Enteral Access Procedures

Published on 11/04/2015 by admin

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CHAPTER 10 Enteral Access Procedures

Benjamin Herdrich, Jon B. Morris

Case Study

A 63-year-old male with an extensive smoking history presents to his physician complaining of 2 months of increasing hoarseness and difficulty swallowing. Workup, including laryngoscopy, reveals a large pharyngeal tumor. Plans are made for radical surgical resection, including partial pharyngectomy. The patient is referred to a general surgeon for placement of a feeding tube at the time of his operation in anticipation of postoperative difficulty tolerating oral intake.

BACKGROUND

Nutritional support is an essential component of the treatment of critically and chronically ill patients. Patients who cannot meet their own nutritional needs through oral intake can be supported with parenteral (intravenous) or enteral (gastrointestinal tract) feeding. Parenteral feeding is an effective means of providing nutritional support to those patients who cannot be fed enterally and provides lifesaving therapy for patients with limited gastrointestinal tract absorptive capacity. The shortcomings of parenteral nutrition, however, have become increasingly evident as experience with this approach has grown; these include high rates of catheter-related, infectious, and metabolic complications as well as liver dysfunction. In contrast, enteral feeding is associated with fewer complications, is less expensive, and is not dependent on central venous access.

A number of options for enteral access exist; each has unique advantages and disadvantages. These include nasoenteric tubes, gastrostomy tubes, and jejunostomy tubes. Nasoenteric tubes, which include large-bore nasogastric tubes and small-bore nasoenteric tubes, can be placed at the bedside without the need for surgery and provide safe, short-term enteral access. Nasoenteric tubes are associated with several complications, including errors in tube placement (e.g., intracranial or intrabronchial intubations), sinusitis, nasal synechiae, and nasal alar necrosis. Surgically placed gastrostomy tubes (G-tubes) provide more durable, long-term enteral access and can be used for feeding or gastric decompression. In appropriate patients, they may be placed percutaneously with endoscopic assistance, obviating the need for larger open incisions. Jejunostomy tubes (J-tubes) are indicated in patients with contraindications to gastrostomy tube placement (e.g., patients undergoing a transhiatal esophagectomy) and patients with severe reflux or delayed gastric emptying. A variety of laparoscopic approaches to tube gastrostomy and jejunsotomy are in use, increasing the options further. This chapter focuses on the most common enteral access procedures: percutaneous endoscopic gastrostomy (PEG) tube placement and open approaches to tube gastrostomy and tube jejunostomy.

CORRECT PLACEMENT OF NASOENTERIC TUBES SHOULD BE CONFIRMED RADIOGRAPHICALLY BEFORE THE INITIATION OF ENTERIC FEEDING.

INDICATIONS FOR SURGERY

I. Nutritional Support: Enteral access is required when patients’ oral intake is insufficient to meet their nutritional needs. Nutritional support should be considered if: (1) a patient has been without nutrition for 5 to 7 days; (2) the duration of the condition is expected to exceed 10 days; or (3) the patient is malnourished. Enteral nutritional support is only feasible in patients with sufficient small bowel absorptive capacity. Patients who do not meet this requirement (e.g., patients with short gut syndrome) require parenteral nutrition.

II. Prophylactic Enteral Access: Patients with upper-airway or foregut cancers who undergo extensive surgical resection and adjuvant radiation and chemotherapy often have difficulty maintaining adequate caloric intake during the treatment period. In anticipation of this, many of these patients undergo either gastrostomy or jejunostomy placement at the time of surgical resection.

III. Decompression: Patients who cannot tolerate gastric feeding because of severe reflux, gastric atony, or inoperable bowel obstruction (e.g., patients with metastatic cancer) may benefit from G-tube placement for gastric decompression.

PREOPERATIVE EVALUATION

I. History: The preoperative history should allow for a determination of the amount of time enteral access will be needed and whether gastric or jejunal feeding is preferable. A history of feeding intolerance should be elicited in patients already being fed through a nasoenteric tube; patients who are not tolerating gastric feeding through a nasogastric tube may be better served by a J-tube (Fig. 10-1).

II. Laboratory Testing: Laboratory testing should include a complete blood count, electrolytes, and coagulation studies. Thrombocytopenia and coagulopathies should be corrected before enteral access procedures.

Figure 10-1 Preoperative evaluation for enteral access.

COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY

Preoperative Considerations

I. Prophylactic antibiotics to cover gram-positive organisms should be given within 1 hour before the procedure.

II. G-tubes and J-tubes are placed under general anesthesia. PEG tubes can be placed with intravenous sedation and local anesthetics.

Positioning and Preparation

I. The patient is placed in the supine position with the arms extended. The head of the bed is elevated.

II. The surgical preparation should extend to the nipples superiorly, the pubic symphysis inferiorly, and the midaxillary lines laterally.

PEG Tube

I. Placement of a PEG tube is best accomplished by two surgeons, one operating the endoscope and the other positioned next to the patient’s abdomen.

II. Passing the Endoscope

A. The endoscope is lubricated and passed through the pharynx and esophagus, into the stomach.

B. The stomach is insufflated with air.

III. Choosing the Gastrostomy Site

A. The ideal site for gastrostomy placement is identified by palpation, transillumination, and needle aspiration. The site is typically two fingerbreadths below the costal margin, just to the left of the midline.

B. Potential sites for tube insertion are palpated with a single finger. The impression of the finger on the stomach wall is noted by the endoscopist. Inability to appreciate this impression suggests interposition of other organs, such as the colon or liver, between the stomach and the abdominal wall (Fig. 10-2).

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