Welcome to ASGE Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I am very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Feeding Tubes. My name is Michael DeLuttre, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping notes. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted to GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to introduce our GI Fellow moderator, Jason Dubroff, from the University of Utah School of Medicine. I will now hand over this presentation to him. I'm Jay Dubroff. I'm a third-year GI Fellow. I'll be the GI Fellow moderator for this ASGE Hangout, and I'll quickly introduce Dr. Fang. Dr. Fang is our Chief of our GI Division here at the University of Utah. He has a particular interest and expertise in feeding tubes. Dr. Fang is also an avid outdoorsman, skier, and just got back from a trek in Nepal. So glad to have him back here, and glad to have him ready to talk to us about feeding tubes. Okay. Thanks a lot, Jay. Jay's a third-year fellow and has been drawn into many a challenging feeding tube case with me. He's also made a very wise decision for both of us and going to join us on our faculty. Okay. So I thought I would just... It's kind of a basic topic, but go over some nuances of choosing the right feeding tube, sort of the right tube for the right patient at the right time, and go over a little bit of how we do it. So the obligatory poll question, which you guys can just think about the answer yourselves. 81-year-old, had a Bill Roth II for peptic ulcer disease 25 years ago, got admitted to neurology after having a stroke, resulting in oropharyngeal dysphagia. His BMI is 27, no heartburn, regurgitation, or history of aspiration pneumonia. So the questions, the type of tubes that we had to choose from are a DALPOF or nasogastric nasojejunal tube, a PEG tube, a PEG with jejunal extension or PEG-J, a direct percutaneous endoscopic jejunostomy or directly into your jejunum, or a DOE tube just starting on TPN. So we'll get back to that. So here's the things I think we all sort of empirically do without necessarily thinking about it out loud or putting it in a checklist, but what are we giving them their feeding for? Is it to provide meds and nutrition, or are we decompressing? What is their GI tract function in any surgical history, certainly? How long are you anticipating needing the tube for? Is the patient having surgery anyway? Aspiration is something we always think about both just procedurally, but, you know, patients receiving feeding tubes, many, if not all of them are at risk for aspiration in one way or the other. Certainly patient preference, perception, religious, moral, ethical issues. And we like this not to be an issue in the GI endoscopy world, but there's local expertise in terms of what tubes are you trained to place or have experience in placing. And I sort of put on the other side the sort of most or least invasive types of tube, whether an orogastric or nasoenteric tube, the various percutaneous tubes that we place. We all know interventional radiology can do it, and I think that's becoming more common and less and less are being done by surgery, although can be done at surgery, again, the most invasive. So let's start with nasoenteric tubes. Classically, you think these are post-pyloric versus an NG tube, which is nasogastric. I do think in many cases, it's a good idea in patients with motility disorders or other things to do a trial of nasoenteric feeding to make sure if there's any question if they can tolerate tube feeding, but in general, in patients less than four to six weeks. For percutaneous tubes of all types that we just talked about, again, they'll need a tube. We anticipate for more than four to six weeks, and we talked about the PEG, the PEG-J, a PEG with a jejunal extension tube through it, and a direct jejunostomy tube placed percutaneously or a D-PEG. So starting off most simply with PEGs, the general indication is you just can't take enough PO. So for nutrition, hydration, meds in more than 30 days, but we still occasionally use them for decompression in patients with end-stage malignancy that you can't bypass endoscopically. You can decompress pretty well through a PEG tube, patients with bowel obstruction that can't otherwise be treated, and then patients with gastroparesis, we'll occasionally place them as well. So more importantly, perhaps, what are the contraindications? I think we've been pretty good with the medical futility aspect of it, even before the patients get referred to us, but I think we should know and still be very aware of the futility in many cases, in terminal cancer and dementia, it hasn't been shown to improve either quality of life or length of life in terms of providing nutrition. And then the technical issues are really pretty brief, as you can see here. It's just you can't get that stomach to rise up against the anterior abdominal wall to find a good spot to place the tube, although you won't know that until you actually try, or you can't pass an endoscope through the esophagus, although you can get around that by using ultra-thin endoscopes. So it has to be a pretty tight structure not to get through that. And then I mentioned social, ethical, often religious issues that we need to be aware of and address. This is a kind of a long list of the relative contraindications, and I would say once you develop some expertise in placing PEG tubes especially, these are all just relative contraindications. So you can see the list there, ascites, coagulopathy, varices, dialysis, hernias, peritoneal disease. Again, you can read the rest, but I can tell you that I