World J. Surg. 23, 603–607, 1999WORLDJournal of

SURGERY© 1999 by the Societe

Internationale de Chirurgie

Use of Gastrostomy and Combined Gastrojejunostomy Tubes for Enteral Feeding

Mark B. Faries, M.D., John L. Rombeau, M.D.

Department of Surgery, School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104, USA

Abstract. Recent economic changes in health care delivery have led tomore frequent feeding by tube enterostomy. Over the last two decadespercutaneous endoscopic gastrostomy (PEG) has been established as thestandard method for long-term enteral access for nutrition, thoughoperative gastrostomy remains indicated in a few conditions. Addition-ally, the combined gastrojejunostomy tube is indicated in selected pa-tients in need of concomitant access to the jejunum and gastric decom-pression. This report reviews data regarding the safety and efficacy of thePEG tube and the indications for operative gastrostomy. Complications offeeding tubes and strategies to avoid or remedy them are also discussed.More recent techniques, including laparoscopic gastrostomy and jejunalaccess via the stomach, are reviewed as are some ethical concernsregarding the appropriateness of feeding enterostomies in certain pa-tients.

Dramatic changes in health care over the last several years haverevolutionized the way enteral nutrition is delivered. A moreaggressive stance toward placement of tube enterostomies forfeeding has been adopted, in part, to achieve either earlier returnto home or transfer of hospitalized patients to chronic carefacilities. Enteral feeding is also increasingly prescribed becausethere is evidence that it is better for the intestine and lessexpensive than total parenteral nutrition (TPN) [1–3]. Access forenteral feeding in long-term patients is most frequently providedthrough either a gastrostomy or jejunostomy. This report brieflyreviews the use of endoscopic and open gastrostomy and com-bined gastrojejunostomy tubes for enteral nutrition. Commentson the ethical concerns of feeding by tube enterostomy in patientswith terminal illnesses are expressed.

Percutaneous Endoscopic Gastrostomy

Since their introduction in 1980, percutaneous endoscopic gas-trostomies (PEGs) have largely replaced operative gastrostomyand have become the gold standard for long-term enteral access[4]. This technique is safe, well tolerated, and cost-effective. Thearray of complications for PEG tubes is similar to that of opengastrostomy. Complications specifically associated with the PEGprocedure are rare: esophageal and oropharyngeal trauma occur-

ring with passage of the endoscope or PEG tube and colonic orhepatic injuries due to interposition of these organs between thestomach and anterior abdominal wall. Large series reviewing PEGhave found the overall complication rate to be lower than that ofopen gastrostomy [5]. Patients whose primary reason for admis-sion to the hospital is enteral access can usually be dischargedwithin a day of placement of the tube. The procedure also requiresless operative time than the open technique. The combination ofdecreased hospital stay and shorter operative time is desirable inthe present economic environment.

Operative Gastrostomy: Open Technique

Open gastrostomy is defined as placement of a tube into thestomach by laparotomy. Despite having been largely replaced bythe PEG procedure, it is still indicated in some settings, such aswhen endoscopic placement is not possible. Examples includepatients with esophageal stricture or other esophageal or oropha-ryngeal lesions that preclude passage of a gastroscope. A PEGmay also be contraindicated for some patients in whom there is noadequate site for percutaneous puncture of the stomach due toadhesions from previous surgery, a small gastric remnant afterprevious gastrectomy, or interposition of the liver or transversecolon between the stomach and abdominal wall. Operative place-ment is also indicated for selected trauma patients and others whoare undergoing abdominal surgery with concomitant need forgastric access.

Care and Complications of Gastrostomy

Postoperatively the tube is placed to allow gravity drainage forapproximately 24 hours. If the patient has not had more than 500ml of drainage, and if his or her bowel function is normal, the tubeis clamped and then used for administration of medications andboluses of 5% dextrose solution. A typical regimen starts withvolumes of 120 ml delivered over 30 minutes every 4 hours.Feedings are begun on the first or second postoperative day if thepatient tolerates the clamping and the dextrose infusions. Isotonicfeeds are used initially until the patient has demonstrated toler-ance of the feeding. The volumes are then advanced as the patienttolerates the progression of enteral formula delivery. Protocols formore rapid initiation of feeding have been shown to be safe in

This paper was presented at a postgraduate course arranged bythe International Association for Surgical Metabolism and Nutrition(IASMEN) in Acapulco, Mexico, August 24, 1997.

