Bedside Ultrasound-guided Nasointestinal Tube Placement in Critically Ill Patients in Intensive Care Unit.

Objective: To verify the efficacy and safety of bedside ultrasound-guided nasointestinal tube (NIT) placement techniques in critically ill patients in the ICU. Methods: 100 Critically ill patients were selected and were randomly enrolled into a bedside ultrasound guidance (BUG) group (BUG guiding the NIT placement) and a traditional blind insertion (TBI) group, with 50 cases in both. The efficacy and safety of these tube placements were compared. Results: The success rate of intubation in the BUG group (74%) was higher than that in the TBI group (44%). The proportion of patients in the BUG group who had catheterization sites in the intestine (72%) was higher than that in the TBI group (46%) (P < .05). The average number of tube insertions and mean time of successful intubation time in the BUG group was slightly higher than those in the TBI group [(1.22 ± 0.00) times vs. (1.20 ± 1.00) times and (24.40 ± 0.50) min vs. (20.72 ± 0.50) min) (P > .05) respectively]. Conclusions: Bedside ultrasound-guided nasojejunal tube has a good outcome in ICU patients with critical conditions, can improve the success rate of intubation, and has a certain safety.

Patients Participating in Nasogastric Tube Insertion through Hypnoanalgesia during High-dose Chemotherapy-induced Aplasia.

The insertion of a nasogastric (NG) tube is often a difficult experience for both patients and caregivers. This often results in a high failure rate of NG insertion. This pilot study aimed to evaluate the effectiveness, tolerance, and acceptability of hypnoanalgesia to assist self-insertion of an NG tube. Patients undergoing high-dose chemotherapy for autologous or allogeneic hematopoietic stem cell transplantation (HSCT) or acute leukemia and with high risk of aplasia were included in the study. A total of 38 patients were included during 6 consecutive months. They all achieved successful NG tube self-insertion. The NG tube remained in place during hospitalization in 32 cases for an average duration of 15 days. Six patients rejected the NG tube during vomiting but they all voluntarily attempted it again later on and succeeded. The discomfort related to NG-tube insertion was mild. This pilot study suggests that NG tube self-insertion assisted by hypnoanalgesia may be effective, well-accepted, and well-tolerated in patients. These promising findings will need further confirmation.

Fecal Microbiota Transplantation (FMT) with Colonoscopy Is Superior to Enema and Nasogastric Tube While Comparable to Capsule for the Treatment of Recurrent Clostridioides difficile Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: Several routes of fecal microbiota transplantation (FMT) administration are available for treating recurrent Clostridioides difficile infections (CDI), the most recent of which are capsules. AIM: To assess the efficacy of colonoscopy, capsule, enema, and nasogastric tube (NGT) FMT for the treatment of recurrent CDI. METHODS: We reported clinical outcomes of colonoscopy, capsule, enema, and NGT FMT for the treatment of recurrent CDI according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. During January 2000 to January 2018, three databases were searched: PubMed, EMBASE, and CINAHL. Primary outcome was overall cure rate which was assessed using a random effects model; secondary outcomes included adverse effects as well as subgroup analyses comparing donor relationship, sample preparation, and study design. RESULTS: Twenty-six studies (1309 patients) were included in the study. FMT was administered using colonoscopy in 16 studies (483 patients), NGT in five studies (149 patients), enema in four studies (360 patients), and capsules in four studies (301 patients). The random effects of pooled FMT cure rates were colonoscopy 94.8% (CI 92.4-96.8%; I2 15.6%), capsule 92.1% (CI 88.6-95.0%; I2 7.1%), enema 87.2% (CI 83.4-90.5%; I2 0%), and NGT/NDT 78.1% (CI 71.6-84.1%; I2 0%). On subgroup analysis of colonoscopy FMT, sample preparation methods had comparable cure rates: fresh 94.9% compared to 94.5%. Similarly, cure rates were unaffected by donor relationship: mixed 94.5% compared to unrelated donor 95.7%. CONCLUSION: CDI cure rates with FMT performed with colonoscopy are superior to enema and NGT FMT, while those with FMT with colonoscopy and capsule are comparable.

Colonic transendoscopic tube-delivered enteral therapy (with video): a prospective study.

