Injury Vol. 26, No. 3, pp. 177-180, 1995 Copyright 0 1995 Elsevier Science Ltd

Printed in Great Britain. All rights reserved 0020.I383/95 $10.00 + 0.00

Insertion of a transpyloric feeding tube during laparotomy in the critically injured: rationale and plea for routine use

B. R. Boulanger, F. D. Brennemann, S. B. Rizoli and R. Nayman Departments of Surgery, Clinical Nutrition and the Trauma Program, Sunnybrook HSC, University of Toronto, Toronto, Canada

Although clinical and experimental evidence favours early enferal feeding in the critically injured, provision of such enferul feeds cun be difficult. Gastric feeds are often not tolerated and may lead to aspiration. An infolerance of gasfric feeds leads to a cumulative energy and protein deficit and may result in the inifiufion of expensive parenferal nufrifion (TPN). An alfernafive and under-utilized fech- nique to ensure enferul access in trauma victims is the insertion of a

franspyloric (nasojejunal) feeding tube during emergent laparotomy. We have employed this method of enferal access with success. In fhe following report, we describe fkis technique, provide an illustrative case wifh a cost comparison between nasojejunal feeds and TPN, presenf fhe rafionale for such a mode of enferal access and outline fhe indications and confraindicufions. Enferal uccess by the infra-operufive insertion of a franspyloric feeding tube allows immediafe/early enferal feeding that is easy, safe! reliable and inexpensive.

Injury, Vol. 26, No. 3, 177-180, 1995

Introduction

Optimal nutritional support is necessary to reduce both morbidity and mortality during critical illness. Although this concept has been generally,accepted in the past, the implementation of consistent and specific feeding strategies has been lacking. Recently, early enteral feeding has become the goal of nutritional support in severely injured or burned patients’-‘. The provision of enteral support soon after injury has been shown, both experi- mentally and clinically, to decrease septic complications, attenuate the hypermetabolic response to injury and possibly, reduce mortality’,*. In addition, enteral feeding is less expensive that the parenteral routes (i.e. TPN) and has fewer metabolic and catheter-related complications4,5.

Given the evidence that early enteral feeding appears beneficial in the critically injured, the challenge for the clinician has been to provide a simple and reliable method of enteral access. In most trauma centres, enteral access has been limited to nasogastric (NG) and surgical jejunostomy tubes. Although nasogastric feeding is popular because of the relative ease of access, it is associated with two main

problems: a risk of aspiration and intolerance, as demon- strated by gastric retention of feeds. Intolerance leads to a delay in feeding and an inability to provide the required protein and energy. The routine use of gastrointestinal (GI) motility agents may decrease such intolerance, but not in all cases. In addition, parenteral nutrition, with associated costs and complications, is often initiated when gastric feeds are not successful. Aspiration of gastric feeds is common and may lead to pulmonary sepsis or death’,‘. In contrast, surgical jejunostomy feeding, commonly employed at some centres, is well tolerated and has no associated risk of aspiration. However, surgical jejunost- omy tubes are not free of associated morbidity.

The intra-operative insertion of a nasojejunal (NJ) tube provides an alternative mode of enteral access that com- bines the advantages of an NG tube and a surgical jejunostomy. Specifically, insertion is easy with no need for an enterostomy and there is a negligible risk of aspiration while maintaining excellent tolerance. In injured patients not requiring a laparotomy, NJ tubes may be inserted in the critical care unit endoscopically, fluoroscopically or expectantly by the fortuitous migration of an NG tube. However, endoscopic insertion of NJ tubes is at times technically difficult and requires the availability of endo- scopists. In addition, the endoscopic insertion of feeding tubes after recent trauma may be contraindicated by confirmed or suspected cervical spine injury, head injury, facial fractures or respiratory instability.

The passage of a transpyloric feeding tube at the time of laparotomy for injury appears to offer several advantages over other feeding modalities in this patient population. Although this technique is employed inconsistently at some trauma centres, it is generally an under-utilized method of enteral access. It is our belief that the ability of this method to provide early, reliable and safe enteral access mandates more routine use in the critically injured.

The purpose of the present report is to: (I) describe a technique for provision of early enteral feeding in trauma patients that require a laparotomy, (2) outline the rationale for the insertion of transpyloric feeding tubes, and (3) propose guidelines for the use of transpyloric feeding tubes in injured patients that require a laparotomy.

