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Percutaneous enterostomy tubes are indicated when long-term enteral access of 4 weeks is necessary; these may be placed by endoscopic, fluoroscopic, or surgical techniques. The administration of a single dose of a broad-spectrum antibiotic pre-procedurally has been shown to reduce the risk of wound infection [60-68] and be cost-effective for percutaneous endoscopic gastrostomy. It is also recommended for other enterostomy placements as well [35] (Table 10.4).

3.1. Gastrostomy Tubes 3.1.1. Techniques for Placement Endoscopically. The most common means of obtaining long-term gastric access is percutaneous endoscopic gastrostomy (PEG), the second most common indication for endoscopy of the upper gastrointestinal tract [69]. Typically performed under conscious sedation, it may also be performed at the bedside of critically ill patients [70]. Absolute contraindications to PEG placement are the same as those of upper gastrointestinal endoscopy as well as an inability to transilluminate the abdominal wall and appose the anterior gastric wall. Relative contraindications to PEG placement include coagulopathy, gastric varices, morbid obesity, prior gastrointestinal surgery, ascites, chronic ambulatory peritoneal dialysis, and neoplastic, infil-trative, or inflammatory disease of the abdominal wall [71].

Table 10.4

Randomized Controlled Trials Evaluating Efficacy of Antibiotic Prophylaxis in Percutaneous Endoscopic Gastrostomy

Table 10.4

Randomized Controlled Trials Evaluating Efficacy of Antibiotic Prophylaxis in Percutaneous Endoscopic Gastrostomy


—Treatment group-11—

—Control group—













Cefoxitin 1 g IV








Cefazolin 1 g IV








Am 3 g/Clav 1.2 g IV



No treatment





Cefazolin 1 g IV








Cefotaxime 2 g IV or



No treatment




Pip 4 g/Tazo 0.5 g IV

Am 1 g/Clav 1.2 g IV








Ceftriaxone 1 g IV



No treatment





Cefuroxime 750 mg IV








Am 1 g/Clav 1.2 g IV







or Cefotaxime 2 g IV

or Cefotaxime 2 g IV

IV = intravenous; N.S. = not significant; Am = amoxicillin; Clav = clavulanic acid; Pip = piperacillin; Tazo = tazobactam

Percutaneous endoscopic gastrostomy tubes are most commonly placed using the Ponsky ("pull") technique, first described in 1981 [20]. After advancement of the endoscope, the stomach is insufflated with air, and an optimal site for PEG placement is determined by simultaneously transilluminating the gastric/abdominal wall and indenting the abdominal wall with a finger while visualizing that indention endoscop-ically. After a small incision is made, a needle/trocar is inserted through the abdominal wall and into the stomach. A guidewire is passed through this needle/trocar and grasped endoscopically. The guide wire is then withdrawn through the mouth, and a gastrostomy tube is affixed to it. Finally, the guidewire is pulled back through the esophagus, stomach, and abdominal wall and held into place by an internal retention device and an external bumper.

Advantages of PEG for obtaining gastric enteral access are the avoidance of general anesthesia, travel to the radiology suite, and radiation exposure that are required by other techniques. Fluoroscopically. First described in 1981 [72], fluoroscop-ically guided gastrostomy is performed in the radiology suite and may be performed with only local anesthetic. After insufflation of the stomach with a nasogastric tube, a puncture is created using a needle; the location of the needle is confirmed by injection of contrast medium or aspiration of air bubbles. Usually T-fasteners are inserted around the puncture site to maintain apposition of the stomach and anterior abdominal wall. The gastrostomy tract is created in the center of the T-fasteners with serial dilation. The gastrostomy tube is placed through a peelaway sheath and the nasogastric tube removed [73].

Fluoroscopic gastrostomy is an attractive alternative in that typically only local anesthesia or light sedation is required. It also remains an option for those patients with obstructive pharyngeal or esophageal pathology that renders upper GI endoscopy difficult or impossible. Surgically. First performed in 1876, surgical gastrostomy was the only means of ensuring long-term enteral nutrition until the late 1970s. A gastrostomy tube placed using the open or laparo-scopic methods is typically performed in the operating room under general anesthesia; however, local anesthesia combined with conscious sedation may also be used. The most commonly used method, the Stamm technique, requires a small laparotomy in the medial upper abdomen. A small incision is made into the stomach, and the feeding tube is inserted and secured with purse-string sutures. The stomach is then affixed to the anterior abdominal wall, and the tube is often kept in place with an inflated balloon or by attachment to the abdominal wall [18, 74].

