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Gastrostomy's advantages

Gastric tubes are hidden under the clothes when not in use

Safe, efficient and low-risk enteral feeding method

Home care use of enteral feeding eliminates nursing home long term care

Helps patients maintain a normal nutrition condition


Feeding tubes may be inserted through the nasal passageway for short-term use, but for those patients who require longer use of the feeding tube, it is customary to place a stomach feeding tube directly into the stomach through the abdominal wall. This second method is called a percutaneous endoscopic gastrostomy (PEG) tube. The stomach feeding tube may also be put in place in anticipation of other treatments such as radiation or chemotherapy, allowing the patient to adapt to its use prior to treatments. Feeding tubes or gastric tubes are not painful and are not easily visible when wearing normal clothes. When not in use, feeding tubes can simple be taped to the patients stomach to prevent them from moving around under clothing.

The gastric tubes are placed with the aid of an endoscope, the scope going down the throat to assist in guiding the placement of the feeding tube through the wall of the stomach. The surgery is simple and involves little risk or discomfort. The procedure takes about 20 minutes. The feeding tube extends from the interior of the stomach to outside the body through a small incision only slightly larger than the tube itself in the abdominal wall. The feeding tube is prevented from coming out of the stomach by one of several methods.

Removal of the stomach feeding tube simply involves cutting the wire which created the pigtail, or deflating the balloon section of the feeding tube allowing it to slip easily from the stomach. About three inches of tubing will protrude from the incision area. Initially, there may be some discomfort while getting used to using the enteral feeding system, from gas or air, or from adjusting to the liquid foods themselves.

An important care is required during the first week the stomach feeding tube is in place, as the surgery has just been performed. The area around the wound must be kept thoroughly clean and covered with clean, gauze. During this period of time the feeding tube may occasionally pull away from the abdominal wall, resulting in leakage around the insertion site. Leakage may also occur if the stoma site becomes enlarged. Excessive tension may cause the stomach feeding tube to be pulled out prematurely.

Enteral Nutrition

Feeding Regimens
Enteral feeding regimens will be devised by a dietitian, using the most appropriate feed for the patient's medical condition. The aim is to get the patient established on the feed they will require at home, prior to discharge, so any difficulties can be dealt with in hospital.


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There are a variety of different types of feed which the dietitian may opt to use. Standard feeds are generally 1kcal/ml, with higher energy alternatives (1.2 or 1.5kcal/ml) for patients who need more calories in a shorter period of time, or who do not tolerate large volumes. There are also fiber-containing feeds which help both diarrhea and constipation. In rarer cases, a more specialist feed may be the choice.





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There are 3 main methods of enteral tube feeding:
1. Pump feeding: this is where an electronic feeding device delivers feed, through a giving set, at a set rate per hour over a pre set dose or time period.
2. Bolus feeding: this is where feed is administered directly into the feeding tube through a syringe.
3. Gravity feeding: this method is rarely used these days, and involves the feed bag attached, through a giving set, to the enteral feeding tube and feed drips in through gravity.


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Patients using home health care enteral nutrition may be nil by mouth, in which case they rely solely on the artificial feed. Some patients will be allowed to eat but are unable to eat adequate amounts to improve or maintain their nutritional status, and the enteral feeding tube is used as a back up to ensure nutritional requirements are met.

In some cases a combination of pump feeding and bolus feeding may be the regimen of choice. This may be in order to reach the appropriate energy requirements, to minimize wastage or to be more convenient for the patient's daily routine. The bolus may also mimic a meal and help satiety during the day. We have to remember, for many enteral tube feeding patients, one of life's pleasures has been taken away from them, i.e. eating.

The dietitian is likely to change the regimen as the patient's circumstances change. For example, the patient may be gaining too much weight and may require less feed, they may start eating so the feed needs to be reduced, or there may be problems tolerating the feed.

Problems in tolerating enteral tube feeding
A number of problems have been noted in respect of tolerating enteral tube feeding, most commonly diarrhea or constipation. Before the type of feed or regimen is altered, it is important to rule out side effects of any medication or pathogenic cause. Stool samples may highlight any bacterial infections. If no other cause can be identified, the dietitian may suggest a different type of feed, e.g. fiber-containing or semi-elemental. Abdominal bloating, nausea and vomiting can be common side effects, in which case the rate or method of administration need to be reviewed. Some patients fail to tolerate large volumes at one time, in which case the pump rate may need to be slowed, a higher energy feed used or frequent rest periods may be advised to allow gastric emptying.

Discharge planning
Planning for discharge on home care enteral feeding should begin at the earliest opportunity and involve all the relevant health care professionals and community staff, whilst discussing with the patient and caregivers what to expect on a daily basis when administering home enteral tube feeding. In practice, to ensure smooth running, it often takes five working days to properly plan a discharge. Early and inadequately planned discharges may cause anxiety with the patient or caregiver and are potentially unsafe. However, with hospital bed crises and consultants eager for a quick discharge, home health care enteral tube feeding is often actioned prematurely.

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Other than the practicalities of the feeding regimen, patients and caregivers need to be trained on caring for the tube, hygiene issues, safety and basic problem solving, and must be clear regarding arrangements for supply of feed and equipment.

Conclusion
Enteral tube feeding is becoming more and more widely used, and patients are being discharged from hospital sooner for their tube feeding to be managed in their own homes or in residential care home. Improved systems need to be put into place to ensure patients and caregivers are adequately trained and aware of where to get help after discharge. All healthcare professionals, both pre- and post-discharge, have a role in this process, and it must be recognized that care does not end once the patient leaves the hospital.

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