734529

research-article2017
NCPXXX10.1177/0884533617734529Nutrition in Clinical PracticeStrollo et al

Invited Review
Nutrition in Clinical Practice
Volume XX Number X
Complications of Home Enteral Nutrition: Mechanical Month 201X 1­–7
© 2017 American Society
Complications and Access Issues in the Home Setting for Parenteral and Enteral Nutrition
DOI: 10.1177/0884533617734529
https://doi.org/10.1177/0884533617734529
journals.sagepub.com/home/ncp

Brian P. Strollo, MD1; Stephen A. McClave, MD2; and Keith R. Miller, MD1

Abstract
Home enteral nutrition (HEN) is an essential component in the care of patients with an array of underlying etiologies resulting in the
inability to meet caloric needs through volitional intake alone. Although some would include oral nutrition supplementation as HEN, for
the purposes of this review, the term is limited to a patient’s requiring an enteral access device for the delivery of exogenous nutrients.
Complications related to such devices remain a difficult problem in the hospital setting, and these issues are often amplified when
encountered in the home setting. Focused multidisciplinary teams and close follow-up are essential in optimizing outcomes for patients
receiving HEN, but all healthcare providers should have foundational knowledge regarding commonly encountered complications of
HEN access and the initial management of these issues. (Nutr Clin Pract. XXXX;xx:xx-xx)

Keywords
enteral nutrition; home care services; nutritional support; complications

The importance of adequate nutrition has long been established
in the surgical and medical literature, with malnourished
patients being susceptible to impaired healing, infectious com-
plications, and compromised immune function. Enteral feed-
ing remains the preferred method for nutrition support, as
compared with parenteral delivery, in inpatient and outpatient
settings. Enteral tube feeding often becomes the primary
method of nutrient delivery for the critically ill, those with
poor voluntary intake, and individuals with abnormal gut func-
tion or dysphagia (neurologic or mechanical). Although there
remains regional variation with regard to home enteral nutri-
tion (HEN) practices, neurologic diseases and malignancies
constitute common indications necessitating enteral access and
HEN.1 Neurologic diseases may result in dysphagia, aspira-
tion, or a lack of swallowing coordination. Neoplastic pro-
cesses of the head, neck, or gastrointestinal tract commonly
require enteral access in the neoadjuvant, postoperative, and
long-term setting. Patients may have dysphagia secondary to
the primary tumor or may require enteral access following
major surgical resection.2 In the aforementioned patient popu-
lations, oral intake is often inadequate or impossible in achiev-
ing caloric goals, and placement of an enteral access device for
the delivery of enteral nutrition (EN) must be considered.
HEN has been demonstrated to have improved outcomes as
compared with home PN with regard to morbidity, mortality,
and readmission rates in retrospective and propensity matched
studies.3,4 HEN has been demonstrated to improve quality of
life in longitudinal studies.5 HEN has also been demonstrated
to assist in sustaining body weight and completion of chemo-
therapy in gastrointestinal cancers, and access routes remain
lifesaving conduits for many of these patients.6
Options for long-term enteral feeding access in the home
setting include nasoenteric tubes (NETs), percutaneous endo-
scopic and radiologic enteral feeding tubes, and enteral access
placed by surgical means.7 Regional variation likely persists
with regard to the more invasive techniques for achieving
enteral access for the provision of enteral formulations.
Following eventual transition from the hospital to home set-
ting, multiple issues may arise, which can generate anxiety and
lead to morbidity in this patient population when indwelling
tubes are present. Although the majority of tube issues can be
resolved in the home setting, nearly a quarter of patients are
readmitted within the first 6 months following transition to the
home setting.8,9 Studies have demonstrated 3–5 unplanned vis-
its in the setting of HEN, secondary to associated issues
with indwelling tubes in the first 10–18 months following
placement.10,11 Common complications included tube dislodg-
ment, clogging or occlusion, peristomal dermatitis, growth of
hypergranulation tissue, leakage, and diarrhea. Complications
From the 1Department of Surgery, University of Louisville, Louisville,
Kentucky, USA; and 2Department of Medicine, University of Louisville,
Louisville, Kentucky, USA.
Financial disclosure: None declared.
Conflicts of interest: Drs Miller and McClave are faculty for the Nestlé
Nutrition Fellowship—no conflict with regard to this manuscript
pertaining to complications of access devices in home enteral nutrition.
