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769

Enteral Using

David J. Ott1 Huitt E. Mattox2 David W. Gelfand1 Michael Y. M. Chen1 Wallace C. Wu2

Feeding

Tubes:

Fluoroscopy

Fluoroscopy feeding tubes,

and endoscopy but the relative

clear. Consequently,

and Endoscopy

are both advantages

we studied

immediately

effective for guiding placement of enteral and limitations of the two methods are less

i04 consecutive

scopic placement of a Frederick-Miller room times, and tube position were

was followed

Placement by

patients

referred

for primary

fluoro-

feeding catheter. Success rate, fluoroscopic and determined. Unsuccessful fluoroscopic placement

by an endoscopic

attempt.

The success

rate for fluoroscopic

placement was 90% (94/i04), 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 mm (mean ± SD) and 2i.7 ± 8.4 mm, respectively. For the iO unsuccessful placements, the fluoroscopic and room times were i6.2 ± 5.4 mm (mean ± SD) and 45.6 ± i8.4 mm, respectively. Both time differences were significant statistically. Endoscopic placement was successful in all seven patients in whom it was

attempted, jejunum

with a mean time of i3.4 mm. The tubes in 29%

and

in the

duodenum

placed

endoscopically

were in the

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 i5 mm. Endoscopic placement of feeding tubes is successful after fluoroscopic failure. AJR

i57:769-77i,

October

i99i

Enteral feeding has become an important means of providing nutritional support to seriously ill patients [1 J. As infusion of feeding solutions beyond the pylorus presumably lessens the chance of aspiration, placement of enteral tubes into the

duodenum

Received

March

1 8, 1991

accepted

;

after

revi-

sion April 18, 1991. 1

Department

of

Radiology,

Bowman

Gray

School

of Medicine, Wake Forest University, Winston-Salem, NC 271 03. Address reprint requests to D. J. Ott. 2 Department of Medicine, Bowman Gray School of

Medicine,

Salem,

Wake

Forest

University,

NC 27103.

0361-803X/91/1 574-0769 © American Roentgen Ray Society

Winston-

or preferably

into the jejunum

is a major goal [2]. A variety of nasoenteral

tubes are available, and techniques for their placement include blind approaches that use periodic abdominal films to verify placement or fluoroscopic and endoscopic methods [2-i 2]. Between i 983 and 1 990, direct fluoroscopic placement of enteral catheters at our institution increased from none to over 400 procedures annually (Fig. i). Directed placement of enteral tubes with fluoroscopy or endoscopy has been recommended to expedite the procedure [2, 6, 8, i 0-i 2]. Both methods have been successful and have permitted rapid enteric intubation and immediate feeding of the patient. However, the relative advantages and limitations of the use of fluoroscopy and endoscopy for this purpose are less clear. As a result, we compared the success of fluoroscopic and endoscopic placement of the FrederickMiller feeding catheter (Cook Inc., Bloomington, IN) in 1 04 consecutive patients [5].

Materials

and

Methods

During a 4-month period, 1 04 consecutive patients were referred for primary fluoroscopic placement of an enteral feeding tube. The group consisted of 46 women and 58 men with a mean age of 66 years (range, 19-100 years). The Frederick-Miller catheter (8-French, 120-

770

OTT

ET AL.

AJA:157,

October

1991

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No. Patients

5.0-c

Fig. 1.-Bar scopic feeding

cm length;

Na. Patients

graph shows marked annual increase in number of fluorotube placements at our institution between 1983 and 1990.

Teflon-coated

guidewire)

selection and preparation nasally while the patient

was

used

in all patients.

guidance. position,

needed, for further manipulation and into the distal duodenum fluoroscopic placement beyond

The patient was then turned and supported by a bolster

of the catheter

through

or jejunum.

The

the pylorus,

fluoroscopic

to if

the pylorus

success

rate

for

and total

times, and tube position were determined. Fluoroscopists in their experience and included radiology residents at different

varied levels

room

of training and, less often, faculty specialized in gastrointestinal radiology. Unsuccessful fluoroscopic placement was followed immediately by an endoscopic attempt. A modified Frederick-Miller tube with the closed

distal

tip clipped

off was

passed

transnasally

and recovered

from the mouth. An Olympus GIF-XQ1 0 endoscope (Olympus Corp., Lake Success, NY) was then advanced into the distal duodenum, avoiding floppy-tipped

excessive

gastric

guidewire

insufflation.