Correspondence to: J.L. Rombeau, M.D.

several studies and may be used in appropriate patient popula-tions [6].

Though generally considered a fairly routine operation, gastros-tomy is associated with a number of complications (Table 1) thatcan arise within the perioperative period or during long-term use.Perioperative problems include bleeding at the gastrotomy siteand injury to other abdominal structures during placement of thetube. Postoperative problems include wound infections, intraperi-toneal soilage, peritubular leaks, ileus, and dehiscence. There isalso substantial perioperative mortality most often related to thegenerally poor overall condition of the patient undergoing theprocedure [7, 9–11].

Though the stomach is generally accessed without difficulty andapposed to the anterior abdominal wall, perforation of theduodenum and esophagus as well as development of gastrocolicfistulas have been reported [7, 10]. Bleeding, a fairly uncommoncomplication of gastrostomy, can usually be prevented by ensuringnormal coagulation prior to tube placement. If bleeding persistsafter tube insertion and a tube with an internal balloon (e.g., Foleycatheter) has been placed, gentle traction can be applied to thetube to help control hemorrhage at the gastrotomy. Iced salinelavage and injection of vasopressin may also help reduce bleedingfrom the gastrostomy site [7]. Reoperation for bleeding is seldomrequired.

Wound infections are relatively frequent. To reduce the inci-dence of wound infections, care should be taken to avoid spillinggastric contents by ensuring the tube is ready to be inserted andthe purse-string sutures are in place prior to making the gastros-tomy. A dose of prophylactic preoperative antibiotics is oftengiven [12].

Though operative manipulation of intraabdominal structures isgenerally minimal, ileus can occur postoperatively. Gravity drainagevia the gastrostomy to vent swallowed air is generally the onlytreatment required until the ileus resolves. If the ileus is prolonged,it is often due to focal peritonitis from intraperitoneal spillage ofgastric contents. This complication can be serious and may requirelaparotomy for definitive treatment. If a gastrostomy tube is prema-turely or partially withdrawn, intraperitoneal leakage of gastriccontents may occur. Placement of omentum or tacking suturesaround the tube site at the time of placement helps prevent intra-peritoneal soilage by either sealing the gastrotomy or facilitating exitof gastric fluid via the skin opening. Gastric leakage is diagnosed byinjecting water-soluble contrast material through the tube.

Inadvertent leakage of gastric fluid onto the skin through theexit site of the tube is another potential problem. To help preventthis problem, the skin opening for exit of the tube should be thesame length as the tube diameter. Every effort must be made toprotect the patient’s skin from irritation [9, 13]. Frequent dressing

changes are made if the volume of effluent leakage is not large;ostomy appliances are indicated for larger amounts of drainage.The assistance of an enterostomal therapist is helpful whentreating this problem. In the presence of a leak around the tube,the tube should be placed so it can drain, enabling gastricsecretions to pass through the tube rather than around it. Thetube should be kept stabilized on the skin with secure sutures ora stoma appliance to prevent undue manipulation of the tube. Ifthese measures fail, the tract is allowed to close partially orcompletely by removing the tube for approximately 4 hours. Thetube is then replaced with a similar-size or larger tube after thetract has partially closed. If this approach fails, the tube isremoved and the tract allowed to close completely. An interven-tional radiologist then replaces the gastrostomy percutaneously.

Gastrostomy tubes also cause obstruction of the stomach if theymigrate distally [9]. This problem can be prevented by firmlysecuring the tube at the level of the skin. Care is taken to ensurethat the retaining balloon or bumper is not pulled so tightlyagainst the abdominal wall as to lead to necrosis of the wall anderosion of the tube through the wall.