BACKGROUND: Colonic transendoscopic enteral tubing (TET) refers to colonic transendoscopic tube-delivered enteral therapy. Colonic TET has been successfully used for frequent colonic administration of drugs or multiple fecal microbiota transplantations (FMTs). This prospective observational study aimed to evaluate possible factors affecting methodology, feasibility and safety of colonic TET. METHODS: Patients who underwent colonic TET at our center from October 2014 to November 2018 were included. The feasibility, efficacy, and safety of TET were evaluated. RESULTS: In total, 224 patients were analyzed. The success rate of TET was 100%. The median retention time of TET tube within the colonic lumen was 8.5 (IQR 7-11) days in 158 patients with tube falling out spontaneously, and the maximum retention time was up to 28 days. These patients were divided into the short-retention group (≤ 8.5 days) and the long-retention group (> 8.5 days). Univariate and multivariate analysis demonstrated that the type of endoscopic clip (p = 0.001) was an independent factor for the retention time. The larger clips as well as a greater number of clips significantly affected the retention time (p = 0.013). No severe adverse event was observed during and after TET. CONCLUSIONS: Colonic TET is a feasible, practical, and safe colon-targeted drug delivery technique with a high degree of patients' satisfaction. Two to four large endoscopic clips are recommended to maintain stability of the TET tube within the colon for over 7 days.

Evaluation of ultrasound-guided Freka-Trelumina enteral nutrition tube placement in the treatment of acute pancreatitis.

BACKGROUND: Enteral nutrition should be implemented as early as possible in patients with moderate or severe acute pancreatitis. This study was designed to evaluate the feasibility and Deffectiveness of ultrasound-guided Freka-Trelumina tube placement for enteral nutrition in acute pancreatitis. METHODS: Patients with severe acute pancreatitis admitted to Shengjing Hospital of China Medical University who needed Freka-Trelumina tube placement for enteral nutrition and gastrointestinal decompression were included in the current study. The relevant evaluation indicators of tube placement included the success rate of tube placement, tube placement time, tube shift rate, and blocking rate. In addition, the evaluation indicators of ultrasound-guided tube placement (from 1 January 2018 to 31 July 2019) were compared with those of previous endoscope-guided placement (from 1 January 2015 to 31 December 2017) by analysing the data from the electronic medical record system. RESULTS: The success rate of ultrasound-guided tube placement was 90.7% (49/54). All 49 patients tolerated the Freka-Trelumina feeding tube. The average ultrasound-guided tube placement time for the 49 patients was 18.4 ± 12.8 min (range, 5-36 min). The Freka-Trelumina feeding tube had a shift rate of 10.2% (5/49). The blocking rate of the Freka-Trelumina feeding tube was 12.2% (6/49). The success rate of tube placement, tube shift rate and blocking rate for endoscope-guided tube placement were 100% (62/62), 11.3% (7/62), and 12.9% (8/62), respectively. The average endoscope-guided tube placement time for the 62 patients was 16.5 ± 5.7 min (range, 12-31 min). The comparison between the ultrasound-guided group and the endoscope-guided group showed that the success rate of tube placement, tube placement time, tube shift rate and blocking rate were similar. CONCLUSION: The ultrasound-guided method can be done non-invasively at the bedside, which is safe and convenient, and the Freka-Trelumina feeding tube can be placed in time to achieve the goal of early enteral nutrition and gastrointestinal decompression.

Simo decoction versus domperidone suspension for post-pyloric spiral nasoenteric tube placement: A multicenter, randomized, non-inferiority trial.