A 4-rn, 0.035-in.

(Wilson-Cook

Medical,

Teflon-coated

lnc.,Winston-Salem,

NC) was placed into the duodenum via the biopsy channel of the endoscope, which was withdrawn, leaving the guidewire in place. The guidewire was transferred from the mouth to the nose by using the Frederick-Miller

catheter

as a transfer

tube.

The feeding

catheter

was then advanced over the guidewire into the small bowel. Duration of the procedure was recorded, and tube position was determined by fluoroscopic observation or plain radiography.

Results

The fluoroscopic

success

tip of the Frederick-Miller

rate was 90% (94/i 04), with the

catheter

placed

into the distal

duo-

denum in 44 patients (47%) and into the jejunum in 50 patients (53%). The fluoroscopic and room times in the successful placements were 8.6 ± 5.6 mm (mean ± SD) and 2i .7 ± 8.4 mm, respectively. In the i 0 unsuccessful procedures, the mean fluoroscopic and room times were i 6.2 ± 5.4 mm and 45.6 ± 1 8.4 mm, respectively. Both time differences were significant statistically (p < .01). Unsuccessful attempts increased proportionately for fluoroscopic times above i 5 mm (Fig. 2). No complications occurred in this group of patients. The main reasons for terminating the unsuccessful fluoroscopic

procedures

looping

of the catheter

were

patients’

in the stomach.

discomfort Endoscopic

-

15-1

20-24.9

Time Intervals

Success

(mins.)

Failure

Fig. 2.-Stacked bar graph of successful tube placements during 5-mm intervals.

and failed fluoroscopic feeding

After

of a naris, the catheter was placed transwas supine and passed into the gastric

antrum under fluoroscopic the left posterior oblique

10-14.9

Fluoroscopic

or persistent placement

was

attempted

in seven

scopic placements completed in all

of the i 0 patients

were patients

in whom

unsuccessful and was without complications.

fluoro-

successfully The mean

endoscopic time was i 3.4 mm, and the tip of the modified Frederick-Miller catheter was placed into the duodenum in five (7i %) patients and into the jejunum in two (29%). Endoscopy was not used in the remaining three patients because of clinical considerations or unavailability of the endoscopic team. Discussion

The advantages administration

of enteral over parenteral

of solutions

the stomach

to prevent

into

the small

feeding bowel

reflux and aspiration

the demand for placement Blind placement of feeding

and the

rather

than

have increased

of enteral feeding tubes [3, 4, 6]. tubes with weighted tips followed

by plain films of the abdomen to document their position is often done initially. However, this method is less effective than fluoroscopic or endoscopically guided techniques and is more time consuming [3, 4]. We evaluated fluoroscopic placement of the Frederick-Miller catheter and assessed the use of a specific endoscopic method of placing a modified tube if the fluoroscopic attempt failed. The Frederick-Miller tube is a soft, flexible, fine-bore (8French) catheter with a nonweighted tip that facilitates radiologic positioning as compared with alternative tubes with weighted tips [5]. The end of the catheter is closed and contains

a small

fluoroscopically.

embedded

metal

A Teflon-coated

plug, guidewire

which

is easily

is packaged

seen with

the catheter. The technique used for fluoroscopic placement of the Frederick-Miller tube is similar to that described for hypotonic

duodenography

and enteroclysis.

The use of water-

soluble contrast material to identify anatomy or metoclopramide hydrochloride to stimulate peristalsis may assist in advancement

of the tube,

Our fluoroscopic

especially

through

the pylorus.

success rate for placement of the Frederick-Miller catheter was 90%, similar to the 93% success reported in the original description of this tube [5]. However,

AJA:157,

the mean successful original variable

fluoroscopic placement

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FEEDING

time in our study was 8.6 mm for compared with 3.3 mm found in the

report. This time difference most experience of radiology residents

in their training, this procedure. soenteric

ENTERAL

October1991

likely reflects the at different levels

who were primarily responsible for performing Other types of fluoroscopically guided na-

tubes,

particularly

Medical Products, Somerville, success rates [2, 8].

