X线透视下超滑导丝辅助放置鼻空肠营养管的操作技术

目的:解决需肠内营养(EN)治疗病人的营养治疗途径问题. 方法:在既往操作经验的基础上,运用“九字诀”法行X线透视下超滑导丝辅助放置鼻空肠营养管. 结果:本组共置管162例次,成功159例次,成功率为98.15％.鼻空肠营养管放置位置符合EN治疗要求.置管时间为5～30(10.8 ±4.9)min. 结论:运用“九字诀”法行X线透视下超滑导丝辅助放置鼻空肠营养管具有无创、简单、快捷,是临床EN治疗途径首选的置管方式.     

X线辅助超滑导丝法置鼻空肠营养管

目的:解决上消化道存在功能和(或)解剖连续性中断的病人实施非永久性肠内营养支持的途径问题.方法:采用X线辅助超滑导丝法置鼻空肠营养管.结果:置管成功率为97.96%,操作时间为5～11(平均7.4±2.8)min;导管位置全部符合临床实施肠内营养支持要求,导管留置时间为28～92(平均84.4±7.2)天.置管、导管留置、经导管实施肠内营养支持过程中所有病人耐受良好,无不适及并发症发生.结论:X线辅助超滑导丝法置鼻空肠营养管,是解决上消化道存在功能和(或)解剖连续性中断的病人实施非永久性肠内营养支持途径问题的首选之道.     

内镜下放置鼻空肠管在危重病人的应用

目的:总结危重病人内镜辅助下床边放置鼻空肠管的经验,探讨内镜置管的具体方法及其在危重病人中的应用.方法:1997年1月至2005年1月间共107例重症病人接受内镜辅助下放置鼻空肠管,观察置管的时间、成功率、并发症及留置时间.结果:置管时间为(12.3±7.8)min,成功率为98.1%,未发生置管相关并发症,置管后并发症发生率为2.8%(3/107).导管留置时间为(20.7±8.4)d.结论:内镜辅助放置鼻空肠管具有简单、快捷、安全,易于护理、病人痛苦小和易于耐受等优点,尤其适于危重病人使用.     

介入方法在胃镜下鼻空肠营养管困难置管中的应用

目的:评价对胃镜直视下鼻空肠营养管困难置管的病人,应用介入方法辅助置管有效性和安全性。方法:对44例常规胃镜下鼻空肠营养管置管失败的病人,通过X线引导,在胃镜直视下用黄斑马导丝辅助置入鼻空肠营养管。结果:介入方法辅助胃镜下鼻空肠营养管困难置管成功率为95.5%,操作时间12～28 min,病人耐受较好,没有发生鼻咽部损伤、腹痛、穿孔、消化道出血等并发症,留置鼻空肠营养管2周内未发生堵管。结论:介入方法辅助胃镜下鼻空肠营养管困难置管的方法有效、安全、可靠。     

内镜下放置鼻空肠营养管的方法和营养效果分析

目的:探讨分析内镜下放置空肠营养管的方法和营养支持效果。方法:选择106例需放置空肠营养管的病人随机分为观察组54例和对照组52例。此外,选择同期行鼻胃管肠内营养病人43例作为鼻胃管组。对照组采用传统内镜下经鼻空肠营养管置管术;观察组采用改良后内镜下经鼻空肠营养管置管术;鼻胃管组采取常规鼻胃管肠内营养。比较三组病人手术时间、一次性置管成功率、置管后并发症发生率以及病人置管后营养指标变化情况。结果:观察组和鼻胃管组病人手术时间显著短于对照组(P0.05),一次性置管成功率显著高于对照组(P0.05)。三组病人置管后并发症发生率无显著性差异(P0.05)。三组病人置管后血红蛋白、血清清蛋白以及前清蛋白水平均较治疗前显著改善(P0.05)。观察组和对照组病人置管前后营养指标比较均无显著性差异(P0.05),而鼻胃管组病人置管后血红蛋白、血清清蛋白和前清蛋白水平显著低于观察组和对照组(P0.05)。结论:改良内镜下鼻空肠管置管术能有效缩短置管手术时间,提高一次性置管成功率,降低病人置管手术的痛苦。置管后病人营养支持效果显著。     

