Enteral nutrition support has been widely recognized as a means of support for patients with clinically critical and complex conditions. However, it is not easy to place the nutrition tube at a distance of more than 30 cm from the flexor ligament. The method we present can be achieved on an ordinary X-ray gastrointestinal machine. The method is simple, effective and easy to use. It is introduced as follows.
I. Clinical data
From January 2004 to December 2007, we implemented the “three-step method” to place jejuno-nasal feeding tubes in 64 cases, of which 41 were male and 23 were female, aged 19-80 years (average age 44 years). The diseases suffered were acute severe pancreatitis in 47 cases, high intestinal fistula in 3 cases, and gastroduodenal ulcer perforation with cardiopulmonary complications in 2 cases. Acute severe pancreatitis with gastroparesis was found in 12 cases.
II. Materials and methods
1.Materials.
(1) Ordinary X-ray gastrointestinal machine or C-arm machine;
(2) F18 common silicone gastric tube;
(3) Ordinary disposable infusion tube (distal section of drip pot) about 130 cm long;
(4)F6 serpentine catheter from Cook, USA;
(5) One 2.6m vascular super-slip guidewire.
2. Method.
Step 1: The distal end of the F18 common silicone gastric tube was cut off and the F6 snake tube was inserted into the gastric tube, and this double cannula was inserted into the stomach through the patient’s nasal cavity. Send the F6 snake tube into the stomach with its distal end in a natural curved form and the head end pointing in the direction of the pylorus, and continue to send the tube to reach the vicinity of the pylorus. A small amount of 76% pantethine is injected into the stomach via the F6 snake tube to show the pylorus.
Step 2: A 2.6m vascular superslip guidewire is inserted through the F6 snake tube toward the pylorus, and the guidewire is passed through the pylorus and duodenum to the distal 20-40cm of the flexor ligament. The F6 snake tube and the gastric tube, which are double-sleeved together, are removed at the same time as the guidewire is delivered.
Step 3: Insert a plastic catheter for general infusion through this guidewire to reach the upper jejunum. A 76% pantopamine contrast agent is injected to confirm the ideal position of the end of the tube, and if the catheter is felt to be too shallow, the guide wire can be reinserted and the nutrition tube placed deeper. Immediately after the patient’s nasojejunal tube was left in place, 150 ml of ‘Da Cheng Qi Tang’ was administered to promote gastrointestinal motility. After intestinal patency, 500ml of Bupropion was given at a uniform rate by pushing using a drug pump within the first 24 hours to adapt the intestine to enteral nutrition.
After there are no side effects such as bloating and diarrhea, the drug pump was switched to a uniform rate of 1000ml per day for 18-20 hours to give the intestine some rest time. At the same time, intravenous infusion of glutamine was used to protect the integrity of the intestinal mucosa and prevent bacterial translocation and intestinal toxins from entering the bloodstream. The duration of enteral nutrition was used for 4-8 weeks, with an average of 6 weeks, followed by a gradual transition to transoral feeding.
3. Results.
All cases in this group had successful catheter placement, and no complications related to catheter placement operation occurred. The nutritional solution and enteral medication infused through the catheter fully met the caloric requirements and therapeutic needs of the patients. The nutritional catheter placement has become an indispensable and important component of the treatment of some patients’ diseases.
III. Discussion
1.Comparison with other nutritional support methods
The enteral nutrition tube feeding route is divided into nasogastric tube and nasoenteric tube according to the level of the outlet end of the nutrition tube. According to the operation method, it is divided into gastrostomy and jejunostomy. There are certain indications associated with the surgical approach. Both gastrostomy and jejunostomy are used. The method of nasogastric tube placement under non-surgical conditions is simpler and easier to achieve, and has been widely used in clinical practice, but it also has certain indications and cannot meet the requirements for the treatment of diseases in the upper gastrointestinal tract and part of the upper jejunum that require gastrointestinal openings and cannot have the passage of chyme.
Nasal intestinal tube for nutritional support is the most basic and perfect means to achieve modern nutritional therapy in clinical practice. However, the difficulty lies in how to place the nasal-intestinal tube. In recent years, the most common method is to transfer the nutrition tube into the duodenum through the pylorus of the stomach with the help of gastroscopy. The disadvantage is that many critically ill patients who need nutritional support and have concurrent cardiovascular, cerebrovascular and respiratory diseases can hardly tolerate the shock of gastroscopy placement, which is very risky for the patient. The placement of the nutrition tube is not always satisfactory.
The method has some limitations. Some of the nasogastric tubes introduced from abroad, although they do not require gastroscopic support, require the basic element of gastrointestinal motility. It happens that a considerable number of critically ill patients lack gastrointestinal motility at this time due to decreased gastrointestinal function. Therefore, this method also cannot reliably and definitively place a partial nutrition tube, and cannot achieve nutritional support. The “three-step” nasal-intestinal tube placement method has a wide range of indications. As long as there is no obstacle to the natural passage of the upper gastrointestinal tract. It is suitable for all patients who need nutritional support.
It is non-invasive and risk-free, with little interference with the patient’s heart, brain and lung functions. The equipment required for implementation is simple and generally available in primary care units. The method is simple and easy to grasp by the general medical staff, so it is more suitable for popularization. It is more economical for patients and provides a better support platform for curing complex diseases.
2.The significance of the “three-step” jejunostomy tube placement on the treatment of diseases
The “three-step” jejuno-nasal feeding tube is not only a supplementary treatment of nutritional elements, but also has therapeutic significance in some complicated and difficult diseases. In this group of clinical data, there were () cases of severe pancreatitis in which enteral nutrition was injected through timely placement of nutrition tubes, which not only provided energy supplementation to the body, but also protected the integrity of gastrointestinal mucosa and prevented the hemorrhage of gastrointestinal mucosa and hematogenous dissemination of intestinal bacteria to the whole body due to stress.
During the recovery period of severe pancreatitis, because the indwelling catheter is not limited by time, it can still ensure the nutritional demand of the body after the cessation of parenteral nutrition therapy. At the same time, because there is no oral feeding, no chyme enters the gastroduodenum and no exocrine food stimulation is formed to the pancreas, so that the pancreas can get valuable recovery time in the near future. The possibility of recurrence of pancreatitis is reduced in the long term. In this group, there was a case of complex extra-intestinal fistula in the upper duodenum, and the patient’s general condition improved significantly after the “three-step” catheter was placed to supplement enteral nutrition.
The disorders of water, electrolytes and acid-base balance were corrected in time, which gave the patient valuable recovery time and led to an honorable elective surgery to cure the enterocutaneous fistula. In this group, there were () cases of perforated duodenal bulb ulcer (which is an indication for surgery). Due to the patient’s advanced age and cardiopulmonary insufficiency, the patient could not tolerate surgical blows, and under conservative treatment, the patient usually has almost no possibility of survival.
However, after the “three-step” placement of jejunal nutrition tube, gastrointestinal decompression, enteral nutrition, catheter injection of Chinese medicine for laxative and anti-inflammatory measures, the patient’s condition stabilized and the ulcer perforation healed on its own without complications of peptic ulcer perforation such as subphrenic abscess, inter-intestinal abscess, pelvic abscess and adhesive intestinal obstruction, and the patient The patient was cured by the treatment.
In conclusion: the “three-step” nasojejunal nutrition tube placement method provides an effective means of support and treatment for the physician for many diseases, and is economical and easy to accept for the patient. It is an easy-to-learn and highly practical technique.