Short-Term Surgical Pre- and Postpyloric Tubes

Introduction

V. Short-Term Surgical Pre- and Postpyloric Tubes

A. Gastrostomy. If a patient is already undergoing laparotomy, a gastrostomy or jejunostomy tube can easily be placed even for short- term use. For example, someone undergoing a partial gastrectomy may have a gastrostomy and jejunostomy tube placed. The gastrostomy would initially be used for decompression; the jejunostomy would be used for immediate postoperative feedings. See Section VI.A.3.

B. Jejunostomy (standard). See above and Section VII.A.3.

C. NCJ These are small-caliber jejunal tubes that can be easily placed at surgery. Older models were 5F, which predisposed them to clogging. Newer versions are 7F or 8F, which allows administration of enteral formulations with extra protein or fiber.

1. Pros. These are easily placed, with a low risk of enteric leak if inadvertently dislodged.

2. Cons. They require diligent nursing care because they are easily occluded. Infusion pumps are required for administration of enteral formulations. Medications can rarely be infused through NCJs.

3. Complications (Table 3-2)

D. Surgical nasoenteric. Some surgeons provide short-term enteral access postoperatively by manually guiding a nasoenteric tube through the stomach, then through the duodenum, and into the small bowel during laparotomy. The frequency and success of this practice are not known.

VI. Long-Term Prepyloric Tubes.

Gastrostomy. Although surgical gastrostomy has been performed for over 150 years, technical advances and procedural improvements have made PEG a preferred method of gastrostomy placement if the patient is not undergoing laparotomy for another reason.¹⁶Gastrostomies can also be placed radiologically or laparoscopically. There are no significant differences Nasal mucosal ulceration Gastrointestinal bleeding

Clogging Epistaxis

Esophageal perforation Otitis media

Pneumothorax Pulmonary aspiration

Pulmonary intubation Pyriform sinus perforation Adapted with permission from Kirby DF, DeLegge MH. Enteral nutrition: the challenge of access. In: Kirby DF, Dudrick SJ, eds. Practical Handbook of Nutrition in Clinical Practice. Boca Raton, FL: CRC Press; 1994:87–117.

Table 3-1. Potential Complications of Nasogastric and Nasoenteric Tubes

Pneumatosis intestinalis Bowel obstruction

Bleeding Tube occlusion

Dislodgment Stomal leakage

Tube deterioration Wound infection Volvulus

Adapted with permission from Kirby DF, DeLegge MH. Enteral nutrition: the challenge of access. In: Kirby DF, Dudrick SJ, eds. Practical Handbook of Nutrition in Clinical Practice. Boca Raton, FL: CRC Press; 1994:87–117.

Table 3-2. Potential Complications of Jejunostomy (All Methods)

S E C T I O N I Fundamentals of Nutrition Support Practice and Management

in complication rates among the different methods of gastrostomy insertion; however, nonoperative access is less costly.¹⁷Local expertise is an important deciding factor for determining how a gastrostomy is placed.

A. Gastrostomy insertion methods.

1. PEG. Prior to an attempt to place a PEG, a screening upper endoscopy is performed to make sure that there are no contraindications to the procedure such as a large ulcer (higher risk of ulcer perforation) or a gastric or duodenal mass or obstruction.

Conscious sedation is usually sufficient to perform the procedure, but occasionally deep sedation with propofol or even general anesthesia may be required.

After the initial endoscopy, the patient is placed supine and an area of transillumination in the left upper quadrant is identi- fied. When a proposed site is located, palpation with a finger is used to indent the insufflated stomach. The site is then prepped with iodine swabs and infiltrated with 1% lidocaine solution. A 1-cm skin incision is made, and a catheter is placed through the incision into the stomach. A suture or guidewire is placed through the catheter and grasped with a snare. The endoscope, snare, and suture are removed from the patient. The PEG tube is tied onto the suture coming from the mouth and then pulled through the mouth, esophagus, and stomach to reach the anterior abdominal wall. The endoscope is reinserted and the intra- gastric position of the PEG bumper is visualized. The endoscope is removed from the patient, and the external bumper and a feeding adapter are placed.

