.     

Percutaneous radiologic gastrostomy using push-type gastrostomy tubes with CT and fluoroscopic guidance

OBJECTIVE: The purpose of this study was to evaluate the safety and feasibility of percutaneous radiologic gastrostomy with endoscopic push-type gastrostomy tubes using CT and fluoroscopic guidance. CONCLUSION: Percutaneous radiologic gastrostomy using CT and fluoroscopic guidance with push-type tubes is a safe and effective means of gastric feeding that has few complications and offers an alternative to introducer-placed gastrostomy tubes.     

Replacement of Mushroom Cage Gastrostomy Tube Using a Modified Technique to Allow Percutaneous Replacement with an Endoscopic Tube in Patients with Amyotrophic Lateral Sclerosis

Radiologic inserted gastrostomy (RIG) is the preferred method in our institution for enteral feeding in amyotrophic lateral sclerosis (ALS). Skin-level primary-placed mushroom cage gastrostomy tubes become tight with weight gain. We describe a minimally invasive radiologic technique for replacing mushroom gastrostomy tubes with endoscopic mushroom cage tubes in ALS. All patients with ALS who underwent replacement of a RIG tube were included. Patients were selected for a modified replacement when the tube length of the primary placed RIG tube was insufficient to allow like-for-like replacement. Replacement was performed under local anesthetic and fluoroscopic guidance according to a preset technique, with modification of an endoscopic mushroom cage gastrostomy tube to allow percutaneous placement. Assessment of the success, safety, and durability of the modified technique was undertaken. Over a 60-month period, 104 primary placement mushroom cage tubes in ALS were performed. A total of 20 (19.2%) of 104 patients had a replacement tube positioned, 10 (9.6%) of 104 with the modified technique (male n = 4, female n = 6, mean age 65.5 years, range 48–85 years). All tubes were successfully replaced using this modified technique, with two minor complications (superficial wound infection and minor hemorrhage). The mean length of time of tube durability was 158.5 days (range 6–471 days), with all but one patient dying with a functional tube in place. We have devised a modification to allow percutaneous replacement of mushroom cage gastrostomy feeding tubes with minimal compromise to ALS patients. This technique allows tube replacement under local anesthetic, without the need for sedation, an important consideration in ALS.     

X线透视下经鼻十二指肠营养管的置入及临床应用

目的探讨X线透视下十二指肠营养管的置入及其临床应用价值。方法从2003年6月3日至2007年8月17日,59例患者在X线透视下行经鼻十二指肠营养管置入,置管成功后营养管末端位于十二指肠空肠连接部。结果59例患者中首次成功放置空肠营养管57例,成功率96.6%,2例患者因明显胃扩张首次置管失败后在充分胃肠减压后置管成功。置管时间为3.9～68.6 min,平均17.8 min。置管中及置管后未发生严重并发症。结论X线透视下经鼻十二指肠营养管置入是一种安全、经济、有效的肠内营养途径,因而具有广泛的临床应用价值。     

Gastrointestinal interventional radiology. Technics and preliminary results

Gastrointestinal interventional radiology allows the positioning of feeding tubes in difficult situations, as well as the balloon dilatation of stenoses and the transintestinal drainage of fistulas and collections, with some advantages over endoscopic and surgical procedures. In the present series feeding tubes were positioned in 26 patients, both to get over the strictures in the upper gastrointestinal tract and to exclude fistulous tracts or anastomotic leaks from alimentary transit. Balloon dilatation was performed in 10 patients with stenoses of different aetiologies, at different levels of the gastrointestinal tract: in all cases the clinical symptoms diminished. All the 7 non-neoplastic stenoses were successfully treated (follow-up 6-27 months). The draining of abscesses through the enteric fistulous tract did allow the reduction/resolution of all collections in a short time. These procedures are simple and safe, and help to reduce the interval between diagnosis and therapy. Their failure does not prevent the use of other therapeutic procedures.     

Stability of Balloon-Retention Gastrostomy Tubes with Different Concentrations of Contrast Material: In Vitro Study

The purpose of this study was to determine the performance of two balloon-retention-type gastrostomy tubes when the balloons are inflated with two types of contrast materials at different concentrations. Two commonly used balloon-retention-type tubes (MIC and Tri-Funnel) were inflated to the manufacturer’s recommended volumes (4 and 20 cm³, respectively) with normal saline or normal saline plus different concentrations of contrast material. Five tubes of each brand were inflated with normal saline and 0%, 25%, 50%, 75%, and 100% contrast material dilutions, using either nonionic hyperosmolar contrast, or nonionic iso-osmolar contrast. The tubes were submerged in a glass basin containing a solution with a pH of 4. Every week the tubes were visually inspected to determine the integrity of the balloons, and the diameter of the balloons was measured with a caliper. The tests were repeated every week for a total of 12 weeks. The MIC balloons deflated slightly faster over time than the Tri-Funnel balloons. The Tri-Funnel balloons remained relatively stable over the study period for the different concentrations of contrast materials. The deflation rates of the MIC balloons were proportionally related to the concentration of saline and inversely related to the concentration of the contrast material. At high contrast material concentrations, solidification of the balloons was observed. In conclusion, this in vitro study confirms that the use of diluted amounts of nonionic contrast materials is safe for inflating the balloons of two types of balloon-retention feeding tubes. High concentrations of contrast could result in solidification of the balloons and should be avoided.     

