are two main advantages to a surgically placed G‐tube compared to a PEG procedure. First, a mature tract forms in 4 weeks with a laparoscopic procedure compared to 6–12 weeks with a PEG procedure. Second, a surgically placed G‐tube provides direct visualization of the anatomy, whereas, with an endoscopically placed G‐tube, there is always the risk of a bowel perforation if a portion of bowel is caught between the abdominal wall and the gastric wall during G‐tube placement.
Low‐Profile G‐Tube
Low‐profile G‐tubes have a port that sits flush with the skin surface (Figure 1.1c). They are more easily hidden than the standard G‐tubes simply by the nature of their size, and patients tend to prefer them for this reason. In addition, the smooth surface of a G‐tube port site without tubing is less prone to accidental dislodgement compared to standard G‐tubes. However, there are drawbacks to a low‐profile tube. First, external tubing has to be attached in order to deliver a feed, which creates one additional step and an additional piece of equipment that can malfunction. Second, low‐profile tubes cannot be adjusted to accommodate increased abdominal wall thickness and must be replaced with a tube that has a longer shaft length when there are signs of abdominal wall compression.
Although they were not designed to be placed primarily, low‐profile G‐tubes can be placed laparoscopically. In pediatric surgical practice, the laparoscopic primary G‐button gastrostomy is now widely performed. In this approach, one trocar is placed through the umbilicus and another through a small incision in the left upper quadrant. A stitch is placed in the anterior wall of the stomach and passed through the trocar in the left upper quadrant. Once the suture material is outside the abdomen, the trocar is removed and the anterior wall is pulled through the initial trocar site. The stomach and abdominal walls are sutured together. The gastrostomy is made in the portion of stomach wall that is exposed. The appropriate button is then placed in the gastrostomy and sutured in place. Similar to a surgically placed standard G‐tube, a low‐profile G‐tube tract matures in four weeks.
Jejunal Tubes
NJ, gastro‐jejunal (GJ), and J‐tubes are ideal for patients with gastric dysmotility, severe gastroesophageal reflux, recurrent emesis, and those at risk for pulmonary aspiration. The jejunum is fed continuously and at a lower rate compared to bolus feeds given through a G‐tube. Whereas the NJ and J‐tubes provide direct access to the jejunum, GJ tubes are a hybrid with both gastric and jejunal ports. The gastric port is used for medications or venting the stomach, while the jejunal port is used for continuous enteral nutrition. J‐tubes are secured to the abdominal wall with an internal retention device in the jejunum, while GJ tubes have an internal retention device within the gastric cavity and a jejunal extension that passes through the G‐tube and bypasses the stomach. Jejunal extensions carry the added risk of tube migration, volvulus around the extension tubing, and higher rates of tube clogging secondary to smaller tube size. Percutaneous J‐tubes are rarely used because of the thinness of the jejunal wall and increased risk of complications.
NJ and GJ tube placement requires fluoroscopic or endoscopic guidance for placement. Percutaneous J‐tubes are placed surgically.
Indications
Enteral feeding devices are indicated when a patient has a functional GI tract but cannot safely or adequately feed by mouth. This includes patients with a swallowing dysfunction or neurologic disorder. Similarly, patients on a ventilator or those with severe reflux require enteral feeding to prevent aspiration. Finally, patients with inadequate nutrition or in a hypermetabolic state (i.e. cardiac disease, renal disease, or pulmonary disease) may not be able to meet their nutritional demands with oral feeding alone and require enteral feeding as supplementation. The indication for enteral nutrition and duration of feeding needed determine the type of tube recommended. Contraindications specific to each feeding device are listed in Table 1.2.
Management
Routine Care
Enteral feeding devices require daily care to ensure the tube is patent and to protect the surrounding skin from irritation. All feeding devices need to be flushed with room temperature water following each feed or medication administration to prevent clogging. The tubes should also be monitored for tube deterioration that indicates the tube needs to be changed: discoloration, foul smell, and tube deformity. NG and OG tubes need to be monitored for pressure necrosis at the point of insertion and retaped as needed. Similarly, G‐tubes and GJ tubes can cause pressure ulcers if the tissue between the internal and external retention devices is compressed too tightly. Standard G‐tubes should be turned regularly and evaluated to ensure the external retention device sits 1–2 mm above the skin surface without creating a dimple in the skin. Finally, internal balloon retention devices should be checked regularly to confirm the appropriate amount of fluid is in the balloon to prevent tube dislodgement.
Routine Replacement
Temporary Tubes
NG and OG tubes can be placed and replaced by home nursing or properly trained family members (Table 1.3). NG/OG tubes should be replaced approximately every 7–10 days. Properly sizing the tubing is necessary prior to placement. When choosing a tube size, most feedings can be given with a 6 or 8 Fr tube in pediatric patients and a 12–14 Fr tube in adult patients. Appropriate tube insertion depth is classically measured by taking the feeding tube and measuring from the tip of the nose to the ear lobe and finally to the xyphoid. Several pediatric studies have found that this measurement may underestimate tube depth and result in tubes that terminate in the distal esophagus and pose an aspiration risk. Therefore, in pediatric patients, a better measurement is either using published age‐related height‐based measurements or by measuring from the tip of the nose to the ear lobe and then to the midpoint between the xyphoid and umbilicus. For OG tubes, the measurement should start at the mouth. Once the appropriate tube size and depth of insertion are determined, the same steps may be followed for either NG or OG tube placement, substituting the nasal passages for the oropharynx in the place of OG placement (Table 1.3). Finally, NG/OG tube placement is an uncomfortable procedure, and patients should be treated with topical lidocaine either as 4% lidocaine spray, 2% lidocaine jelly, or nebulized 4% lidocaine prior to the procedure.
Table 1.2 Enteric feeding device contraindications.
| NG/OG feeding tubes | G‐tubes | J‐tubes |
| Maxillofacial disordersEsophageal or oropharyngeal tumors or traumaLaryngectomyConfirmed skull or cervical spine injury above C4Clotting dysfunctionIngestion of corrosive substance | Severe gastroesophageal refluxGastric dysmotilityGastric outlet obstruction | AscitesCrohn’s diseaseImmunosuppression |
Discuss with appropriate consulting service prior to NG/OG placement
Table 1.3 NG tube insertion.
| Supplies |
| Nasogastric tubeSterile water50 mL catheter tip syringeTape to secure tubing |