Kits are commercially available with tube sizes from 14F to 28F. Adults commonly have 20F tubes placed. Larger tubes may be required to insert a smaller feeding tube into the small intestine if small bowel feedings are desired. Infants and children often have 14F tubes placed, but later 18F to 20F tubes are necessary to facilitate flow rates commensurate with growth.

2. Radiologic. Gastrostomy tubes may be placed with radiologic guidance, which avoids passage of the endoscope through a bacteria-laden oral cavity. This reduces the risk of contamination of the subcutaneous tissues and avoids general anesthesia that may be required for surgical placement. In patients with head and neck cancer, there is a very small but real risk of causing PEG stoma site metastases when pulling a tube through the oropharynx.

This risk can be obviated by doing the procedure radiologically or endoscopically by the introducer technique.^18,19Fluoroscopy is the most commonly used imaging modality; however, ultra- sonography or computed tomography can provide additional information about intra-abdominal structures that may be over- lying the stomach or provide a safe tract when endoscopic transillumination fails. The size of feeding tubes varies from 10F to 28F. The two most common complications associated with radiologic placement are tube clogging and displacement; these complications often lead to catheter replacement. If stabilizing sutures are used, larger tubes with a lower rate of dislodgment or clogging can be inserted.

3. Surgical. Most operative gastrostomies are performed under general anesthesia in an operating room, but doing so can escalate costs. Surgical gastrostomies have been performed under conscious sedation. Operative gastrostomies are very cost-effective when done during another intra-abdominal procedure. An operative alternative to laparotomy is laparoscopic insertion.²⁰

Surgical placement in pediatric patients is most commonly achieved with a Stamm gastrostomy procedure. This is technically

a temporary gastrostomy because the tract closes spontaneously after the tube is removed. A gastropexy is performed in which the stomach is sutured to the abdominal wall. Once postproce- dure healing is complete, a reliable, established tract for replac- ing tubes exists. Gastrostomy tube placement itself may alter the contour of the stomach enough to cause some gastroesophageal reflux. Children with documented gastroesophageal reflux or gastric aspiration may need a fundoplication procedure performed with the surgical gastrostomy, which may obviate the need for postpyloric feedings. A pyloroplasty may be performed also if delayed gastric emptying has been documented.

B. Pros. These tubes allow long-term access and are easily cared for and replaceable. Bolus feeding and administration of medication are possible because of the large caliber of the tube.

C. Cons. Compared with the oral or nasal route, this technique is more invasive.

D. Complications (Table 3-3)

VII. Long-Term Postpyloric Tubes. Jejunostomy.

As with gastrostomy, many methods of jejunostomy insertion are now possible, including operative, percutaneous endoscopic, radiologic, and laparoscopic placement. Indications for jejunal access include reflux esophagitis, gastric aspiration, gastroparesis, insufficient stomach rem- nant because of previous resection, and establishment of access for postoperative feeding after major surgical procedures and of feeding access in patients who have unresectable gastric or pancreatic cancers. During urgent abdominal surgery, jejunostomy placement to facilitate early postoperative feeding should be considered.

A. Methods of insertion^21–23

1. Percutaneous gastrojejunostomy—also called a JET-PEG or jejunal extension through a PEG. This jejunal feeding tube is a small 9F to 12F tube that is dragged or passed over a guidewire into the small bowel through a previously placed PEG. Initial versions of this tube were unsatisfactory in their design, were difficult to place past the proximal duodenum, and often migrated back into the stomach. Devices now available are easier to place in the distal duodenum or jejunum and are more reliable because the like- lihood of migration is greatly decreased. To decrease the inci- dence of TFRA, the feeding port must be located in the distal duodenum or jejunum. Although placement of a primary Per- cutaneous Endoscopic Jejunostomy (PEJ) tube (tube placed with the PEG technique directly into the small intestine) as the initial procedure is not as common as the PEG procedure, it is becom- ing more widely practiced. It has been performed in patients with normal anatomy and in those who have had gastric resection.^24–27 There are also commercially available dual-lumen tubes that have both a gastric and a jejunal port. These are usually placed

Aspiration Bleeding Tube occlusion

Dislodgment Pneumoperitoneum Stomal leakage Tube deterioration Wound infection

Table 3-3. Potential Complications of Gastrostomy (All Methods)

S E C T I O N I Fundamentals of Nutrition Support Practice and Management

through mature gastrostomy tracts and can be placed radiologically or endoscopically. The fact that the internal retention device is a balloon often limits these devices’ use. When the balloon fails (usually within 3 months), the entire tube must be replaced.

