Gastroenterology

Gastroenterology

Volume 141, Issue 2, August 2011, Pages 742-765
Gastroenterology

AGA
Multidisciplinary Practical Guidelines for Gastrointestinal Access for Enteral Nutrition and Decompression From the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, With Endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE)

https://doi.org/10.1053/j.gastro.2011.06.001Get rights and content

Introduction

Tube feeding has been practiced for more than 400 years.1 In addition to feeding, gastrointestinal (GI) access can be used for decompression in cases of enteral obstruction.

Temporary access can be achieved with a nasogastric (NG), oral gastric (OG), nasojejunal (NJ), or oral jejunal (OJ) feeding tube. These tubes can be placed “blindly” at the bedside, with the use of image guidance (eg, fluoroscopy, ultrasound), or with the use of endoscopic guidance. Unfortunately, natural orifice tubes often fail because of clogging as a result of their relatively small diameter or inadvertent dislodgement.2 More permanent enteral access can be obtained surgically (open or laparoscopic) or percutaneously with endoscopic or image guidance, resulting in a gastrostomy, a jejunostomy, or a combination gastrojejunostomy. Although the indications for these enteral access devices are often similar, there are specific situations in which a particular enteral access tube may be more appropriate. More recently, the placement of a tube into the cecum (ie, cecostomy) has been described for GI decompression and as a treatment of fecal incontinence and constipation.3

This document was written to be used as a practical guideline for the health care providers involved in creating and maintaining percutaneous gastroenteric access in adult patents, and covers the following topics: (i) patient selection, (ii) preprocedure evaluation, (iii) technical aspects of the procedures, and (iv) maintenance of the access. Quality assurance outcome measures for these processes, such as indications, success rates, and complication rates, are reported in this document.

Section snippets

Definitions

Gastroenteric access is the establishment of an artificial access into the GI tract to provide feeding and decompression. This communication to the GI tract can be percutaneous or through natural orifices.

An NG/NJ tube is a flexible synthetic tube that is inserted into the stomach/jejunum through the nostril to provide feeding and/or decompression.

Orogastric/Orojejunal tube is a flexible synthetic tube that is inserted into the stomach/jejunum through the mouth to provide feeding and/or

Oral or Nasal Enteric Tubes

NG, OG, NJ, or OJ tubes are generally recommended for short-term use (ie, from a few days to 6 weeks). This can be for gastric or small bowel feeding or gastric decompression.

In general, patients who have facial trauma, nasal injury, or abnormal nasal anatomy that precludes nasal access are candidates for oroenteric tubes.4 There have been published data that indicate that patients with nasal airway intubation have more episodes of sinusitis than patients with oral airway intubation.5 From this

Absolute Contraindications

Absolute contraindications to tube placement include mechanical obstruction of the GI tract (unless the procedure is indicated for decompression), active peritonitis, uncorrectable coagulopathy, or bowel ischemia.

Relative Contraindications

A number of other conditions represent relative contraindications to enteral access, such as recent GI bleeding, hemodynamic instability, ascites, respiratory compromise, and certain anatomic alterations. Recent GI bleeding from peptic ulcer disease with a visible vessel or from

Management of Anticoagulant and Antiplatelet Therapy

Recently, the American Society for Gastrointestinal Endoscopy (ASGE) and Society of Interventional Radiology (SIR) issued recommendations regarding the management of patients receiving anticoagulant or antiplatelet therapy and patients with coagulopathy.28, 29 Similar in essence, these recommendations are different in their approach. For that reason, both sets of recommendations are included here.

ASGE Recommendations

According to the ASGE recommendations,30 the risk from bleeding related to the procedure itself

Technical Aspects

Since its original description in 1980, multiple variations of the percutaneous enteric access technique using different guidance modalities (eg, endoscopic, fluoroscopic and US) have been published. However, regardless of the guidance method, the main difference between the percutaneous techniques is the route by which the feeding/decompression tube is introduced into the intestinal tract: through the abdominal wall or through the natural orifices. At the beginning, the guidance modality was

Gastric Bypass

Excessive weight loss postoperatively in patients with gastric bypass and Roux-en-Y anastomosis may necessitate enteral feeding. However, the stomach may not be accessible by routine endoscopy. Several options for tube placement in this situation are possible. First, percutaneous gastrostomy may be performed at the time of the original bypass surgery.131 Although this is certainly not required in the vast majority of patients, placement of a gastrostomy tube at the time of surgery in patients

Tube Dressing and Positioning

The gastrostomy site should be cleaned with mild soap and water; hydrogen peroxide should not be used after the first week after placement as it can irritate the skin and contribute to stomal leaks. Cut drain sponges should be placed over rather than under the external bumper, so as not to apply excessive tension to the gastrostomy site. Occlusive dressings should not be used, as they can lead to peristomal skin maceration and breakdown. Should excessive granulation tissue develop at the

Gastrostomy

Overall complication rates (major and minor) are similar for endoscopy-guided and image-guided gastrostomies, and range from 0.4% to 22.5% and from 13% to 43%, respectively (Table 4).106, 136, 171, 172 Procedure-related mortality rates are very low, ranging from 0% to 2%.173 Thirty-day mortality rates vary from 6.7% to 26%, and mortality is related to the underlying comorbidities of this debilitated population.174, 175, 176, 177 It should be noted that the incidence of mortality associated with

Ethical Issues

Medical ethics as applied to achievement of enteral access and provision of artificial specialized nutritional therapy follows five basic principles.234 Autonomy refers to self-autonomy, justice, beneficence, nonmaleficence, and futility. The direct application of these principles means that a competent adult has the right to decide for him- or herself whether a feeding tube is placed and feedings are started. No tubes should be placed without informed and educated consent. Patient autonomy

Conclusions

Gastroenteric access is an integral part of the patient care provided by a variety of health care professionals. Transabdominal and natural-orifice approaches have been proven to be successful and safe under endoscopic or image guidance.

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      Gastrostomy creation is the most common intervention for long-term enteral access to facilitate a bolus feeding regimen.9 A gastrostomy can also be used for multiple reasons other than nutrition, including retrograde intestinal access to the biliary system for facilitation of ERCP in surgically altered anatomy or other procedures.9,20 Gastrostomy has evolved from an open surgical technique with high mortality to varying methodologies including endoscopic, fluoroscopic, and laparoscopic or open surgical methods.21

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    Conflicts of interest M.H.D. is a paid consultant for Cook Medical (Bloomington, Indiana). S.A.M. is a consultant for Kimberly Clark, Covidien, Nestle, and Abbott and is a recipient of research funds from Nestle and ACM Technologies. None of the other authors have identified a conflict of interest.

    This article is being published concurrently in the Journal of Vascular and Interventional Radiology 22(8), 2011. The articles are identical except for minor stylistic differences in keeping with each journal's style. Either citation can be used when citing this article. Permission to reproduce this article can only be granted by the copyright holder, the Society of Interventional Radiology. To request permission to print this article in a journal, Web site, or other publication, please contact the SIR at [email protected].

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