Abby Bloch

Direct percutaneous endoscopic jejunostomies for enteral feeding

Abstract Background: Enteral feeding through percutaneous endoscopic gastrostomy (PEG) is increasingly utilized in hospitals, homes, and institutions. However, PEGs have two major limitations: (1) risk for aspiration, which occurs in up to 30% of patients, and (2) it does not allow enteral feeding in patients with gastric outlet obstruction, gastroparesis, or gastric resection. Methods: A new endoscopic method for placement of direct percutaneous endoscopic jejunostomy (DPEJ) was attempted in 150 patients with or without a history of major abdominal surgery. Patients were followed-up until tube utilization ceased because of death or resumption of oral feeding. Results: There were 129 (86%) successful procedures and 21 (14%) unsuccessful attempts. Procedure-related complications included nine (6%) incisional infections. Bleeding, abscess, and colonic perforation each occurred in one patient (.6%), and all required surgical intervention. On long-term follow-up (n = 97), tube malfunction occurred in 3 patients (3%) and aspiration in 3 (3%). Duration of tube use in this population was 113 ± 173 days. Conclusions: DPEJs can be performed successfully with a low complication rate. Enteral feeding through DPEJs drastically reduces aspiration, which commonly occurs with PEG feeding. DPEJs allow feeding and hydration of patients with gastric outlet obstruction due to cancer who are not surgical candidates, eliminate the need for intravenous hydration and feeding, and can cut costs of hospitalization and treatment. (Gastrointest Endosc 1996;44:536-40.)

Position of The American Dietetic Association: phytochemicals and functional foods

Never before has the focus on the health benefits of commonly available foods been so strong. The philosophy that food can be health promoting beyond its nutritional value is gaining acceptance within the public arena and among the scientific community as mounting research links diet/food components to disease prevention and treatment. Dietitians are uniquely qualified and positioned to translate the available sound scientific evidence into practical dietary applications for the consumer and to provide the food industry and the government with valuable insight and expertise for future research, product development, and regulation of phytochemicals and functional foods. Increasing the availability of healthful foods, including functional foods, in the American diet is critical to ensuring a healthier population. As the nutrition experts, dietetics professionals must be the leaders in this new, exciting, and meaningful field as it evolves.

Percutaneous endoscopic gastrostomy and jejunostomy for long-term feeding in patients with cancer of the head and neck.

Enteral feeding is often required in patients with cancer of the head and neck. Percutaneous endoscopic gastrostomies (PEGs) and Jejunostomies (PEJs) can facilitate enteral feeding in patients who require this treatment. The endoscopic technique allows for the placement of feeding gastrostomies and Jejunostomies without a surgical procedure and eliminates the need for nasal tubes for long-term enteral feeding. Forty-two patients with head and neck tumors were referred for placement of PEGs because of severe dysphagia induced by tumors, surgery, radiation, or chemotherapy. The procedure was performed in the gastroenterology suite. Patients were sedated with intravenous meperidine and diazepam, and local anesthetic with lidocaine was applied to the area of incision. Average procedure time was approximately 20 minutes. The procedure was successful in 39 patients in whom tubes were placed ranging in diameter from 15F to 22F. PEGs were placed in 36 patients with intact stomachs and PEJs in three patients with previous gastrectomies. The remaining three procedures were unsuccessful because of technical reasons. There were three localized skin infections, and all responded to antibiotic therapy. Neither peritonitis nor any other immediate complication occurred. In 16 nonhospitalized patients, the procedure was performed on an outpatient basis. After a mean followup of 4.5 ± 6 months of enteral feeding in the home, there was only one case of aspiration and subsequent pneumonia, and this case responded to antibiotics. No other long-term complications were noted. Thus feeding gastrostomies and Jejunostomies can be placed safely and easily in patients with cancers of the head and neck by endoscopic methods without abdominal surgery. These tubes can be used for enteral feeding and eliminate the need for nasogastric tubes. They are better tolerated, are of a wider diameter, and have a reduced risk for migration, clogging, and aspiration-related complications.