178 Injury: International Journal of the Care of the Injured Vol. 26, No. 3, 1995

Figure 1. Delivery of nasojejunal enteral feeds with gastric decompression following trauma laparotomy.

Technique

The intra-operative insertion of a transpyloric feeding tube is not difficult and has only three prerequisites: (I) awareness of the technique, (2) a standard enteral feeding tube (weighted tip, if available), and (3) cooperation with either the anaesthetist or a nonsterile operative assistant.

The most efficient time for the insertion of a nasojejunal (NJ) feeding tube occurs when the laparotomy for trauma is complete, and the abdomen is ready to be closed. At our institution, it has become routine to consider NJ tube placement at this stage of the laparotomy in all trauma patients. If the feeding tube is placed at an earlier stage of the laparotomy, the tube is often displaced during the remainder of the operation.

The enteral feeding tube employed is a single lumen, radioopaque, polyurethane tube with a tungsten weighted end (Keofeed II, Model A98301, IVAC Corporation, San Diego, CA, USA 92121-1579). Similar feeding tubes are stocked at most centres and are commercially available from a number of manufacturers. The wire within the feeding tube should be left in place for insertion. To allow for an unobstructed passage of the NJ tube, it is best to first remove the standard nasogastric tube. The anaesthetist (or nonsterile assistant) is then asked to pass the feeding tube through the nose into the stomach. The surgeon guides the tip through the pyloms into the duodenum. This man- oeuvre is easier for the surgeon on the left side of the operating table and is facilitated by a cooperative effort between the anaesthetist and surgeon. The goal is to achieve a transpyloric feeding tube, but it is our experience that the feeding tube can often be advanced beyond the ligament of Treitz into the proximal jejunum. Having

accomplished this, the surgeon now holds the NJ tube in position while the anaesthetist slowly and carefully removes the guidewire. After the NJ tube is in position, it is taped securely to the nose. A standard sump gastric tube is then reinserted via the mouth or nose by the anaesthetist (Figwe I).

In the critical care unit, the transpyloric feeding tube should be intermittently flushed with water to maintain patency until continuous enteral feeds are initiated. It is unnecessary to perform plain radiographs in the critical care unit to check feeding tube position. The feeds may be commenced almost immediately and increased to meet nutritional requirements. Elemental feeds are unnecessary. In our experience, enteral feeds delivered via a transpyloric tube are well tolerated, even in trauma patients with intra-abdominal and retroperitoneal injuries. The gastric tube allows for gastric decompression with simultaneous small bowel feedings. It has been our routine to administer sucralfate via the gastric tube for stress ulcer prophylaxis. NJ feeds present in the gastric aspirate should alert staff to the possibility of feeding tube displacement or GI intolerance. If the transpyloric feeding tube is operatively placed distal to the ligament of Treitz, displacement of the distal end into the stomach is uncommon. In contrast to gastric feeds, there is no clear indication to withhold NJ feeds prior to surgery. This tends to minimize the cumulat- ive energy/protein deficit in injured patients requiring multiple operations. Critical care unit personnel should exercise caution with the NJ tube to prevent inadvertent removal. The smaller, more flexible enteral feeding tubes are better tolerated by patients than standard gastric tubes. The NJ feeds can be continued until the patient is able to safely tolerate oral feedings. Further, a trial of oral feeds can be initiated with the NJ tube in situ.

Case report A 25-year-old male was a front-seat passenger in a frontal road traffic accident. Injuries identified included a thoracic aortic rupture, a ruptured left hemidiaphragm and a right humeral fracture. The patient was orotracheally intubated. At laparotomy, an anterior radial tear of the diaphragm was repaired and there were no other injuries. There were no facial fractures and no basal skull fracture. A nasojejunal feeding tube and an orogastric sump tube were inserted at the conclusion of the laparotomy. The thoracic aortic rupture was then repaired via a left thoracotomy.

Continuous nasojejunal feeds (Traumacal, 1.5 kcal (6.3 J)/ml, Mead-Johnson, Canada) were commenced at 25 ml/h the day following surgery (day 2). The gastric tube was maintained on suction and sucralfate was intermittently administered. No feeding solution was aspirated via the gastric tube and the NJ feeds were advanced to 75 ml/h on day 3. The resting energy expenditure (REE), as measured by indirect calorimetry, was 2899kcals (12129 J)/day on day 3. The total daily energy expenditure was estimated to be 1.1 x REE, 3200 kcals (13389 J)/day. Thus, to meet the measured energy requirements, the NJ feeds were increased to 9OmI/h on day 4. The patient remained on the NJ feeds while intubated (7 days) and the feeds were well tolerated without the need for GI motility agents. NJ feeds were tapered with the initiation of oral feedings.