These tubes are too large to be used in infants and small pediatric patients.

2. Radiologic jejunostomy. Radiologists can insert a small feeding tube through the stomach and fluoroscopically guide it through the pylorus to the duodenojejunal flexure. This provides small- bowel feeding with a reduced risk of TFRA, but because smaller catheters (10F) are placed by this technique, a higher obstruction rate is expected. One series retrospectively compared surgical gastrostomy with radiologic percutaneous jejunostomy transgastric, in which ultrasound and fluoroscopy were used to insert a feeding tube through the stomach wall and then a 10F catheter was passed to the duodenojejunal junction.²⁸Complications were fewer in the nonsurgical jejunostomy group, despite the fact that the stomach wall was not fixed to the anterior abdominal wall. However, radiologic techniques do not allow for placement of feeding tubes of sufficient size to provide both gastric and small-bowel access.

Some centers are now performing dual-lumen gastrojejunos- tomies. The gastric port is 16F with a 10F jejunal port. While this may allow for decompression of the stomach or medication administration and feeding into the jejunum, the tube sizes may be associated with a higher rate of occlusion. More long-term data are needed. Direct percutaneous access to the jejunum has been performed under radiologic control; however, this is technically more difficult.

3. Open surgery. Surgical placement of jejunostomy tubes has been performed for over 100 years. A variety of techniques are available, including Witzel jejunostomy (probably the most common), Roux—en-Y jejunostomy, serosal tunnel jejunostomy, button jejunostomy, and laparoscopic jejunostomy.^29,30Numerous tubes have been used, including red rubber catheters, biliary T tubes, and dialysis catheters. Surgical gastrojejunostomy tubes, which allow gastric decompression or medication administration in addition to jejunal feeding, are also available. The common belief that only elemental diets should be given through jejunostomy tubes has been shown to be untrue.³¹Standard polymeric diets containing fiber can be used; however, the catheter must be flushed routinely to maintain tube patency.

B. Pros. These tubes decrease the risk of TFRA. Early postoperative feeding is possible in most patients except those who are hemo- dynamically unstable, have peritonitis, or have a bowel obstruction.

C. Cons. An infusion pump is required. Administration of medication is precluded in some instances but is dependent on the size of the T-tube. Invasive procedures are required for access. Outside con- nectors are prone to break and may require replacement of the entire T-tube. The tubes are difficult if not impossible to replace unless a mature tract has developed.

D. Complications: similar to PEG (Table 3-2)

VIII. Selection of Access Device Features.

When a par- ticular enteral access device is being selected, the tube’s composition, intended use, estimated length of time required, cost-effectiveness, and features (eg, stylet, weighted tip, length of tube) should be considered.

A. Tube composition

1. In the presence of gastric secretions, polyvinyl chloride tubes harden and become brittle with time, which may cause tissue irritation or necrosis. Thus, these tubes should be used only for short

periods for gastric drainage, decompression, lavage, or diagnostic procedures.³²

2. Polyurethane or silicone tubes are better for long-term use because they are more flexible and less irritating to tissue. Most small-bowel feeding tubes are made of polyurethane or silicone.

Polyurethane tubes may have improved longevity, but this concept needs further investigation.³³Silicone tubes are flexible and may collapse when assessing gastric residuals. Fungal coloniza- tion has been associated with silicone rubber PEG tubes and may contribute to tube failure over time.³⁴

3. Latex tubes are still available but should not be used in patients who are allergic to or at high risk of developing an allergy to latex.

In addition, latex tubes need to be replaced more frequently because of susceptibility to degradation by microbes and gastric acid.

4. Red rubber catheters are soft and pliable, which makes them easy to place at the time of surgery. Although the tubes are generally large enough to infuse enteral formulations and medications, they are subject to gastric acid degradation and are used mostly for gastric gavage feeding or jejunostomies. If long-term feeding is required, another feeding tube material should be considered after the short-term problem has been addressed.