Does nutritionist review of a self-administered food frequency questionnaire improve data quality?

OBJECTIVE This study sought to evaluate the benefit of utilizing a nutritionist review of a self-administered food frequency questionnaire (FFQ), to determine whether accuracy could be improved beyond that produced by the self-administered questionnaire alone. DESIGN Participants randomized into a dietary intervention trial completed both a FFQ and a 4-day food record (FR) at baseline before entry into the intervention. The FFQ was self-administered, photocopied and then reviewed by a nutritionist who used additional probes to help complete the questionnaire. Both the versions before nutritionist review and after nutritionist review - were individually compared on specific nutrients to the FR by means, correlations and per cent agreement into quintiles. SETTINGS AND SUBJECTS Three hundred and twenty-four people, a subset of participants from the Polyp Prevention Trial - a randomized controlled trial examining the effect of a low-fat, high-fibre, high fruit and vegetable dietary pattern on the recurrence of adenomatous polyps - were recruited from clinical centres at the University of Utah, University of Buffalo, Memorial Sloan Kettering Cancer Center in New York and Kaiser Permanente Medical Program in Oakland. RESULTS Reviewing the FFQ increased correlations with the FR for every nutrient, and per cent agreement into quintiles for all nutrients except calcium. Energy was underestimated in both versions of the FFQ but to a lesser degree in the version with review. CONCLUSIONS One must further evaluate whether the increases seen with nutritionist review of the FFQ will enhance our ability to predict diet-disease relationships and whether it is cost-effective when participant burden and money spent utilizing trained personnel are considered.

Direct percutaneous endoscopic jejunostomies for enteral feeding.

BACKGROUND Enteral feeding through percutaneous endoscopic gastrostomy (PEG) is increasingly utilized in hospitals, homes, and institutions. However, PEGs have two major limitations: (1) risk for aspiration, which occurs in up to 30% of patients, and (2) it does not allow enteral feeding in patients with gastric outlet obstruction, gastroparesis, or gastric resection. METHODS A new endoscopic method for placement of direct percutaneous endoscopic jejunostomy (DPEJ) was attempted in 150 patients with or without a history of major abdominal surgery. Patients were followed-up until tube utilization ceased because of death or resumption of oral feeding. RESULTS There were 129 (86%) successful procedures and 21 (14%) unsuccessful attempts. Procedure-related complications included nine (6%) incisional infections. Bleeding, abscess, and colonic perforation each occurred in one patient (.6%), and all required surgical intervention. On long-term follow-up (n = 97), tube malfunction occurred in 3 patients (3%) and aspiration in 3 (3%). Duration of tube use in this population was 113 +/- 173 days. CONCLUSIONS DPEJs can be performed successfully with a low complication rate. Enteral feeding through DPEJs drastically reduces aspiration, which commonly occurs with PEG feeding. DPEJs allow feeding and hydration of patients with gastric outlet obstruction due to cancer who are not surgical candidates, eliminate the need for intravenous hydration and feeding, and can cut costs of hospitalization and treatment.