Rationale

There are several advantages to the intra-operative inser- tion of transpyloric feeding tubes in trauma patients. The

Kelly et al.: Management of impalement injury 179

Table I. Indications and contraindications for intraoperative insertion and use of a nasojejunal feeding tube

Indications Requirement for laparotomy in multi-system trauma and one or more of the following:

1. Anticipated prolonged endotracheal intubation 2. Need for multiple, delayed operations 3. Head injury that precludes safe oral or gastric feeds 4. Pre-morbid gastric motility disorder

Contraindications (1) To feeding tube insertion:

Absolute Basal skull fracture Hemodynamic instability at conclusion of laparotomy Abbreviated laparotomy”

Relative Facial fractures Abnormal duodenal anatomy

(2) To administration of enteral feeds: Relative Jejunal or ileal injuries

Pancreatic injuries?

“Brenneman et al.”

insertion of the feeding tube is not difficult and is easily learned. In addition, no ancillary equipment is necessary, as most centres stock enteral feeding tubes. The key to implementation of this technique is for the operating surgeon to consider insertion of an NJ tube at the conclusion of all laparotomies for trauma. A review of the indications and contraindications, outlined in Table I, dem- onstrates that many injured patients are candidates for this method of enteral access.

There has been a recent emphasis on the early enteral feeding of injury victims in an effort to minimize septic complications, organ dysfunction, duration of hospital stay and mortality’,2,8,9. Both laboratory studies and clinical trials have demonstrated a decrease in morbidity and mortality after injury when enteral, rather than parenteral, nutrition is provided3,4,9. The translocation of enteric organisms has been documented in animals and humans after injury although the clinical relevance has yet to be determined. Enteral feeding decreases the likelihood of bacterial translocation by maintaining gut mucosal integ- rity and inhibiting bacterial overgrowth“‘,“. Further, enteral feeds have positive effects on the neuroendocrine and immunological responses to injury”-r4. It remains to be determined whether enteral feeds decrease the fre- quency of acute acalculous cholecystitis in injury victims. In addition, the most critically injured patients are likely to be the ones to benefit most from early enteral feeding. The intraoperative insertion of an NJ tube provides access for feeding in the early post-traumatic period and may therefore, have therapeutic benefits.

In addition to providing easy enteral access and poten- tial therapeutic benefits, enteral feeding via a transpyloric feeding tube is associated with fewer complications than alternative techniques. Gastric feeds are associated with a greater risk of aspiration/pneumonia than are jejunal feedsIs. Jejunal feeds tend to be better tolerated and result in a more reliable delivery of nutritional requirements. For instance, in contrast to jejunal feeds, gastric feeds are routinely withheld for several hours prior to surgical intervention to minimize the risk of aspiration during anaesthesia. This interruption in nutritional support can result in a large energy/protein deficit in the critically injured patient requiring multiple delayed operations.

A surgical jejunostomy mandates an enterostomy with the associated risk of leak with secondary abscess forma-

Table II. Cost comparison of NJ feeds and TPN for illustrative case report

Date after injury NJ’ TPN’

Operative day

Pav 1) Day 2 Day 3 Day 4-7 Total costs (day l-7)

None

$3.01124 h $9.03124 h

$10.01/24 h $52.08

None

$169.75124 h $188.00/24 h $188.00/24 h

$1109.75

Cost of enteral feed (Traumacal) or TPN solutions (see text) with nutritional goal of 3200 kcal (13389 J)/24 h and 150 g, protein/ 24 h. *NJ feeds: Operative day, none; Day 2, 600 ml/24 h; Day 3, 1800 ml/24 h; Days 4-7,216O ml/24 h ‘TPN: Operative day, none; Day 2, 1800ml/24 h amino acid/ dextrose and 500 ml/24 h, 20% lipid; Days 3-7, 2400 ml/24 h amino acid/dextrose and 500ml/24 h 20% lipid.

tion, fistula or peritonitis. In addition, both mechanical obstruction and bowel ischaemia can occur after surgical jejunostomyr’. Further, agitated patients may inadvert- ently remove a new surgical jejunostomy with the risk of leak. Nasojejunal feeding tubes have none of the potential disadvantages of surgical jejunostomies while retaining all of the advantages.

