Many patients are unable to take in food by mouth, esophagus, or stomach. A number of conditions can render a person unable to take in nutrition through the normal pathways. Neurological conditions or injuries, injuries to the mouth or throat, obstructions of the stomach, cancer or ulcerative conditions of the gastrointestinal tract, and certain surgical procedures can make it impossible for a person to receive oral nutrition. Tube feeding is indicated for patients unable to ingest adequate nutrition by mouth, but who may have a cleared passage in the esophagus and stomach, and even partial functioning of gastrointestinal tract. Enteral nutrition procedures that utilize the gastrointestinal tract are preferred over intravenous feeding or parenteral nutrition because they maintain the function of the intestines, provide for immunity to infection, and avoid complications related to intravenous feeding.
Tube enterostomy, a feeding tube placed directly into the intestines or jejunum, is one such enteral procedure. It is used if the need for enteral feeding lasts longer than six weeks, or if it improves the outcomes of drastic surgeries such as removal or resection of the intestines.
There are a variety of enteral nutritional products, liquid feedings with the nutritional quality of solid food. Patients with normal gastrointestinal function can benefit from these products. Other patients must have nutritional counseling, monitoring, and precise nutritional diets developed by a health care professional.
Tube enterostomy provides temporary enteral nutrition to patients with injuries as well as inflammatory, obstructive, and other intestinal, esophageal, and abdominal conditions. Other uses include patients with pediatric abnormalities, and those who have had surgery for cancerous tumors of the gastroesophageal junction (many of these cases are associated with Barrett's epithelium). Intestinal cancers in the United States have declined since the 1950s. However, this endemic form of gastric cancer is one of the most common causes of death from malignant disease, with an estimated 798,000 annual cases worldwide; 21,900 in the United States. As gastric cancer has declined, esophageal cancers have increased, requiring surgeries that resect and reconstruct the passage between the esophagus and intestine.
Tube enterostomy refers to placement via a number of surgical approaches:
- esophagostomy (open surgery via the esophagus)
- stomach (gastrostomy or PEG)
- upper intestines or jejunum (jejunostomy)
The appropriate method depends on the clinical prognosis, anticipated duration of feeding, risk of aspirating or inhaling gastric contents, and patient preference. Whether through a standard operation or with laparascopic surgical techniques, the surgeon fashions a stoma or opening into the esophagus, stomach or intestines, and inserts a tube from the outside through which nutrition will be introduced. These tubes are made of silicone or polyurethane, and contain weighted tips and insertion features that facilitate placement. The surgery is fairly simple to perform, and most patients have good outcomes with stoma placement.
A number of conditions necessitate tube enterostomy for nutritional support. Many are chronic and require a complete medical evaluation including history, physical examination, and extensive imaging tests. Some conditions are critical or acute, and may emerge from injuries or serious inflammatory conditions in which the patient is not systematically prepared for the surgery. In many cases, the patient undergoing this type of surgery has been ill for a period of time. Sometimes the patient is a small child or adult who accidentally swallowed a caustic substance. Some are elderly patients who have obstructive carcinoma of the esophagus or stomach.
Optimal preparation includes an evaluation of the patient's nutritional status, and his or her potential requirement for blood transfusions and antibiotics. Patients who do not have gastrointestinal inflammatory or obstructive conditions are usually required to undergo bowel preparation that flushes the intestines of all material. The bowel preparation reduces the chances of infection.
The patient's acceptance of tube feeding as a substitute for eating is of paramount importance. Health care providers must be sensitive to these problems, and offer early assistance and feedback in the self-care that the tube enterostomy requires.
In preparation for surgery, patients learn that the tube enterostomy will be an artificial orifice placed outside the abdomen through which they will deliver their nutritional support. Patients are taught how to care for the stoma, cleaning and making sure it functions optimally. In addition, patients are prepared for the loss of the function of eating and its place in their lives. They must be made aware that their physical body will be altered, and that this may have social implications and affect their intimate activities.
Tube enterostomy requires monitoring the patient for infection or bleeding, and educating him or her on the proper use of the enterostomy. According to the type
Tube enterostomies are not considered high risk surgeries. Insertions have been completed in over 90% of attempts. Possible complications include diarrhea, skin irritation due to leakage around the stoma, and difficulties with tube placement.
Tube enterostomy is becoming more frequent due to great advances in minimally invasive techniques and new materials used for stoma construction. However, one recent radiograph study of 289 patients who had jejunostomy found that 14% of patients suffered one or more complications, 19% had problems related to the location or function of the tube, and 9% developed thickened small-bowel folds.
Morbidity and mortality rates
Some feeding or tube stomas have the likelihood of complications. A review of 1,000 patients indicated that PEG tube placement has mortality in 0.5%, with major complications (stomal leakage, peritonitis [infection in the abdomen], traumatized tissue of the abdominal wall, and gastric [stomach] hemorrhage) in 1% of cases. Wound infection, leaks, tube movement or migration, and fever occurred in 8% of patients. In a review of seven published studies, researchers found that a single intravenous dose of a broad-spectrum antibiotic was very effective in reducing infections with the stoma. Open surgery always carries with it a small percentage of cardiac complications, blood clots, and infections. Many gastric stoma patients have complicated diseases that increase the likelihood of surgical complications.
Oral routes are always the preferred method of providing nutritional intake. Intravenous fluid intake can be used as an eating substitute, but only for a short period of time. It is the preferred alternative when adequate protein and calories cannot be provided by oral or other enteral routes, or when the gastrointestinal system is not functioning.
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American Society Parenteral and Enteral Nutrition. 8630 Fenton St., Suite 412, Silver Springs, Maryland 20910. (301) 587-6315. Fax: (301) 587-2365. <www.clinnutr.org>.
United Ostomy Association, Inc. 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. <www.uoa.org>.
Tube Feeding. Patient Handout, MDConsult, <www.MDConsult.com>.
Nancy McKenzie, Ph.D.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Gastrointestinal surgeons and surgical oncologists perform this surgery in general hospital settings.