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Metoclopramide for post-pyloric placement of naso-enteral feeding tubes.
Silva, CC, Bennett, C, Saconato, H, Atallah, ÁN
The Cochrane database of systematic reviews. 2015;(1):CD003353
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Abstract
BACKGROUND Enteral nutrition by feeding tube is a common and efficient method of providing nutritional support to prevent malnutrition in hospitalised patients who have adequate gastrointestinal function but who are unable to eat. Gastric feeding may be associated with higher rates of food aspiration and pneumonia than post-pyloric naso-enteral tubes. Thus, enteral feeding tubes are placed directly into the small intestine rather than the stomach, and the use of metoclopramide, a prokinetic agent, has been recommended to achieve post-pyloric placement, but its efficacy is controversial. Moreover, metoclopramide may include adverse reactions, which with high doses or prolonged use may be serious and irreversible. OBJECTIVES To determine the effect of intravenous metoclopramide on post-pyloric placement of the naso-enteral tube in adults. SEARCH METHODS Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 10) which includes the CUGPD group's specialised register of trials, MEDLINE (1996 to 21 October 2014), EMBASE (1988 to 21 October 2014), LILACS (2005 to 21 October 2014) We did not confine our search to English language publications. Searches in all databases were updated originally in January 2005, then in November 2008 and again in October 2014. No new studies were found in 2008 or in 2014. SELECTION CRITERIA We selected randomised controlled trials of adults needing enteral nutrition, who received intravenous or intramuscular metoclopramide to aid placement of transpyloric naso-enteral feeding tubes, compared to placebo or no intervention. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. All analyses were performed according to the intention-to-treat method. We present risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS Four studies, with a total of 204 participants were included and analysed. The trials compared metoclopramide with placebo (two trials) or with no intervention (two trials). Metoclopramide was investigated at doses of 10 mg (two trials) and 20 mg (two trials). There was no statistically significant difference between metoclopramide versus placebo or no intervention administered to promote tube placement (RR 0.82, 95% CI 0.61 to 1.10). Metoclopramide at doses of 10 mg (RR 0.82, 95% CI 0.60 to 1.11) and 20 mg (RR 0.62, 95% CI 0.15 to 2.62) were equally ineffective in facilitating post-pyloric intubation when compared with placebo or no intervention. AUTHORS' CONCLUSIONS In this review, we found only four studies that fitted our inclusion criteria. These were small, underpowered studies, in which metoclopramide was given at doses of 10 mg and 20 mg. Our analysis showed that metoclopramide did not assist post-pyloric placement of naso-enteral feeding tubes.Ideally randomised clinical trials should be performed that have a significant sample size, administering metoclopramide against control, however, given the lack of efficacy revealed by this review it is unlikely that further studies will be performed.
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Is nasogastric or nasojejunal decompression necessary following gastrectomy for gastric cancer? A systematic review and meta-analysis of randomised controlled trials.
Wang, D, Li, T, Yu, J, Hu, Y, Liu, H, Li, G
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2015;(1):195-204
Abstract
Whether nasogastric or nasojejunal decompression (ND) prevents anastomotic leakage, hastens the return of bowel function, and shortens hospital stay after gastrectomy for gastric cancer has long been controversial. We evaluated the necessity of routine ND after radical gastrectomy for gastric cancer with a systematic review and meta-analysis. We searched literature published prior to January 2014 in PubMed, Embase, Cochrane Library, Web of Science, and BIOSIS Previews for relevant randomized controlled trials (RCTs). Only prospective RCTs comparing individuals with and without ND after gastrectomy for gastric cancer were included. Outcome measures included time to first flatus, time to starting oral diet, anastomotic leakage, pulmonary complications, wound dehiscence, length of hospital stay, morbidity, and mortality. Cochrane Collaboration RevMan 5.2 software was used for the meta-analysis. Eight RCT studies fulfilled our inclusion criteria. Of the 1,141 patients in those RCTs, 570 received nasogastric or nasojejunal decompression and 571 did not. Anastomotic leakage, pulmonary complications, wound dehiscence, morbidity, and mortality were comparable between the groups. Stratified by the type of gastrectomy or gastrojejunostomy, no significant differences in above mentioned outcomes were observed in subgroup analyses. The no ND group displayed a significantly shorter time to oral diet (weighted mean difference [WMD] = 0.45, 95% confidence interval [CI] = 0.29 to 0.61, p < 0.001) and a marginally shorter end of hospital stay (WMD = 0.48, 95% CI = -0.01 to 0.98, p = 0.05). The ND group significantly shortened time to first flatus (WMD = -0.7, 95% CI = -1.13 to -0.27, p = 0.001), especially with Roux-en-Y reconstruction (WMD = -1.0, 95 % CI = -1.52 to -0.48, p = 0.0002) and prolonged time to starting oral diet (WMD = 0.52, 95% CI = 0.13 to 0.90, p = 0.009) in the patients with subtotal gastrectomy. Routine ND appears to be unnecessary after gastrectomy for gastric cancer, irrespective of the extent of resection, and the type of digestive reconstruction.