The intra-operative insertion of a nasojejunal feeding tube is an inexpensive technique of nutritional support. Although most clinicians favour the dictum ‘If the gut works, use it’, in clinical practice TPN is often favoured due to its reliability and ease of administration. However, in the contemporary era of health-care cost containment, TPN is vastly inferior to the delivery of enteral feeds via an NJ tube. In an effort to evaluate this disparity, the cost of enteral feeds (Traumacal, Mead-Johnson, Canada) was compared to equivalent TPN (6.2 per cent/20 per cent amino acid dextrose in 12OOm1, Clinitec Nutrition Co., Canada; 20 per cent Intralipid, Kabi-Pharmacia, Stockholm, Sweden) for the first seven hospital days of the case report see above. The nutritional goal of both enteral feeding and TPN was 3200 kcals (13389 J)/day and 150 g protein/day (Table II). Cost figures are based on 1993 institutional costs in Canadian dollars. As demonstrated in TubleIl, a 7 day regimen of NJ feeds costs $52.09, while to provide the

180 Injury: International Journal of the Care of the Injured Vol. 26, No. 3, 1995

equivalent nutritional support for 7 days with TPN would cost $1109.75. This cost discrepancy would be even greater if the costs of materials (central venous catheter kits vs feeding tubes), TPN preparation, TPN-specific bloodwork and sepsis-related costs (cultures and line changes) were included in the analysis. Given the evidence for a decrease in sepsis and hospital stay with entera] versus parenteral nutrition, further cost savings may be realized.

Indications and contraindications

The indications and contraindications for the intraoperat- ive insertion of a transpyloric feeding tube during laparotomy in the critically injured are not difficult to define (Table I ). The indications include multi-system injury victims who are undergoing laparotomy and in whom adequate oral nutritional intake is unforeseen in the near future. This group primarily includes patients who are predicted to require prolonged endotracheal intubation with or without mechanical ventilation. However, patients that will not require prolonged intubation are also can- didates if they will have multiple delayed operations or have a concomitant head injury that precludes safe oral or gastric feeds. A further indication may be the unusual patient with a known gastric motility disorder.

The contraindications to the operative placement of an NJ feeding tube can be divided into those that relate to tube insertion and those regarding the delivery of feeds to the GI tract. Contraindications to NJ tube insertion include trauma victims with a basal skull fracture or a severe facial smash. However, patients with facial fractures and inter- dental wires may particularly benefit from an NJ tube. Those with previous upper abdominal surgery or chronic peptic ulcer disease may have altered duodenal anatomy, prohibiting the transpyloric manipulation of the tube. Finally, the time should not be taken to insert an NJ tube in any trauma victim that is hemodynamically or meta- bolically unstable at the conclusion of the laparotomy.

Although traditional surgical teaching dictates that enteral feeds are contraindicated following injuries to the GI tract, there are definite exceptions. For instance, a gastric or duodenal injury does not preclude jejunal feeding. A colostomy or a colon repair/resection is not a contraindication to the institution of jejunal feeds early in the post-operative course. The controversy regarding the safety of enteral feeds after bowel injury tends to focus on jejunal and ileal injuries. It is our institutional belief that a patient with a traumatic small bowel perforation, treated with either repair or resection and anastomosis, requires a period of bowel rest before resuming enteral nutrition. This philosophy is in contradistinction to that of other groups and may prove to be overly conservative’. In addition, injury victims with pancreatic injuries may be best managed with complete bowel rest, although there are differing views on this issue.

Conclusions

In conclusion, the insertion of a transpyloric feeding tube during laparotomy in the critically injured has both practical and theoretical advantages over other techniques of enteral access and nutritional support. A transpyloric feeding tube is easy to insert intraoperatively and provides a safe, reliable and inexpensive route for enteral feeding. Although this technique is neither new nor difficult, it is

under-utilized at present. During trauma laparotomies, insertion of a transpyloric feeding tube should be routinely considered.

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Paper accepted 22 November 19%

Requests for reprints should be addressed to: Bernard R. Boulanger MD FRCSC, Sunnybrook HSC, University of Toronto, 2075 Bayview Ave. H-170, North York, Ontario, Canada M4N 3M5.