placed PEG tubes in every single one of these relative contraindications. And then I think in many cases, you just got to try, and sometimes you won't be able to with these relative contraindications. But honestly, in most cases you can, and just make, as long as everyone's aware from the patients and the sort of referring services that your placement success may not be as high and or your complication rate might be a little bit lower or higher. But if the benefits outweighs the risk, it's often worth trying in these relative contraindication states. So everyone seems to be on DOACs these days. Here's the sort of combination of the official ASGE and ESGE guidelines. It is considered a high-risk procedure for PEGs, you get about a 2% bleeding risk. So patient risk, if they're low risk for having a thrombotic event, just hold it. If they're higher risk, you can hold it and then bridge them, although as you know, bridging really hasn't been shown to be effective. So in general, we just hold it. You can always use a DOB off in the interim. We always consider aspirins and non-steroidals. You can see the platelet count and INR count you'd like to shoot for, but if you can't, in many cases, it's still okay to do it. They'll just have a slightly higher risk of bleeding. In terms of when to stop it, if they're on a low molecular weight heparin the night before, COAX in general, a day or two is fine because they're fast off, Warfarin, five days if you can. Clopidogrel comes up a lot. It should be five to seven days if you have the time, but there's a lot of data for even shorter. And there's going to be new ASGE guidelines that I think are going to be a little more permissive in terms of their antithrombotics and holding them. And then when to restart Warfarin, because it takes a while to get to therapeutic levels. You can do it the evening of, low molecular weight, heparin the day after, and DOAX, because they're such quick onset, you have to wait longer, like 48 hours. I mentioned that interventional radiology is placing a lot more of these feeding tubes. And I think in many institutions and areas, they're the ones primarily placing them. But there's actually a fair amount of data now that pegs placed endoscopically actually have fewer complications and overall better outcomes. This table on the right there is from a paper a couple of years ago, looking at the national inpatient sample. We have a paper that we're publishing now for PEG-J showing basically the same thing, is there's decreased bleeding, infection, sooner discharges, and less readmissions when we place them endoscopically versus IR. And the reasons I've listed here is that the IR guys tend to place smaller diameter tubes that are often at pigtails or balloon internal bolsters, where we place larger tubes with solid bolsters, and we always give antibiotics. And maybe we're just better internal medicine docs overall and anticipate and treat complications better. So actually, in the latest European Intra- and Parental Society, they actually recommended placing pegs endoscopically over IR-placed tubes. So this is a big issue that comes up, should you do it in the stomach or small bowel? And here's sort of the benefits in comparison of gastric versus jejunal. Gastric is more physiologic, that's how we normally eat. You can give either isotonic or hypertonic formulas. You can do bolus as opposed to continuous feeds. However, it can be less reliable overall because patients can have intolerance of nausea, vomiting, bloating, gastroparesis. I'm clear if it really decreases reflux or aspiration, but there is some data that it might if you have less reflux and aspiration if you feed jejunally. And you can feed because the small bowel wakes up after surgery the fastest. You can have less stoppages if patients are going to surgery on the inpatient setting. Here's some data showing maybe small bowel feeding is associated with less aspiration. This is a decade-old study, but just showing on the left where the feeding tube site was, D1, proximal duodenum versus stomach, second, third portion of duodenum, and then very distal duodenum and jejunum. And you can see the odds ratio for pneumonia appears to go down the farther and more distal you feed. So some not perfect data that jejunal feeding may result in less aspiration. So let's go to jejunal access. When are you going to think about it? People have problems with their stomach, basically, so gastroparesis, they don't have all their stomach because of previous surgery, they have a gastrointestinal obstruction. There are some patients, you can't place a peg, they have, again, previous surgery, so they have not much of a stomach and what's there, whether it's partially resected or intact. Some people just have very high-lying stomachs, probably just really domed diaphragms, and you just can't find a good window, and you'll see that the stomach appears to be in the ribcage. Patients with pancreatitis, who you may not want to stimulate the pancreas, they're not tolerating feeding into their stomach. Again, in the hospital setting, you get improved nutrient delivery. And then there's this somewhat controversial issue related to aspiration to consider jejunal access. Again, not everyone is comfortable placing a PEG-J or a DIRECT-J, but I would argue that most should be, and like with anything, the more experience you get, the better you are at it. This is a PEG-J, when you want to feed into this small intestine, you can't do simultaneous gastric decompression. It's usually a larger 20-24 French PEG that you put a smaller 9-12 French jejunal extension tube through it. And I