B. Weighted versus nonweighted. It is commonly believed that weighted tubes are easier to pass into the small bowel when they are being placed blindly; however, nonweighted tubes have actually been shown to pass at a higher rate.³⁵In theory, weight may help keep the tube in place, but this concept has not been proven.

C. Use of a stylet. A stylet may facilitate passage of a small, very pliable tube. Reinsertion of the stylet after removal is not recommended because it may pass through the wall of the tube and perforate the gastrointestinal tract. Stylets may need to be lubricated before the tube is used. Obtain information about any product before using it, espe- cially for the first time; do not assume that all tubes are alike.

D. Tube length. The length of a nasoenteric tube may influence its ability to pass the duodenojejunal junction. In adults, tubes longer than 105 cm are preferred if passage past the ligament of Treitz is desired.¹¹

E. Low-profile device (LPD) versus standard gastrostomy

1. LPDs are cosmetically appealing to patients and may decrease the possibility of pyloric obstruction from inward migration of the feeding tube. LPDs are composed of an internal stabilizer, a shaft, an external stabilizer, a connecting tube, and an antireflux valve to keep gastric contents from leaking onto the skin. It is important to choose the appropriate shaft length. If the shaft is too short, the patient may develop pressure necrosis of the skin or the internal stabilizer may become embedded in the wall of the stomach. If the adult patient gains or loses 10 pounds, the shaft length should be reevaluated.³⁶In infants and children, the size must be reevaluated routinely and the shaft replaced to accommodate growth. One design allows the physician to customize the shaft length, as the tube resembles a standard PEG tube. The shaft length is deter- mined and then a valve-and-collar assembly is put into place. This obviates the need for multiple LPDs with various shaft lengths in inventory.

2. Initial placement of an LPD should be performed by a physician. Contraindications to switching to an LPD are gastrostomies placed by the Witzel and Janeway surgical techniques or patients who require gastric decompression. LPDs may not be a good choice for patients with tracheostomies, neurology patients with spastic posturing, or other patients with increased abdominal pressure. In these patients, forceful coughing or movement can

S E C T I O N I Fundamentals of Nutrition Support Practice and Management

damage or expel the device or cause leakage of gastric contents and lead to maceration of the abdominal wall.^37,38

IX. Care of Feeding Tubes.

Feeding tubes require regular assessment and monitoring to ensure continued correct placement and to avoid complications such as skin breakdown or infection.

When problems arise, early intervention is key to maintaining enteral access. This section reviews significant care issues for each type of feeding tube, with special emphasis on routine tube care, skin care, and replacement.

A. Oro- or nasogastric and oro- or nasoenteric tubes. Care of orally or nasally inserted tubes requires vigilance in checking placement, protecting the mucosal surfaces, and flushing routinely.

1. Checking placement. Placement of the tube should be checked every 8 hours during continuous feedings and before each intermittent feeding. Verification methods include x-ray, marking the tube where it exits the patient and measuring it, checking the pH of the aspirate, observing the color of the aspirate, and ausculta- tion.³⁹Any time tube misplacement or displacement is suspected, a roentgenogram should be taken.

2. Protecting the mucosal surfaces.⁴⁰ Mucosal irritation of the nasopharynx may occur anywhere along the path of the feeding tube.

a) Inspect the nares, mouth, and pharynx daily for skin irritation, ulceration, pressure necrosis, and lesions.

b) Clean the nares daily with warm water or saline and keep mucous membranes moist with petroleum jelly. If the nares are crusty, clean them with dilute hydrogen peroxide and then moisturize.

c) Change the fixator device or tape on the nose or mouth as needed if loose or soiled and at least every 3 to 5 days. In- correct taping can lead to pressure necrosis.

d) Maintain good oral hygiene. Even when patients are not eat- ing, their teeth should be brushed at least twice a day. If gum inflammation is present, the patient may benefit from an oral antiseptic rinse (eg chlorhexidene gluconate). Tube-fed patients receiving antibiotics may benefit from an oral antifungal formulation (eg, nystatin 500, 000 units applied to the oral cavity 4 times a day) to help prevent overgrowth of fungus.