BACKGROUND & AIMS: Leveraging prokinetics to facilitate trans-pyloric migration is a conventional strategy. However, due to restrictions on the use of domperidone suspension, oral prokinetics is relatively modest. The study aims to assess the effectiveness of simo decoction as an alternative to domperidone suspension in facilitating post-pyloric placement of spiral nasoenteric tubes. METHODS: A prospective, open-label, parallel, and non-inferiority randomized controlled trial was performed involving critically ill adults in 6 university hospitals in China between September 2017 and May 2019. Patients were randomly assigned to receive either simo decoction 20 ml q8h, or domperidone suspension 20 mg/20 ml q6h for 24 h. The primary outcome was procedure success defined as post-pyloric placement (spiral nasoenteric tubes reached the first portion of the duodenum or beyond confirmed by abdominal X-ray 24 h after tube insertion). RESULTS: Of 268 patients assessed for eligibility, 224 patients were enrolled and randomly assigned to the simo decoction group or the domperidone suspension group (n = 112 per group). The success rate of post-pyloric placement was 41.1% (46/112) in the simo decoction group, as compared with 47.3% (53/112) in the domperidone suspension group (a risk difference of -6.3%, 95% CI, -19.2% to 6.7%, adjusted risk difference -3.7%, 95% CI -16.3% to 9.0%), in the intention-to-treat analysis, crossing the prespecified margin of -10% for non-inferiority. There were no differences between groups in the success rates of post-D1 (reaching the second portion of the duodenum or beyond), post-D2 (reaching the third portion of the duodenum or beyond), post-D3 (reaching the fourth portion of the duodenum or beyond) and proximal jejunum placement, the incidences of any adverse events, length of ICU stay or mortality in ICU. CONCLUSIONS: Non-inferiority of simo decoction to domperidone suspension was not confirmed in facilitating post-pyloric placement of spiral nasoenteric tubes. Registration: The trial was registered with the Chinese Clinical Trial Registry at http://www.chictr.org.cn (registration number ChiCTR-INR-17011311).

Malone appendicostomy versus cecostomy tube insertion for children with intractable constipation: A systematic review and meta-analysis.

PURPOSE: Children with intractable constipation are often treated with antegrade continence enemas. This requires the creation of a Malone appendicostomy in the operating room or insertion of a cecostomy tube using endoscopic, radiologic, or surgical techniques. The purpose of this study was to assess the evidence regarding these procedures. METHODS: We conducted a search of Embase, Medline, CINAHL, and Web of Science up to October 2016. We included comparative studies of children treated with Malone appendicostomy or cecostomy tube insertion. Two reviewers screened abstracts, reviewed studies, and extracted data. RESULTS: We identified 166 children from three retrospective studies who underwent Malone appendicostomy (n=82) or cecostomy tube insertion (n=84). There were no differences in the number of patients who achieved continence (80% versus 70%, p=0.76), but the need for additional surgery was higher in children treated with Malone appendicostomy (30% versus 12%, p=0.01). Studies reported a variety of tube and stoma-related complications, but quality of life was not assessed using validated measures. CONCLUSION: Malone appendicostomy and cecostomy tube insertion are comparable in terms of achieving continence. Children treated with Malone appendicostomy appear to be more likely to require additional surgery due to early or late complications. LEVEL OF EVIDENCE: Therapeutic, 1c.

Stroke: ineffective tube securement reduces nutrition and drug treatment.

Stroke patients with dysphagia often depend on nutrition, hydration and medication via nasogastric (NG) feeding tubes. Securing tubes using tape is associated with repeated tube loss. In this study, the authors determined cause and effect by auditing tube placement methods, delays incurred, duration and costs. Of 202 NG tube placements in 75 patients, 67 placements occurred in 17 patients over a full course of enteral nutrition (EN) and 40 of these placements were tracked. Tubes were secured by tape in 100%, mittens 31% and special observation 5.4%. However, over an EN course, inadvertent tube loss occurred in 82% of patients and was associated with age (p=0.049) and mitten use (p<0.001): 64% of tubes were lost due to patients and 9% slipped. Average 'tube life' was 2 days, less than 25% of the EN episode (p<0.001). While tube placement occurred within 2.55 hours of request, X-ray confirmation led to a delay in feed and drugs of 8-9 hours per tube placement and loss of 18.8% of feeding time per EN episode. Delays exceeded the 1-hour and 4-hour limits for antibiotics and other medicines in 20% and 80%, respectively. In the 17 tracked patients, it was estimated that 55% of the £5979 direct costs could be saved by nasal bridle use. In conclusion, most tubes studied were lost to inadvertent tube removal, leading to clinically significant delays to nutrition, hydration and drug treatments; this may impair recovery. Reducing tube loss is likely to reduce patient distress, treatment cost and enhance recovery.

