title: Endoscopic clip-assisted feeding tube placement reduces repeat endoscopy rate: results from a randomized controlled trial.
abstract: OBJECTIVE
  To determine whether endoscopic clip-assisted nasoenteral feeding tube placement is more effective than standard feeding tube placement with transnasal endoscopy.
  
  
  METHODS
  Between August 2009 and February 2011, 143 patients referred for endoscopic nasoenteral feeding tube placement were randomized between clip-assisted and standard nasoenteral tube placement. Endoscopies were performed in the endoscopy unit and intensive care unit in a tertiary referral center in the Netherlands. For the clip-assisted procedure, the feeding tube was introduced with a suture fixed to the tip, picked up in the stomach with an endoclip and attached (as distal as possible) to the duodenal wall. In the standard group, a guide wire was placed in the duodenum using a transnasal endoscope, followed by blind insertion of a feeding tube over the guide wire. Primary end point was a repeat endoscopy for incorrect tube placement or spontaneous retrograde tube migration. Secondary end points were incorrect tube placement, spontaneous migration of feeding tube, directs medical costs, and procedure-related (serious) adverse event (SAE).
  
  
  RESULTS
  Of the 143 patients included, 71 were randomly assigned to clip-assisted tube placement, and 72 to standard tube placement. Four (5.6%) repeat endoscopies were performed in the clip-assisted group vs. 19 (26.4%) in the standard group (relative risk reduction (RRR) 0.79; 95% confidence interval (CI) 0.40-0.92). The number needed to clip to avoid one repeat endoscopy was 4.8 (95% CI 3.1-11.3). Repeat endoscopies were mostly performed for incorrectly placed tubes, 3 (4.2%) in the clip-assisted group vs. 16 (22.2%, RRR 0.81; 95% CI 0.38-0.94) in the standard group. Spontaneous retrograde tube migration occurred in one (1.4%) clip-assisted placement and three (4.2%) standard tubes. Median costs were higher for clip-assisted tube placement (€519 vs. €423, P<0.01). Four (5.6%) SAEs occurred after clip-assisted feeding tube placement vs. one (1.4%) after standard feeding tube placement (P=0.21).
  
  
  CONCLUSIONS
  Clip-assisted endoscopic nasoenteral feeding tube placement results in fewer repeat endoscopies than standard endoscopic nasoenteral tube placement, due to a higher success rate of initial placement. When tubes are adequately placed, retrograde tube migration rarely occurs.
authors: Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands. M.M.C.Hirdes@umcutrecht.nl
authors: Meike M C
authors: MM
authors: Hirdes
authors: Jan F
authors: JF
authors: Monkelbaan
authors: Jasper J
authors: JJ
authors: Haringman
authors: Martijn G H
authors: MG
authors: van Oijen
authors: Peter D
authors: PD
authors: Siersema
authors: Hendrikus J M
authors: HJ
authors: Pullens
authors: Paul H J M
authors: PH
authors: Pullens
authors: Jozef
authors: J
authors: Kesecioglu
authors: Frank P
authors: FP
authors: Vleggaar
mesh_terms: D004724:Endoscopy; D004750:Enteral Nutrition; D005260:Female; D006801:Humans; D007441:Intubation, Gastrointestinal / Q000295:instrumentation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D013525:Surgical Instruments