3. Flushing routinely. Tubes should be flushed with water every 6 hours during continuous feeds, between and after medications, after intermittent feeds, after residuals are checked, and if feeds need to be turned off for more than 4 to 6 hours.

In children, the flushing volume should be scaled down to the size of the child.

4. Replacement. Orally or nasally placed tubes should be replaced only when necessary (eg, tube occlusion, problems at the insertion site). Any time a tube is replaced, placement should be ver- ified (see Section III.A.3). Some parents/caregivers learn to place and remove their infant’s or child’s orogastric or nasogastric feeding tube and do so routinely at home. The American Academy of Pediatrics recommends that NGTs be changed from one nostril to the other every 1 to 3 weeks to decrease sinus and ear infections.

B. Gastrostomy and jejunostomy tubes. The care of these tubes in- cludes maintaining patency, protecting the skin at the exit site, and preserving proper placement and integrity of the tube.^37,40–42 1. Checking placement

a) For traditional gastrostomy and jejunostomy tubes, measure the length of the tube protruding from the abdomen and docu-

ment the external length in the medical record daily. If no external markings are on the tube, an indelible mark can be made on the tube and used to monitor position.³⁴Gastrostomy tubes with internal bumpers should be pushed in several cen- timeters and the tube rotated 360°. In pediatric patients, the tube is rotated 360°but not pushed in. If this is not possible, a buried bumper may be developing, and the patient will need to be referred to an experienced health care provider for further care and ultimate replacement.^1,43

b) LPDs should also be monitored daily. The tube should have some movement (ie, you should be able to slide the tube in and out about 0.5 inch). An LPD should be gently pushed in approximately 0.5 inch and rotated 360°daily to prevent the balloon or internal bumper from adhering to the gastric wall.

For infants and small children, the LPD should be pushed in approximately one-eighth inch and rotated.

2. Care of exit site and tube

a) Exit site assessment. Check for erythema (initially, a small amount of serosanguineous drainage can be expected), edema, warmth, and exudate. Foul-smelling drainage is a sign of infection. Also monitor for skin breakdown, pressure necrosis, hypergranulation (keep site dry), gastric leakage (identify the cause; do not just try to repair), displacement (tube movement

>1 inch for adults and >0.25 inches for infants and small children), and enlargement of the stoma tract (stabilize tube; avoid excessive tube movement.

b) Skin care. When the tube tract is new and has drainage or crust- ing, clean the exit site with diluted hydrogen peroxide. After the tract is healed, clean the site daily with soap and water. Clean carefully under external bumpers or disks to keep dry and clean and to check for excessive pressure. External bumpers and disks should be just above skin level and not taut against the skin.

c) Dressings. Dressings are commonly used for 48 hours after initial placement when the tract is considered an open wound, when the tract is soiled, or when the patient is at high risk for inadvertent tube removal.

3. Tube stabilization. Stabilizing a tube can reduce the risk of tube displacement, pain, and enlargement of the tract.

a) Sutures or T- fasteners may be present to secure gastrostomy or jejunostomy tubes. If a gastrostomy tube has anchoring sutures or T- fasteners, check with the physician about possible removal when the tract is healed. Most jejunostomy tubes require a secure suture at all times.

b) Anchoring devices can secure the tube and protect the skin from the effects of frequent dressing changes.^44,45Anchoring devices typically last twice as long as tape. Examples of anchoring devices are Hollister Drain/ Tube Attachment Device (Hol- lister, Libertyville, IL), Cath-Secure (MC Johnson, Naples, FL), and Flexi-Trak (ConvaTec, Skillman, NJ). If adhesive tube holders are used, the exit site must be cleaned around the tube daily and as needed to prevent accumulation of tissue debris.

c) If the tube has a balloon, check the water in the balloon at least once a week.

d) Patients with enteral devices or tubes may shower or bathe according to the directions of their health care provider.

If a bumper or disk is present, the skin underneath it should be dried carefully to prevent maceration from trapped moisture.^36,37

4. Irrigation (see Section IX.A.3) 5. Replacement of gastrostomy tubes

Dalam dokumen The A.S.P.E.N. Nutrition Support Practice Manual, 2nd Edition (Halaman 76-80)