Procedures for measuring and verifying gastric tube placement in newborns: an integrative review / Procedimentos de mensuração e verificação de posicionamento da sonda gástrica em recém-nascidos: revisão integrativa / Procedimientos de medición y verificación de posicionamiento de la sonda gástrica en recién nacidos: revisión integradora

ABSTRACT Objective: to investigate evidence in the literature on procedures for measuring gastric tube insertion in newborns and verifying its placement, using alternative procedures to radiological examination. Method: an integrative review of the literature carried out in the Cochrane, LILACS, CINAHL, EMBASE, MEDLINE and Scopus databases using the descriptors "Intubation, gastrointestinal" and "newborns" in original articles. Results: seventeen publications were included and categorized as "measuring method" or "technique for verifying placement". Regarding measuring methods, the measurements of two morphological distances and the application of two formulas, one based on weight and another based on height, were found. Regarding the techniques for assessing placement, the following were found: electromagnetic tracing, diaphragm electrical activity, CO2 detection, indigo carmine solution, epigastrium auscultation, gastric secretion aspiration, color inspection, and evaluation of pH, enzymes and bilirubin. Conclusion: the measuring method using nose to earlobe to a point midway between the xiphoid process and the umbilicus measurement presents the best evidence. Equations based on weight and height need to be experimentally tested. The return of secretion into the tube aspiration, color assessment and secretion pH are reliable indicators to identify gastric tube placement, and are the currently indicated techniques.

RESUMO Objetivo: investigar, na literatura, evidências sobre procedimentos de mensuração da sonda gástrica em recém-nascidos e de verificação do seu posicionamento, procedimentos alternativos ao exame radiológico. Método: revisão integrativa da literatura nas bases Biblioteca Cochrane, LILACS, CINAHL, EMBASE, MEDLINE e Scopus, utilizando os descritores "intubação gastrointestinal" e "recém-nascido" em artigos originais. Resultados: dezessete publicações foram incluídas e categorizadas em "método de mensuração" ou "técnica de verificação do posicionamento". Como métodos de mensuração, foram encontrados os de tomada de duas distâncias morfológicas e os de aplicação de duas fórmulas, uma baseada no peso e outra na altura. Para técnicas de verificação do posicionamento, encontrou-se traçado eletromagnético, atividade elétrica do diafragma, detecção de CO2, solução de índigo carmim, ausculta do epigástrio, aspiração de secreção gástrica, inspeção da cor, avaliação de pH, enzimas e bilirrubina. Conclusão: o método de mensuração que utiliza as medidas do nariz ao lóbulo da orelha ao ponto médio entre apêndice xifoide e cicatriz umbilical apresenta melhores evidências. As equações baseadas em peso e altura necessitam ser testadas experimentalmente. O retorno de secreção na aspiração da sonda, avaliação da cor e do pH da secreção são indicadores confiáveis na identificação do posicionamento da sonda gástrica, e são as técnicas atualmente indicadas.

RESUMEN Objetivo: investigar, en la literatura, evidencias sobre procedimientos de medición de la sonda gástrica en recién nacidos y de verificación de su posicionamiento, procedimientos alternativos al examen radiológico. Método: revisión integradora de la literatura en las bases Biblioteca Cochrane, LILACS, CINAHL, EMBASE, MEDLINE y Scopus, utilizando los descriptores "intubación gastrointestinal" y "recién nacido" en artículos originales. Resultados: diecisiete publicaciones fueron incluidas y categorizadas en "método de medición" o "técnica de verificación del posicionamiento". Como métodos de medición, fueron encontrados los de medida de dos distancias morfológicas y los de aplicación de dos fórmulas (una basada en el peso y otra en la altura). Para las técnicas de verificación del posicionamiento, se encontró: trazado electromagnético, actividad eléctrica del diafragma, detección de CO2, solución de índigo carmín, auscultación del epigastrio, aspiración de secreción gástrica, inspección del color, evaluación de pH, enzimas y bilirrubina. Conclusión: el método de medición que utiliza las medidas de la nariz al lóbulo de la oreja al punto medio entre apéndice xifoideo y cicatriz umbilical, presenta las mejores evidencias. Las ecuaciones basadas en peso y altura necesitan ser comprobadas experimentalmente. El retorno de secreción en la aspiración de la sonda, evaluación del color y del pH de la secreción son indicadores confiables en la identificación del posicionamiento de la sonda gástrica, y son las técnicas actualmente indicadas.

Fecal microbiota transplantation via fluoroscopy-guided nasojejunal catheter placement: indications, technique, and the role of radiology.