Tubes can become dislodged with excess traction or failure of aretaining balloon or bumper. If this occurs before a tract hasformed between the stomach and skin, peritonitis may result.More commonly, tubes are inadvertently displaced during pro-longed use. If this problem is identified early, a new tube can beeasily inserted via the existing tract. Delay in replacing the tubequickly results in closure of the gastrostomy tract. A new tubemust then be placed percutaneously by an interventional radiol-ogist. The safety of this replacement is facilitated by the initialplacement of tacking sutures, which secure the stomach to theanterior abdominal wall.

Tubes commonly become clogged with formulas or precipitatedmedications. It is rare, however, that a tube must be replaced forthis reason. Gentle alternating aspiration and pressure applied byinjecting water through the tube over a period of several minutesusually clears the obstruction. A number of irrigating solutionshave been proposed to clear such blockages, including carbonatedbeverages and pancreatic enzymes; but warm water is generallysufficient. Failing this, clearing of obstructions with either endo-scopic brushes or flexible guide wires is often efficacious.

Diarrhea is often associated with but not necessarily due to thedelivery of tube feedings. Causes of diarrhea include antibiotictherapy, infected tube feedings, and concomitant use of osmoticallyactive medications [8, 14–16]. One should search for the cause ofdiarrhea rather than simply discontinue the tube feeding. Antibioticsare the most common cause of diarrhea and can mediate their effectsin several ways. The most serious effect is due to overgrowth ofClostridium difficile leading to pseudomembranous colitis. However,

Table 1. Complications and mortality in patients with feeding tubes.

Study No.

Patients withcomplications

Mortality (at which month) CommentsNo. %

Bergstrom [7] 54 31 57 21% (1), 51% (6), 64% (12) Includes mortality in surgical jejunostomy patientsEdelman [8] 14 1 7 35% (1) LaparoscopicStiegmann [9] 57 14 26 9% (?) Randomized vs. PEGShellito [10] 424 56 13.2 0.5% Only tube-related mortality reported

PEG: percutaneous endoscopic gastrostomy.

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changes produced by antibiotics in gut flora, even without overtcolitis, can act synergistically with tube feedings to cause diarrhea. Asample of stool should be sent for C. difficile evaluation, and anyunnecessary antibiotics are discontinued.

Treatment with antimotility agents in the setting of infection-induced diarrhea is contraindicated because it decreases clear-ance of toxins and contributes to toxic megacolon. Initial treat-ment should include mild antidiarrheal agents (e.g., Kaopectate)that help bind and clear bacterial toxins.

Infected formula is another possible source of diarrhea and ismore common with powdered formulas mixed with tap water.Symptoms caused by infected feeds include not only diarrhea butalso fever, nausea, and vomiting. In some studies contaminationwas as high as 15% to 21%; and if gastrointestinal symptomsoccurred within 24 hours of initiating feeds, contaminated dietswere found in 67% of patients [14].

Laxatives and osmotically active medications frequently inducediarrhea and should be discontinued if possible. This groupespecially includes medications that contain sorbitol, such astheophylline, paracentonol, cough syrups, cimetidine, isoniazid,lithium, and some vitamins.

Once an infectious etiology has been eliminated, antimotilityagents such as loperamide, codeine, tincture of opium, or pare-goric can be used to control diarrhea. Addition of fiber to enteraldiets can also be therapeutic in patients receiving long-termenteral feeding. Short-chain fatty acids, the breakdown productsof dietary fiber and undigested polysaccharides, are avidly ab-sorbed in the colon and enhance water and sodium absorption[16]. Fiber may reduce diarrhea by this mechanism but only if thecolonic microflora has not been significantly altered.

Operative Gastrostomy: Laparoscopic Technique

Gastrostomy placement is also possible using laparoscopic tech-niques with carbon dioxide insufflation or a gasless approach. Thistechnique has many of the same indications as open gastrostomy,including inability to place a tube endoscopically. Advantages oflaparoscopy include the ability to inspect the abdominal cavitythoroughly at the time of tube placement. The laparoscopicapproach is particularly appealing in children, most of whomrequire general anesthesia even if a PEG is inserted.

