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Choice betweenGastrostomy and Jejunostomy
Ri 蘇彥榮
AGA guideline: Enteral nutrition
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 only
absolute contraindication to enteral feeding.
Methods of Feeding
Complications of Tube Feeding
Infection Aspiration Diarrhea Alterations in drug absorption and
metabolism Metabolic disturbances
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
Gastrostomy (2)
For gastric access using conscious sedation, PEG is usually preferred.
Surgical gastrostomy is comparable but is more expensive and requires more recovery time.
Percutaneous endoscopic gastrostomy (PEG)
Jejunostomy
Percutaneous endoscopic jejunostomy (PEJ)
Extension through an existing gastrostomy tube (PEG-J)
Surgical jejunostomy Radiological jejunostomy
Percutaneous endoscopic jejunostomy (PEJ)
PEG-J
When Should a Gastrostomy Be Used?
Requires prolonged tube feeding (>30 days)
Adequate function and structure of stomach and low esophageal sphincter No history of :
Recurrent aspiration of gastric contents Esophageal dysmotility or regurgition Delayed gastric emptying
When Should Jejunostomy Tubes Be Used?
Pulmonary aspiration Severe GER and reflux esophagitis Gastroparesis Insufficient stomach from previous
resection Post surgery/multiple trauma Access in a patient with
unresectable gastric or pancreatic cancer
Adavntages of Gastrostomy
More physiological Ease of placement Convenience
Bolus feeding Greater flexibility in choosing formula
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 osmolarity
formula
Adavntages of Jejunostomy
Minimize aspiration risk Benefits in acute pancretitis Role in critically ill patients
In the critically ill adult patient, we recommend the routine use of small bowel feedings in units where obtaining small bowel access is feasible.
Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated, Critically Ill Adult Patients.JOURNAL OF PARENTERAL AND ENTERAL NUTRITION, 2003, Vol. 27, No. 5
Early use of post-pyloric feeding instead of gastric feeding in critically ill adult patients with no evidence of impaired gastric emptying was not associated with significant clinical benefits.
A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis. Intensive Care Med (2006) 32:639–649
Disadavntages of Jejunostomy
Difficulty with placement and ease of displacement
Feeding tolerance Dumping syndrome
Slow feeding rate Change in formula
Long-term use of gastrostomy and jejunostomy
If gastrostomy are no longer tolerated Surgical jejunostomy PEG-J
If jejunostomy are no longer tolerated TPN
Summary
Most patients can be started on low volume contineous intragastric feeding.
Beginning with jejunal feeding may be considered in patients with severe GER and esophagitis, post surgery/multiple trauma, and gastric dysmotility.