Choice between Gastrostomy and Jejunostomy

Ri

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 Comparable to PEG, but is more expensive and requires more recovery time

Surgical gastrostomy

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 Elevation of head Reduce feeding rate and volume More hydrolyzed or lower osmolarity formula

Gastroesophageal reflex and aspiration

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) 32:639649

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.