When a permanent tube will be used, the primary type used for gastroparesis is a J-tube (jejunal). J-tubes are placed directly into the small intestine, and can be placed either percutaneously, laparoscopically, or surgically via a laparotomy.
A percutaneous J-tube (PEJ) is placed through the skin and into the small intestine via endoscopy. The doctor advances a lighted scope down past the duodenum. When the light can be seen through the abdomen, the doctor then punctures the abdomen in that spot and places the J-tube through it. It is anchored by a hard bumper on the inside. After the procedure, the patient usually goes home, or will only stay overnight.
Feedings can be started at a slow rate within 4-12 hours after the procedure. Jejunal feedings are administered around-the-clock through a pump. Depending on the caloric needs of a patient, and whether or not he/she is able to take in supplemental nutrition orally, feeds might be limited to overnight, or a certain number of hours a day. Portable pumps and backpacks are available, making it possible for a patient to be active and mobile.
When a J-tube is placed by laparoscopy, it is a minimally invasive surgery. A laparotomy entails an open surgical procedure. Both place the J-tube into the small bowel in a different manner than a PEJ. They are generally anchored by a balloon, and sometimes a few sutures. Balloons can burst from pressure and spasms in the small bowel, which means the J-tube can suddenly fall out. If that happens, the patient must get to the hospital as soon as possible because the stoma, the opening which the tube was placed into, can close very quickly. A surgeon or interventional radiologist may not be available to replace the tube at that point, but a temporary tube will be placed into the stoma in order to keep it open until it can be replaced.
Surgical placement of a J-tube requires a hospital stay of at least 3 days. Feedings are not usually started for 24 hours, which allows the small bowel to awaken following anesthesia. The feeding rate is usually started off slowly, and gradually increased. The patient is released once an adequate feeding rate is achieved. All patients with feeding tubes are placed under the care of a home health agency which can provide feeding pumps, supplies, and instruction in their use.
The final type of tube that can be used for Gastroparesis is the G/J-tube (gastro-jejunal). The G/J is a percutaneously placed combination tube, a PEG/J. A g-tube (large lumen) is placed into the stomach in the same manner that the PEJ was placed. Once the g-tube is in place, a smaller lumen tube is threaded to it and into the jejunum. The PEG/J has 2 ports on the end of it. One runs to the stomach and the other runs to the small bowel. The G/J tube has the advantage of allowing a patient to administer medicine through the gport, and to decompress the stomach, even while feeding through the jport. The stomach can be relieved of air or fluid by draining the contents into a bag. This could also be accomplished by a separate g-tube (PEG tube) for those with a j-tube, but the G/J eliminates the need for 2 separate incision sites. However, for gastroparetics with severe vomiting and/or intestinal spasms, the j-tube portion can be dislodged from the jejunum and curl up into the stomach, causing the formula to back up into the stomach and require the tube be pulled and a new one be placed. Because of this, some doctors will not use a G/J tube for the treatment of Gastroparesis, but there are a number of patients with Gastroparesis who are doing quite well with a G/J.
Patients who have a G/J can usually go home on the same day, or after an overnight hospital stay.
Complications can include, pain, granulation tissue at the stoma site, bowel obstruction, intolerance of the feeding, abdominal infections, and peristomal infections. G/J-tubes have a slightly lower risk of abdominal infection since the stomach is punctured and not the small intestine. However, the complications from enteral tubes are generally less serious than those of parenteral nutrition, making it a better option for long term nutritional support.
Tubes Are Not Just For Feeding!
Feeding tubes can also be used to manage the symptoms of Gastroparesis, and not for nutritional purposes only. Gastric secretions and undigested foods can accumulate in the stomach, causing nausea, fullness, pain, discomfort, and gas. By venting or decompressing the stomach, symptom relief can occur. As a temporary measure, an NG can be placed through the nose and into the stomach. This is sometimes done during a flare up that requires hospitalization. For a more permanent solution, a g-tube can be placed percutaneously (PEG). This is usually done in conjunction with a J-tube or PEJ, but is not necessary. Some patients can maintain an adequate oral intake, but struggle with severe nausea and gas. A separate PEG can be very helpful for them. The option of a G/J tube, as described earlier, combines the nutritional support of a j-tube with the abdominal relief provided by a PEG.