find, when I place them, I try to do them with floral, I just find it easier to make sure you get that tube all the way down without any kinks or looping. This video I tried earlier, I couldn't get it to work, I bet you it still won't work. Yeah, sorry. This was the drag-and-pull method for placing a PEG-J. You have your PEG in place, you put this J on with this loop of suture through it, you grab it with a reclosable clip, and you basically carry it all the way down to the jejunum and then clip it in place. And sometimes I'll place the second clip, and that holds it in place while you pull your pediatric colonoscope back so you don't dislodge the tube you've just placed. There's also this through-the-scope method that works really well either with a big PEG, 28 French, basically a PEG that you can put your ultrathin scope through, or if they previously had a PEG or you're replacing a PEG-J, it goes well, you can use the ultrathin right through the stoma. And it goes super fast, and in some patients you don't even need to use sedation because you're just going through their gastric stoma tract. So you just drive the scope down, it's easy to get past the ligament trites, pass a floppy wire, pull the scope out, leave the wire in place, and then just pass the J-tube over. This goes super fast, like 10 minutes, and I think this video will play. So I've already driven down to pass the ligament trites, passing a stiff floppy wire down. Again, flora always helps. I'm just pulling the scope out while pushing the wire in to make sure it stays in place, and then you just pass the feeding tube over the wire, and it goes lickety-split. And you'll see here, I've got a flora shot coming up next, but you're just advancing the tube while giving back tension on the wire so the wire doesn't move in place and the tube moves over the wire. This is a low-profile G-J-tube, which patients often really like who are more functional. Pulling the wire out there, and yeah, here's a flora. Pass the ligament trites, putting out the wire, leaving the…and pulling out the scope, then pushing the tube over, and you can see it's passed the ligament trites when we inject a contrast. So the problem with PEGJs is they tend to kink, migrate, and clog. So these are from a couple studies showing that the average survival time was about 30 to 40 days, and you tend to do a lot of re-interventions with this kind of tube. So if you have to use it, you should, and I think more people are comfortable with these versus a direct J, but that's the issue with those. So that's why we often will do a direct J. We use a pediatric colonoscope, drive down to past the logarithmic trites, find a good spot, and then it's placed much like a peg. And the advantages of it are because it goes right into the small intestine, it doesn't migrate, it doesn't kink, it doesn't clog. Often you can get it farther past the ligament than a GJ tube because they're larger tubes in general than the jejunal extension tube and a peg J tube. It's better for infusing and decompression and you'll get less clogging and certainly a lot less morbidity than a surgical jejunostomy if you have the expertise to do it. Here's a couple studies comparing peg Js to direct Js in terms of days to re-intervention and the cumulative patency rate on the left there showing the solid line with a direct J, Kaplan-Meier type curves on both of these that last longer. Basically the same thing on the right from another study, cumulative survival of the tube of a combination peg direct J versus a peg J, the dotted line on the right again just showing because they're more stable tubes basically. This is an older study that we did showing that in patients who refer for a direct J after having aspiration events on a peg that they decrease their aspiration events after having the D-pedge or direct J placed. Again, it's a really small study but again suggestive that you may decrease it in terms of aspiration with jejunal feeding in a patient who's at very high risk or had aspiration already. Here's how it goes. Again, we always use a pediatric colonoscope. We never use fluoroscopy. We drive down past the ligament trites and find a good spot to place our finder needle and trocar and once you get that, you're in pretty good shape. We always do these under general anesthesia because we have patients on their back for a fair amount of time so that risk for aspiration don't want to happen during our procedure. Here's a short video of how we do it. We found a good spot. We put the finder needle through. We snare the finder needle to hold the small bowel in place. We need to fix it to some degree because as you might remember, your small bowel is really mobile. It's not really fixed. Here we poke the trocar straight through, almost poke the scope itself, and then we let go of the finder needle, grab the trocar. Just like with a PEG now, you can see here, and we'll put the wire through, the loop guy wire through, grab it, and just pull it out the mouth. As I said before, like with anything, the more experience you get with this, the better you are. We just looked back at our data and we're hitting 90-95% success rate. Not quite as high as a PEG, but still pretty high. Some tips for success. It's definitely easier the skinnier you are, which is true for a PEG tube. Actually, we found it's easier in post-surgical patients because they often have adhesions holding the small bowel up against the anterior abdominal wall. It can be useful to use translumination on your endoscope to find the spot. Usually, we can find a spot and don't need to use translumination, but it can help you when