Clostridium difficile is a well-established cause of nosocomial gastrointestinal disease. Although antibiotics remain an effective first-line treatment for C. difficile colitis (CDC), relapse and recurrence are common. FMT has emerged as one of the safest and most effective known therapies available for recurrent or refractory CDC, which is likely due to restoration of the protective microbiotic barrier of the gastrointestinal tract. FMT varies greatly across institutions by route of delivery, dose, and protocol. We present our experience with FMT via fluoroscopic-guided nasojejunal catheter placement. The discussion will include indications and contraindications, protocol, and procedural technique, and include a case presentation incorporating original CT and fluoroscopic images. Specifically, we will address the advantages and disadvantages of image-guided FMT via the upper GI tract with respect to nasogastric-, colonoscopic-, and enema-based delivery. The efficacy of FMT for the treatment of C. difficile has been widely demonstrated in several prospective and case studies. We feel that nasojejunal FMT is an underutilized radiologic procedure which can benefit selected patients, particularly given the advantages in risk profile, cost, convenience, and lack of routine sedation.

ACG Clinical Guideline: Nutrition Therapy in the Adult Hospitalized Patient.

The value of nutrition therapy for the adult hospitalized patient is derived from the outcome benefits achieved by the delivery of early enteral feeding. Nutritional assessment should identify those patients at high nutritional risk, determined by both disease severity and nutritional status. For such patients if they are unable to maintain volitional intake, enteral access should be attained and enteral nutrition (EN) initiated within 24-48 h of admission. Orogastric or nasogastric feeding is most appropriate when starting EN, switching to post-pyloric or deep jejunal feeding only in those patients who are intolerant of gastric feeds or at high risk for aspiration. Percutaneous access should be used for those patients anticipated to require EN for >4 weeks. Patients receiving EN should be monitored for risk of aspiration, tolerance, and adequacy of feeding (determined by percent of goal calories and protein delivered). Intentional permissive underfeeding (and even trophic feeding) is appropriate temporarily for certain subsets of hospitalized patients. Although a standard polymeric formula should be used routinely in most patients, an immune-modulating formula (with arginine and fish oil) should be reserved for patients who have had major surgery in a surgical ICU setting. Adequacy of nutrition therapy is enhanced by establishing nurse-driven enteral feeding protocols, increasing delivery by volume-based or top-down feeding strategies, minimizing interruptions, and eliminating the practice of gastric residual volumes. Parenteral nutrition should be used in patients at high nutritional risk when EN is not feasible or after the first week of hospitalization if EN is not sufficient. Because of their knowledge base and skill set, the gastroenterologist endoscopist is an asset to the Nutrition Support Team and should participate in providing optimal nutrition therapy to the hospitalized adult patient.

A prospective study comparing prophylactic gastrostomy to nutritional counselling with a therapeutic feeding tube if required in head and neck cancer patients undergoing chemoradiotherapy in Thai real-world practice.

BACKGROUND: Concurrent chemoradiotherapy (CRT) is the standard treatment for head and neck (HN) cancer patients. Most patients experience malnutrition and weight loss during treatment because of mucositis and difficulty in swallowing. Prevention of malnutrition may allow more patients to complete their treatment. The present study aimed to examine whether prophylactic gastrostomy tube (PGT) could reduce treatment interruption, prevent malnutrition and maintain quality of life, especially in Thai patients who generally do not accept feeding tubes. METHODS: A prospective study was performed on HN cancer patients undergoing CRT at a tertiary hospital in Thailand (n = 95). Before starting CRT, all patients received nutritional assessment and were counselled about the risks and benefits of PGT. According to patient discretion, they chose to have a PGT (experimental group) or only nutritional counselling with a therapeutic feeding tube if required (control group). During CRT, weight, degree of mucositis, delayed chemotherapy and/or radiotherapy, and nutritional status were recorded. Quality of life (Functional Assessment of Cancer Therapy - Head and Neck Scale; FACT-H&N) was compared between two groups. RESULTS: There was no significant difference in the rates of delayed treatment. Mean weight loss was 3.1 and 4.8 kg in the experimental and control groups, respectively (P = 0.04). A higher proportion of patients in the control group experienced ≥10% weight loss (24% versus 4%; P = 0.03). In terms of quality of life, no significant difference in FACT-H&N score was found. CONCLUSIONS: The results of the present study suggest that PGT provided similar quality of life without a reduction in treatment interruption. However, patients with PGT had significantly less weight loss (P = 0.04) during CRT.