Corresponding Author:
Keith R. Miller, MD, Department of Surgery, University of Louisville,
550 South Jackson Street, Louisville, KY 40202, USA.
Email: keith.miller@louisville.edu
2 Nutrition in Clinical Practice XX(X)
are typically classified as mechanical (tube related), gastroin-
testinal (diarrhea, reflux, aspiration, etc), and metabolic in
nature.8 This review focuses predominately on mechanical/
tube-related complications. The underlying disease process
that necessitates the need for the tube placement appears to be
a powerful predictor of future tube complications, with neuro-
logic disorders seemingly having higher complication rates.9
Regardless of the type of tube and indication for HEN, mul-
tidisciplinary teams dedicated to the care of these patients are
essential in reducing readmissions and addressing complica-
tions as they arise.8 One study suggested that the presence of a
dedicated HEN support team resulted in the reduction of read-
mission rates from 23% to 2%.8 The majority of issues encoun-
tered were resolved by phone consultation (69%), with fewer
clinic visits (45%) and emergency room visits (35%) and with
a minority resulting in hospital admission.11,12 Finally, it should
be emphasized that the presence of a tube does not inherently
improve overall well-being or the nutrition status of the patient
if the tube is not appropriately utilized. To this point, among
older adults (mean age, 68 years) receiving HEN without close
follow-up, patients experienced a 63% complication rate, lost
an average of 4 lb, and were receiving < half of their water
requirements as determined by 3-month follow-up.13 When
HEN is not utilized appropriately, patients assume all of the
same risks as those who are optimizing the utility of the access
tube without the potential for maximum benefit. Physicians
and multidisciplinary teams caring for these patients should be
aware of the intricacies of these commonly encountered issues,
but all healthcare workers should have foundational knowl-
edge with regard to the initial management of tube-related
complications.
Nasoenteric Tubes
Nasal or oral enteric tubes are often utilized in the inpatient
setting for temporary nutrition support and provide the “sim-
plest” and most inexpensive system for nutrition support. For
patients with severe gastroparesis, for example, short-term
feeding via a NET is often used to confirm tolerance of small
bowel feeding prior to placement of a percutaneous jejunos-
tomy tube for HEN. NET feeding has been demonstrated to
have lower average daily costs than feeding via gastrostomy
tubes, although indirect costs associated with tube issues were
not factored in and NETs more commonly required attention
and replacement.14 NETs are placed blindly at the bedside or
under fluoroscopic, endoscopic, or electromagnetic guidance.
NETs generally provide nutrition support for 4–6 weeks, but
the increased potential for significant complications arises
with longer-term use of nasoenteric feeding access.15 The most
common long-term morbidities include sinusitis, erosion of the
nasal cartilage, esophageal stricture, and disruption of the
integrity of the upper and lower esophageal sphincter, leading
to gastroesophageal reflux, aspiration, and pneumonia.1
Although NETs are predominately placed in the healthcare
setting, intermittent self-insertion of the nasogastric tube
(NGT) has been described primarily for the pediatric patient
population. Anecdotally, this method appeals to the parents of
these children involved in the complex management of certain
medical conditions for its apparent lack of complications or
side effects. There are relatively limited data regarding the
details of care in these populations. In a recent study, 74% of
parents/caregivers denied complications as a result of incorrect
placement during home NGT placement, with the majority of
inappropriately positioned tubes being recognized by clinical
findings including coughing, vomiting, choking, and gasping.
The authors highlight the knowledge gap regarding who and
how these tubes should be managed to optimize outcomes and
prevent harm.16
In 1 adult series, patients received HEN for a variety of con-
ditions through intermittent NGT insertion for 1–27 months
following a therapeutic patient education program.17 NGT
placement was tolerated in the series of 29 patients, with
median weight gain of 3.1 kg (median starting weight, 44 kg).
The 10 patients questioned following the conclusion of the
intervention all believed that they would have preferred the
self-insertion technique to a continuous indwelling NGT
approach. Only 2 complications were reported in this case
series, and they included minor epistaxis that resolved sponta-
neously and abdominal pain.17
Given the paucity of data and the issues described so far for
patients who require long-term support (defined as >1 month),
guidelines typically recommend placement of a long-term
enteral access device, most commonly inserted percutaneously
into the gastrointestinal lumen.18,19
Percutaneous Tubes
First introduced in 1980 by Gauderer et al, a revolutionary new
endoscopic method for achieving enteral access was described
that did not require a laparotomy.20 Since the original report of
this technique of percutaneous endoscopic gastrostomy (PEG)
tube placement, multiple variations of the insertion procedure
have been described, including the Ponsky pull, the Sacks-
Vine push, and the Russell introducer methods.21 PEG tubes
are a common form of enteral access and are generally thought
to be relatively benign from the standpoint of procedure-related
morbidity and mortality.22 As a point of clarification, PEG
tubes have become so prevalent that this terminology has,
unfortunately, been used in describing all gastrostomy tubes.
