CHAPTER 39 Percutaneous tube management

1. Identify two primary reasons for using percutaneous tubes.

2. Distinguish among the placement approaches for gastrostomy and jejunostomy, including indications and overview of technique.

3. Explain why tube stabilization is a priority in the management of the patient with a percutaneous tube.

4. Describe at least two options for stabilizing gastrostomy or jejunostomy tubes.

5. For each complication listed, identify a prevention and management approach: peritubular leakage, tube migration, candidiasis, and tube occlusion.

6. Identify percutaneous tubes that can be irrigated and those that cannot be irrigated.

7. Describe routine site care for the patient with a percutaneous tube.

Although described in the thirteenth century, planned surgical gastrostomy as a procedure was first proposed in 1837 and performed 12 years later in 1849, with the first reported survival of the procedure performed by S. Jones in 1876 (Wu and Soper, 2004). Today the use of tubes is commonplace within the gastrointestinal (GI) tract, as well as other organs and spaces, on a temporary or a long-term basis. Percutaneous tubes are placed for a variety of purposes, including feeding, decompression, and drainage. The tubes are inserted into the desired body part by an interventional radiologist using computed tomographic or fluoroscopic guidance.

Malfunction of these tubes can result in skin erosion, denudement, inflammation, and pain such that referral to the wound care nurse becomes necessary. This chapter reviews the different types of percutaneous tubes, their purpose, procedures for placement, nursing management, and potential complications.

Effective nursing management of the patient with a percutaneous tube requires an understanding of the anatomy and physiology of the affected body system, the pathology involved, the rationale for tube placement, the method of tube insertion, and the anticipated length of time that the tube will be necessary. Although specific care procedures vary depending on the body system involved and the purpose of tube placement, management should always include routine care designed to maintain tube function and prevent peritubular complications, patient/caregiver education, and routine surveillance for tube dysfunction or complications. Comprehensive care is best provided with a collaborative team approach involving, but not limited to, the interventional radiologist, interventional radiology nurse, gastroenterologist, surgeon or internist, and nurse.

Gastrostomy and jejunostomy devices

A gastrostomy is an opening into the stomach, and a jejunostomy is an opening into the jejunum. Such procedures may be used to provide decompression or enteral support for a patient unable to ingest adequate nutrients orally (DeChicco and Matarese, 2003). Enteral nutrition offers many potential advantages over parenteral nutrition, including lower rates of infectious and metabolic complications, decreased hospital length of stay, and reduced cost. Many of the benefits of enteral feeding are in part due to preservation of gut integrity (histologic structure and physical viability) better than parenteral feeding (Fish and Seidner, 2003; Harbison, 2007). Enteral support is generally appropriate through a nasogastric or nasoenteric feeding tube for short-term access (i.e., less than 3 to 4 weeks) in the patient who is at low risk for aspiration (Bloch and Mueller, 2004; DeChicco and Matarese, 2003; Wu and Soper, 2004). When the risk of aspiration exists, postpyloric placement of a tube is preferred. The patient’s history and results of physical examination, barium studies, fluoroscopy, and manometry are useful when evaluating the patient’s risk for aspiration. Consultation with the neurologist and speech pathologist also is beneficial. Box 39-1 lists the risk factors for aspiration.

BOX 39-1 Risk Factors for Aspiration

• Altered mental status

• Swallowing dysfunction

• History of aspiration

• Severe gastroesophageal reflux

• Gastric outlet obstruction

• Gastroparesis

From Gorman RC, Nance ML, Morris JB: Enteral feeding techniques. In Torosian MH: Nutrition for the hospitalized patient: basic science and principles of practice, New York, 1995, Marcel Dekker.

Placement approaches

For more than a century, gastrostomy placement required surgical intervention involving anesthesia and the traditional preoperative preparation for abdominal surgery. Historically, a suture was placed around the base of the tube at skin level and then through the skin to immobilize the gastrostomy tube. Gastrostomy tubes usually were connected to suction for 12 to 24 hours to reduce tension on the suture line. Feedings were delayed until bowel sounds, tube patency, and proper placement of the tube were confirmed.

Today, a gastrostomy or jejunostomy is created by one of three approaches: surgical, endoscopic, or interventional radiologic. Open laparotomy is rarely performed due to the success of the much less invasive endoscopic and laparoscopic techniques (Duh and McQuaid, 2000). Figure 39-1 presents an algorithm for determining the most appropriate means of enteral access.

FIGURE 39-1 Enteral access algorithm for selecting the most appropriate technique for an individual patient.

(From Gorman RC, Morris JB: Minimally invasive access to the gastrointestinal tract. In Rombeau JL, Rolandelli RH: Clinical nutrition: enteral and tube feeding, ed 3, Philadelphia, 1997, WB Saunders.)

