The provision of a percutaneously placed enteral tube feeding service

Abstract

There is overwhelming evidence that the maintenance of enteral feeding is beneficial in patients in whom oral access has been diminished or lost. Short-term enteral access is usually achieved via naso-enteral tube placement. For longer term tube feeding there are recognised advantages for enteral feeding tubes placed percutaneously. The provision of a percutaneous enteral tube feeding service should be within the remit of the hospital nutrition support team (NST). This designated team should provide a framework for patient selection, pre-assessment and post-procedural care. Close working relations with community-based services should be established. An accredited therapeutic endoscopist should be a member of the NST and direct the technical aspects of the service. Every endoscopy unit in an acute hospital setting should provide a basic percutaneous endoscopic gastrostomy (PEG) service. This should include provision for fitting a PEG jejunal extension (PEGJ) if required. Specialist units should be identified where a more comprehensive service is provided, including direct jejunal placement (DPEJ), as well as radiological and laparoscopically placed tubes. Good understanding of the indications for percutaneous enteral tube feeding will prevent inappropriate procedures and ensure that the correct feeding route is selected at the appropriate time. Each unit should adopt and become familiar with a limited range of PEG tube equipment. Careful adherence to the important technical details of tube insertion will reduce peri-procedural complications. Post-procedural complications remain relatively common, however, and an awareness of the correct approach to managing them is essential for all clinicians involved in providing a percutaneous enteral tube feeding service. Finally, ethical considerations should always be taken into account when considering long-term enteral feeding, especially for patients with a poor quality of life.

Managing patients with gastrostomy tubes in the community: Can a dedicated enteral feed dietetic service reduce hospital readmissions?

“…26 An alternative theory could be that there has been a genuine improvement in practice with regard to gastrostomy aftercare and in the use of prophylactic antibiotics following recent guidelines, which has led to improvements in peristomal wound infection rates. 1,11,27 In this study, aftercare varied dependent upon the underlying condition for which the gastrostomy had been inserted and also by the patient's current residency status. The HEF team had far more contacts with patients with oropharyngeal malignancy than with any other group and had more contacts with individuals residing within their own homes than with patients residing in residential or nursing homes.…”

“…1 Previous studies have demonstrated mortality and nutritional benefits of gastrostomy feeding in certain subgroups of patients. 2,3 However, the demands for this procedure have increased, including conditions where the evidence base is often lacking.…”

Pneumonia and mortality after percutaneous endoscopic gastrostomy insertion

“…Families and caregivers are frequently told about the plan to insert a PEG tube before it has been properly discussed. This can create unrealistic expectations, which make subsequent discussions with the family more difficult (8). Patients receiving a PEG are usually seriously ill, often with major neurologic disabilities.…”

“…These guidelines highlighted the importance of adequate selection of patients for long-term enteral nutrition (8,9). The NCEPOD report revealed a 1-week mortality of 43% after PEG insertion, and in 19% of cases, the procedure was deemed futile by the same panel (10).…”

PEG placement for patients with oropharyngeal/oeosphageal cancers

“…National guidelines 3 highlight this issue and state that the alternative, direct puncture technique, has not been demonstrated to result in metastases, but they do not go as far as to make recommendations for clinical practice. Most recently a prospective trial has attempted to address this question.…”