you're having trouble. We do demand that you've got both great translumination and discrete finger indention because there is the risk that you could put it through the colon or put it through another piece of small bowel first. We don't use fluoroscopy at all. There is some data that using single or double balloon endoscopes can increase your success rate, but our success rate is high enough that we don't find it all that useful. We do use a safe track technique, so when you pass your finder needle and trocar, you're pulling back on the syringe attached to that needle. When you see the tip of those needles in the lumen, you should get air back at the same time in your syringe. If you get air back first, you put the needle through the transverse colon, stomach, or another piece of small bowel first, and that's okay as long as you don't try to put the tube through there. You just have to find another site. We do find that glucagon can help if your small bowel's moving all over the place, and like I said, we do always do them under general anesthesia. So we talked about endoscopy versus radiologic placement. Here are some other specifics. Obviously they're getting endoscopy for another reason. We do find that endoscopy, we find other things that may change the patient's management or other endoscopic abnormalities. You can go right to the bedside to place all these tubes, unlike interventional radiology where they have to go down to the fluoroscopy suite. If they're at risk for inadvertent removal, again, as I stated, we tend to place solid bolster tubes that are hard to remove. One consideration for placing them by radiology is there's some concern that in a patient with an active aerodigestive cancer, if you pull that peg through, you might see the tract, although my suspicion is in the new ASG guidelines that are going to come out that that's not going to be considered to be a significant issue. And with radiology, you can use less sedation because you're not scoping them, so that's a consideration that might favor radiologic placement. So this is my conclusion slide. Again, right tube at the right time in the right patient. The initial consideration is a DAW-PAW for nasal tube versus a percutaneous tube. You got to decide whether you want to put it in the stomach, stomach into the jejunum or directly into the jejunum. It can be placed by us, IR or surgery. When is it better for one versus the other? In most cases or in many cases, endoscopy is preferred, but there are situations where IR or even surgery would be preferred. And hopefully by going to talks like this and some of the hands-on things that the ASGE does, everyone will feel like they have that local expertise. So, sorry if I went a few minutes over, but happy to take any questions or other stuff. Hey, I haven't seen any questions come through the chat so far, but if you have any questions, you can put them through the chat or the Q&A. If not, I might start giving Dr. Feng some questions. Yeah, maybe Jay, what are the questions that you're asking me or I'm asking you when we're placing these tubes together? Oh, we got one question from Shivantha. She says, thanks. What has your experience been with placing PEGs in cirrhotic patients with ascites since it's a relative contraindication? Yeah, well, so you sort of have two relative contraindications. One's the ascites and two is the cirrhosis and potentially increased bleeding complications. So, you know, if they can't have a Dobhoff, we prefer that if they're not going to need it for too long. But whether they have ascites from cirrhosis or ascites from malignancy, you can definitely still place the tubes. And the considerations there are, one, you just got to get that ascites drained before you place the tube. So we'll have a good ultrasound guided, drain it as much as they can. And oftentimes, if we're worried they're going to reaccumulate relatively quick in 48 to 72 hours, we'll have them recheck and drain more if needed. The other thing that we'll do is we'll usually place T-fasteners at the same time we do the PEG. And there's some commercial kits out there that are super easy to use. And we'll place the PEG first, and then we'll put two or three T-fasteners around that. And that's to just get more of the stomach wall adhesed and attached to the anterior abdominal wall, the peritoneal side, so they form a good stoma tract. And we found that works pretty well. The other thing we tend to do in cirrhotics is we tend to give them three days of antibiotics instead of just the one pre-procedure dose. And that's totally anecdotal based on no data. They just feel like they're at increased risk of infection. They may have some ascites anyway. So that's how we do it in that case. And then if they have malignant ascites, again, get them drained just for that period around the procedure, T-fasteners, and knock on wood, in both those cases, malignant ascites and cirrhotic ascites, we've placed them without complication. I guess I'll just add a piggyback question onto that. If a patient had a history of SBP or was at increased risk of SBP with low protein in their ascites, is that something that would give you pause or more of a risk benefit depending on the scenario? Yeah, certainly with all those guys, the benefits got to be higher because the risk is relatively higher. But I don't think that having real low protein other than giving a few extra days of antibiotics would concern me too much. I guess if their ascites was completely uncontrollable in terms of getting it relatively dry for 48 to 72 hours, that would be a problem. I'd get maybe a little more worried. But