1. Administer 60 % pantothenic glucosamine 50 ml orally under the gastrointestinal X-ray machine to observe the esophagus, stomach and fistula. Clarify the location of duodenum.
2.Prepare the gastric pack, paraffin oil, Flocare nasogastric tube, and super-slip guidewire placed into the vertebral artery catheter with the tip of the guidewire located in the vertebral artery catheter.
3.The patient is placed in a low-pillow supine position or left lateral position, and the patient can be given local anesthesia in the pharynx if the patient is poorly tolerated. The vertebral artery catheter is inserted into the stomach through the nostril on one side, and the assistant fixes the catheter at the nostril.
4.Adjust the position of the tip of the catheter under X-ray fluoroscopy, fix the catheter, insert the guidewire, adjust the direction of the tip and gradually advance the vertebral artery catheter, insert the guidewire deeply under fluoroscopy through the duodenum until the upper jejunum is 20 cm from the flexor ligament;
5, synchronize the deep insertion of the guidewire while retreating the vertebral artery catheter to ensure that the guidewire exits the vertebral artery catheter under deep insertion; fix the guidewire.
6.Insert the Flocare nasal intestinal tube into the proximal jejunum via the guidewire, fix the insertion depth of the catheter, and slowly withdraw the guidewire;
7.Inject 60% pantopamine to test the patency of the nasal intestinal tube, and adjust the position of the tip of the nasal intestinal tube to 20 cm from the flexor ligament in the upper jejunum under X-ray fluoroscopy, that is, external fixation of the nasal intestinal tube.
Postoperative observation
After the nasal intestinal tube is placed, the location of the tip of the tube can be determined according to the normal physiological curvature by X-ray fluoroscopy. In case of doubt, a small amount of 60% pantopamine can be injected to confirm the position of the nasal intestinal tube, and then nutrition can be performed.
Discussion
The widespread use of nutritional support in clinical practice has led to the recognition of the shortcomings of total parenteral nutrition, namely, complications such as catheter infection and liver function impairment. Enteral nutrition, on the other hand, can avoid these complications. This recognition has led to an evolution in the paradigm of nutritional support from the past enthusiasm for total parenteral nutrition support to timely enteral nutrition support. The primary prerequisite for the implementation of enteral nutrition is the route of infusion, and the placement of a nasojejunal tube is a technical challenge in the implementation of enteral nutrition in patients with parenteral fistula. There are many methods of tube placement, the simplest method is blinded tube placement, but the success rate of tube placement is very low. The success rate of spiral tube placement is higher, but it takes many times of repetition to get the catheter into the small intestine, and the placement time is long. It is not possible in patients with gastroduodenal lesions because the tube is pushed into the duodenum mainly by peristalsis of the gastric sinus.
Gastroscopy-assisted tube placement avoids the disadvantages of blind tube placement and can be done in a fixed position to ensure the accuracy of tube placement; it can avoid radiation damage to patients and medical staff; it has a high success rate; however, it is not well tolerated by patients. It requires specific equipment and the collaboration of relevant departments to complete, and few surgeons can independently perform gastroscopy, so it is difficult to promote in primary hospitals.
Other tube feeding techniques include gastrostomy and jejunostomy, which must be performed under anesthesia and have certain complications, such as wound infection, incision dehiscence, bleeding, etc., especially in malnourished patients, which can lead to gastric or jejunostomy fistula. In view of this, endoscopic percutaneous gastrostomy/enterostomy (PEG/PEJ) has been performed since 1980, which does not require special anesthesia and is relatively simple and safe, but it is contraindicated in patients with ascites or a history of upper abdominal surgery, and complications such as local skin infection, subcutaneous emphysema, bleeding, and even gastro/enteric fistula can occur.
Compared to the above placement methods, fluoroscopic placement has many advantages:
1, X-ray fluoroscopic placement, avoiding the shortcomings of blind placement, and can be done in a fixed position to ensure the accuracy of placement;
2, high success rate;
3, short placement time for skilled surgeons, only 10~32 min;
4, completely non-invasive, none of the patients in this group had tube complications;
5.The patient tolerates it well and the trauma is small.
6.The operation of tube placement is simple and suitable for primary surgeons to carry out and promote independently.
7, less equipment required, low cost. However, this method also has the following disadvantages, such as the patient is too weak to move, and often lack of bedside fluoroscopy machine; patients and health care workers suffer from radiation damage problems.
In conclusion, when implementing enteral nutrition in patients with high parenteral fistula, the placement of nasojejunal tube under X-ray fluoroscopy is simple, fast and safe, and easy to care for, and the patient is less painful and easy to accept, which can provide a new way for the implementation of enteral nutrition in similar patients in the future.