Edelman and colleagues compared laparoscopic gastrostomywith PEG in 1993 [8]. Their study reviewed 17 PEGs and 14laparoscopic gastrostomies, and the procedures were found tobe equivalent as to efficacy and complications. They concludedthat laparoscopic gastrostomy should not replace PEG but thatit was an acceptable alternative in patients who could notundergo PEG.

One disadvantage of laparoscopy is that it usually requiresgeneral anesthesia for insufflation and adequate visualization.Recent reports of laparoscopic gastrostomies have featured tech-niques requiring only local anesthetic involving low-pressureinsufflation or a gasless technique. The latter is described by Vianiand coworkers and uses a fan-shaped retractor inserted at anumbilical port site to provide a field of view above the stomach[17]. The procedure is then completed with local anesthetic andsedation.

Combined Gastrostomy-Jejunostomy Tube

The combined gastrostomy-jejunostomy feeding tube enters thestomach and provides separate ports for the stomach and jeju-num. It provides simultaneous jejunal feeding and gastric drain-age while potentially decreasing the risk of aspiration. An addi-tional advantage is the function of two tubes while creating onlyone enterotomy. It eliminates the need for opening the jejunumand therefore eliminates the risks such as peritoneal leak, luminalnarrowing and intestinal volvulus associated with a second ente-rotomy in the jejunum. Patients who might benefit from thesetubes are those who have gastric atony or who have undergoneBillroth II procedures. The gastrostomy-jejunostomy tube alsoeliminates the need for nasogastric tubes and provides a means todeliver medications directly into the stomach.

Placement of a gastrostomy-jejunostomy feeding tube is accom-plished in a number of ways. First, the gastric large-bore tube ispositioned in the stomach like a standard gastrostomy. Thesmall-bore jejunal tube can then be passed through the gastros-tomy and advanced into the distal duodenum or jejunum inseveral ways. If the gastrostomy placement is open, the jejunalportion can be passed through the pylorus and advanced manuallyand palpated when positioned in the jejunum. If the gastrostomytube is placed percutaneously, the jejunal tube is inserted throughthe PEG, grasped with biopsy forceps, and advanced with anendoscope inserted into the stomach. Once in position in thejejunum, the endoscope is withdrawn leaving the jejunal tube inplace. Finally, and most commonly the jejunal tube is positionedwith the aid of a guidewire and fluoroscopy [18–20].

Simultaneous jejunal feeding and gastric drainage should be anideal method of providing nutrition while avoiding aspiration. Anumber of studies have tried to determine which method offeeding is accompanied by the least frequency of aspiration.Results and conclusions differ primarily due to large variations instudy methods. Most studies are limited by being retrospectiveand including widely varied patient populations. Additional con-cerns include the lack of a standard method of delivery of feeds(i.e., patient position, bolus versus continuous, time of initiation)and inadequate follow-up. It is difficult, therefore, to makedefinitive conclusions regarding the effectiveness of the gastros-tomy-jejunal tube in preventing aspiration during enteral feeding.In general the clinical impression is that if the tubes are placedproperly and used correctly, aspiration is probably reduced. Thetheoretic advantage of this combined tube remains attractiveenough that interest continues in its use and improvement.Modifications to the gastric portion of the tube have beenproposed to improve gastric drainage by extending the gastric portso its tip rests more posteriorly [21]. The method of positioningthe jejunal tube continues to be refined. Vigilant nursing care withregard to patient positioning and tube maintenance remainsparamount in preventing tube complications with this device aswith any feeding tube.

Ethical Considerations of Feeding by Tube Enterostomy

Ethical concerns have arisen regarding invasive placement offeeding tubes, particularly in terminally ill patients. Generally, aprocedure or treatment is indicated if its benefits outweigh therisks and costs. In practice, many feeding tubes are placed inpatients who are in the last stages of dying. One series demon-

Faries and Rombeau: Enteral Feeding 605

strated that 23% of patients who underwent placement of a PEGdid not survive to leave the hospital [22]. In another series, the1-month mortality after placement of gastrostomy was found to be35% [18]. With such a limited prognosis for these patients, thejustification for invasive placement of feeding tubes must beclosely examined.