A randomised controlled feasibility and proof-of-concept trial in delayed gastric emptying when metoclopramide fails: We should revisit nasointestinal feeding versus dual prokinetic treatment: Achieving goal nutrition in critical illness and delayed gastric emptying: Trial of nasointestinal feeding versus nasogastric feeding plus prokinetics.

BACKGROUND & AIMS: Delayed gastric emptying (DGE) commonly limits the use of enteral nutrition (EN) and may increase ventilator-associated pneumonia. Nasointestinal feeding has not been tested against dual prokinetic treatment (Metoclopramide and Erythromycin) in DGE refractory to metoclopramide. This trial tests the feasibility of recruiting this 'treatment-failed' population and the proof of concept that nasointestinal (NI) feeding can increase the amount of feed tolerated (% goal) when compared to nasogastric (NG) feeding plus metoclopramide and erythromycin treatment. METHODS: Eligible patients were those who were mechanically ventilated and over 20 years old, with delayed gastric emptying (DGE), defined as a gastric residual volume ≥250 ml or vomiting, and who failed to respond to first-line prokinetic treatment of 3 doses of 10 mg IV metoclopramide over 24 h. When assent was obtained, patients were randomised to receive immediate nasointestinal tube placement and feeding or nasogastric feeding plus metoclopramide and erythromycin (prokinetic) treatment. RESULTS: Of 208 patients with DGE, 77 were eligible, 2 refused assent, 25 had contraindications to intervention, almost exclusively prokinetic treatment, and it was feasible to recruit 50. Compared to patients receiving prokinetics (n = 25) those randomised to nasointestinal feeding (n = 25) tolerated more of their feed goal over 5 days (87-95% vs 50-89%) and had a greater area under the curve (median [IQR] 432 [253-464]% vs 350 [213-381]%, p = 0.026) demonstrating proof of concept. However, nasointestinally fed patients also had a larger gastric loss (not feed) associated with the NI route but not with the fluid volume or energy delivered. CONCLUSIONS: This is first study showing that in DGE refractory to metoclopramide NI feeding can increase the feed goal tolerated when compared to dual prokinetic treatment. Future studies should investigate the effect on clinical outcomes. EU CLINICAL TRIALS REGISTER: EudraCT number: 2012-001374-29.

Bleeding Associated With Feeding Tube Placement in Critically Ill Oncology Patients With Thrombocytopenia.

BACKGROUND: Existing trials have not evaluated the feasibility of oral or nasal feeding tube (FT) placement in the critically ill thrombocytopenic oncology population. Thrombocytopenia (TCP) may be considered a contraindication to FT placement due to the potential risk of bleeding complications. METHODS: Medical intensive care unit (ICU) adult oncology patients with attempted nasal or oral FT placement were evaluated in a 52-bed ICU at a comprehensive cancer center. End points were compared between patients with and without TCP (platelet count <150,000/µL). Primary outcomes of overt and clinically important bleeding (gastrointestinal and point of entry) were evaluated within 72 hours of FT placement. RESULTS: Fifty-nine patients were enrolled (TCP, n = 42; no TCP, n = 17; baseline platelet count, 41 ± 48 vs 249 ± 85 [× 10(3)/µL], P < .001). Patients with TCP were more likely to have a hematologic malignancy and lower baseline hemoglobin and platelet count (P < .01). More patients with TCP received blood products 24 hours prior to FT placement (86% vs 12%, P < .01). There was no difference in overt (7.1% vs 0%, P = .55) or clinically important (2.4% vs 5.9%, P = .5) bleeding complications within 72 hours of attempted FT placement among patients with TCP versus those without. CONCLUSIONS: Critically ill oncology patients with TCP do not appear to be at a higher risk for bleeding complications after FT placement compared with those without TCP, which may be related to blood product transfusion within 24 hours prior to FT placement.

Fecal microbiota transplant for relapsing Clostridium difficile infection using a frozen inoculum from unrelated donors: a randomized, open-label, controlled pilot study.

