The Evolving Role of Post–Ligament of Trietz Nasojejunal Feeding in Enteral Nutrition and the Need for Improved Feeding Tube Design and Placement Methods

Abstract

Nutrition support is an important link in the chain of therapy for intensive care unit patients. The early institution of nutrition support significantly reduces the incidence of septic complications, reduces mortality, and shortens hospital stay. Unfortunately, impaired gastrointestinal function, particularly gastric atony, restricts the use of nasogastric enteral tube feeding, and the use of this route of administration in these patients can lead to regurgitation, aspiration, and the development of pneumonia. Postpyloric enteral feeding was heralded as a means of overcoming many of these problems. Overall, the results of controlled studies do not support a role of postpyloric duodenal feeding in reducing the incidence of aspiration pneumonia. As a consequence, post–ligament of Treitz nasojejunal enteral feeding is proposed as the technique of choice in these patients. Feeding tube design must incorporate a gastric aspiration port to overcome problems of gastroesophageal acid reflux, duodenogastric bile reflux, and increased gastric acid secretion, problems that occur during “downstream” jejunal feeding. Tube placement technique will need to be refined and patients will need to receive a predigested enteral diet. In postoperative surgical patients in the intensive care unit, there is also a need for a newly designed dual‐purpose nasogastric tube capable initially of providing a means of undertaking gastric aspiration and decompression and subsequently a means of initiating nasogastric enteral feeding.

Gastroenteric tube feeding: Techniques, problems and solutions

“…8514 July 14, 2014|Volume 20|Issue 26| WJG|www.wjgnet.com [212] . However, while feeding via PEG may reduce the risk of aspiration, it will not eliminate it altogether [164] , especially in patients in whom GI motility disturbances inhibit this route of feeding [158,165] .…”

“…Since it has been shown that even in patients with normal intestinal motility both naso-and gastrojejunal tubes, once correctly positioned, will be moved in a proximal direction by the phase Ⅱ migrating motor complex, placement of enteral nutrition tubes ≥ 40 cm distal to the ligament of Treitz is considered the optimal method [165,168] .…”

Dual‐Purpose Gastric Decompression and Enteral Feeding Tubes Rationale and Design of Novel Nasogastric and Nasogastrojejunal Tubes

“…The development of a nasoenteral tube that would simultaneously provide a means of early postoperative gastric decompression as well as post–ligament of Treitz jejunal enteral feeding would not only satisfy the requirements of current ERAS protocols in patients undergoing major upper gastroesophageal 18 hepatobiliary and pancreatic surgery 19 but would also play an important role in the feeding of patients in the ICU who are not able to tolerate nasogastric feeding 38 . North American guidelines recommend small bowel feeding of ICU patients who are not able to tolerate nasogastric feeding 16 .…”

Jejunal Casein Feeding Is Followed by More Rapid Protein Digestion and Amino Acid Absorption When Compared with Gastric Feeding in Healthy Young Men,

“…Although jejunal feeding is generally well tolerated, whether it modulates and impairs proper dietary protein digestion and absorption is unknown. It has been suggested that jejunal feeding requires a predigested rather than a polymeric diet (12)(13)(14).…”