1. Intubation And Drainage Learning Objectives 1. Describe the use of nasobiliary/nasopancreatic catheters and biliary/pancreatic stents. 2. Discuss procedures for gastric lavage, clonic decompression, and abdominal paracentesis.

2. Nasogastric tube insertion ◦ Indications for nasogastric intubation  Treatment of gastric distention or gastric outlet obstruction  Assessment and treatment of upper GI bleeding  Certain gastric/esophageal test  Gastric lavage  Aspiration of gastric secretions  Prevention of vomiting by decompressing the stomach after major surgery and empting the upper GI tract before emergency surgery.

3. Most common tubes used ◦ Leven tube- one lumen, ◦ Salem sump tube- has a primary suction- drainage lumen and a smaller vent lumen. Intermittent high suction or continuous low suction my be used with this pump ◦ Extended-use nasogastric feeding tubes. Are made of soft, flexible plastic material, with either a weighted or unweighted tip. May use guidewire to faciltitate insertion.

4. Moss tube- is a double lumen tube with a gastric retention balloon, a port for distal duodenal feeding and several esophageal, gastric, and proximal duodenal aspiration ports. Compat tube- is a 9fr nasojejunal feeding tube combined with an 18fr gastric suction port lumen. The gastric port serves for decompression and drainage as well as providing a port to administer medication. Use of fluoroscopy is recommended for placement.

5. Intubation and Drainage Esophageal prostheses ◦ Provide a patent lumen for purposes of nourishment and oral secretions in patients with terminal, obstructive esophageal cancer. ◦ Endoscopic placement required ◦ Early 1990’s esophageal prostheses were made of silicone rubber or latex ◦ With the advent of self expanding metal stents these are no longer used.

6. Indications for placement of prothesis ◦ Malignant carinoma of the lower two thirds of the esophagus with dysphagia becomes a problem ◦ Esophageal-pulmonary fistulas or extrinsics compression of esophagus.

7. Contraindications of placement of prosthesis ◦ When another medical condition takes priority ◦ For cancers that are less than 2 cm below the upper esophageal sphincter ◦ If tumor invaion compressed the trachea and/or bronchus ◦ If the stricture cannot be adequately diated ◦ In uncooperative or unmotivated patients.

8. Gastic Lavage ◦ Involves insertion of a gastric tube through the nose or mouth. ◦ Its is indicated in patients wit acute GI bleeding when preparing the stomach for endoscopy after barium or food ingestion, and for evacuating the stomach after ingestion of toxic substances.

9. Different tube of gastric tubes ◦ Double-lumen orogastric “stomach pump” tube is indicated in situations where intermittent gastric lavage and evacuation are required. ◦ Single-lumen tube with several opening at the distal end is usually passed orally, but it can be inserted nasally. Allows rapid lavage and evacuation of large volumes of fluid, but continuous irrigation is not possible, because the same lumen must be used for both.

10. Nasobiliary/nasopancreatic catheters ◦ Nasobiliary catheter (NBCs) and (NPCs) nasopancreatic catheters are used for short- term decompression or perfusion within the biliary and pancreatic ductal systems.

11. Indication for NBC placements ◦ Decompression of obstructed bile duct in acute suppurative cholangitis. ◦ Prevention of stone impaction after endoscopic sphincterotomy. ◦ Temporary biliary decompression in patients who are septic or who have sever coagulopathy ◦ Facilitating the healing process in traumatic or surgical biliary fistulas. ◦ Management of common bile duct stones.

12. Nasobiliary/Nasopancreatic Catheter Placement ◦ ERCP is performed with side viewing scope. ◦ Biliary stents  Pigtail stent-one or both ends of the tubes or coiled  Barbed stents have projections or “barbs,” at each end that result from a diagonal cut of the stent wall.

13. Indications for a biliary stent ◦ Relief of obstructive jaundice in patients with benign or malignant strictures or the bile duct. ◦ Palliative treatment of inoperable or metastatic pancreatic or periampullar neoplams. ◦ Pre-op decompression to decrease complications associated with high bilirubin levels ◦ Maintaining biliary decompression in cases of sclerosin ◦ Cholangitis with stricture of the extrahepatic bile ducts ◦ Poscholecystectomy biliary leak

14. Pancreatic stents ◦ Indications for pancreatic stenting  Unresolved pancreatitis  Idiopathic acute pancreatitis  Pancreas divisum with syptomatology  Pancreatic duct disruption, traumatic carcinoma, and idiopathic  Prevention of post ERCP pancreatitis  Pancreatic strictures and or stones  Sphincter of Odi dyspfunction

15. Metal stents ◦ Self-expanding metal stents (SEMS) are currently available endoscopically for esophageal, tracheobranchial, duodenal, biliary, and colonic placement. ◦ They are permanent ◦ Not removable with surgery ◦ Only inserted endoscopically for palliation of the patient who has been diagnosed with an obstruction neoplasm.

16. Temporary Expandable Stents. ◦ With the advent of expandable polyester silicone covered stents, we can now remove or reposition. ◦ Useful in treating refractory benign esophageal strictures.

17. Intestinal (Nasoenteric)Intubation ◦ The Cantor tube, Kaslow tube, harris tube and the Miller-Abbott tubes were use with the injection of mercury as a weight, but are not used today because of the danger of mercury. ◦ Nasoenteric tubes are longer than nasogastric tubes.

18. Indications for intestinal nasoenteric intubation ◦ To aspirate intestinal contents for exmination ◦ To treat intestinal obstruction by providing intestinal decompression, relieving dilatation porximal to the obstruction, decreasing and diverting intestinal secretions and gas formation, and providing intestinal stenting. ◦ To prepare the intestinal tract for surgery by removing intestinal contents. ◦ Cont…

19. To prevent post-operative nausea, vomiting and abdominal distention. To provide enteral alimentation post- operatively until edema at the operatrive site has subsided, or until peristalsis returns To provide enteral alimentation when the patient’s condition prohibits gastric feeding

20. Colon decompression ◦ Involves placement of a tube in the rectum or colon to relieve colonic distention.  Indications  Patients with colonic psedo-obstruction (non-toxic megacolon or Ogilvie’s syndrome),  Post-operative ileus,  Colon distention secondary to flexible sigmoidoscopy or colonoscopy.  Ogilvie’s syndrome occurs in elderly pt’s who have a preexisting disease that necessitates bed rest.

21. Rectal tubes ◦ Small lumen decompression tube, can be passed through the biopsy channel of a colonoscope to the cecum. Colonoscope is then removed while the tube is continual advanced through the channel. ◦ Large lumen decompression tube can be used the channel of the scope and a suture is tied around the distal end of the decompression tube.

22. Abdominal Paracentesis ◦ Involves withdrawal of fluid fro the peritoneal space for diagnostic and therapeuitc purposes, using a large-bore needle or a trocare and cannula inserted in the abdominal wall.  Indication for paracentesis  Evaluation of ascities  Determination of a perforated viscue following blunt trauma or symptoms of acute abdomen and relief of dyspnea or abdominal pain secondary to tense ascites

23. Contraindicated for paracentesis ◦ Severe coagulopathy ◦ Thrombocytopenia ◦ Intestinal obstruction ◦ Abdominal wall infection ◦ Previous multiple abdominal surgeries ◦ Portal hypertension with abdominal collateral circulation