The Polyp Prevention Trial

Abstract The Polyp Prevention Trial (PPT) is a randomized clinical trial sponsored by the National Cancer Institute. National Institutes of Health, that tests the relationship between diet and the formation of large bowel adenomatous polyps, the precursor lesion for most large bowel cancers. Approximately 2000 participants from 8 Clinical Centers have been randomized into the trial. Half were assigned to the intervention group and asked to adopt a low-fat (20% of calories from fat), high-fiber (18grams/1000kcal), high fruit and vegetable (5 to 8 daily servings) eating plan. Numerous epidemiological studies suggest that these dietary factors may be protective for large bowel cancer. The remaining participants were assigned to the control group, maintaining their usual diet. Registered dietitians play a central and critical role in the PPT. The 4-year intervention program is delivered solely by RDs. The success of the intervention depends to a great degree on the abilities of these nutritionists to deliver the program effectively as well as to help participants sustain a high level of motivation for making long-term dietary changes. In addition, RDs at both the Coordinating Center and at the Clinical Centers play a vital role in ensuring standardization of the delivery and documentation of the intervention program. RDs also have the primary responsibility for administering the baseline and annual dietary assessments and for assuring quality and standardization of dietary assessment activities. The Polyp Prevention Trial provides opportunities not available to RDs working in typical clinical settings. For example, the study design allows for approximately 50 hours of in-person counseling for each participant along with resources to assist participants in making long-term changes. The PPT also presents unique challenges to nutritionists in their multiple roles of providing nutrition education and behavioral counseling; administering dietary assessments; maintaining objectivity and standardization; and performing administrative, organizational, and managerial activities.

Methods of nutritional support in the home

Recent advances in nutrition support methods now offer home patients the possibility of maintaining nutritional adequacy when intake is compromised. Using either enteral or parenteral feeding when appropriate allows patients to achieve an improved quality of life at home. Options for management offer a wide variety of choices in feeding methods, formulations, delivery systems, rates and scheduling as well as services provided for a given need. Team management of these patients is necessary to assure proper medical care and support.

Nocturnal tube feedings

Nutritional management of severely ill patients can be approached in several ways. Tube feeding may be the only way to ensure adequate nutrition, or it may be used to supplement inadequate oral intake. In many hospitals, tube feedings are administered only during daytime or evening hours. The potential uses of nocturnal administration are reviewed. Experience of 200 patients with and without cancer using this technique are presented.Nutritional management of severely ill patients can be approached in several ways. Tube feeding may be the only way to ensure adequate nutrition, or it may be used to supplement inadequate oral intake. In many hospitals, tube feedings are administered only during daytime or evening hours. The potential uses of nocturnal administration are reviewed. Experience of 200 patients with and without cancer using this technique are presented.

The Use Of Direct Percutaneous Endoscopic Jejunostomies

Abstract Direct percutaneous endoscopic jejunostomies (DPEJ) were evaluated to determine feasibility of technique, nutrition related outcomes and length of tube use in a cancer population. DPEJ is a technique using a tube placed directly into a proximal jejunual loop, pulling anteriorly with the endoscope and discreetly transluminating the jejunum. Patients were followed for duration of tube use. Results for the period of 1991–1995 follow: In 127 patients, (103 inpatients, 24 outpatients), in whom the technique was attempted, DPEJs were successfully placed in 122 (96%), while 5 (4%) could not be placed for technical reasons. Of the successful placements 115 were used for feeding and 7 for drainage. Indications for the procedure were: gastric outlet obstruction (37%), recurrent or potential aspiration (35%), anorexia (12%), small bowel obstruction (9%), gastroesophageal anastomotic leak (4%), and gastroparesis (3%). There were 4 severe complications (abdominal bleeding, abdominal abscess, jejunal perforation, and colonic perforation), but no deaths occurred as a result of the procedure. Eighty-two males and 45 females, with a mean age of 64 ± 12 years were given DPEJs. At the time of procedure mean weight loss was 15% of usual body weight and mean po intake was approximately 370 Kcal. In the 92 patients for which follow-up data was available, the mean period of DPEJ utilization was 114 ± 169 days: reasons for ending tube utilization were death (78%) or adequate po intake (22%). Method of feeding delivery was predominantly by pump (97%), with (3%) using gravity. Mean formula caloric intake at follow-up was 89% of the caloric goal determined by 30–40 Kcal/kg of baseline weight. An increase of 2% mean body weight and 33% mean po intake occurred in this DPEJ population. These results suggest that DPEJ can be placed safely and may be a viable procedure for achieving nutritional goals in patients where jejunal feedings are indicated.