Abstract
There is overwhelming evidence that the maintenance of enteral feeding is beneficial in patients in whom oral access has been diminished or lost. Short-term enteral access is usually achieved via naso-enteral tube placement. For longer term tube feeding there are recognised advantages for enteral feeding tubes placed percutaneously. The provision of a percutaneous enteral tube feeding service should be within the remit of the hospital nutrition support team (NST). This designated team should provide a framework for patient selection, pre-assessment and post-procedural care. Close working relations with community-based services should be established. An accredited therapeutic endoscopist should be a member of the NST and direct the technical aspects of the service. Every endoscopy unit in an acute hospital setting should provide a basic percutaneous endoscopic gastrostomy (PEG) service. This should include provision for fitting a PEG jejunal extension (PEGJ) if required. Specialist units should be identified where a more comprehensive service is provided, including direct jejunal placement (DPEJ), as well as radiological and laparoscopically placed tubes. Good understanding of the indications for percutaneous enteral tube feeding will prevent inappropriate procedures and ensure that the correct feeding route is selected at the appropriate time. Each unit should adopt and become familiar with a limited range of PEG tube equipment. Careful adherence to the important technical details of tube insertion will reduce peri-procedural complications. Post-procedural complications remain relatively common, however, and an awareness of the correct approach to managing them is essential for all clinicians involved in providing a percutaneous enteral tube feeding service. Finally, ethical considerations should always be taken into account when considering long-term enteral feeding, especially for patients with a poor quality of life.
Development of the guideline
This guideline, relating to the provision of a percutaneously placed enteral tube feeding service, is focused upon a specific area of nutrition provision that has not been previously targeted. It should be read in the context of other recent guidelines, whichhave covered the wider field of nutrition provision. The present guideline includes a summary of the ethical issues associated with enteral tube feeding, but these issues are dealt with in detail by the Royal College of Physicians working party report on oral feeding. Furthermore there is no reference to the provision and make-up of the enteral feeds themselves (an area well covered in the reports referred to). The aim of the guideline is to identify the role of percutaneously placed enteral feeding tubes within the wider context of nutrition provision. Guidance is provided for patient selection, the technical aspects of tube placement as well as the prevention and management of associated complications, with an emphasis on endoscopic tube placement (rather than radiological or surgical techniques). The target audience is wide, and includes consultants and specialist registrars in gastroenterology, surgery and radiology, nurse endoscopists and endoscopy nurses, dietitians and nutrition nurse specialists (both hospital and community based). This guideline also provides a basis upon which a primary care trust can purchase enteral nutrition services. The working party is comprised of four gastroenterologists and a nurse consultant who have a specific interest in the provision of enteral tube feeding. The chair (DW) is a current member of the BSG Endoscopy committee and DS is the chair of the Small Bowel and Nutrition committee. Throughout this guideline the strength of statements on evidence and of recommendations is categorised according to the North of England Evidence-based Guidelines Development Project (see box 1).
