Chapter 10. Enteral Access

Gastrostomy

• Long-term (> 4–6 weeks) gastric feeding required under the following circumstances:
  • Patient is unable to swallow.
  • Oral feeding is precluded.
  • Oral intake alone is inadequate.
• Long-term gastric decompression.
• Intolerance to nasogastric or Dobbhoff tube, or both.
  • In cases requiring access to the gastric lumen for < 4–6 weeks, a nasogastric or Dobbhoff tube generally suffices.
• Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice, when feasible, for gastrostomy placement alone. If the stomach is not accessible percutaneously or if gastrostomy is performed at the time of another upper abdominal operation, an open technique is used.

Witzel Jejunostomy

• Secondary procedure during extensive upper digestive tract surgery (eg, esophagectomy, total gastrectomy) to enable early enteral feeding, particularly when recovery is expected to be long and potentially complicated.
• Sole procedure in patients in whom oral feeding is precluded and postpyloric feeding is desired (eg, patients with duodenal trauma, gastroparesis, or pancreatitis).

Gastrostomy

Absolute

• Absence of stomach (subtotal gastrectomy, transhiatal esophagectomy with gastric pullup).
• For PEG, esophageal obstruction. (Stamm gastrostomy remains feasible.)
• For PEG, lack of access to esophagus (eg, trismus, teeth wired shut). (Stamm gastrostomy remains feasible.)

Relative

• Severe gastroesophageal reflux or incompetent lower esophageal sphincter.
• Anatomy that prevents direct apposition of the stomach with the abdominal wall (eg, interposition of an enlarged liver; severe kyphoscoliosis).
• For PEG, morbid obesity. (Stamm gastrostomy remains feasible.)
• Ascites.
• Irreversible coagulopathy.

Witzel Jejunostomy

Absolute

• Distal intestinal obstruction.
• Small bowel dysmotility.

Relative

• Hostile abdomen (adhesions, malignancy).
• Inflammatory bowel disease or postradiation enteritis involving the jejunum.
• Ascites.
• Irreversible coagulopathy.
• Significant bowel wall edema.
• Severe immunodeficiency.

Percutaneous Endoscopic Gastrostomy

• The patient should be supine.
• The head of the bed may be elevated to 45 degrees as the scope is passed, but the best percutaneous access to the stomach is achieved when the patient is fully supine.

Stamm Gastrostomy and Witzel Jejunostomy

• The patient should be supine.

Percutaneous Endoscopic Gastrostomy

• A percutaneous gastrostomy may be used for medication administration immediately and for feeding within 6–12 hours. The patient should be instructed that the retention bar, which is initially snug, may be loosened slightly after 24–48 hours.

Stamm Gastrostomy

• Unlike a PEG, an open gastrostomy tube is connected to gravity drainage for 12–24 hours before being used for feeding. This allows for verification that gastric emptying is taking place.

Witzel Jejunostomy

• The jejunostomy tube can be used immediately following the procedure.
• Tube feedings should be started slowly, at one-fourth or one-half strength, to avoid ...