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Laparoscopic GI Feeding Access

To provide nutritional support and prevent or treat malnutrition, enteral feedings are better than parenteral feedings if the gut is functional and accessible. Feeding via the gastrointestinal (GI) route is easier, safer, less expensive, and more physiologic: The body utilizes nutrients more efficiently when they're delivered into the GI tract rather than the bloodstream.

Enteral feedings maintain the structure and functional integrity of the GI tract by preventing atrophic changes; they also play a role in the prevention of cholestasis by stimulating bile flow. Compared with parenteral feeding, enteral nutrition improves systemic immunity and lowers the infection risk.

If the GI tract can tolerate only limited feeding, the patient may receive a combination of enteral and parenteral feedings. Even though most of the calories may be delivered parenterally, providing small amounts of nutrients via the gut still produces physiologic benefits.

Selecting an enteral access device

Feeding tubes may be placed into the stomach or the small intestine, either in the distal duodenum or the proximal jejunum. The small intestine is less prone to ileus than the stomach and large intestine, so it can accept enteral feedings immediately--soon after surgery or a traumatic injury or during a critical illness--if the patient is hemodynamically stable.

When deciding which tube to select, evaluate the anticipated duration of nutritional support, aspiration risk, function of the GI tract, the patient's overall condition, and placement technique.

A nasoenteric tube (NET) is generally indicated for short-term therapy; a more permanent enterostomal device, such as a gastrostomy or jejunostomy tube, is appropriate for therapy expected to last a month to 6 weeks or more. Depending on the device and site, the tube may be placed at the bedside or by special procedures (laparotomy, laparoscopy, fluoroscopy, or endoscopy).

Natural approach to feeding

Nasogastric tubes offer the most natural approach to enteral feeding by delivering nutrition directly into the stomach. Gastric feedings may be delivered continuously, nocturnally, by bolus, or by intermittent gravity drip.

Gastric feeding is appropriate for patients who have intact gag and cough reflexes and adequate gastric emptying. Possible contraindications include a history of gastric malignancy or pulmonary aspiration, gastroesophageal reflux, delayed gastric emptying, or intractable vomiting.

Nasoduodenal tubes (NDT) and nasojejunal tubes (NJT), which are advanced distal to the pylorus, are generally indicated for critically ill patients at risk for pulmonary aspiration or delayed gastric emptying. When placed at the bedside, about 80% of NDTs and NJTs pass into the small intestine within 24 hours.

Tubes advanced beyond the pylorus are smaller in diameter, which improves patient tolerance and comfort. However, their smaller size also makes them more prone to clogging. Some tubes have dual lumens that permit simultaneous gastric decompression and small intestinal feedings.

Jejunal feedings are delivered continuously via an enteral feeding pump because bolus feeding into the small intestine may produce overdistension of the small intestine and signs and symptoms of dumping syndrome. Triggered by cold formula or too-rapid administration of formula, dumping syndrome causes diarrhea, cramping, weakness, light-headedness, palpitations, and diaphoresis.