X线下放置鼻空肠营养管在危重症早期肠内营养中的应用

目的:探讨X线下放置鼻空肠营养管,在危重症病人早期肠内营养中的临床应用价值.方法:在X线监视下,将带有金属导丝的营养管自鼻腔经胃、十二指肠,置入空肠,拔出导丝,注入造影剂,确认营养管前端已进入Treitz韧带后30 cm以远.结果:X线下可将营养管放置至Treitz韧带30 cm以远的空肠部位,置管成功率为100%,置管时间为10～40(平均20)min.置管后营养管在位良好,喂养过程顺利.结论:X线下放置鼻空肠营养管,是一种操作简便快捷、安全可靠的置管技术,为危重症病人早期肠内营养支持提供了一条更有效的营养途径.     

胃镜辅助下放置空肠营养管的方法

目的:探讨内镜下放置空肠营养管的方法.方法:给148例病人放置空肠营养管,116例病人在胃镜下用异物钳钳夹胃腔内空肠营养管,推送胃镜将其送至Treitz韧带以下.32例经鼻超细胃镜放置导丝后,再经导丝放入空肠营养管.结果:两种空肠营养管放置成功率均为100%,其中鼻肠管126例,三腔鼻肠管22例.两组均无严重并发症,1例病人置管后出现血淀粉酶升高.结论:两种空肠营养管放置的方法成功率均高,不良反应小,操作简单安全.     

重症急性胰腺炎的早期肠内营养支持

目的:通过对15例重症急性胰腺炎(SAP)病人进行早期肠内营养支持,探讨SAP时早期肠内营养的可行性、安全性及有效性.方法:对我院普通外科2002年4月至2003年6月间15例SAP病人在入院3～5天时放置空肠螺旋管,在到达空肠后,进行肠内营养支持.观察病人的一般情况、营养状况、免疫功能及并发症的发生率等.结果:11例病人在置管2～3天后到达空肠,3例置管第4天时在X线透视辅助下置入空肠,1例在置管第4天时在内镜辅助下进入空肠.所有病人对早期肠内营养耐受良好,无胰腺炎复发,而且肠内营养开始后1～2周营养状况及免疫功能与营养支持前比较明显好转,无胰腺坏死组织继发感染的发生.结论:对SAP进行早期肠内营养支持是可行、安全和有效的,能改善SAP病人的营养状况及免疫功能.     

经皮内镜下胃/空肠造口置管术在重症急性胰腺炎病人肠内营养治疗中的应用

目的:经皮内镜下胃/空肠造口置管术(PEG/J)在重症急性胰腺炎(SAP)病人肠内营养(EN)治疗中的可行性. 方法:观察92例SAP病人接受PEG/J的置管时间、成功率、并发症和导管留置时间等指标. 结果:平均置管时间为(17.7±4.2) min,成功率为97.8％(90/92),未发生置管相关并发症,置管后并发症的发生率为7.7％ (7/90),平均导管留置时间为(76.6±26.8)d. 结论:采用PEG/J对SAP病人早期行EN支持治疗具有操作简便、安全有效、病人耐受良好、可长期带管等优点.     

经鼻胃镜放置鼻空肠营养管的临床应用

目的:探讨经鼻胃镜放置鼻空肠营养管的临床价值。方法:对2008年5月至2011年9月复旦大学附属中山医院内镜中心采用经鼻胃镜导丝引导下放置鼻空肠营养管进行空肠营养支持的257例病人临床资料进行回顾性分析。结果:其中256例在鼻胃镜引导下放置空肠营养管成功,成功率为99.6%,平均放置时间为8.4±4.2min。置管并发症为胃黏膜损伤18例(7.0%)和鼻黏膜出血26例(10.1%),无消化道穿孔及大出血等严重并发症,病人耐受良好。结论:经鼻胃镜放置鼻空肠营养管方法便捷,可靠,值得临床推广。     