Laparoscopic gastrostomy placement likewise occurs in the operating room under general anesthesia or conscious sedation. A gastrostomy tube is placed over a guidewire into the stomach under direct visualization from outside the stomach. T-fasteners are used to affix the stomach to the anterior abdominal wall. The procedure then takes place similarly to fluoroscopic placement except monitoring occurs intraperitoneally [75-78].

Benefits of surgical gastrostomy over endoscopic and fluoro-scopic methods are limited. Gastrostomy tubes may be placed during other operative procedures, thus eliminating the need for additional sedation/anesthesia for a second procedure. Surgical gastrostomy also remains an option in patients with obstructive pharyngeal or esophageal pathology that renders endoscopy or nasogastric tube passage impossible.

Endoscopic and fluoroscopic methods are associated with less morbidity and cost than surgical methods, but the overall success rates are similar [16, 79-87], with published success rates typically greater than 90%. Factors that can lead to unsuccessful gastrostomy placement include unexpected obstruction of the pharynx or esophagus, deterioration of the clinical status of the patient intraprocedurally, incidental finding of gastric cancer, development of a hematoma at the gastrostomy site, and prior surgery that has altered esophageal, abdominal, or gastric anatomy [88].

3.1.2. Complications

As with nasal feeding tubes, complications of gastrostomy tubes can be divided into procedural and post-procedure complications (Table 10.5).

Table 10.5

Complications of Percutaneous Endoscopic Gastrostomy (PEG) Tubes

Table 10.5

Complications of Percutaneous Endoscopic Gastrostomy (PEG) Tubes




-Peristomal infection


-Stomal leakage

-Perforation of abdominal viscera

-Buried bumper syndrome

-Prolonged ileus

-Fistulous tracts


-Inadvertent removal

-Cardiopulmonary complications

-Gastric ulcer

related to sedation

-Tumor implantation Procedural Complications. The procedural and long-term mortality rate directly related to gastrostomy placement is very low; however, the overall mortality of patients receiving gastrostomy tubes is up to 50% [89]. This high rate reflects the significant co-morbidities present in this population receiving PEGs rather than the procedure itself. Serious complications related to the procedure itself are comparable among methods of placement and range from 0.1-4% of cases. These include intraprocedural aspiration, hemorrhage, perforation of abdominal viscera, and prolonged ileus [84, 90, 91]. Risk factors for intraprocedural aspiration include supine position, advanced age, excessive sedation, and neurological impairment. The clinician can minimize the risk of intraprocedural aspiration by avoiding over-sedation, minimizing air insufflation of the stomach, and thoroughly emptying the gastric contents prior to the procedure [71].

Acute hemorrhage during gastrostomy placement is uncommon, but is likely increased in the setting of a coagulopathy, iatrogenic or otherwise. Checking coagulation studies prior to the procedure is recommended [81]. On the other hand, pneumoperitoneum as a result of percutaneous approaches is common and of no clinical consequence in the absence of signs of peritoneal irritation [92]. Post-Procedural Complications. The overall post-procedural complication rate of gastrostomy tubes ranges from 4.8-10.8% regardless of the method of placement [84, 93]. Peristomal infection is the most common complication of gastrostomy placement, but the vast majority of infections are mild and easily treated with oral antibiotics [64, 94]. To minimize morbidity and even mortality of peristomal infections, the administration of prophylactic antibiotics prior to placement, early recognition of wound infections, treatment with antibiotics, and local wound care are fundamental to the successful management of peristomal infections [61, 62, 64].

Leakage around the gastrostomy site is a common problem [95]. Peristomal infection, excessive cleansing with irritating solutions (e.g., full strength hydrogen peroxide and betadine), and excessive tension and side torsion on the external portion of the feeding tube all increase risk of leakage. Management of excessive leakage consists of treating infection if present, providing quality ostomy skin care, loosening the outer bumper to minimize tension, and stabilizing the external gastrostomy tube to prevent side torsion [47].