The benefits of enteral nutrition are clear and sufficient tojustify placing a feeding tube for patients in whom impairment istemporary or limited to the mechanics of oral intake. It is alsoclear that patients who will derive no benefit from enteral feeding,such as patients with cachexia due to untreatable cancer or thosein a persistent vegetative state, should not undergo the procedurefor enteral nutrition. More ambiguity exists for patients who sufferfrom impairments in quality of life beyond oral intake. In suchinstances the patient and the family must weigh the benefits ofnutritional supplementation with the risks of the procedure itselfand the risk of prolonging suffering or a meaningless existence. Ininstances where the patient is unable to decide, a surrogate mustassume responsibility based on what the patient’s wishes wouldhave been. The physician has an important obligation to provideinformation based on knowledge and experience to allow thepatient or surrogate to understand what each option entails andwhat life will be like with each treatment option.

Conclusions

Percutaneous endoscopic gastrostomy is the gold standard forfeeding enterostomies. The procedure is cost-effective and as safeas the open technique. Operative gastrostomy is the procedure ofchoice in patients for whom passage of a gastroscope is notpossible. It is also indicated for patients who require gastric accessfor feeding and are undergoing laparotomy for nonnutritionalindications. Complications are unavoidable, particularly in thegastrostomy patient population. Careful tube placement, meticu-lous maintenance, and use of a tube-feeding protocol help preventsome of the complications. In some centers laparoscopic place-ment of gastrostomy tubes is the procedure of choice in patientswho require an operative gastrostomy. Techniques using localanesthetic with sedation have reduced the need for a generalanesthetic. Combined gastrojejunal tubes can also be used for thepassage of feeding tubes into the jejunum for simultaneousenteral feeding and gastric drainage. In theory this should providea decreased risk for aspiration; however, published studies havenumerous shortcomings and further study is warranted. Recentimprovements in design and placement of such devices will mostlikely lead to their increased utility. Though techniques forplacement of a wide variety of feeding tubes continue to improve,it is important to determine whether they will improve quality oflife or prolong suffering. This issue is especially relevant in theterminally ill patient.

Resume

En raison de certaines modifications economiques, on a vu,recemment, une augmentation du nombre de patients ayant unealimentation enterale par stomie digestive. Dans les deux derni-eres decennies, malgre le nombre limite d’indications, la gastros-tomie endoscopique par voie percutanee (GEP) est devenue lamethode de reference pour l’acces enteral a long terme. De plus,la gastro-jejunostomie est indiquee chez un certain nombre de

patients ayant besoin d’une jejunostomie d’alimentation et d’unegastostomie de decompression concomitante. Cette revue etudiela securite et l’efficacite de la GEP ainsi que les indications de lagastrostomie chirurgicale. Les complications dues aux tubes uti-lises pour l’alimentation enterale et les strategies pour les eviterou les corriger sont egalement abordees. Les techniques plusrecentes comme la gastrostomie par voie laparoscopique et l’accesau jejunum par l’estomac sont decrites. Les problemes ethiquesposees par l’alimentation enterale dans certaines situations sontegalement exposes.

Resumen

Cambios recientes en los sistemas de salud han llevado a unamayor utilizacion de la enterostomıa para alimentacion. En elcurso de los ultimos dos decenios se establecio la gastrostomıapercutanea endoscopica (GPE) como el metodo estandar deacceso enteral para nutricion a largo plazo, aunque la gastros-tomıa operatoria todavıa tiene indicacion en unas pocas situacio-nes. Por lo demas, el tubo de gastroyeyunostomıa combinada estaindicado en pacientes seleccionados que requieren acceso alyeyuno concomitante con descompresion gastrica. En el presenteinforme se revisan datos pertinentes a la seguridad y eficacia de laGPE, ası como las indicaciones para gastrostomıa operatoria.Tambien se discuten las complicaciones de los tubos para ali-mentacion y las estrategias para prevenirlas y tratarlas. Se revisanotras tecnicas mas recientes, incluyendo la gastrostomıa laparo-scopica y el acceso yeyunal por vıa del estomago, junto con lasconsideraciones eticas pertinentes a la racionalidad de proveernutricion por enterostomıa en determinados pacientes.

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