Comparison of Primary Jejunostomy Tubes versus Gastrojejunostomy Tubes for Percutaneous Enteral Nutrition

PurposeTo evaluate technical success and long-term outcomes of percutaneous primary jejunostomy tubes for postpyloric enteral feeding compared with percutaneous gastrojejunostomy (GJ) tubes.Materials and MethodsOver a 25-month interval, 41 consecutive patients (26 male; mean age, 55.9 y) underwent attempted fluoroscopy-guided direct percutaneous jejunostomy tube insertion. Insertions at previous jejunostomy tube sites were excluded. The comparison group consisted of all primary GJ tube insertions performed over a 12-month interval concomitant with the jejunostomy tube interval (N = 169; 105 male; mean age, 59.4 y). Procedural, radiologic, and clinical data were retrospectively reviewed. Intervention rates were expressed as events per 100 catheter-days.ResultsThe technical success rate for percutaneous jejunostomy tube insertion was 96%, versus 93% for GJ tubes (P = .47). Mean fluoroscopy times were similar for jejunostomy and GJ tubes (9.8 vs 10.0 min, respectively; P value not significant). Jejunostomy tubes exhibited a lower rate of catheter dysfunction than GJ tubes, with catheter exchange rates of 0.24 versus 0.93, respectively, per 100 catheter-days (P = .045). GJ tube tip retraction into the stomach occurred in 9.5% of cases, at a rate of 0.21 per 100 catheter-days. Intervention rates related to leakage were 0.19 and 0.03 for jejunostomy and GJ tubes, respectively (P < .01). Jejunostomy and GJ tubes exhibited similar rates of catheter exchange for occlusion and replacement as a result of inadvertent removal. No major complications were encountered in either group.ConclusionsPercutaneous insertion of primary jejunostomy tubes demonstrated technical success and complication rates similar to those of GJ tubes. Jejunostomy tubes exhibited a lower dysfunction rate but a higher leakage rate compared with GJ tubes.     

Assessment of complication rates based on time of feeding initiation in radiologically guided gastrostomy tubes: a retrospective study

PURPOSEWe aimed to assess the association between complication rate and time to feeding in a cohort of patients undergoing radiologically guided placement of gastrostomy tubes.METHODSA retrospective study was conducted of all patients receiving pull-type and push-type gastrostomy tubes placed by interventional radiologists between January 1^st, 2017 and December 31^st, 2018 at a single institution. Primary outcomes included procedural and tube-related complications per medical chart review with a follow-up interval of 30 days. Exclusion criteria were enteral nutrition delayed more than 48 hours, no feeding information, and tubes placed for venting (n=20). Overall, 303 gastrostomy tubes (pull-type, n=184; push-type, n=119) were included. The most common indications for placement included head and neck carcinoma for push-type tubes (n=76, 63.9%) and cerebral vascular accident for pull-type tubes (n=78, 42.4%).RESULTSIn a multiple regression analysis, there was no statistically significant association between complications and time to feeding (p = 0.096), age (p = 0.758), gender (p = 0.127), indication for tube placement (p = 0.206), or type of tube placed (p = 0.437). Average time to initiation of enteral nutrition was 12.3 hours for the pull-type and 21.7 hours for the push-type cohort (p < 0.001). Additional multiple regression analyses of pull-type tubes and push-type tubes separately also did not find any significant association between complications and the above factors (p > 0.05).CONCLUSIONThere was no statistically significant correlation between time to feed and complications, suggesting that there is no clinical difference between early and late feeding following gastrostomy tube placement.

Percutaneous radiologic gastrostomy is a well-established safe and effective feeding method (1–5). Early initiation of feeding after tube placement has several benefits, including decreased hospital stay and shorter time on intravenous nutrition, but the theoretical risk of increased complication rate has led many physicians to delay feeding initiation. While several studies have found that early initiation of feeding after tube placement is safe in the endoscopic literature (6–10), the association between time to feed and complications has been less frequently studied in the radiologic literature. Studies that have done so have been limited in the methods of tube placement included, sample size, and types of patients included (11, 12). Furthermore, despite evidence in the endoscopic literature, many physicians do not initiate early feeding after either endoscopic or radiologic gastrostomy placement (13).Within interventional radiology, the time to initiation of enteric feeding is one variable that remains discrepant between institutions and may pose consequence with respect to complications in the early post-placement setting (6–9, 11, 14, 15). Fora of interventional radiologists have demonstrated physicians are using a wide variety of fasting times following tube placement ranging from “early” (commonly less than 6 hours) to “delayed” (commonly 24 hours or greater) that is neither directly based on evidence nor guideline based (16). Furthermore, time to feeding following gastrostomy remains an important clinical metric that may impact initiation of therapy, feeding, and hospital discharge. The purpose of this study was to analyze the rate of feeding related complications in a cohort of all patients undergoing either “push” or “pull” type radiologic gastrostomy placement at a single institution based on time to initiation of feeding following tube placement.     