Buried bumper syndrome results from the partial or complete growth of gastric mucosa over the internal bumper of the gastrostomy tube and can result in migration of the bumper externally where it may lodge anywhere along the gastrostomy tract. Risk factors include excessive tension between the internal and external bumpers, poor wound healing, and significant weight gain [36]. Clinically, buried bumper syndrome leads to peristomal leakage or infection, abdominal pain, an immobile catheter, or resistance with infusion of formula. The buried bumper can be confirmed endoscopically when possible, or by gastrografin study with the patient in the prone position. Treatment consists of salvaging the stoma tract while returning the internal bumper back into the lumen of the stomach [96, 97].

Fistulous tracts connecting the stomach, colon, and skin are uncommon, but potentially life-threatening complications of gastrostomy tubes. If the colon is inadvertently punctured during endoscopic or fluoroscopic gastrostomy placement, or less commonly, if the tube erodes into the adjacent colon, patients may present acutely ill with colonic perforation. If the colon is traversed inadvertently during initial placement the patient may be asymptomatic until gastrostomy tube replacement when the replacement tube is inserted only as far as the colon. Then patients will present with leakage of stool around the gastrostomy site and diarrhea resembling feeding formula. Diagnosis can be made by infusion of gastrografin into the gastrostomy tube and observing the filling of the colon radiographically. Elevation of the head of the bed to displace the colon inferiorly and use of the safe track technique may minimize the risk of inadvertent puncture of the colon (Fig. 10.2) [98]. Treatment usually consists of gastrostomy tube removal, but surgical repair is indicated if peritoneal signs are present.

Inadvertent gastrostomy tube removal should be managed urgently. Gastrostomy tract maturation usually occurs within the first 7-10 days, but in the presence of malnutrition or poor wound healing it may be delayed as long as 4-6 weeks [90]. A gastrostomy tube that is inadvertently removed during this time period should be promptly replaced endoscopically or fluoroscopically as the tract may be immature and the stomach and anterior abdominal wall can separate, resulting in free perforation. If recognition is delayed, management includes nasogastric decompression, broad-spectrum antibiotics, and repeat gastrostomy after 7-10 days. Surgical exploration is indicated in patients with clinical evidence of peritonitis. Once maturation of the tract has occurred, a replacement tube may be placed at the bedside without endoscopic or fluoroscopic guidance if done without delay. Patients prone to pulling at tubes may receive benefit from an abdominal binder or placement of a low profile device (button) [90].

Peg Technique
Fig. 10.2. Safe tract technique.

3.2. Jejunal Tubes 3.2.1. Gastrojejunal Tubes

In the setting of impaired gastric motility, pancreatitis, risk for reflux and/or aspiration, gastric outlet obstruction or any time enteral feeding into the small bowel with simultaneous gastric decompression is desired, a gastrojejunal tube should be placed [22, 99]. Techniques for Placement. Endoscopically The jejunal arm of a percutaneous endoscopic gastrojejunostomy (PEG-J) tube is placed using an initially placed PEG tube. Most commonly, a guidewire is placed through an existing gastrostomy, and it is grasped endoscopically and carried into the jejunum. The guidewire is left in the jejunum and the endoscope withdrawn. The jejunal extension tube is then threaded over the guidewire into the small bowel [33, 100]. Advantages of PEG-J are similar to those of PEG; additionally, if a patient already has a PEG tube in place, conversion to PEG-J does not require an additional skin puncture. Success rates over 90% have been reported for PEG-J [101-104].

Fluoroscopically and Surgically Gastrojejunal tubes may be placed fluoroscopically or during laparotomy or laparoscopy. Fluroscopic technique is similar to endoscopic PEG-J. Using an existing gastrostomy, a guidewire is advanced through the stomach past the ligament of Treitz, and the jejunal extension tube is advanced over the wire into the jejunum under fluoroscopic guidance. Gastrojejunal tubes can be placed during laparotomy or laparoscopy methods using any of the above methods. Using manual and/or endoscopic methods the jejunal tube is positioned into the small bowel. The gastric component of the tube is left in the stomach. These modalities have success rates that are comparable to those of PEG-J [105].

3.2.2. Direct Jejunal Tubes

In patients without a need for gastric decompression, it may be desirable to place a enterostomy tube directly into the jejunum. Jejunostomy tubes are placed primarily endoscopically or surgically. Advantages and disadvantages of endoscopic vs. surgical methods are similar to those of gastrostomy placement. Techniques for Placement. Endoscopically Direct percutaneous endoscopic jejunostomy (D-PEJ) is performed in a manner similar to that of the PEG 'pull' technique. A pediatric colonoscopy or enteroscope is advanced to the small bowel, and transillumination and finger indentation are performed over the jejunum rather than the stomach. A needle/trocar is inserted through the abdominal wall into the jejunum, and an insertion wire is passed through the trocar and grasped endoscopically. The remainder of the procedure is as described for the PEG 'pull' technique [106, 107]. In comparison studies, D-PEJ has been demonstrated to have greater longevity and decreased need for re-intervention compared PEG-J [101, 108, 109]. Therefore, in some cases it may be advantageous to place separate direct gastrostomy and jejunostomy tubes rather than a single combined gastrojejunal tube.