Strictly speaking, the term percutaneous endoscopic gastros-
tomy should be limited to percutaneous gastrostomies placed
endoscopically. Percutaneous gastrostomies can also be placed
radiologically. Success rates of placement, regardless of tech-
nique, approached 95%–98% in several studies.23-30 This pro-
cedure has been performed in both inpatient and outpatient
settings. Common failures during initial attempts at placement
Strollo et al 3
are often secondary to obstruction from tumor, inadequate
transillumination, decline in clinical status during the proce-
dure, or anatomic alterations, such as diaphragmatic hernia,
esophageal stricture, or previous gastrectomy with reconstruc-
tion encountered during attempted placement.23 Many of these
factors should be anticipated from the history and physical
examination but do not absolutely preclude attempts at endo-
scopic placement. Radiologic gastrostomy tubes are often per-
formed when the stomach is not amenable to endoscopic access
(as in patients with an excluded stomach following gastric
bypass). Here the stomach is insufflated via a NET or angio-
catheter, and a combination of fluoroscopy, ultrasound, or
computed tomography is utilized to gain wire access into the
lumen of the stomach.31 Once PEG tubes or radiologic gastros-
tomies are established, they are generally well tolerated and
provide reliable enteral access in the home setting. In contrast
to manufacturer recommendations, placement of percutaneous
tubes does not require scheduled routine replacement per se in
most instances. Nonetheless, scheduled replacement remains
the most common indication for replacement (followed by tube
dislodgment).32
Major complications related to the insertion of a PEG tube
are infrequent, occurring in 1.5%–4% of cases.23 While aspira-
tion occurs infrequently, it is a known complication, occurring
in 0.3%–1.0% of procedures performed.23 Risk factors for
aspiration include supine positioning, patients of advanced
age, increased sedation, and those with neurologic impairment.23
Mitigating these risks can be achieved by performing the pro-
cedure expeditiously, minimizing sedation, being judicious
with insufflation, and aspirating gastric contents before com-
pletion of the procedure.23 Other procedure-related complica-
tions include acute hemorrhage, which occurs in an estimated
1% of cases and typically resolves without further interven-
tion. Transient pneumoperitoneum is discovered in up to
20%33,34 of cases (although it probably occurs to some degree
in all patients), but it has no clinical relevance and does not
preclude the initiation of feeding through the PEG tube at 4
hours postprocedure. Inadvertent organ injury, predominately
the liver and colon, is uncommon and rarely requires operative
intervention. Injury to these organs may be prevented by thor-
oughly percussing the abdomen to rule out for a low-lying liver
edge below the costal margin and by performing a “safe track”
technique prior to placing the initial trocar to rule out an inter-
vening loop of bowel.35
As the patient transitions to the home setting following the
access procedure, inadvertent dislodgment of the percutane-
ous tube may occur at any time but is particularly dangerous
when it occurs prior to mature tract formation. Early on, the
stomach is not adherent to the abdominal wall; therefore, dis-
lodgment prior to the formation of a mature tract may result in
spillage of gastric contents and diffuse peritonitis. Maturation
of the tract varies, usually occurring over the first 7–10 days,
but can be delayed in the setting of impaired wound healing,
systemic steroids, immunosuppression, and a variety of other
factors. If the dislodgment occurs in the first 2 weeks and is
appreciated expediently, the patient should be brought back to
the endoscopy suite, and an attempt may be made to replace
the tube endoscopically. If unable to be replaced, successful
conservative management has been described with bowel rest,
NGT decompression, and initiation of broad-spectrum antibi-
otics.36 In 5–7 days, if the patient has remained stable with no
signs peritonitis, repeat percutaneous placement may be
attempted. If, at any time, the patient exhibits peritonitis,
immediate surgical intervention is generally warranted.2 If
dislodgment occurs after this 7- to 10-day period, manual
attempts at bedside replacement should be made, followed by
confirmation of the tube location with a water-soluble con-
trast study.35
If percutaneous tube dislodgment occurs >1 month after
placement, the circumstances are generally much different. By
this time, a mature tract has typically formed, and a new tube
may be reinserted through the stomal tract. However, this must
be performed in a timely fashion, as the tract will close within
a few hours after the tube is removed.2 Patients in the home
setting should be counseled and have some level of comfort in
replacing the tube. Anecdotally, we have found it useful for the
patients to be given a balloon replacement gastrostomy of sim-
ilar size to easily reintubate the stoma and maintain patency
until they can be seen in a nonurgent manner. In rare occur-
rences in the absence of an available commercial tube, a Foley
catheter can be utilized to maintain tract patency until an
appropriate replacement is obtained when the alternative is the
loss of a mature tract necessitating increasingly invasive inter-
vention. Again, although not universally necessary in the set-
ting of long-standing tubes, if there remains any question with
regard to the location of the tube, a water-soluble contrast
study should be performed for confirmation.