Traumatic complications from placement of thoracic catheters and tubes

The volume of critically ill patients requiring stabilization in emergency departments (EDs) throughout the USA has increased from 42 million per year in 1960 to over 92 million in 1990, as reported by Goldstein [Crit Care Clinics 21(1):81–89, 2005] and Rivers et al. [Curr Opin Crit Care 8(6):600–606, 2002]. With the increase in this patient population, the number of procedures, both invasive and noninvasive, performed in the ED to improve clinical outcomes has also increased. Therefore, emergency medicine physicians must add to their repertoire the ability to recognize potentially fatal traumatic complications. This review will provide readers with imaging findings of traumatic complications from placement of thoracic catheters and tubes and briefly discuss pitfalls of performing these procedures. In particular, complications arising from placement of hemodialysis catheters, central venous catheters, Swan–Ganz catheters, chest tubes, nasogastric and feeding tubes, and endotracheal tubes will be reviewed.     

Initial Experience with Computed Tomography and Fluoroscopically Guided Placement of Push-Type Gastrostomy Tubes Using a Rupture-Free Balloon Catheter

The purpose of this study was to evaluate the safety and feasibility of percutaneous radiologic gastrostomy placement of push-type gastrostomy tubes using a rupture-free balloon (RFB) catheter under computed tomography (CT) and fluoroscopic guidance. A total of 35 patients (23 men and 12 women; age range 57–93 years [mean 71.7]) underwent percutaneous CT and fluoroscopically guided gastrostomy placement of a push-type gastrostomy tube using an RFB catheter between April 2005 and July 2008. Technical success, procedure duration, and complications were analyzed. Percutaneous radiologic gastrostomy placement was considered technically successful in all patients. The median procedure time was 39 ± 13 (SD) min (range 24–78). The average follow-up time interval was 103 days (range 7–812). No major complications related to the procedure were encountered. No tubes failed because of blockage, and neither tube dislodgement nor intraperitoneal leakage occurred during the follow-up period. The investigators conclude that percutaneous CT and fluoroscopically guided gastrostomy placement with push-type tubes using an RFB catheter is a safe and effective means of gastric feeding when performed by radiologists.     

Fluoroscopically guided nasoenteric feeding tube placement: results of a 1-year study

Nasoenteric tube feeding is a widely used alternative to parenteral intravenous nutritional support or gastrostomy tube placement. Unmonitored tube passage may result in complications and delays the beginning of tube feedings. The authors studied the results of 882 fluoroscopically guided feeding tube placements in 448 patients in 1 year to determine rates of success and complications, as well as the long-term outcome of this population of patients. Seven hundred sixty-four attempts (86.6%) were successful in positioning the tube distal to the third portion of the duodenum. Four major complications (three fatal arrhythmias and one tracheobronchial injury) were encountered. Only seven patients (2%) experienced aspiration events that were due to positioning of the tube in the distal duodenum. Seventy-seven percent of patients required either one or two tubes; the average "tube life" was 7.8 days. Most repositionings were required because of patient noncompliance or inappropriate administration of solid medications. Fluoroscopically guided nasoenteric tube passage is safe, easily performed, and highly successful, and has resulted in widespread clinical acceptance in our institution.     

Perkutane Gastrostomie mit Ballon-PEG-Ersatzsonden durch den Radiologen Eine interventionelle Technik zur einfachen Einlage von Ernährungskathetern ohne chirurgischen oder endoskopischen Eingriff

Patients afflicted with stenotic head and neck or esophageal tumors often require artificial enteral feeding. Frequently passage of an endoscope through the esophagus is impossible in these patients. Interventional, fluoroscopically assisted, percutaneous gastrostomy (PG) by balloon replacement tubes is a feasible and successful alternative to percutaneous endoscopic gastrostomy (PEG) and the method of choice in patients where the esophagus cannot be passed with an endoscope anymore. Technical success rate is very high and serious complications are rare. Radiological PG is a feasible, equivalent alternative to PEG also in all other patients. We recommend PG with ballon gastrostomy tubes in conjunction with gastropexy performed with three to four T-fasteners, which are left in place for seven days in order to prevent dislocation and leakage.     

带膜可回收支架置入治疗自发性食管破裂（附8例报告）

目的：探讨带膜支架置入治疗自发性食管破裂。方法：8例自发性食管破裂患者均先放置胸腔闭式引流,冲洗胸腔,通过导丝经口置入带膜可回收支架,经口进食,每天经胸腔引流管冲洗胸腔,5-7 d拔除胸引管及鼻腔冲洗管,1个月后取出支架。结果：全部病例支架均置入成功,恢复正常进食,1个月后取出支架,正常进食结论：带膜支架置入治疗食管自发性破裂安全有效的方法,其疗效确切,宜在临床上推广使用。