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• W2085366840 abstract "With the acceptance of the importance of nutritional support in surgical patients, a “knee-jerk response” of placing subclavian catheters for hyperalimentation in many patients without adequate indications has often ensued. Many “enteral advocates” have attempted to convince colleagues that the intestinal route provides a safe and physiologic alternative at a fraction of the cost. The article on needle catheter jejunostomy after major abdominal operations, by Sarr and Mayo in this issue of the Proceedings (pages 565 to 572), makes this point convincingly. This report is especially important currently, when the cost of medical care is skyrocketing and this simple method of volume and nutritional support in postoperative patients continues to be ignored by most surgeons. As Sarr and Mayo point out, theirs is one of numerous studies showing the clear benefits of such methods without major complications. Of the several published reports that have described poor results, most merely have failed to find tolerance to early postoperative feedings, but rarely have substantial complications been noted. Most feeding-induced side effects do not endanger the patient. The primary problem is diarrhea, which is a nuisance but certainly more acceptable than the life-threatening septic and other serious complications associated with parenteral hyperalimentation. Almost all complications or side effects occur only within the first week of therapy, because of efforts to advance too rapidly. It has become increasingly clear that considerably fewer calories and grams of nitrogen are necessary when nutrients are being delivered by way of the portal circulation, where the first pass is through the liver. My colleagues and I1Hoover Jr, HC Ryan JA Anderson EJ Fischer JE Nutritional benefits of immediate postoperative jejunal feeding of an elemental diet.Am J Surg. 1980; 139: 153-159Abstract Full Text PDF PubMed Scopus (140) Google Scholar have shown that, after major upper gastrointestinal resections, patients are in positive nitrogen balance by the fourth postoperative day despite slow advancement with enteral feedings. Current studies suggest that the gut, when totally by-passed because nothing is being administered orally, atrophies substantially within a few days, even with total parenteral nutrition. This change can allow bacteria to migrate from the gut into both lymphatic and vascular channels, a situation possibly contributing to systemic sepsis. Apparently, the intestinal mucosal barrier can be preserved with even small quantities of enteral feedings. Sarr and Mayo report several other observations that bear emphasis. The use of the needle catheter jejunostomy to provide fluids for the patient without an intravenous catheter is no small benefit. Delany and associates,2Delany HM Carnevale NJ Garvey JW Jejunostomy by a needle catheter technique.Surgery. 1973; 73: 786-790PubMed Google Scholar in fact, developed the needle catheter jejunostomy for exactly that purpose and only later used it for nutritional support. Page and colleagues3Page CP Ryan Jr, JA Haff RC Continual catheter administration of an elemental diet.Surg Gynecol Obstet. 1976; 142: 184-188PubMed Google Scholar clearly showed that jejunal feedings could actually be started in the recovery room. Delivery of critical medications, especially those that necessitate intestinal absorption, is another important use. I would caution against the injection of crushed tablets unless they are soluble, as needle catheter jejunostomies plug easily and cannot be replaced unless a guidewire can be inserted completely through the catheter. Of importance, Sarr and Mayo emphasize the use of different diets for various circumstances and the slow but steady progression to higher concentrations. Many of the previous studies that reported poor results used products that were ill-suited to the immediate postoperative state, and the feedings were progressed too rapidly. With the vast array of elemental and nonelemental products now available, finding a tolerable diet should be possible, and slow progression and titration with opiates will usually yield good results. Why, then, are surgeons reluctant to use these techniques? Occasionally, lack of knowledge is a deterrent but should no longer be a warranted excuse, because of the numerous recent publications on the topic. Hesitation to abandon standard practice is perhaps the major reason. Most patients who undergo a successful operation will do well, and major problems after extensive upper gastrointestinal resections are seldom encountered by most surgeons. To place a catheter prophylactically in all “high-risk” patients might legitimately seem excessive—especially because determining the importance of nutritional support in the prevention of complications is difficult. This argument would have merit except for the substantial experience now showing that needle catheter jejunostomies are associated with a low rate of morbidity and that patients have a definite preference to be free of intravenous catheters. Even if the potential nutritional benefits of immediate postoperative jejunal feedings are totally disregarded, the access to the intestine for repletion of fluids and administration of medications, in conjunction with the early removal of intravenous catheters and the freedom of movement thereby encouraged, is a considerable benefit. Additionally, in the occasional patient in whom prolonged gastric atony or an anastomotic leak develops, access to the gut allows excellent nutritional support without further intervention. In my experience, patients have used these catheters at home for as long as 1 year, but in most patients, the support is discontinued on the day of dismissal from the hospital. With experienced surgeons, the needle catheter jejunostomy necessitates only 5 to 7 minutes of additional time in the operating room yet can save the patient untold discomfort from intravenous lines and thousands of dollars in nutritional costs with almost negligible risk. Such a benefit-to-risk ratio is rare. Furthermore, patients appreciate the availability of needle catheter jejunostomy and often request it if a subsequent laparotomy becomes necessary. The cost is a fraction of that for total parenteral nutrition and is little more than that for routine intravenous fluids. For these reasons, the routine use of needle catheter jejunostomy is strongly recommended in patients undergoing major resections of the upper gastrointestinal tract. The current excellent article by Sarr and Mayo should help to convince surgeons that “if the gut works, it should be used.” Needle catheter jejunostomy provides safe and convenient access to the gut; thus, it should be considered a friend." @default.
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• W2085366840 title "Needle Catheter Jejunostomy—Friend or Foe?" @default.
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