Surgical approaches

A surgically placed gastrostomy or jejunostomy tube can be accomplished through an open surgical procedure or a laparoscopic procedure. Surgical placement is relatively expensive, requires anesthesia and the use of sterile dressings, and exposes the patient to many potential complications. The surgical approach is reserved for the patient with pharyngeal, esophageal, or gastric obstructions or upper GI tumors, or for the patient in whom abdominal surgery is already being performed for other purposes. Surgical placement is also performed when endoscopic placement has failed (Beyers, 2003).

Open surgical procedure.

The most common open surgical procedures for gastrostomy tube placement are the Stamm, the Witzel, and the Janeway. The Stamm and the Witzel are the simplest procedures and are considered temporary; the Janeway is more of a long-term or permanent procedure (Bloch and Mueller, 2004; Gincherman and Torosian, 1996).

Stamm gastrostomy.

Stamm gastrostomy is the standard open gastrostomy, the gold standard for transabdominal gastric access (Harbison, 2007). Creation of a Stamm gastrostomy begins by making a small incision in the left upper quadrant of the abdomen. Another small incision is made over and through the body of the stomach, through which a catheter (Foley, mushroom, Malecot, or gastrostomy replacement tube) is inserted (Figure 39-2). Several pursestring sutures are used to invaginate the stomach around the tube. The stomach is then fixed to the abdominal wall at the catheter site, and traditionally a nonabsorbable suture is used to secure the catheter to the skin. Although the Stamm gastrostomy is the simplest surgical technique to perform and remove, it is frequently difficult to manage and is plagued with complications such as peritubular leakage, wound infection, peritonitis, and tube dislodgment (Beyers, 2003).

FIGURE 39-2 Stamm gastrostomy tube technique, oblique view. An incision is placed through the abdominal wall into the stomach, through which a catheter is passed.

Witzel gastrostomy.

Witzel gastrostomy is created similarly to the Stamm gastrostomy, with the additional construction of a 4- to 6-cm seromuscular tunnel of the stomach wall through which the gastrostomy tube is placed (Figure 39-3). The seromuscular tunnel is designed to reduce the risk of peritubular leakage, particularly when the stomach is distended or the tube is removed.

FIGURE 39-3 Witzel gastrostomy. This is similar to the Stamm gastrostomy with the addition of a 4- to 6-cm seromuscular tunnel of the stomach wall, through which the gastrostomy tube is placed.

(From Patterson RS: Enteral nutrition delivery systems. In Grant JA, Kennedy-Caldwell C, editors: Nutritional support nursing, Philadelphia, 1988, Grune & Stratton.)

Janeway gastrostomy.

Janeway gastrostomy is a surgically constructed, mucosa-lined gastric passageway that is brought out onto the abdominal surface as a permanent mucocutaneous stoma. Figure 39-4 illustrates how the Janeway gastrostomy is constructed. Postoperatively, an inflated balloon-tip catheter is placed in the tract. Once the tract has matured (7–10 days), the tube is removed. A tube is inserted into the Janeway gastrostomy during each feeding and then removed. This type of permanent gastrostomy requires more operative time than the Stamm gastrostomy and results in many similar complications (Gorman et al, 1995).

FIGURE 39-4 Janeway gastrostomy. A surgically constructed, mucosa-lined gastric passageway is brought out onto the abdominal surface as a permanent mucocutaneous stoma.

Witzel jejunostomy.

The Witzel technique is the most common technique for surgically placed jejunostomy. The Witzel technique can be used to create a jejunostomy either at the conclusion of a surgical procedure or as an isolated procedure. The usual site is the left upper quadrant. A loop of jejunum 15 to 20 cm from the ligament of Treitz is brought up to the wound, and a circular pursestring suture is placed in the antimesenteric border. An incision through the center of the pursestring suture is made, and a 14-French (14Fr) feeding catheter is inserted into the jejunal lumen and advanced. A serosal tunnel is constructed at the exit site in the jejunal wall, extending approximately 5 to 6 cm proximally. The catheter is brought to the skin through a separate incision and secured, typically with sutures. The loop of intestine is anchored to the anterior abdominal wall (Wu and Soper, 2004).

Needle catheter jejunostomy.

The needle jejunostomy is a simple procedure that is most often done at the conclusion of a surgical procedure when prolonged enteral support is anticipated. At approximately 30 to 40 cm distal to the ligament of Treitz, a 14- to 16-gauge needle is inserted into the jejunal wall. A feeding catheter is advanced through the needle 30 to 40 cm distally, and the needle is withdrawn. A pursestring suture is made around the tube to close the jejunal opening around the catheter. The loop of bowel is anchored to the anterior abdominal wall, and the catheter is secured to the skin (Figure 39-5) (Harbison, 2007).