BACKGROUND: Recurrent Clostridium difficile infection (CDI) with poor response to standard antimicrobial therapy is a growing medical concern. We aimed to investigate the outcomes of fecal microbiota transplant (FMT) for relapsing CDI using a frozen suspension from unrelated donors, comparing colonoscopic and nasogastric tube (NGT) administration. METHODS: Healthy volunteer donors were screened and a frozen fecal suspension was generated. Patients with relapsing/refractory CDI were randomized to receive an infusion of donor stools by colonoscopy or NGT. The primary endpoint was clinical resolution of diarrhea without relapse after 8 weeks. The secondary endpoint was self-reported health score using standardized questionnaires. RESULTS: A total of 20 patients were enrolled, 10 in each treatment arm. Patients had a median of 4 (range, 2-16) relapses prior to study enrollment, with 5 (range, 3-15) antibiotic treatment failures. Resolution of diarrhea was achieved in 14 patients (70%) after a single FMT (8 of 10 in the colonoscopy group and 6 of 10 in the NGT group). Five patients were retreated, with 4 obtaining cure, resulting in an overall cure rate of 90%. Daily number of bowel movements changed from a median of 7 (interquartile range [IQR], 5-10) the day prior to FMT to 2 (IQR, 1-2) after the infusion. Self-ranked health score improved significantly, from a median of 4 (IQR, 2-6) before transplant to 8 (IQR, 5-9) after transplant. No serious or unexpected adverse events occurred. CONCLUSIONS: In our initial feasibility study, FMT using a frozen inoculum from unrelated donors is effective in treating relapsing CDI. NGT administration appears to be as effective as colonoscopic administration. CLINICAL TRIALS REGISTRATION: NCT01704937.

Clinical effect of hyperbaric oxygen therapy in adhesive postoperative small bowel obstruction.

BACKGROUND: Hyperbaric oxygen (HBO) therapy is a controversial treatment for adhesive postoperative small bowel obstruction, with only a few small studies reported. The aim of this study was to assess the clinical value of HBO therapy in the treatment of adhesive postoperative small bowel obstruction. METHODS: Between April 2006 and March 2012, all patients with adhesive postoperative small bowel obstruction were treated using either decompression therapy or HBO. Patients undergoing HBO therapy were treated once a day at a pressure of 2·0 atmospheres absolute and received 100 per cent oxygen. Patients showing no clinical and radiological improvement with HBO therapy were converted to decompression therapy by means of a long tube. Medical records were reviewed and outcomes analysed. RESULTS: A total of 305 patients were treated, of whom 142 underwent tube decompression therapy during the first 3 years and the remaining 163 had HBO therapy during the last 3 years. The median number of HBO treatments was 3 (range 1-7). A total of 143 patients (87·7 per cent) were treated successfully with HBO without long-tube decompression. HBO therapy was associated with earlier resumption of oral intake (mean 4·7 versus 6·5 days; P = 0·001) and a shorter hospital stay (mean 10·3 versus 14·1 days; P = 0·001). The rate of operation was 7·4 per cent in the HBO group and 14·8 per cent in group treated by decompression alone (P = 0·037). CONCLUSION: In this study, HBO therapy was safe for the treatment of adhesive postoperative small bowel obstruction. It reduced the need for surgery and time to recovery as well as the hospital stay.

Colonic decompression and direct intraluminal medical therapy for Clostridium difficile-associated megacolon using a tube placed endoscopically in the proximal colon.

AIM: Urgent colectomy for severe Clostridium difficile infection can be associated with increased morbidity and mortality. We aimed to use endoscopic methods for treatment. METHOD: We describe a technique of placing an intracolonic tube facilitating decompression and direct delivery of vancomycin to the proximal colon along with enemas on a regular and frequent basis that may not be possible with vancomycin enemas alone. RESULTS: Successful resolution of the C. difficile infection and avoidance of surgery. CONCLUSION: While further long-term evaluation is required, our initial results have shown it to be effective in treating select patients with recalcitrant Clostridium difficile-associated megacolon.

[Value of nasojejunal nutrition in the treatment of children with acute pancreatitis].