With use of any balloon-type internal bolster device as a
replacement for a dislodged percutaneous tube, it is possible to
have migration of the catheter into the pylorus, duodenum, or
proximal jejunum with subsequent partial or complete luminal
obstruction.37 Patients will oftentimes present with abdominal
pain, nausea, vomiting, or increased drainage around the tube.
The diagnosis is confirmed by visualizing that the length of
the external tube has shortened significantly. To alleviate the
obstruction, the balloon is deflated, the tube retracted, and the
balloon reinflated. An external bolster should then be created
prior to placement, to anchor the tube in place and prevent
migration. Patients should be counseled on this possibility in
the event that they are utilizing a Foley catheter to replace a
dislodged tube in the home setting.
Clogging or occlusion of the tube is a commonly encoun-
tered issue, with a described incidence of 25%–35%.32 It is
more common with energy-dense enteral feeds, use of fiber
supplements, or the inappropriate delivery of medications
through the tube. Preventive techniques include avoiding the
measurement of gastric residual volumes, as pH values <4 are
known to promote protein coagulation of the formula.38 Also,
4 Nutrition in Clinical Practice XX(X)
tubes should be flushed with 40–50 mL of water before the
delivery of medications or bulking agents and following medi-
cation delivery.19 Medications should be completely dissolved
in water prior to administration through the tube. Treatment of
tube clogging can generally be accomplished with warm-water
flushes. If this proves unsuccessful, pancreatic enzymes in
combination with bicarbonate have been found to be superior
to carbonated beverages in clog dissolution, but carbonated
beverages are likely more readily obtainable and can be uti-
lized with good success.39-41 Last, clogged tubes may be cleared
mechanically with catheters, wire, or cytology brushes, but this
should generally be avoided, particularly in the home setting
due to the potential for tube perforation or bowel injury.42
Wound complications are the most frequent complication
associated with PEG tubes as well as any other percutaneous
access point. Factors increasing the risk of infection include
patient-related factors affecting wound healing (diabetes, obe-
sity, malnutrition, corticosteroid use),23 small peristomal inci-
sions, lack of preprocedural antibiotics against skin flora,
moisture accumulation around the tube, and excess tension on
the tube (which may lead to tissue ischemia and necrosis). The
majority (>70%) of skin infections from PEG tubes are minor,
with only a small number requiring medical or surgical inter-
vention (<1.6%).23 An appropriate skin incision at the time of
PEG placement allows for egress of secretions, possibly help-
ing to diminish infection rates.2 It has been demonstrated in 3
prospective randomized controlled trials that a single dose of
prophylactic antibiotics significantly reduces infectious com-
plications.23 Of note, as with any surgical antibiotic prophy-
laxis regimen, it is not necessary to administer additional doses
of preprocedure antibiotics if the patient is already on adequate
coverage for another purpose.
