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.

Gastrostomy

Expected Benefits

• Permits gastric feeding or decompression more conveniently and comfortably than by nasogastric tube.

Potential Risks

• Gastric leak.
• Injury to adjacent organs, including colon, small intestine, and liver.
• Gastrocutaneous fistula.
• Bleeding.
• Infection.
• Risks inherent to sedation or general anesthesia.
• Metastatic oropharyngeal cancer rarely occurs at the PEG site (< 1% occurrence), and usually occurs in rapidly progressive disease with other sites of metastasis.

Witzel Jejunostomy

Expected Benefits

• Provides a means for enteral feeding that bypasses the stomach and upper digestive system.

Potential Risks

• Damage to surrounding structures, including bowel wall injury.
• Enteroenteric or enterocutaneous fistula.
• Bleeding.
• Infection.
• Risks inherent to general anesthesia.

Percutaneous Endoscopic Gastrostomy

• Upper gastrointestinal endoscope.
• PEG kit (commercially available).

Stamm Gastrostomy

• 18–22 French Malecot, Pezzer, or equivalent catheter, such as a 20 French ...