Feeding the gut early after digestive surgery: results of a nine-year experience

BACKGROUND AND AIMS: Early enteral nutrition (EEN) after surgery should be preferred to parenteral feeding, but its clinical use is limited for concerns about possible gastrointestinal (GI) adverse effects and feeding tube-related complications. Thus we evaluated our experience focusing on safety and tolerance of early postoperative jejunal feeding and possible risk factors for gastrointestinal adverse effects. METHODS: 650 subjects treated with EEN after major digestive surgery for cancer were prospectively studied. EEN was started within 12 hours after operation via a naso-jejunal (NJ) feeding tube or a catheter-feeding jejunostomy. The rate of infusion was progressively increased to reach the nutritional goal (25 kcal/kg/day) within the 4th postoperative day. Rigorous treatment protocols for diet delivery and EEN-related GI adverse effects were applied. RESULTS: 402 patients had a jejunostomy and 248 patients a NJ tube. EEN-related GI adverse effects were observed in 194/650 patients (29.8%). In 136/194 patients, these events were successfully handled by treatment protocols. Overall the nutritional goal was achieved in 592/650 patients (91.1%). Fifty-eight (8.9%) subjects had to be switched to parenteral feeding because of refractory intolerance to EEN. Intra-abdominal surgical complications and low serum albumin (<30 g/L) were the two major factors affecting tolerance. Severe jejunostomy-related complications occurred in 7/402 (1.7%) patients. EEN-related mortality was 0.1% (1/650). CONCLUSIONS: The use of the gut early after surgery is safe and well-tolerated and it should represent the first choice for nutritional support in this type of patients.     

超声辅助四步法鼻空肠管置入在ICU中的应用

目的:探讨超声辅助四步法鼻空肠管置入在ICU重症病人中的应用价值。方法:33例拟行肠内营养支持的ICU重症病人采用超声引导四步法进行鼻空肠管置入,即通过超声判断鼻空肠管置入食道内、鼻空肠管置入胃内、鼻空肠管置入幽门后、最后确认鼻空肠管位置。结果:成功置入28例,失败3例,失败原因为通过幽门之假象及病人胃蠕动消失,鼻空肠管末端贴于胃大弯处,无法弯曲进入胃窦、幽门。结论:超声辅助四步法床旁鼻空肠管置入技术是一种新的鼻空肠管置入技术,操作简单,有效、无创,可重复性且成功率较高,可预防或减少并发症的发生。     

Transnasal endoscopic placement of feeding tubes in the intensive care unit

BACKGROUND: There is an increasing demand for enteral feeding in intensive care unit (ICU) patients. However, gastroparesis is common, and jejunal placement with gastric decompression leads to delays in feeding. In an attempt to minimize delays, we describe our technique and results with transnasal endoscopic placement of double-lumen gastric aspiration, jejunal feeding tubes (DLFT). METHODS: Fifty-one consecutive ICU patients referred for nutrition support were studied; 29% had respiratory failure, 28% acute head injury, and 33% acute pancreatitis. A 5.8-mm ultraslim video endoscope was used to place a guidewire through the nose terminating beyond the Ligament of Treitz. After withdrawal of the endoscope, a DLFT was passed over the wire. Final position of the tube was checked and adjusted under direct vision by reendoscopy though the opposite nasal passage. RESULTS: Initial placement of the guidewire and DLFT was successful in 46 of 51 patients. Massive gastric dilatation and acute pancreatitis complicated by duodenal compression impeded full duodenoscopy in 5 patients, necessitating fluoroscopy for correct guidewire deployment. In confirming correct tube placement, there was near perfect concordance between reendoscopy and x-ray (45/46). Previously unrecognized upper gastrointestinal tract pathology was detected in most patients, with acute gastritis in 47, superficial gastric ulceration in 24, and erosive esophagitis in 5. CONCLUSIONS: Transnasal endoscopic placement of feeding tubes in the ICU is quick, effective, and minimally disruptive of intensive therapy. In addition, it can reveal unrecognized pathology, which potentially could lead to improvements in overall medical care.     

Percutaneous Gastrostomy Tube Placement Using a Balloon Catheter in Patients With Head and Neck Cancer