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How to Promote Bedside Placement of the Postpyloric Feeding Tube: A Network Meta-Analysis of Randomized Controlled Trials.
Tiancha, H, Jiyong, J, Min, Y
JPEN. Journal of parenteral and enteral nutrition. 2015;(5):521-30
Abstract
BACKGROUND The optimal method of achieving fast, safe, and accurate postpyloric tube placement at the bedside remains controversial. This study investigated whether facilitating techniques of bedside placement would improve the rate of successful placement of postpyloric tubes when compared with the standard technique and whether strategies should be confined to adult or pediatric patients. METHODS We searched electronic databases for eligible literatures that compared different methods of postpyloric tube placement, evaluating the successful rate of postpyloric tube placement. Two reviewers reviewed the quality of the studies and performed data extraction independently. Pairwise and network meta-analyses were performed to integrate the efficacy. RESULTS Fourteen clinical trials involving 753 patients were included. Pairwise meta-analyses demonstrated that prokinetic agents (odds ratio [OR], 2.263; 95% confidence interval [CI]: 1.140-4.490; P = .02) were associated with a higher success rate as compared with the standard technique, and gastric air insufflation was associated with a higher success rate as compared with prokinetic agents (OR, 3.462; 95% CI, 1.63-7.346; P = .001) in adult patients. In network analyses, prokinetic agents and gastric air insufflation were also consistently associated with a higher success rate in adult patients. Trend analyses of rank probabilities revealed gastric air insufflation had the cumulative probability of being the most efficacious strategy (78%), especially in adult patients (88%). CONCLUSIONS Gastric air insufflation seems to be clinically better for promoting bedside placement of postpyloric feeding tubes in adults. Clinicians should no longer use prokinetic agents in pediatric patients or patients without impaired motility.
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Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for patients with head and neck cancer: a systematic review.
Wang, J, Liu, M, Liu, C, Ye, Y, Huang, G
Journal of radiation research. 2014;(3):559-67
Abstract
There are two main enteral feeding strategies-namely nasogastric (NG) tube feeding and percutaneous gastrostomy-used to improve the nutritional status of patients with head and neck cancer (HNC). But up till now there has been no consistent evidence about which method of enteral feeding is the optimal method for this patient group. To compare the effectiveness of percutaneous gastrostomy and NGT feeding in patients with HNC, relevant literature was identified through Medline, Embase, Pubmed, Cochrane, Wiley and manual searches. We included randomized controlled trials (RCTs) and non-experimental studies comparing percutaneous gastrostomy-including percutaneous endoscopic gastrostomy (PEG) and percutaneous fluoroscopic gastrostomy (PFG) -with NG for HNC patients. Data extraction recorded characteristics of intervention, type of study and factors that contributed to the methodological quality of the individual studies. Data were then compared with respect to nutritional status, duration of feeding, complications, radiotherapy delays, disease-free survival and overall survival. Methodological quality of RCTs and non-experimental studies were assessed with separate standard grading scales. It became apparent from our studies that both feeding strategies have advantages and disadvantages.
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Comparison of postpyloric tube feeding and gastric tube feeding in intensive care unit patients: a meta-analysis.
