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 only absolute
  contraindication to enteral feeding.

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Methods of Feeding
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Complications of Tube Feeding

• Infection
• Aspiration
• Diarrhea
• Alterations in drug absorption and metabolism
• 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 but is more
  expensive and requires more recovery time.

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Percutaneous endoscopic gastrostomy (PEG)
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Jejunostomy

• Percutaneous endoscopic jejunostomy (PEJ)
• Extension through an existing gastrostomy 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 Be Used?

• Requires prolonged tube feeding (gt30 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

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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

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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 osmolarity formula

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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, 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

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• 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)
  32639649

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Disadavntages of Jejunostomy

• Difficulty with placement and ease of
  displacement
• Feeding tolerance
• Dumping syndrome
• Slow feeding rate
• Change in formula

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Long-term use of gastrostomy 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 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.