the Entriflex

catheter

(Biosearch

NJ), have shown

comparably

fluoroscopic

placements

required

approxi-

mately twice the fluoroscopic and room times as the successful placements did, with more failures occurring in the i 5-20 mm fluoroscopic time interval. A similar experience has been observed with the Entriflex tube, in which successful placements were accomplished in less than 10 to 15 mm [2, 8]. These studies indicate that entenc intubation by using fluoroscopy

and

an appropriate

catheter

is achieved

in 90%

or more of patients, usually within 5-i 0 mm. We think that prolonging fluoroscopy beyond i 5 mm is unlikely to produce success and an alternative approach should be chosen, such as endoscopy. A variety of endoscopic methods have been described for placement of enteral feeding tubes [i 0-i 2]. The technique that

we

have

used

combines

endoscopic

placement

of a

guidewire and a modified Frederick-Miller catheter. This technique has been safe, effective, and rapid. Endoscopic placement was successful in all seven patients in whom it was attempted, with a mean time for the procedures of only 13.4 mm. This experience is similar to other recent reports indicating

that

endoscopy

is an excellent

option

for

placement

of

feeding tubes [i i , i 2]. A difference between our successful fluoroscopic and endoscopic placements was the final loca-

tion of the catheter

tip. The tip of the Frederick-Miller

was

jejunum

placed

in the

more

reliably

with

tube

fluoroscopy

(53%) than with endoscopy (29%). Duodenal placements may be associated with gastric reflux or retrograde migration of the tube into the stomach. Thus, the duration of the duodenal placement may be shorter, but further study is needed to determine

the relevance

In conclusion, that fluoroscopic

of this factor

PLACEMENT

77i

have a high success rate. In order to avoid undue radiation exposure to the radiologist and patient, a fluoroscopic time limit

of

1 5 mm

is

suggested

because

success

is unlikely

beyond that time. Endoscopic placement of feeding tubes by using guidewire-assisted techniques has been successful

after unsuccessful fluoroscopic as an initial method of entenc

placement intubation.

and may be used In patients unable

to be transported safely to the radiology department, endoscopic placement of the feeding tube is an excellent option, although the use of portable fluoroscopy is also possible. We

high

Unsuccessful

TUBE

[8].

our results and other reports have shown and endoscopic placement of enteral tubes

have adopted particularly

unstable

endoscopy

in patients

rather in the

than bedside

intensive

care

fluoroscopy, unit

who

are

or who require anesthesia.

REFERENCES 1 . Silk DBA, Aees AG, Keohane PP. Attrill H. Clinical efficacy and design changes of fine bore” nasogastnc feeding tubes: a seven-year experience involving 809 intubations in 403 patients. J Parenter Enteral Nutr 1987;1 1:378-383 2. Grant JP, Curtas MS. Kelvin FM. Fluoroscopic placement of nasojejunal feeding tubes with immediate feeding using a nonelemental diet. J Parenter Enteral Nutr 1983;7:299-303 3. Aamos SM, Lindine P. Inexpensive, safe and simple nasoenteral intubation: an alternative for the cost conscious. J Parenter Enteral Nutr i986;10: 78-81 4. Thurlow PM. Bedside enteral feeding tube placement into duodenum and jejunum. J Parenter Enteral Nutr 1986:10:104-105 5. Frederick PR, Miller MH, Morrison WJ. Feeding tube for fluoroscopic placement. Radiology 1982; 145: 847 6. Prager A, Laboy V. venus B, Mathru M. Value of fluoroscopic assistance during transpyloric intubation. Crit Care Med 1986;1 4:151-152 7. Woodall BH, Winfield DF, Bisset GS Ill. Inadvertent tracheobronchial placement of feeding tubes. Radiology 1987;165:727-729 8. Gutierrez ED, Balfe DM. Fluoroscopically guided nasoenteric feeding tube placement: results of a 1 -year study. Radiology 1991:178:759-762 9. Lewis BS, Mauer K, Bush A. The rapid placement of jejunal feeding tubes: the Seldinger technique applied to the gut. Gastrointest Endosc 1990;36: 139-141 10. Chung ASK, Denbesten L. Improved technique for placement of intestinal feeding tube with the fiberoptic endoscope. Gut 1976:17:264-266 1 1 . Pleatman MA, Naunheim KS. Endoscopic placement of feeding tubes in the critically ill patient. Surg Gynecol Obstet 1987:165:69-70 12. Aives DA, LeRoy JL, Hawkins ML, Bowden TA Jr. Endoscopically assisted nasojejunal feeding tube placement. Am Surg 1989;55:88-91