Surgically There are three basic types of surgical jejunostomy techniques in use: the Witzel technique, Roux-en-Y jejunostomy, and needle catheter jejunostomy. In the Witzel technique, the surgeon creates a submucosal tunnel in the small bowel through which the jejunostomy tube is threaded. In doing so, leakage of small bowel contents is minimized [19]. Needle catheter jejunostomy may be placed by laparotomy or laparoscopy; in this case a needle is threaded into the small bowel, and a guidewire is passed into the jejunum. A small jejunostomy catheter is passed over the guidewire into the jejunum. However, the smaller size of this catheter may lead to more frequent occlusion.

Jejunostomies may also be placed laparoscopically. After ports are placed in the left upper quadrant and medial lower abdomen, the jejunum is approximated to the anterior abdominal wall using T-fasteners. A guidewire is then passed into the jejunum, and a jejunostomy tube is advanced into the small bowel [76, 110]. Direct percutaneous endoscopic jejunostomy placement is successful in 68-100% of attempts [101, 106, 111, 112], while success rates approach 100% with surgical jejunostomy [76].

3.2.3. Complications

Complications of jejunal tubes are similar to those of gastrostomy tubes described above. It deserves mention that gastrojejunal feeding tubes have a higher incidence of malfunction (up to 70%), migration, and/or occlusion of the distal, smaller jejunal extension tube [103,113]. Additional complications of direct jejunostomy tubes include jejunal volvulus and small bowel perforation [112]. Despite expert opinion, the data are controversial as to whether more distal feeding with jejunal tubes decreases a patient's aspiration risk significantly [50, 114].

4. care of the feeding tube 4.1. Skin Care

The skin around tube enterostomies should be cleaned with mild soap and water, then rinsed and dried thoroughly. Use of irritant cleansers or full strength hydrogen peroxide should be avoided as they may lead to poor wound healing and leakage around the tube. Likewise, routine use of antibiotic ointments is not advised, and dressings at the tube insertion site are not necessary unless there is drainage at the site.

Skin care of the nasal area is important in patients with nasal tubes as the tubes can be irritating, and there is often prolonged exposure to adhesive products. Additionally, regular repositioning of the nasal tube reduces the risk of pressure necrosis.

Regardless of the method of placement, oral hygiene is appropriate for patients with feeding tubes. This is especially important in patients with a decreased level of consciousness or those on mechanical ventilation.

4.2. Prevention of Clogging

Tubes with smaller lumens are more prone to clogging, but maintenance of all sizes of tube is important to minimize clogging. Flushing with water regularly is paramount. Other causes of clogging include accumulation of pill fragments, frequent checking of residuals, and formulas containing high protein concentrations [115, 116]. Use of medications in liquid form is recommended, as is flushing after each medication administration [117].

4.3. Replacement Enterostomies

The external portion of gastrostomy and gastrojejunostomy tubes may be several centimeters long, requiring that caution be used to avoid traction or side torsion, which may promote tube leakage. In patients at high risk of pulling at the tube, or in patients desiring a more cosmetically acceptable option, a low-profile port ("button") may be used. The internal retention bolster of percutaneous tubes is constructed of either solid material (silicone or polyurethane) or a silicone balloon. Solid internal bolsters may last a year or longer and are most commonly used in initial endoscopic enterostomy tube placement. Balloon-type internal bolsters have a lifespan of 3-6 months and are more commonly used in radiological tube placements as well as replacement tubes due to the ease of placement [118].

5. conclusions

Enteral nutrition is the route of choice in patients with a functioning gastrointestinal tract. A number of enteral access options are available to patients in need of nutritional support. Consideration of the appropriate device, level in the gastrointestinal tract, and insertion method are critical to ensure optimal outcomes. In addition, appropriate aftercare and monitoring with early recognition and treatment of any complications are crucial to the success of enteral nutrition access.


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