in general, we haven't had a case come up where we've declined to do the case because of that. All right, so we have a couple more questions. Ahmad is asking, one issue we commonly deal with is leakage around previously placed peg site with no sign of infection. How would you tackle that? Yeah, this is a really difficult problem. Yeah, again, you want to first rule out infection, Barry Bumper syndrome, all those things. But a lot of times, if it's a standard profile tube, so not a low profile tube, we think the problem is that there was just not good healing around the tube itself. And there's a little bit of a post-hole phenomenon where the tube is moving around, enlarging the tract, and it doesn't seal very well. So we'll often, in that case, switch into a low profile tube. Sometimes we'll put them on PPIs because that'll decrease the overall gastric fluid volume and then good wound care. Sometimes stoma nurses can be helpful, but just make sure that fluid gets absorbed off the anterior abdominal wall skin as good as possible. We tend not to replace it with a bigger peg tube because sometimes what can happen is whatever caused the leakage in the first place will now cause leakage again, and now you just have a bigger hole to leak around. And then, worst case scenario, there's three options. Some people believe if you change a peg to a peg J and divert the feeding formula downstream, that may help. We haven't found that to be super helpful, but I wouldn't rule it out. Two, you can just take out the peg, let it heal over, and then place another one, but then they've got to be on something in the interim, like a Dobov. And then one thing that sometimes works too, and this is a difficult problem, so not one thing works on everyone, is sometimes we'll take out the peg, leave it out till the next day, and then go back and place the same size peg in that site. And then we'll, again, do that change from a standard profile to a low profile, hopefully to seal that stomacite better around the tube. So, those are the things we do right now. That's great. This segues nicely into the next question. Any suggestions, or how do you approach endoscopic management of buried bumper syndrome in a newly placed tube? Well, that's a really good question, although I would argue you shouldn't have buried bumper in a newly placed tube. So, you know, prevention is worth an ounce of prevention, worth a pound of cure. But, you know, when you place your peg tube, they don't have to be overly tight. You want to have a half a centimeter to a centimeter of play. That stoma tract will form fine. There's a dog study from decades ago where they didn't even fix the outer bumper and the stoma tract still formed. So, the only reason to put that tube down tight initially is if you have some bleeding that you're worried about and buried procedurally. And if that occurs, it's okay to snug it down a little bit, but then we'll go back basically the next day or the day after and loosen up that bumper. So, in a newly placed tube, most of the time, honestly, you can just shove that tube bumper back into the gastric lumen and you'll be fine, and then just pull back the external bumper so it's not too tight. I might as well just say a minute or two about buried bumper when it occurs later, which is by far the most common scenario that we'll see. It almost always happens in patients who have a solid internal bolster tube. Very, very rarely, if at all, happens with a balloon internal bolster tube. And almost the quickest and easiest thing to do, in most cases, doesn't work at all, but most cases, as long as you can get a wire through that buried bumper tube, put it in externally, put in the loop guide wire from a new kit, as long as you can get it into the gastric lumen, just get that wire in and then pull out completely out the buried bumper tube percutaneously. So, you know, pull it out like that, and you have the wire in place, then just pull down a new tube. And that's the quickest, easiest way to deal with buried bumper. After that, if you can't get the wire through, then you got to start MacGyvering things. Thanks so much, Dr. Fang. Thanks, Jay, for staying and thanks for everyone who attended. Thank you again to our content expert, Dr. Fang, and the GI fellow moderator, Dr. Dubroff, for tonight's presentation. Before we close out, I want to let the audience know to make sure to check out our upcoming ASGE educational events. Registration is open. Visit the ASGE website for the complete lineup of 2023 ASGE events and 2024 events, and you can register today. The next Endo Hangout session, Management of Post-Bariatric Complications, will take place on Thursday, December 7th from 7 to about 8.30 p.m. Registration, again, is open. At the conclusion of this webinar, you will receive a short survey, and we would appreciate your feedback. Your experience with these learning events is important to ASGE, and we want to make sure we are offering interactive sessions that fit your educational needs. As a final reminder, ASGE membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website and make sure to sign up. In closing, I want to thank Dr. Fang again and Dr. Dubroff for this excellent presentation, and thank you again to our audience for making this session interactive. We hope this information has been useful to you, and with that, I will conclude our presentation. Have a good night. you

feeding tubes

types of feeding tubes

choosing the right tube

placing feeding tubes

patient considerations

contraindications for feeding tubes

management of feeding tube issues

endoscopic placement of feeding tubes