Excessive tension on the tube may lead to progressive
enlargement of the stoma or buried bumper syndrome (BBS),
which occurs in up to 9% of cases.43 BBS is defined as a migra-
tion of the internal fixation device (bumper) into the stoma
tract, and the bumper can end up anywhere between the stom-
ach mucosa and the surface of the skin.23,44 This issue is typi-
cally discovered weeks to months following initial tube
placement and is less likely to be discovered in the home set-
ting. Clinical manifestations of BBS vary in severity from
minor skin ulceration and inability to flush the tube to erosion
of the tube through the gastric and abdominal walls with resul-
tant necrotizing soft tissue infection.23
The common characteristic triggering this complication is
overly excessive tension between the internal and external bol-
sters of the tube.23 Excessive pressure may lead to ischemia,
necrosis, and infection, and subsequent inflammatory changes
may precipitate BBS.44,45 Other causes include severe preexist-
ing malnutrition, poor wound healing, and significant weight
gain. Weight gain often results in increased soft tissue between
the external and internal bolsters. Thus, the external bolster
should routinely be assessed and modified in this setting. The
spectrum of clinical presentation is vast and may be as simple
as leakage of gastric content and erythema at the skin to ero-
sion of the internal disc through the skin.44 BBS may be further
complicated by gastrointestinal bleeding, perforation, peritoni-
tis, and intra-abdominal or abdominal wall abscesses.44
The best preventive measure to avoid BBS is to appropri-
ately position the external bolster in the first few days follow-
ing initial placement. The distance of the external bolster at the
time of initial placement is closer or tighter against the skin to
allow apposition of the gastric and abdominal walls for the first
4 days to avoid peritoneal leakage.23 Subsequently, at about 4
days postplacement, the external bolster should be moved back
to approximately 1 cm from the skin. Most important, com-
munication is key among all those involved in the patient’s
care, including the patient and the patient’s family, nurses, phy-
sicians, and nutrition specialists. Adequate and appropriate
information should be provided to caregivers regarding appro-
priate tension on the PEG tube.46
With long-term enteral access, some leakage around the
tube at times seems inevitable. Excessive leakage is probably
underreported at approximately 1%–2% of patients but
increases with local fungal colonization of the skin, hypergran-
ulation tissue surrounding the stoma, side torsion on the tube,
BBS, or the absence of an external bolster.23,47,48 Upon initial
examination for excessive leakage, the tube should be inspected
to ensure that the tube itself is mobile and moves in and out to
rule out BBS. Torsion of the tube on the side wall of the tract is
a common issue resulting in leakage and is clinically evident in
ulcerations observed around the tube tract. This is a difficult
issue, and patient education is paramount. Vertical clamping
devices applied around the tube site help to stabilize the tube
and prevent side torsion, but this strategy may require days to
weeks to resolve this issue and allow for healing of the peristo-
mal ulcerations. The site underlying the device should be
examined at regular intervals to ensure that the underlying skin
is not compromised by the device itself due to trapping of
moisture under the device.23 For leakage in general, treatment
often consists of the addition of a proton pump inhibitor, topi-
cal treatment with antifungal ointments as necessary, place-
ment of the vertical clamping device, application of silver
nitrate sticks to reduce excess peristomal hypergranulation tis-
sue, and, in some cases, conversion of the PEG to a percutane-
ous endoscopic gastrojejunostomy (PEGJ) to divert the level of
formula infusion lower in the gastrointestinal tract. In 1 study
of pediatric patients, sprinkling salt applications consisting of
1–2 mL of table salt applied daily was successful in reducing
hypergranulation tissue in 7 days.49 In more severe cases of
leakage not amenable to the aforementioned methods, it may
be necessary to remove the tube altogether and replace with
NET access to allow the tract and site to heal.23
Jejunal Access
Jejunal access is an alternative method for long-term EN in
subgroups of patients, such as those who have esophageal
Strollo et al 5
cancers and require resection where the stomach will be used
as a conduit during esophagectomy; those with altered foregut
anatomy subsequent to esophagectomy, partial/total gastrec-
tomy, or bypass procedures; those with severe gastroparesis;
and those at high risk for aspiration.50,51 Multiple techniques
have been described to obtain jejunal access via a jejunal
extension through a previously placed PEG tube (PEGJ) or via
the placement of a direct percutaneous endoscopic jejunos-
tomy tube (DPEJ). Both the Johlin and Kirby techniques have
been described for placement of the jejunostomy tube exten-
sion, and either may be done at any time once the original PEG
is placed (even at the time of initial PEG procedure). In those
patients with a mature stomal tract, a 1-piece PEGJ may be
placed to optimize long-term simultaneous aspiration with
deep jejunal feeding. PEGJ tubes are fraught with complica-
tions, with a greater propensity to clog, malfunction, or migrate
proximally as compared with other methods for jejunal access.
