CASO CLÍNICO

"Ectopic enteral tube" insertion in patients with head, neck and other pathologies when natural tracts are impracticable or inadvisable. A new method

Instalación de "sondas digestivas ectopicas" en pacientes con patología de cabeza y cuello y otras diversas, cuando las vías naturales no son practicables o no se consideran convenientes. Una nueva metodología

F. Hernández-Altemir¹, S. Hernández-Montero², S. Hernández-Montero³, E. Hernández-Montero⁴, M. Moros-Peña⁵

1 Jefe del Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario Miguel Servet de Zaragoza y Hospital MAZ, Zaragoza, España
2 Práctica Privada Cirugía Oral y Maxilofacial y Profesora y Coordinadora. Universidad Alfonso X el Sabio (Facultad de Odontología), Madrid, España
3 Práctica Privada (Endodoncia), Zaragoza, España
4 Hospital de Viladecans e Instituto de Otoneurocirugía García-Ibáñez, Barcelona, España
5 Práctica privada Pediatría y Puericultura (Dibujante), Zaragoza, España

Correspondence

ABSTRACT

Introduction. Patients with a variety of general pathologies and oral and maxillofacial pathologies often require extraordinary measures for to ensure enteral feeding and aspiration. We report a new method for inserting what we call "ectopic enteral tubes" (EET).
Material and Method. Conventional enteral tubes are inserted into the digestive tract using "ectopic" insertion routes. At present, the most common routes available are the pericranial or submental routes, as well as wounds and trajectories that are present or created expressly for this purpose in the craniofacial area. We report the clinical case of a patient with comminuted fractures of the temporal and left suprazygomatic region, where the EET was inserted.
Results. This new method obviates the need for more aggressive techniques, such as surgical or percutaneous gastrostomy, and the use of natural facial orifices when not practicable or not indicated while maintaining a viable route for enteral feeding and aspiration.
Conclusions. EET is a useful addition to our therapeutic arsenal.

Key words: Ectopic enteral tubes; Pericranial route; Submental route.

RESUMEN

Introducción. Es frecuente que en los pacientes con patología general diversa y del territorio oral y maxilofacial tengamos que dotarles de medios extraordinarios para facilitar la alimentación y aspiración digestiva. Presentamos una nueva metodología para la instalación de lo que denominamos Sondas Digestivas Ectópicas (SDE).
Material y Método. Empleamos las sondas digestivas convencionales, sólo que haciéndolas llegar al tramo digestivo por lo que denominamos vías ectópicas de instalación y entre las más habituales en nuestras manos estaría, la sonda digestiva pericraneal o submental o a través de heridas y trayectos creados o no del territorio craneofacial. Presentamos un caso clínico de un paciente con fracturas conminutadas del territorio craneomaxilofacial al que la SDE se instaló en la región temporal y supracigomática izquierda.
Resultados. Conseguimos con esta nueva metodología evitar técnicas más agresivas como la gastrostomía percutánea o quirúrgica y evitar el uso de los la via nasal u oral, cuando éstos no son practicables o no están indicados manteniendo una vía fiable de aspiración y alimentación digestiva.
Conclusiones. Los beneficios de esta técnica deben hacer que incorporemos la SDE en nuestro arsenal terapéutico.

Palabras clave: Sonda digestiva ectópica; Vías pericraneal; Vía submental.

Introduction

Extraordinary measures often are needed in patients with a variety of general pathologies and specific oral, maxillofacial and head and neck pathologies to ensure enteral feeding and aspiration postoperatively and at other times. The nasal or oral tracts cannot always be intubated and more invasive techniques may be used temporarily, such as percutaneous gastrostomy¹ (PG) or surgical gastrostomy (SG), which should be avoided. We propose the use of what we call "ectopic enteral tubes" (EET), which are conventional tubes inserted at some point other than the respiratory and digestive orifices of the face.

Material and Method

We insert conventional enteral tubes into the digestive tract by what we call "ectopic" routes. Among the routes most often used are the pericranial and submental routes (the latter similar to our submental endotracheal intubation technique). ^2,3 Wounds and passages in the craniofacial area that are present or opened expressly for the purpose are also used. These routes are suitable for exceptional situations, such as when the natural orifices are impracticable or unsuitable due to the nature of the pathology and/or patient idiosyncrasies. Patients occasionally cannot tolerate a nasally or orally inserted gastric tube and sometimes go so far as to pull the tube out. Ectopic routes can be less invasive, by avoiding the natural nasal or oral spaces, which undoubtedly are very sensitive to the presence and passage of "foreign bodies" (Figs. 1 to 5).

We report the clinical case of a patient with comminuted fractures of the craniomaxillofacial area (Figs. 6 and 7). The EET was inserted pericranially in the temporal and left suprazygomatic region by seeking out the oral space through the retromaxillary vestibule and lateropharyngeal space, and terminating in the gastric fundus. The position was verified peroperatively by insufflating with air under stethoscopic control by the anesthesiologist. The proximal end of the EET was secured with silk suture around the pericranial wound, in this patient by wrapping the suture around the tube two or three times. In the first patient in which we used this route, the ectopic enteral tube functioned for fifteen days and then was removed when the patient recovered swallowing function (Fig. 8).

The pericranial tube is inserted behind the hairline or through local wounds, if suitable. In the case of submental intubation, an oblique route going from the skin and backward is used to prevent fistula formation after the tube is removed.

Pericranial EETs should be removed as aseptically as possible, without extracting the digestive end of the tube through the route of insertion. Whenever possible, the tube should be sectioned and extracted orally under imaging control. In patients with intermaxillary fixation, submentally inserted EETs must be extracted via the route of insertion.

If enteral intubation must be maintained for a prolonged period of time, as generally occurs in patients who undergo surgery for oral and maxillofacial pathology, the EET will be replaced after the critical phase. Whenever possible, a conventional nasotracheal tube will be inserted. If permanent enteral intubation is necessary, EET or gastrostomy should be considered.

Discussion

The ectopic enteral tube insertion procedure should be performed by a head and neck specialist who is familiar with the indications and can perform the most appropriate surgical procedure for each case. We propose our procedure for use by specialists in endocrinology and nutrition, intensive care units, anesthesiology and reanimation departments, etc., for adults as well as newborns. We particularly recommend it to head and neck specialists like oral and maxillofacial surgeons, ear, nose and throat specialists, plastic surgeons, burn specialists, and general and specialized oncologists. Our procedure avoids having to use more invasive conventional or technical routes,⁴ such as percutaneous or surgical gastrostomy, with parenteral nutrition or without it if the only aim is to feed the patient.

Conclusions

Non-conventional insertion routes can be used instead of conventional ones and may become routine procedures for selected cases as experience accrues.

Ectopic gastric tube insertion broadens the options available in the therapeutic arsenal.

Correspondence:
Dr. Francisco Hernández Altemir
Hospital Universitario Miguel Servet
Pº Isabel la Católica 1-3
50009 Zaragoza, España
Email: drhernandezaltemir@yahoo.es

Recibido: 31.01.07
Aceptado: 31.10.07

References

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4. Pavan Patil M, Neelkant Warad M, Rajshekar Patil N, Kotrashetti SM,. Belgaum, India KLE Institute of Dental Sciences, Rajiv Gandhi University of Health Sciences: Cervical pharyngostomy: an alternative approach to enteral feeding. Oral Surg, Oral Med, Oral Pathol, Oral Radiol, and Endod 102:736-40.        [ Links ]