Feeding Tube Insertion
What is Feeding Tube Insertion?
After being afflicted with stroke or other medical conditions, patients can have difficulty swallowing. Food is at risk of getting into the lung during the swallowing process. Sometimes eating becomes so inefficient that they cannot eat enough to meet their nutritional needs.
In these situations, feeding tubes that deliver food into the stomach, bypassing the swallowing process, become necessary. Two main methods of doing this include Naso-Gastric (NG) Tube Feeding and Percutaneous Enteral Gastrostomy (PEG) Feeding.
A third method is used when the stomach needs to be bypassed. This method is nasojejunal tube feeding. The slim feeding tube is inserted from the nostril into the small intestine, either endoscopically or with radiological guidance.
NG tube is normally inserted by a nurse by the bedside, going through the nostril and inserted into the stomach. This can be done at home by a home nurse.
PEG insertion, which is done by a trained gastroenterologist, goes directly into the stomach through the abdominal wall. The procedure takes about 15-30 minutes and it is done under moderate sedation. This is an inpatient procedure.
NJ feeding can be done either endoscopically or with radiological guidance. It is accomplished by inserting a guidewire deep into the jejunum and then inserting the thin feeding tube into the jejunum. This is also an inpatient procedure.
All patients with persistent swallowing difficulty should consider a PEG tube feeding. The advantages of PEG feeding vs NG feeding are the following:
- PEG tube is more comfortable. NG tube goes through the nostril and the back of the throat into the stomach. Patient with an NG tube will have persistent discomfort in the nose as well as the back of the throat.
- PEG tube is safer. NG tube needs to be replaced as frequently as 2-6 weekly and each insertion carries a risk of accidental insertion into the lung, which usually results in a fatal aspiration pneumonia.
The disadvantages of PEG feeding are the following:
- It is more expensive and requires the expertise of a trained gastroenterologist team
- It has short term procedure risk
NJ feeding is reserved for people that need food to be delivered to the small intestine, bypassing the stomach.
Assessment for suitability of PEG insertion needs to be carried out before the procedure. Some patients may not be suitable for it and some contraindications include:
- Poor skin over the stomach for various skin conditions or previous surgery.
- Water in the abdominal cavity (ascites)
- Those at risk of severe bleeding
- Severe kyphoscoliosis
- Life expectancy of less than 3 months
There is substantial coordination in preparation for a PEG insertion. This involves the booking of two gastroenterologists, one anaesthetist, a procedure room and an inpatient bed. This procedure should ideally be done during office hours to allow nurses to monitor the patient properly.
The patient is admitted to the hospital for the procedure. The patient would need to fast for 6 hours before the procedure. Antibiotics will be given before the procedure to prevent infection.
Some blood thinners will have to be discontinued before the procedure. Likewise, the patient should not be taking their diabetic medication on the day of the procedure. The other medications should be continued as usual.
Proper consent is needed before the procedure. As most patient undergoing this procedure will not be able to give consent because of their neurological condition, the consent is usually given by the family members with the power of attorney.
For PEG insertion, the patient is put under moderate sedation and this ensures that they are comfortable throughout the procedure. This is usually done by an anaesthetist, who will monitor the patient carefully during the procedure.
The gastroscope (a slim instrument with camera and operation channels) is then inserted through the mouth to examine the oesophagus, stomach and duodenum to ensure that procedure is suitable. The precise point of insertion is then located using indentation, transillumination and needle probe.
The PEG tube is then inserted using a pull technique involving trocar and guidewire with local anaesthesia. The tube goes through the abdominal wall and goes directly into the stomach cavity. Gastroscopy is again carried out to check the position of the feeding tube.
The whole procedure usually takes about 15-30 minutes.
The patient is monitored carefully when they recover from the moderate sedation. Feeding is resumed after a few hours of monitoring, starting with a small amount of water and monitoring overnight.
Usually, full feeding can start the next day.
The patient can be monitored a day or two after the procedure. The medical team will be looking out for any signs of infection or bleeding.
The patient can be discharged after caregiver training is completed, usually at day 2-3 post procedure.
The PEG tube can be replaced in an outpatient or even in the patient’s home in 6-9 months. No endoscopy procedure is needed.
PEG insertion carries a major risk of less than 5%. The risk includes:
- Major infection
Severe complications may lead to death.
Long term complications include tube migration, tube blockage and leakage.
Overall, experts feel that PEG carries less risk than repeated NG tube insertion at home in the long term.
The quality and safety of PEG insertion depend largely on the training and experience of the medical team.
Patient selection, pre-procedure preparation, actual procedure as well as post-procedure care are the many aspects that must not be overlooked.
It is difficult to measure the quality of PEG insertion and there is no internationally agreed performance indicator for quality unlike other procedures. This is because PEG is usually performed for a patient that is unwell and often malnourished in the first place.
Typically, the cost of PEG insertion includes professional fees of at least 2 gastroenterologists, and one anaesthetist,, facility fees, inpatient fees, medications and the material cost of the insertion kit. The typical overall bill size in Singapore is about 6000 to 10000 SGD depending on the length of stay and complications.