Post-pyloric feeding, in which nutrition therapy is delivered directly into the duodenum or the jejunum by means of a nasoenteral (i.e., nasoduodenal or nasojejunal) tubes or jejunostomy, represents a route option in patients with gastric feeding intolerance (i.e., gastroparesis) or at high risk of aspiration [1-4]. It is commonly considered as alternative route of feeding after intolerance of enteral nutrition not solved by prokinetics (i.e., metoclopramide and/or erythromycin) [1-3].
Feasibility/Equipment: The placement of post-pyloric tube requires expertise and it may be associated with some delay in the administration of nutrition therapy. Endoscopic-guided placement is the preferred approach, which needs an endoscopist and two or more healthcare professionals to perform this procedure using a guidewire technique. The position of the tube needs to be confirmed with fluoroscopy or radiography, which eventually may require transfer of the patient to the radiology department. Electromagnetic-guided placement represents an alternative for post-pyloric tube placement could be performed by a single trained healthcare professional (e.g., nurse) at the bedside with less equipment, but the benefit of electromagnetic-guided placement needs further evidence [5]. Thus, training and expertise, together with appropriate equipment and collaboration of other specialists, is needed for the placement and performance of post-pyloric feeding [1-5].
Scoring information: There is not any score or scales to evaluate the need or effectiveness of post-pyloric feeding tube due to intolerance of enteral nutrition.
Cost: Costs are mild, and they depend on the procedure of placement and maintenance of post-pyloric feeding.
Evidence: Nutrition therapy may benefit from the administration post-pyloric route in terms of nutrient intake in those patients in whom enteral nutrition is not tolerated. The administration of post-pyloric feeding is safe (i.e., no higher incidence of complications has been reported) and it has been clearly associated with better outcomes, such as less incidence of ventilator-associated pneumonia, when compared with gastric route [3, 6, 7]. However, post-pyloric feeding is not associated with benefits in terms of mortality and ICU length of stay [3, 4, 6, 7].
Accuracy / measurement properties: Post-pyloric feeding has been associated with a reduced risk of pneumonia compared with gastric route (Relative Risk from 0.60 to 0.93; moderate quality evidence) [6, 7], an increase in the percentage of nutrition therapy delivered to the patient (mean average difference from 1.43 to 14.18; low quality evidence) [6, 7], and lower rates of gastrointestinal complications, such as diarrhea (Relative Risk from 0.69 to 0.97; moderate quality evidence) [7]. Despite potential benefits that post-pyloric feeding route entails, their use is not generally used in clinical practice of ICUs when enteral nutrition is not tolerated.
References
1. Herrero Meseguer JI, Lopez-Delgado JC, Martínez García MP: Recommendations for specialized nutritional-metabolic management of the critical patient: Indications, timing and access routes. Med Intensiva (Engl Ed) 2020, 44 Suppl 1: 33-38.2.
2. Niv E, Fireman Z, Vaisman N: Post-pyloric feeding.World J Gastroenterol 2009, 15(11): 1281-8.
3. Alkhawaja S, Martin C, Butler RJ, Gwadry-Sridhar F: Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev 2015, 2015(8): CD008875.
4. Montejo JC, Grau T, Acosta J, Ruiz-Santana S, Planas M, García-De-Lorenzo A, Mesejo A, Cervera M, Sánchez-Alvarez C, Núñez-Ruiz R, López-Martínez J: Multicenter, prospective, randomized, single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients.Crit Care Med 2002, 30(4): 796-800.
5. Watanabe J, Kakehi E, Okamoto M, Ishikawa S, Kataoka Y: Electromagnetic-guided versus endoscopic-guided postpyloric placement of nasoenteral feeding tubes.Cochrane Database Syst Rev 2022, 10(10):CD013865.
6. M Deane Adam, Dhaliwal Rupinder, G Day Andrew, J Ridley Emma, R Davies Andrew, and K Heyland Daren: Comparisons between intragastric and small intestinal delivery of enteral nutrition in the critically ill: a systematic review and meta-analysis. Crit Care 2013; 17(3): R125.
7. Liu Y, Wang Y, Zhang B, Wang J, Sun L, Xiao Q: Gastric-tube versus post-pyloric feeding in critical patients: a systematic review and meta-analysis of pulmonary aspiration- and nutrition-related outcomes. Eur J Clin Nutr 2021, 75(9):1337-1348.