Introduction
Nasojejunal tubes (NJT) are usually inserted into the small intestine with the help of an endoscope, after which they need to be redirected through the nose. The current method of redirection involves using a rerouting tube, a laryngoscope, and forceps, which can be uncomfortable for patients due to the sensitivity of the throat. Besides, this method is resource-intensive and creates sustainability issues, as the instruments are mostly single-use and contain batteries. The National Health Service (NHS) accounts for 5·4% of UK carbon dioxide emissions, one which, in 2015, amounted to 26·6 million tonnes of carbon dioxide equivalent—equating to 39% of all public sector emissions in England. Endoscopy appears to be a significant contributor to health care's environmental footprint, generating about 3·09 kg of waste per bed per day (the third highest emitting hospital department).1
Aims & Methods
We aimed to gather information on the standard practices related to NJT placement and understand the challenges faced by endoscopists and patients as perceived by practitioners such as nurses and endoscopists. For this purpose, we designed a short survey consisting of 16 questions on Survey Monkey. We shared the survey through various channels such as WhatsApp groups, X, and emails from gastroenterologists, endoscopists, and nurse groups. The survey remained open for 30 days and was shared globally.
Results
A total of 146 participants responded to the survey. The majority (73.9%) were from the UK, 13 % from Europe and the remaining from the rest of the world. The majority (88.4%) were medical endoscopists, with a median experience of 6 (1-30) years in NJT placement. The standard "through the scope" method was the preferred technique for NJT insertion (78.8%) of participants. Some (10.9%) preferred a slim scope through the nose and then placing NJT over a wire; others reported mixed methods, including under fluoroscopy guidance. Most respondents used midazolam and an opiate for the procedure (67.1%), only midazolam (13.7%), propofol (16.4%), and only a handful did it without sedation. The most challenging step reported by participants was the NJ tube rerouting from the mouth to the nose (41.7%), followed by avoiding displacement of the NJ tube during scope removal (27.4%). Redirection from the mouth to the nose was also considered the most uncomfortable step for patients, with 71.2% of participants, followed by oesophageal intubation (15.1%). Laryngoscopes were used as a light source during rerouting by 74.7%, out of which 45.9% used disposable laryngoscopes. Similarly, 80% of respondents used Magill’s forceps, half of which were single-use. Notably, 80.8% of participants expressed concern about the environmental impact of single-use instruments in endoscopy.
Conclusion
This study highlights endoscopy practitioners’ primary difficulties when performing NJ tube placement. Rerouting the tube from the mouth to the nose is considered the most challenging and uncomfortable step for patients. The findings emphasise the urgency for improved techniques or equipment to address this challenge, reduce patient discomfort, and consider environmental sustainability in endoscopy.
References
1. Siau, Keith, Bu'Hussain Hayee, and Swapna Gayam. "Endoscopy's current carbon footprint." Techniques and Innovations in Gastrointestinal Endoscopy 23, no. 4 (2021): 344-352.