The DPEJ was first introduced in 1987 by Shike et al in patients
who had undergone previous subtotal or total gastrectomy.52 It
has subsequently been more widely adopted as an access pro-
cedure for long-term EN but requires more specialized exper-
tise. Placement of DPEJ tubes is more technically challenging
than PEG or PEGJ tubes in performing the procedure itself and
identifying a safe window to avoid injury to other intra-abdom-
inal structures.53,54 Long-term complications for DPEJ are
similar to PEG tubes and include enterocutaneous fistulas,
enlarged tracts with excessive leakage, infections surrounding
the tube, and BBS.50
Typically, jejunostomy tubes are smaller in diameter, which
predisposes them to occlusion at a greater rate than percutane-
ous gastrostomy tubes. In 1 large retrospective study, jejunos-
tomy tubes were inferior to gastrostomy tubes, requiring more
frequent replacement due to occlusion and dislodgment in
patients receiving HEN. In this study, the average number of
jejunal tube replacements per 1000 days was 4 times the num-
ber of gastric access devices (3.2 vs 0.8 tube changes per 1000
days).32 Currently, it is not recommended by guidelines from
the European Society for Clinical Nutrition and Metabolism to
replace jejunostomy tubes routinely.55 However, with increased
rates of occlusion or clogging, it is likely that jejunostomy
tubes (percutaneous and surgical tubes) will require earlier and
more frequent monitoring and replacement as compared with
gastrostomy tubes.
Low-profile or skin-level tubes for gastrostomy or jejunos-
tomy access are particularly useful in the HEN setting. Such
devices may be preferable in a high-functioning and ambulat-
ing independent adult, the agitated patient with altered mental
status prone to tube dislodgment, or the highly active pediatric
population.
Surgical Access Procedures
Surgical approaches to long-term enteral feeding access were
the mainstay of access prior to the aforementioned endoscopic
techniques. The formation of serosal lined tracts from the stom-
ach to the anterior abdominal wall as described by both Stamm
and Witzel prior to the 20th century is a technique that is still
used today.35 Typically, open or laparoscopic gastrostomy or
jejunostomy tubes are placed in patients in whom percutaneous
tubes are unable to be placed or are contraindicated. Such cases
include patients with obstructing oropharyngeal or esophageal
lesions that do not allow for safe passage of an endoscope or
patients for whom there is concern regarding anatomic struc-
tures overlying the stomach that compromise the ability to
obtain a safe tract from the abdominal wall to the stomach. The
most common open surgical technique for long-term gastric
access is the Stamm gastrostomy. Laparoscopic modification of
the Stamm technique is commonly performed. Open and lapa-
roscopic jejunostomy techniques are similar to those for gas-
trostomy.2 Technical details, described briefly here, involve
identifying the target organ via a laparotomy or laparoscopic
approach. The Stamm gastrostomy utilizes circumferential
purse-string sutures to secure the tube within the lumen. The
serosa of the stomach or jejunum is generally then sutured to
the abdominal wall (although this component was not part of
the original description). The Witzel technique involves creat-
ing a serosal tunnel as well as an abdominal wall tunnel through
which the tube passes. There is great variation for whether the
target organ is sutured to the abdominal wall, and, anecdotally,
the Witzel gastrostomy is ideal in cases where the stomach can-
not be placed in apposition with the abdominal wall (eg, a rem-
nant stomach following gastric bypass). These details are
relevant when attempting to replace an inadvertently dislodged
tube in the early postoperative setting, as Witzel tubes are much
more difficult to replace blindly due to the elongated tract as a
result of the tunnel and they generally require radiologic assis-
tance.35 As is the case with percutaneous access devices, combi-
nation gastrojejunal tubes achieve access through the stomach
with the distal portion extending into the lumen of the jejunum,
providing multiple access points and potential simultaneous
gastric decompression and jejunal feeding. With regard to lapa-
roscopic vs open techniques in access placement, 1 study dem-
onstrated reduced abdominal wall complications and peristomal
leakage in the laparoscopic group (30%) vs the open technique
(89%) in the HEN setting.56
Conclusion
Long-term enteral access is essential in providing nutrition to
patients who are unable to meet energy or protein requirements
by volitional intake alone in the home setting. Multiple options
exist in achieving enteral access, and an individualized approach
is appropriate dependent on patient characteristics. While the
development of minimally invasive techniques in the establish-
ment of enteral access has simplified the process, long-term
complications remain similar in nature and frequency. Dedicated
multidisciplinary teams and engaged well-educated patient
populations are essential in optimizing outcomes in the HEN
6 Nutrition in Clinical Practice XX(X)
setting. Complications of enteral access will be encountered by
a variety of healthcare workers at the various points in the
healthcare system. For this reason, a foundational knowledge
regarding the management of access tubes is essential for all
those who may at some point be involved in the care of HEN
patients.
Statement of Authorship
All authors contributed to the conception/design of the review; all
authors contributed to acquisition, analysis, or interpretation of the
data; all authors drafted the manuscript; all authors critically
revised the manuscript; and all authors agree to be fully account-
able for ensuring the integrity and accuracy of the work. All
authors read and approved the final manuscript.
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