Background: Patients with head and neck cancer frequently require gastrostomy feeding. The aim of this study was to evaluate the safety and feasibility of percutaneous radiologic gastrostomy with push‐type gastrostomy tubes using a rupture‐free balloon (RFB) catheter under computed tomography (CT) and fluoroscopic guidance in patients with head and neck cancer with swallowing disturbance or trismus. Methods: Percutaneous CT and fluoroscopic gastrostomy placement of push‐type gastrostomy tubes using a RFB catheter was performed in consecutive patients with head and neck cancer between April 2007 and July 2010. The technical success, procedure duration, and major or minor complications were evaluated. Results: Twenty‐one patients (14 men, 7 women; age range, 55–78 years; mean age, 69.3 years) underwent gastrostomy tube placement. The tumor location was the pharynx (n = 8), oral cavity (n = 7), and gingiva (n = 6). Gastrostomy was performed in 15 patients during treatment and 6 patients after treatment. Percutaneous radiologic gastrostomy was technically successful in all patients. The median procedure time was 35 ± 19 (interquartile range) minutes (range, 25–75). The average follow‐up time interval was 221 days (range, 10–920 days). 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 periods. Conclusion: Percutaneous CT and fluoroscopic‐guided gastrostomy with push‐type tubes using a RFB catheter is a relatively safe and effective means of gastric feeding, with high success and low complication rates in patients with head and neck cancer in whom endoscopy was not feasible.     

Clearing obstructed feeding tubes

This is a report of an in vitro study evaluating the ability of six solutions to dissolve clotted enteral feeding, which can cause feeding tube occlusion. The following clotted enteral feeding products were tested: Ensure Plus, Ensure Plus with added protein (Promod 20 g/liter), Osmolite, Enrich, and Pulmocare. Clot dissolution was then tested by adding Adolf's Meat Tenderizer, Viokase, Sprite, Pepsi, Coke, or Mountain Dew. Distilled water served as control. Dissolution score for each mixture was assessed blindly. Best dissolution was observed with Viokase in pH 7.9 solution (p less than 0.01). Similar results were obtained when feeding tube patency was restored in eight in vitro occluded feeding tubes (Dobbhoff, French size 8) by using first Pepsi (two/eight successful) and then Viokase in pH 7.9 (six/six successful). We also report our experience in the first 10 patients with occluded feeding tubes using this Viokase solution injected through a Drum catheter into the feeding tube. In seven patients, this method proved to be successful, and the reasons for failure in three patients include a knotted tube, impacted tablet powder, and a formula clot fo 24 hr duration and 45 cm in length.     

Nasojejunal tube positioning with fluoroscopic guidance

The indication circle of enteral nutrition is continuously enlarging. Looking after this increasing group of patients, is now an everyday practice. Enteral nutrition has more advantages than intravenous. Amongst this, jejunal feeding is most widely applied, but it requires nasojejunal tube. Positioning the tube is possible by the guide of X-ray, endoscope, ultrasound, or simply "blind". Authors present the fluoroscopic technique, as their everyday practice. It does not demand special expertise, skilled endoscopist, or premedication, and can be performed in any hospital. It is fast, cheap, and tolerable. It's disadvantages are that only conscious, cooperating, spontaneously breathing patients can be treated such, and it involves irradiation. Authors have used this method 34 times in the past 3 years and had no major complications. Every patient suffered acute necrotising pancreatitis. Considering cost-benefit principles, they recommend this procedure as safe for all levels of in-patient departments.     

Laparoscopic‐Assisted Percutaneous Endoscopic Gastrostomy

Background/Purpose: Percutaneous endoscopic gastrostomy (PEG) is a simplified catheter placement procedure for alimentation. Although the endoscopic approach to gastrostomy tube placement is a safe and well‐tolerated procedure in most patients, the PEG procedure is difficult in elderly patients disabled since childhood who have severe scoliosis and malpositioning of the stomach. We describe a simple and effective laparoscopic‐assisted PEG (LAPEG) technique that can be used for catheter placement in severely disabled patients. Methods: Thirteen severely disabled patients aged 14–57 years underwent gastrostomy tube placement with the LAPEG technique. After general anesthesia was achieved, an endoscope was placed into the stomach. Then, a 5‐mm camera port was inserted at the umbilicus, and a 3‐mm working port was inserted to identify and lift the optimal site for gastrostomy tube placement. After the 4‐point fixation of the stomach, the 20‐Fr gastrostomy tube was placed under endoscopic and laparoscopic observation. Results: All patients tolerated the procedure well, and there were no major complications. The procedure was successful, and all patients could feed via the tube. Conclusions: Elderly disabled patients who have been bedridden since childhood often have severe scoliosis and malpositioning of the stomach. Our LAPEG procedure is effective, well tolerated, and safe for gastrostomy tube placement in such elderly patients.