Issue 138 Gastrostomy tube feeding

CLINICAL

GASTROSTOMY TUBE FEEDING Louise Edwards Community Team Lead/Specialist Dietitian, Central Cheshire Integrated Care Partnership Louise is a Specialist dietitian working in the NHS. She has an interest in high output stomas and supported the development of a service for this patient group at the Mid Cheshire Hospitals NHS Foundation trust.

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This article will cover the different types of gastrostomy feeding tubes and their indications.

NICE guidelines state that enteral feeding should be considered for individuals who are malnourished or at risk of malnutrition and have an inadequate or unsafe oral intake and a functioning accessible gastrointestinal (GI) tract. Gastrostomy feeding refers to providing liquid nutrition via a feeding tube directly into the stomach and should be considered where enteral tube feeding is likely to be required on a longer-term basis, specifically more than four weeks.1 However, for some patients, there may be contraindications to progress from nasogastric feeding to gastrostomy feeding, such as ascites, previous gastric surgery and gastric varices.21 Clinical indications for gastrostomy feeding may be dysphagia as a result of a stroke, or a neurological condition, i.e. motor neurone disease (MND).

Inadequate oral intake that leads to gastrostomy feeding being considered may be due to surgery (stomach, bowel, head and neck), radiotherapy or chemotherapy. Gastrostomy tube insertion may be prophylactic for those patients with a progressive condition such as MND where worsening dysphagia is likely.

The decision to insert a gastrostomy feeding tube should take into account the impact on the individual’s quality of life, personal wishes and social circumstances.

be assessed individually by the NST and supported by the team during preassessment and post-procedure care.6 Since the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)11 report highlighted concerns regarding morbidity and mortality associated with percutaneous endoscopic gastrostomy (PEG) placement, patient selection is important and all factors should be considered by the NST. The decision-making process requires consideration of psychological, social and ethical factors.6 The NST is paramount to facilitating decision making, with evidence suggesting that complications related to tube feeding are less common in settings where a multidisciplinary nutrition team is set up.12 Patient and carer perceptions and expectations of gastrostomy feeding should be considered. The benefits of the procedure, what the procedure entails and the risk and burden of care should be fully explained before initiating feeding.20

NUTRITION SUPPORT TEAM (NST)

PEG is the preferred method of placement to administer nutritional support in patients with a functional GI system who require long-term enteral nutrition.4

The provision of an enteral tube feeding service should be supported by an NST. Each patient who is referred for gastrostomy tube placement should

TYPES OF TUBES

Insertion of a gastrostomy feeding tube can be performed in three ways: 1 endoscopically - a percutaneous endoscopic gastrostomy tube (PEG); 2 radiologically - a radiologically inserted gastrostomy tube (RIG); or 3 surgically - a surgical gastrostomy.

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CLINICAL

Stroke remains the commonest indication for PEG placement, with gastrostomy feeding being considered at 14 days post stroke.

PEG placement PEG feeding tubes were first used in the 1980s.2 Acceptability of PEG tube feeding still varies with long-term nasogastric feeding more prominent in many Asian nations.3 In order for PEG placement to be appropriate, a patient must be able to lie flat and tolerate an endoscope being passed. Placement should be carried out under full aseptic technique, as the procedure carries risk of bleeding, bowel perforation and peritonitis, etc.6 Infection is reported to occur in 39% of patients post procedure8 and, as such, prophylactic antibiotics are recommended to reduce the incidence of peristomal wound infection.21 Stroke remains the commonest indication for PEG placement, with gastrostomy feeding being considered at 14 days post stroke.6 Dysphagia is common in chronic progressive neuromuscular disease, i.e. MND, Huntington’s disease, etc. Gastrostomy feeding in this patient group is being increasingly used9 with an improvement in functional status, prolonged survival13,14 and improvement of quality of life9 being demonstrated. PEG placement could also be indicated for other clinical conditions such as head injury, Crohn’s disease, short bowel syndrome, AIDs and severe burns.6 Although PEG placement is preferred, it may not always be clinically safe for the patient.

RIG placement might be deemed to be more appropriate.