FIGURE 39-5 Needle catheter jejunostomy. Technique for placement of a needle catheter jejunostomy. A, The catheter is inserted into the lumen of the jejunum for a distance of 40 to 50 cm and secured into place with a pursestring suture. B, The jejunum is secured to the anterior abdominal wall. The feeding catheter is removed postoperatively when the patient can tolerate oral feedings.

(From Bland KI et al: Atlas of surgical oncology, Philadelphia, 1995, WB Saunders.)

Laparoscopic surgical approach.

The laparoscopic approach for insertion of the gastrostomy or jejunostomy has been possible since the introduction of high-resolution video cameras and has the advantages of minimal invasion and few surgical side effects (Georgeson, 1997). This approach also provides the opportunity to selectively determine the site of the tube within the stomach (e.g., lesser-curvature gastrostomy rather than the more commonly selected greater-curvature), which may be important in the patient who is at high risk for reflux or aspiration. A key advantage to a laparoscopic approach is that the abdomen can be examined under direct vision without the need for a large surgical incision so that biopsy specimens can be obtained if necessary or malignancy staging can be conducted (Coates and MacFadyen, 1996). This technique requires a smaller incision than the open surgical approach, but local or general anesthesia is still needed.

Laparoscopic gastrostomy.

The indication for laparoscopic gastrostomy for feeding is the inability to perform percutaneous endoscopic gastrostomy, such as with a morbidly obese patient. A small supraumbilical incision is made through which the camera port is placed, and a 5-mm port is placed in the epigastrium. An atraumatic instrument is used to grasp the stomach, and the site for the proposed gastrostomy is identified. An 18-gauge angiocatheter is passed through the anterior abdomen, at the site chosen for the gastrostomy, and into the stomach. The needle is removed, and a soft J-wire is passed into the stomach. Dilators (12Fr and 14Fr) are placed over this J-wire. A 16Fr peel-away catheter is placed over the dilator, and a 16-Fr catheter is inserted through the sheath. The catheter is positioned against the stomach wall by inflating the balloon or securing the internal bumper. This particular type of gastrostomy is less commonly used than the Stamm due to technical requirements and pneumoperitoneum (Harbison, 2007).

Laparoscopic jejunostomy.

Specific indications for laparoscopic jejunostomy include concomitant laparoscopy for other problems and difficult laparoscopic gastrostomy. It is a minimally invasive procedure with desirable advantages of reduced postoperative pain and shortened recuperative time; general anesthesia is required. The procedure is more expensive than percutaneous or surgical placement. Two methods described by Wu and Soper (2004) are briefly discussed in this section.

The laparoscope is inserted through a small incision above the umbilicus. The proximal small bowel is identified and traced 25 cm distal to the ligament of Treitz, and the antimesenteric border is withdrawn into the umbilical wound. At this location in the small bowel, a Witzel tunnel is created or concentric pursestring sutures are placed, and a 12Fr catheter is inserted into the bowel. The bowel is secured to the fascia around the tube and returned to the abdominal cavity, and the fascia and skin are closed. The catheter is tunneled subcutaneously to exit the skin at the site previously selected on the abdomen.

In another technique, T-fasteners (or tacks) are inserted through the skin into the bowel lumen to anchor and retract the bowel against the abdominal wall (Duh and McQuaid, 2000; Wu and Soper 2004). Once the bowel is anchored, a percutaneous jejunostomy tube can be placed directly through the abdominal wall (Figure 39-6).

FIGURE 39-6 Laparoscopic jejunostomy with T-fasteners, which are inserted through the skin into the bowel lumen to anchor and retract the bowel against the abdominal wall before a percutaneous jejunostomy tube is inserted directly through the abdominal wall.

Endoscopic approach

The endoscopic approach to gastrostomy tube placement, known as percutaneous endoscopic gastrostomy (PEG), was first described by Gauderer and Ponsky (1980) and has quickly become the procedure of choice. These devices can be placed under local anesthesia and conscious sedation outside the operating room, thus avoiding the complications associated with surgical procedures.

Contraindications to PEG include inability to perform upper endoscopy, inability to illuminate the abdominal wall, ascites, esophageal obstruction, hepatomegaly, previous gastric resection, and uncorrectable coagulopathy (Bankhead and Rolandell, 2005).

Variations to the original technique exist; all involve a complete esophagogastroduodenoscopy, insufflation of air into the stomach, and transillumination of the stomach. After application of a topical pharyngeal anesthetic and sedation, an endoscope is passed into the stomach. Air is insufflated into the stomach, which distends the stomach against the anterior abdominal wall. The proposed gastrostomy site is then transilluminated. The endoscopy assistant indents the abdomen at the proposed gastrostomy site, which should be at least 2 cm below costal margin. At this point, several different techniques have been described to insert the PEG.