“Gastrostomy, duodenostomy and jejunostomy nursing responsibilities”

- Assess tube placement by aspirating stomach contents and checking the pH of

aspirate to determine gastric or intestinal placement. A pH of 5 or less indicates
gastric placement the pH is generally 7 or higher with intestinal placement.
- Inspect the skin surrounding the insertion site for healing, redness, swelling, and
the presence of any drainage. If drainage is present, note the color, amount,
consistency, and odor.
- Assess the abdomen for distention, bowel sounds, and tenderness.
- Until the stoma is well healed, use sterile technique for dressing changes and
site care. Clean technique is appropriate for use once healing is complete.
- Wearing clean gloves, remove old dressing. Cleanse the site with saline or soap
and water, and rinse as appropriate.
- Pat dry with 4X4 gauze pads, and allow to air dry. Apply Stomadhesive, karaya,
or other protective agents around tube as needed to protect the skin.
- Redress the wound using a stoma dressing or folded 4X4 gauze pads.
- Irrigate the tube with 30 to 50 mL of water, and clean the tube inside and out as
indicated or ordered. Soft gastric tubes may require cleaning of the inner lumen
with a special brush to maintain patency.
- Provide mouth care or remind the client to do so. When feedings are not being
taken orally, the usual stimulus to do mouthcare is lost. In addition, salivary fluids
may not be as abundant, and oral mucous membranes may become dry and
cracked
- If indicated, teach the client and family how to care for the tube and feedings.
Refer to a home health agency or visiting nurse for support and reinforcement of
learning
 Instruments

Gastrostomy Tube (G-Tube)

Jejunostomy Tube (J-Tube)

Duodenostomy Tube
Gastrostomy Procedures

There are three methods for inserting a G-tube:

- The percutaneous endoscopic gastrostomy (PEG)

- Laparoscopic technique

- An open surgical procedure

PEG Procedure

The PEG procedure, which is the most common technique, uses an endoscope (a thin,
flexible tube with a tiny camera and light at the tip) inserted through the mouth and into
the stomach to guide the doctor's positioning of the G-tube.

After the endoscope is in place, and the right location is found, a small cut is made in
the skin over the stomach. A hollow needle is inserted through the cut and into the
stomach. A thin wire is then passed through the needle and grabbed by a special tip on
the end of the endoscope. The endoscope pulls the wire through the stomach, up the
esophagus, and out through the mouth. This wire will be used as a guide to bring the G-
tube into its proper position.

Next, a G-tube is attached to the wire where it exits the mouth. The wire is then pulled
back out from the abdomen, which brings the G-tube down into the stomach. The G-
tube is pulled until its tip comes out of the small cut in the abdomen, after which the
endoscope and wire can be removed. A tiny plastic device, called a "bumper," holds the
G-tube in place inside the stomach.

Laparoscopic Procedure

In the laparascopic technique, an incision is made in the umbilicus, or belly

button, and a blunt-tipped needle is passed into the abdominal cavity. Then carbon
dioxide gas is used to expand the abdominal area during the procedure so the surgeon
can have a clear view of the organs.

Next, a wire is threaded through the needle and the G-tube is guided along the
wire into the stomach with the help of small instruments inserted through other small
incisions. Stitches and pressure from a tiny balloon are used to keep the stomach in
place against the abdominal wall.

Open Surgery

In the open surgical technique, incisions are made in the middle or on the left
side of the abdomen and through the stomach. A small, hollow tube is inserted into the
stomach and the stomach is stitched like a cuff around the tube. The stomach is then
attached to the abdominal wall with stitches to keep it secure. A tiny balloon holds it in
place within the stomach.

Duodenostomy Procedure

Tube duodenostomy is a simple technique, does not involve an anastomosis and

is easy to perform. After mobilization of the right colon and exposure of the lateral and
anterior walls of the duodenum to provide good visualization, the extent of the defect is
ascertained. A 20F Malencot's catheter is inserted into the duodenum to decompress
the lumen.

To prevent gastric emptying to the duodenum a pyloric exclusion procedure may

be added or a draining gastrostomy tube may be placed. Finally, a feeding jejunostomy
is placed for enteral nutritional support. The duodenal drain should be left in place for a
minimum of 6 weeks in order for a defined track to develop
Jejunostomy Procedure

Jejunostomy is a surgical procedure by which a tube is situated in the lumen of

the proximal jejunum, primarily to administer nutrition. There are many techniques used
for jejunostomy: longitudinal Witzel, transverse Witzel, open gastrojejunostomy, needle
catheter technique, percutaneous endoscopy, and laparoscopy.

During the jejunostomy procedure, the interventional radiologist will puncture the
skin where the tube will be inserted, and then direct the needle under image guidance to
the small intestine. The needle may be attached to an anchor, which the interventional
radiologist will direct into the jejunum using a guidewire. To ensure there is enough
space for the tube, the tract will be expanded using dilators or tiny balloons, which the
interventional radiologist will insert using a separate guidewire.

The interventional radiologist will then insert a jejunostomy tube over the
guidewire, using fluoroscopy to confirm its position. Once it has been confirmed that the
tube is correctly placed, the interventional radiologist will remove the guidewires and
secure the tube to the skin using anchors.