General and Surgical Considerations for Enteral Access.

Durable enteral access with feeding tube placement is critical for patients expected to require enteral nutrition for an extended period. There are different options for enteral access, including gastrostomy tube and jejunostomy tube. Gastrostomy tubes are often preferred for feeding access when possible, as they are generally more physiologic and because the stomach is distensible and can accommodate a large volume, making intermittent bolus feeding possible, which is generally much easier for patient and provider management. Gastrostomy tubes may not be preferred in patients at risk of aspiration. Radiographic gastrostomy tube placement may not be feasible due to gastroesophageal obstruction precluding nasogastric tube placement and insufflation or due to body habitus. In these situations, endoscopic or surgical placement is preferred and a basic understanding of these techniques is helpful. Jejunostomy tubes are generally used when gastrostomy feeding is not possible and typically require surgical placement. Gastrostomy tubes may also serve a palliative role as venting tubes to relieve symptoms of malignant or recurrent bowel obstruction, while jejunostomy tubes are poor choices for palliative venting. Jejunostomy tubes require continuous feeding, are at higher risk of tube impaction, and carry risk of bowel obstruction due to tethering to the abdominal wall. Regardless of indication, diligent tube care is essential to reduce complications such as dislodgement, clogging, malposition, leakage, and peristomal infection. Routine flushing, appropriate medication administration, and proper site care help maintain function and minimize morbidity. Ultimately, a clear understanding the intent of tube placement-nutritional support vs palliative venting-as well as considering patient goals and comorbidities is fundamental to appropriate enteral access selection and method of placement.