Zhang, Z, Xu, X, Ding, J, Ni, H
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2013;(3):371-80
Abstract
BACKGROUND AND OBJECTIVE Enteral feeding is vital in the critical care setting; however, the optimal route of enteral feeding (postpyloric vs gastric feeding) remains debated. We aimed to systematically review the current evidence to see whether postpyloric feeding could provide additional benefits to intensive care unit (ICU) patients. METHOD Randomized controlled trials (RCTs) comparing the efficacy and safety of postpyloric feeding vs gastric feeding were included in our systematic review. Odds ratio (OR) was used for binary outcome data and weighted mean difference (WMD) was used for continuous outcome data. Summary effects were pooled using a fixed or random effects model as appropriate. RESULTS Seventeen RCTs were included in our meta-analysis. Postpyloric tube feeding could deliver higher proportions of estimated energy requirement (WMD, 12%; 95% confidence interval [CI], 5%-18%) and reduce the gastric residual volume (GRV) (WMD, -169.1 mL; 95% CI, -291.995 to -46.196 mL). However, the meta-analysis failed to demonstrate any benefits to critically ill patients with postpyloric tube feeding in terms of mortality (OR, 1.05; 95% CI, 0.77-1.44), new-onset pneumonia (OR, 0.77; 95% CI, 0.53-1.13), and aspiration (OR, 1.20; 95% CI, 0.64-2.25). There was no significant publication bias as represented by an Egger's bias coefficient of 0.21 (95% CI, -1.01 to 1.43; P = .7). CONCLUSION As compared with gastric feeding, postpyloric feeding is able to deliver higher proportions of the estimated energy requirement and can help reduce the GRV.
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Nasal versus oral route for placing feeding tubes in preterm or low birth weight infants.
Watson, J, McGuire, W
The Cochrane database of systematic reviews. 2013;(2):CD003952
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Abstract
BACKGROUND Enteral feeding tubes for preterm or low birth weight infants may be placed via either the nose or mouth. Nasal placement may compromise respiration. However, orally placed tubes may be more prone to displacement, local irritation, and vagal stimulation. OBJECTIVES To determine the effect of nasal versus oral placement of enteral feeding tubes on feed tolerance, growth and development, and the incidence of adverse events in preterm or low birth weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012, Issue 10), MEDLINE, EMBASE, and CINAHL (to September 2012), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised or quasi-randomised controlled trials that compared nasal versus oral placement of enteral feeding tubes in preterm or low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors. We synthesised data using a fixed-effect model and reported typical risk ratio (RR), risk difference (RD), and weighted mean difference (WMD). MAIN RESULTS Three studies fulfilled the review eligibility criteria. Two were parallel group trials (van Someren 1984; Dsilna 2005) and one was a cross-over trial (Bohnhorst 2010). The two parallel group randomised controlled trials enrolled 88 preterm infants. Only one trial reported data on the pre-specified primary outcomes for this review. This trial found no evidence of effect on the time taken to establish enteral feeding or the time taken to regain birth weight. However, the trial was underpowered to exclude modest effect sizes. We identified one randomised cross-over trial in which 35 very preterm infants participated. This study did not find any statistically significant effects on the incidence of apnoea, desaturation, and bradycardia during the study period. AUTHORS' CONCLUSIONS There are insufficient data available to inform practice. A large randomised controlled trial would be required to determine if the use of naso- versus oro-enteric feeding tubes affects feeding, growth and development, and the incidence of adverse events in preterm or low birth weight infants.
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Water intubation method can reduce patients' pain and sedation rate in colonoscopy: a meta-analysis.
Lin, S, Zhu, W, Xiao, K, Su, P, Liu, Y, Chen, P, Bai, Y
Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society. 2013;(3):231-40
Abstract
Several randomized controlled trials (RCT) have shown that water infusion in lieu of air insufflation reduces sedation rate and pain score and increases cecal intubation rate in colonoscopy. The aim of the present study was to confirm the beneficial effects of the water intubation method over the air method. Electronic databases were searched to identify RCT reporting colonoscopy detection using the water method. The pooled data of sedation rate, pain score and other procedure-related outcomes were analyzed. Then, 15 full-text articles were selected and assessed. Nine trials with high-quality scores were enrolled into this meta-analysis including a total of 1414 participants. Pooled odds ratio (OR) of sedation rate was 0.392 (95% confidence interval (CI): 0.288-0.533, P = 0.000). Pooled weighted mean difference (WMD) of pain score was -1.543 (95% CI: -2.107--1.069,P = 0.000). Pooled OR of cecal intubation rate was 1.90 (95% CI: 1.29-2.82, P = 0.001). Pooled OR of polyp detection rate and adenoma detection rate were 0.805 (95% CI: 0.606-1.069, P = 0.134) and 0.913 (95% CI: 0.681-1.223, P = 0.168), respectively. Pooled WMD of cecal intubation time was 0.701 (95% CI: -0.486-1.889, P = 0.247). This meta-analysis confirmed that the water method significantly reduced sedation rate and degree of pain without decreasing cecal intubation rate and disease detection rate and without requiring more cecal intubation time, suggesting that the novel water method is better than the conventional air method in colonoscopy detection.