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.
There are a number of reasons to consider placement of an enteral tube:
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])
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)
Need for an unpalatable elemental diet (e.g. inflammatory bowel disease, various metabolic diseases)
Feeding aversion that is resistant to other therapy
Administration of medications (e.g. for human immunodeficiency virus infection)
Decompression (“venting”) for functional or mechanical bowel obstruction
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).
There are three well-accepted techniques for placement of enterostomy tubes in children:
Surgical (open or laparoscopic)
Percutaneous endoscopic gastrostomy (PEG)
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 ...