With advanced neuromuscular disorders, a RIG may be considered, since sedation required for PEG may represent a significant risk of ventilatory failure.6 This emphasises that timing of gastrostomy tube placement is paramount in this patient group, as supported by recent NICE guidance15 for MND, highlighting that gastrostomy feeding needs to be discussed at an early stage of diagnosis and at regular intervals as the disease progresses. This may partly be due to the evidence that delaying gastrostomy tube placement until severe bulbar dysfunction negates benefit.16 There is limited evidence to suggest that RIG rather than PEG placement in MND patients has increased survival, which is perhaps due to avoiding risk of sedation with a lower forced vital capacity.17 For patients with compromised ventilatory status, endoscopic gastrostomy tube placement should only go ahead following respiratory and anaesthetic assessment. If deemed not safe, then radiological placement should proceed.6

RIG feeding A RIG would be considered for patients who are unable to have an endoscope passed; this may be linked to the presenting clinical condition or their anatomy. RIG feeding tubes may be indicated for individuals with oropharyngeal or oesophageal malignancy, since a PEG would carry the risk of the tumour seeding within the tract.6

For PEG tubes which have been placed with no known complications, gastrostomy feeding can commence four hours post insertion,18 but Trusts may have their own policy on this. For radiologically or surgically placed gastrostomy tubes, often the radiologist or surgeon will advise when nutrition can commence. In my experience, this can be over 24 hours, with water being

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Surgical gastrostomy A surgically placed gastrostomy tube may be used when patients cannot tolerate an endoscopic or radiological placement.

Possible complications are similar to that of PEG placement, being infection, leakage and peritonitis, etc. Oesophageal obstruction could be a potential indication for this method of tube placement.

NUTRITION VIA GASTROSTOMY TUBE

There is limited evidence to suggest that RIG rather than PEG placement in MND patients has increased survival, which is perhaps due to avoiding risk of sedation with a lower forced vital capacity. commenced initially and tolerance monitored.

Bolus or continuous methods of administration of nutrition should be considered, taking into account a patient’s preference, feasibility in the home setting and drug administration.1 CONSENT AND ETHICAL CONSIDERATIONS

There is concern that due to nutrition administration via a PEG tube appearing simple, PEG tubes are being placed with no clinical benefit.3 Ethics need to be considered before placement of a gastrostomy feeding tube is proposed.6 If an individual’s prognosis is weeks, then percutaneous enteral nutrition is deemed inappropriate since the burden of the insertion is likely to outweigh any benefit.6 Evidence suggests that patients with advanced dementia do not benefit from PEG feeding in terms of prolonging life or comfort.6 However, enteral feeding may still be considered in individuals with dementia where the presentation of eating difficulty is not associated with dementia.6 Once the NST has provided the patient with the information of what a gastrostomy tube is, the process of its placement and details of the after care of the tube, the patient can then make an informed decision and give consent. Studies have shown that patients who have had previous PEG tubes do not have issues with tube-related problems such as leakages or blockages,19 but report problems with interference of family life, intimate relationships, social activities and hobbies.19 I think this highlights how important

it is for the NST to provide as much information as possible about ‘life with a gastrostomy feeding tube’ and to offer ongoing support to this patient group.

Capacity should always be assumed unless determined otherwise.6 If an individual is deemed to lack capacity, an assessment must be given as to whether the individual has an advanced decision directive in regards to artificial nutrition provision. If this is not present, the medical team must act in the patient’s best interests. This involves consideration of what the patient would have chosen and the views of family and carers, etc. Often a best-interests meeting with members of the MDT and the patient’s family and carers is the best way to facilitate decision making.

CONCLUSION

In summary, it could be said that successful gastrostomy tube placement requires support of a functioning NST, support of the patient’s wishes and consideration of capacity and ethics.

In my experience, the window of gastrostomy tube insertion is paramount. I have seen individuals who have been referred for a PEG placement, suffer deterioration in respiratory status, which has resulted in radiological placement being required. This poses increased requirements with tube after care. Hence, considering the NICE guidance in regards to MND, if deterioration in swallow is likely, discussions around long-term enteral feeding should happen as early as can be facilitated. www.NHDmag.com October 2018 - Issue 138

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