If the gastrointestinal tract is functioning adequately, enteral nutrition is preferable to parenteral nutrition in the child with medical complexity. When compared with parenteral nutrition, enterostomy tubes are easier to handle and less expensive, and several randomized trials have shown that complications (e.g. sepsis, thrombosis, liver dysfunction) are less common. Enteral feeding prevents mucosal atrophy, maintains gut flora, and plays an important role in preserving the enteral immune system. Supplementation can be complete or partial depending on the child’s ability to feed by mouth.

Gastrostomy (G), jejunostomy (J), and gastrojejunostomy (GJ) tubes have replaced nasogastric (NG) and nasojejunal (NJ) tubes when the anticipated length of enteral feeding exceeds 8 to 12 weeks. Tubes through the nose, although simple to place, are not well tolerated in the long term and are cosmetically unappealing. They may lead to increased secretions, nasal ulceration, and sinusitis and could predispose to gastroesophageal reflux, esophagitis, and strictures. They are easily displaced and may result in aspiration.

Concerns about permanence of the tube, relinquishing of normalcy, loss of autonomy, and loss of the ability to orally feed often make this a difficult decision for caregivers.

This first part of this chapter outlines the indications for enterostomy tube placement and the different techniques available as well as some of the complications and outcomes reported.

INDICATIONS

There are a number of reasons to consider placement of an enteral tube:

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  Oral motor feeding problems, which can result in aspiration of orally ingested food into the lungs or an inability to maintain hydration (especially in children with neurological impairment [NI])

  
  
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  Failure to thrive as a result of oral motor feeding problems, malabsorption, or a specific disease process (e.g. congenital heart disease, cystic fibrosis, chronic renal failure, cancer)

  
  
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  Need for an unpalatable elemental diet (e.g. inflammatory bowel disease, various metabolic diseases)

  
  
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  Feeding aversion that is resistant to other therapy

  
  
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  Administration of medications (e.g. for human immunodeficiency virus infection)

  
  
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  Decompression (“venting”) for functional or mechanical bowel obstruction

  
  
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  As part of palliative care

On occasion, a J or GJ tube may be more appropriate, for example, in the management of severe gastroesophageal reflux disease (GERD) resistant to maximal medical therapy and still symptomatic with NG or G tube feeding. Anatomic or mechanical issues, such as superior mesenteric artery syndrome or gastroparesis, would be another indication for a GJ or J tube (where the tip of the feeding tube is placed distal to the obstruction).

METHOD OF PLACEMENT

There are three well-accepted techniques for placement of enterostomy tubes in children:

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  Surgical (open or laparoscopic)

  
  
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  Percutaneous endoscopic gastrostomy (PEG)

  
  
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  Percutaneous radiologic gastrostomy (PRG)

Surgical gastrostomy is technically simple and has been performed since the late 1800s. Since the 1990s, an increasing number of these procedures are being performed laparoscopically. PEG, first performed in 1980, is a quick and low-cost method of placing a tube percutaneously under endoscopic guidance by the “pull” or “push” technique, according to the preference of the endoscopist. Percutaneous nonendoscopic or radiologic gastrostomy done under fluoroscopic guidance was first performed in 1981 and has the advantage of being able to be performed in children without general anesthesia if necessary, and does not require endoscopy. PEG is presently the most common technique used in North America.

No study has compared the three techniques in a pediatric population, but a meta-analysis of all patients in the literature who underwent enterostomy over a 15-year period, largely an adult population, was performed to evaluate the effectiveness and safety of the different techniques.¹ Rates of successful tube placement varied; it was 100% for surgical G tubes, 99.2% for PRG, and 95.7% for PEG. Major complications were most common after surgical G tube placement at 19.9%, lower at 9.4% in PEG, and least common after PRG at 5.9%.¹

The technique used often depends on what is most readily available in the particular institution. However, certain conditions may be important to consider. In some medically complex patients, avoidance of general anesthesia may be of significant benefit, thus arguing against a surgically placed tube. However, patients requiring another surgical procedure, such as fundoplication, are better served through surgical tube placement at the same time. In patients with portal hypertension and gastric varices, simultaneous endoscopy may be helpful to avoid puncturing a varix and causing bleeding. Unfavorable anatomy, such as previous gastric surgery or interposition of the liver resulting in absence of a safe access route, is a relative contraindication to the PEG or PRG technique.

The use of prophylactic antibiotics prior to the procedure is generally recommended in many guidelines, although the efficacy of a single dose versus multiple doses and which particular type of antibiotic is not clear.

Many different types of G tubes are available, and no single catheter is appropriate for all patients. Most are secured by a pigtail, balloon, or bulb in the stomach, which helps prevent accidental dislodgement (Figure 182-1). After 6 to 12 weeks the tube can be changed to a low-profile device (e.g. MIC-KEY, Bard button) (Figure 182-2), although low-profile tubes tend to not be available in smaller sizes. They are more cosmetically appealing, tend to move less, and are more difficult to remove accidentally.

NEED FOR ANTI-REFLUX SURGERY

Although G tubes are often placed because of concern about the risk for direct aspiration with oral feeding, it is also possible to aspirate saliva as well as refluxed gastric contents. Many children requiring a G tube (e.g. those with NI) are likely at high risk of having GERD in addition to their oral motor feeding problems and FTT. The risk of developing or exacerbating pre-existing GERD after G tube placement is controversial and has been the subject of a number of studies with differing results. Unless the child’s GERD symptoms are very severe despite maximal medical therapy, fundoplication at the time of G tube insertion is not usually recommended. If severe GERD is present, another option would be to feed via a GJ or jejunal tube. Recent studies suggest that pulmonary outcomes, particularly aspiration pneumonia, are comparable between fundoplication and jejunal feeding.