CHAPTER 10 Enteral Access Procedures
INDICATIONS FOR SURGERY
I. Nutritional Support: Enteral access is required when patients’ oral intake is insufficient to meet their nutritional needs. Nutritional support should be considered if: (1) a patient has been without nutrition for 5 to 7 days; (2) the duration of the condition is expected to exceed 10 days; or (3) the patient is malnourished. Enteral nutritional support is only feasible in patients with sufficient small bowel absorptive capacity. Patients who do not meet this requirement (e.g., patients with short gut syndrome) require parenteral nutrition.
II. Prophylactic Enteral Access: Patients with upper-airway or foregut cancers who undergo extensive surgical resection and adjuvant radiation and chemotherapy often have difficulty maintaining adequate caloric intake during the treatment period. In anticipation of this, many of these patients undergo either gastrostomy or jejunostomy placement at the time of surgical resection.
PREOPERATIVE EVALUATION
I. History: The preoperative history should allow for a determination of the amount of time enteral access will be needed and whether gastric or jejunal feeding is preferable. A history of feeding intolerance should be elicited in patients already being fed through a nasoenteric tube; patients who are not tolerating gastric feeding through a nasogastric tube may be better served by a J-tube (Fig. 10-1).
II. Laboratory Testing: Laboratory testing should include a complete blood count, electrolytes, and coagulation studies. Thrombocytopenia and coagulopathies should be corrected before enteral access procedures.
COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY
Preoperative Considerations
I. Prophylactic antibiotics to cover gram-positive organisms should be given within 1 hour before the procedure.
Positioning and Preparation
I. The patient is placed in the supine position with the arms extended. The head of the bed is elevated.
PEG Tube
I. Placement of a PEG tube is best accomplished by two surgeons, one operating the endoscope and the other positioned next to the patient’s abdomen.
III. Choosing the Gastrostomy Site
A. The ideal site for gastrostomy placement is identified by palpation, transillumination, and needle aspiration. The site is typically two fingerbreadths below the costal margin, just to the left of the midline.
B. Potential sites for tube insertion are palpated with a single finger. The impression of the finger on the stomach wall is noted by the endoscopist. Inability to appreciate this impression suggests interposition of other organs, such as the colon or liver, between the stomach and the abdominal wall (Fig. 10-2).