The ability to provide nutritional support to patients who are unable to maintain their own oral intake has dramatically improved surgical outcomes. Nutritional support should be considered for patients who have been NPO for several days, patients whose oral intake is insufficient to meet all of their caloric demands, and patients who are severely malnourished and require surgery.

Nutritional supplementation can be provided via the parenteral (intravenous) or enteral route. Unless specific contraindications exist, enteral nutrition is always preferable for several reasons: (1) enteral feeding is associated with lower rates of infectious complications; (2) enteral feeding does not induce liver dysfunction such as can be seen with parenteral nutrition; (3) enteral feeding prevents atrophy of the absorptive surface of the small bowel; (4) enteral feeding can be initiated immediately with nasogastric tube placement whereas parenteral nutrition requires central venous access and a patient-specific formulation; and (5) enteral nutrition is significantly less costly and labor intensive than parenteral nutrition.

There are several options for enteral access, beginning with the basic nasogastric tube. This is a good choice for patients requiring a short period of enteral nutrition. However, standard nasogastric tubes are made of a firm plastic that can cause pressure-induced necrosis of the nasal septum or alae. If nutritional support greater than a few days is anticipated, a smaller bore, softer tube should be substituted instead. Proper placement in the stomach should be confirmed prior to initiation of tube feeds with either aspiration of gastric contents or a chest X-ray.

Long-term enteral access options include endoscopic or surgical gastrostomy tubes. A percutaneous endoscopic gastrostomy tube (PEG) is the first choice, since it can be accomplished with sedation and local anesthesia, whereas a surgical gastrostomy tube (G-tube) requires general anesthesia. PEG placement is performed by passing a needle through the skin of the abdominal wall directly into the stomach, as visualized by endoscopy. Through a series of steps, this needle is exchanged for a guide wire, which is then attached to the PEG tube. The tube is pulled through the mouth, into the stomach, out the skin, and is anchored into place with a bumper on the gastric aspect (Fig. 13.1).

However, PEG tubes are not suitable for every patient. For example, endoscopic access to the stomach is not possible in patients with an obstructing pharyngeal or esophageal tumor. PEG placement may also not be possible in individuals with extensive prior abdominal surgery because adhesions may interfere with the ability to move the stomach into appropriate position. Proper PEG placement requires that the stomach be brought into direct contact with the anterior abdominal wall at a level below the costal margin. Failure to transilluminate the abdominal wall with the light from the endoscope suggests that other organs may be in the way. In patients who are not candidates for PEG placement, a surgical gastrostomy can be considered.

Aside from providing enteral access for nutrition, gastrostomy tubes can also be used for decompression of the stomach. For example, patients with carcinomatosis may develop intractable bowel obstruction as a result of extensive tumor deposits. A palliative gastrostomy tube allows for gastric decompression and is more comfortable than a long-term nasogastric tube.

A jejunostomy tube (J-tube) provides an alternate route for enteral access that may be more appropriate in certain situations. For example, some patients experience significant esophageal reflux and/or recurrent aspiration with gastric feeding. Jejunal access eliminates this problem by delivering the feeds distal to the pylorus. The downside of jejunostomy tubes is that they typically require surgical placement. Although endoscopic placement of a jejunostomy tube is possible, it is a technically demanding procedure only performed at select centers.