Few phone calls are more annoying for a general surgeon than the inevitably late night ER page about a patient from a nursing home who is "having problems" with a feeding tube that you may or may not have placed. It's clogged. It's leaking. It fell out. It hurts. And most medical personnel are terrified of them. No one knows exactly what to do and so it gets dumped on us.
Feeding tubes are an alternative to stuffing food down your mouth. Instead of filet mignon or smoked salmon, you get to infuse delicious Boost through a thin silastic or rubber tube directly into the stomach or small bowel, bypassing your taste buds and any enjoyment usually associated with eating. This isn't something you want. Unfortunately, certain conditions make them necessary such as strokes, swallowing difficulties, chronic aspiration, esophageal tumors, and other states of inanition. You also find feeding tubes placed in certain post-operative patients (Whipple, Gastric and esophageal tumors) as a way to provide enteral nutrition while more proximal anastomoses are healing.
Feeding tubes come in 2 varieties:
1. Gastrostomy tubes. These tubes are inserted into the stomach. More commonly nowadays, these tubes are placed percutaneously (Percutaneous Endoscopic Gastrostomy...PEG). Open or laparoscopic G-tubes are also an option if the percutaneous route is not available. G-tubes provide a little more flexibility in terms of feeding schedules because the stomach is such a large reservoir. Bolus feeds and continuous feeds are options. It's also easier to give medicines via a G-tubes because generally the tubes themselves are of largr caliber.
2. Jejunostomy tubes. These tubes are best used for feeding purposes when the stomach is not suitable or available. Now the jejunum is of a much narrower caliber than the stomach. Bolus feeds usually don't work and I worry about giving medicines, even crushed, via J-tubes because of clogging issues.
1. Clogged tubes. This is almost universally a result of poor nursing management. Enteral tube feed formulas are like wet cement; as long as the flow is steady and constant there's no worries. But if the feeds are turned off and the wet cement is allowed to stagnate in the tubing, it quickly solidifies and completely obstructs the lumen. The key is prevention and this means q4 hour flushings with saline or water. And any time the feeds are stopped (patient being transported somewhere) you HAVE TO FLUSH THE TUBE! It's an entirely avoidable complication as long as the tube is appropriately flushed on a regular basis. Most of the time I can clear it by power flushing the tube, but sometimes you have no choice but to replace the entire tube. Just thinking about this complication makes my heart rate accelerate because it's due to laziness.
2. Leaking tubes. Over time the exit site on the skin can sometimes enlarge and you can get minor enteric leakge on the abdominal wall. Lots of bile leakage should alert you to the possibility of distal bowel obstruction, or even a defect in the tubing itself.
3. Tubes that fall out. Happens all the time. Usually it's an elderly lady at the nursing home, demented and confused who yanks it out unknowingly. Most of time, especially with G-tubes, I can simply put another tube in through the established tract. Expediency is the key. The more time that elapses with the tube out, the harder it is to place a new one because scar tissue starts to form. J-tubes are a little dicier because I worry about perforating the bowel wall with blind insertion into the narrow jejunum; I like doing these with fluoroscopic guidance to confirm that the tip is actually within the lumen of bowel.