OBJECTIVE: To evaluate the feasibility and effectiveness of placement of nasojejunal feeding tube and nasojejunal nutrition feeding in children with acute pancreatitis. METHOD: Twenty-two patients (of whom 13 had severe acute pancreatitis and 9 acute mild pancreatitis) who needed nutritional intervention were selected. They were from Department of Gastroenterology and Surgery during the years 2009 - 2012, and they were at high nutritional risk after STONGkid nutrition risk screening. The average age of them was 5 - 15 years (9.1 years ± 2.8 years). Assisted by endoscopy, the nasojejunal feeding tube was placed in 22 of 24 patients (in 2 cases of recurrent pancreatitis the tubes were placed again after extubation). Besides the use of regular fasting, antacids, inhibitors of trypsin secretion, and anti-infective treatment, 23 cases of all children got nasojejunal nutrition treatment as well. The outcome measures included the success rate, complications of endoscope-assisted nasojejunal tube placement. The children's tolerance and nutrition indicators (weight, blood lymphocytes count, erythrocytes count, serum albumin, serum creatinine, blood urea nitrogen) were observed before and after enteral nutrition therapy. RESULT: Malnutrition evaluation was done 24 times before treatment among 22 patients, incidence of malnutrition was 33% in 22 cases. Placement of nasojejunal tube placement was attempted for a total of 24 times and was successful on first placement in 22 cases, in two cases the placement was successful on the second placement, so the success rate of the first attempt for placement was 92%. No significant complications were observed in any of the cases. Twenty-three of 24 cases were given standardized enteral nutrition (one case was not given enteral nutrition therapy but underwent ERCP due to obstructive jaundice). Twenty-two of 23 cases could tolerate enteral nutrition well, only 1 case was unable to tolerate enteral nutrition due to the pancreas schizophrenia, paralytic ileus. The treatment of jejunal feeding success rate was 96%. The feeding duration was 2 - 74 d (27.0 d ± 18.3 d). The adverse reactions include plugging of the tube in two cases, constipation in two cases, five cases had abdominal pain, diarrhea in 2 cases, vomiting in 2 cases and 1 case of jejunum retention. No case had nasopharynx ulcers, gastrointestinal perforation, gastrointestinal bleeding, re-feeding syndrome and infection etc. Blood erythrocytes count, serum creatinine, blood urea nitrogen were not significantly changed. Twenty of 23 cases were cured, 2 cases were improved and 1 case was unchanged. CONCLUSION: Endoscope-assisted nasojejunal tube placement for children with acute pancreatitis is safe and feasible. Nasojejunal nutrition therapy is effective for acute pancreatitis patients who are at severe nutritional risk, especially for the improvement of the nutritional status of children.

Insertion depth of oral stomach tubes may affect the fermentation parameters of ruminal fluid collected in dairy cows.

Six rumen-fistulated dairy cows were used in 2 trials to validate the technique for the collection of ruminal fluid by an oral stomach tube (OST). Trial 1 was conducted to compare the differences of ruminal fermentation parameters among rumen sites (cranial dorsal, cranial ventral, central, ventral, caudal dorsal, and caudal ventral). The ruminal fluid was collected once per day for 3 consecutive days through rumen cannula (RC). The samples were analyzed for pH, volatile fatty acids (VFA), ammonia N, sodium, potassium, calcium, chloride, and phosphorus concentrations. The ruminal fermentation parameters varied significantly among rumen sites. Compared with the central or ventral rumen, the cranial dorsal rumen had significantly higher pH, ammonia, and sodium concentrations and lower acetate, propionate, and butyrate concentrations, indicating that the sampling site may be one of the main factors contributing to the difference in ruminal fermentation parameters between the samples collected via the OST and RC. In trial 2, the fermentation parameters of ruminal fluid collected via OST at 2 insertion depths (180 or 200 cm) were compared with those of ruminal fluid collected via RC (ventral sac). Ruminal fluid was collected once per week at 5 to 6h after morning feeding. When the OST was inserted to a depth of 180 cm, the OST head was located in the cranial dorsal (atrium) of the rumen. The ruminal fluid collected via the OST had higher pH and sodium concentrations but lower VFA, potassium, calcium, and phosphorus concentrations than that collected via RC. However, when the OST was inserted to a depth of 200 cm, the OST head could pass through the front rumen pillar and reach the central rumen for sampling. No differences were found in pH, VFA, ammonia N, and ion concentrations between the samples collected via the 2 sampling methods. These results indicated that the OST should be inserted to reach the central rumen to obtain representative rumen fluid samples.