10865926 Choice Between Gastrostomy and Jejunostomy

7/27/2019 10865926 Choice Between Gastrostomy and Jejunostomy

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Choice betweenGastrostomy and Jejunostomy

Ri


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AGA guideline: Enteral

nutrition


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Indications for Tube Feeding Patients who cannot or will not eat

Patients who have a functional gut

Safe method of access is possible.

Mechanical obstruction is the onlyabsolute contraindication to enteralfeeding.


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Methods of Feeding


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Complications of Tube Feeding Infection

Aspiration

Diarrhea

Alterations in drug absorption andmetabolism

Metabolic disturbances


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Gastrostomy (1) Percutaneous endoscopic gastrostomy

(PEG)

First choice of gastric access

Surgical gastrostomy

Comparable to PEG, but is more expensive

and requires more recovery time

Radiological gastrostomy


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Gastrostomy (2) For gastric access using conscious

sedation, PEG is usually preferred.

Surgical gastrostomy is comparable butis more expensive and requires morerecovery time.


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Percutaneous endoscopic

gastrostomy (PEG)


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Jejunostomy Percutaneous endoscopic jejunostomy

(PEJ)

Extension through an existinggastrostomy tube (PEG-J)

Surgical jejunostomy

Radiological jejunostomy


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Percutaneous endoscopic

jejunostomy (PEJ)


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PEG-J


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When Should a Gastrostomy BeUsed?

Requires prolonged tube feeding (>30 days)

Adequate function and structure ofstomach and low esophageal sphincter

No history of :

Recurrent aspiration of gastric contents

Esophageal dysmotility or regurgition

Delayed gastric emptying


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When Should Jejunostomy TubesBe Used?

Pulmonary aspiration

Severe GER and reflux esophagitis

Gastroparesis

Insufficient stomach from previousresection

Post surgery/multiple trauma

Access in a patient with unresectablegastric or pancreatic cancer


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Adavntages of Gastrostomy More physiological

Ease of placement

Convenience

Bolus feeding

Greater flexibility in choosing formula


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Disadavntages of Gastrostomy Delayed gastric emptying

Continueous feeding

Prokinetic drug

Gastroesophageal reflex and aspiration

Elevation of head

Reduce feeding rate and volume

More hydrolyzed or lower osmolarityformula


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Adavntages of Jejunostomy

Minimize aspiration risk

Benefits in acute pancretitis

Role in critically ill patients


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In the critically ill adult patient, werecommend the routine use of small

bowel feedings in units where obtainingsmall bowel access is feasible.

Canadian Clinical Practice Guidelines for Nutrition Support inMechanically Ventilated, Critically Ill Adult Patients.JOURNAL OF PARENTERAL AND ENTERAL NUTRITION, 2003, Vol. 27, No. 5


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Early use of post-pyloric feeding insteadof gastric feeding in critically ill adult

patients with no evidence of impairedgastric emptying was not associatedwith significant clinical benefits.

A comparison of early gastric and post-pyloric feeding in critically illpatients: a meta-analysis.Intensive Care Med (2006) 32:639649


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Disadavntages of Jejunostomy

Difficulty with placement and ease ofdisplacement

Feeding tolerance

Dumping syndrome

Slow feeding rate

Change in formula


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Long-term use ofgastrostomy and jejunostomy

If gastrostomy are no longer tolerated

Surgical jejunostomy PEG-J

If jejunostomy are no longer tolerated

TPN


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Summary

Most patients can be started on lowvolume contineous intragastric feeding.

Beginning with jejunal feeding may beconsidered in patients with severe GERand esophagitis, post surgery/multiple

trauma, and gastric dysmotility.

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10865926 Choice Between Gastrostomy and Jejunostomy