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Tube feeding systems

If you're no longer able to swallow or you are otherwise unable to get the food you need, then you need to get nutrition somehow. This is when you should consider alternative ways of eating. This may be through a nasal tube, a gastronomy (G) tube, a button that is flush against the stomach, or the G tube plus a tube that goes to your small intestine (jejunem).

If you need nutrition long-term and you have sufficient stomach function, your doctor will probably want you to get a Percutaneous Endoscopic Gastronomy (PEG) tube or button. These are the most common form of feeding tubes among oral cancer patients. The surgery for placement of a PEG is easy, involves little risk, and takes no longer than 20 minutes.

PEG tubes are placed--after you've been sedated--with the aid of an endoscope (hence the word "Endoscopic" in the name). The endoscope is a small tube, with a light and camera on the end, which allows surgeons to see into the esophagus and stomach. The scope enters through the mouth, and continues down the throat to assist in guiding placement of the tube through the wall of the stomach. This method allows the doctor to choose the best location in the stomach to place the PEG tube. Once a location for the tube is chosen, a small incision is made on the outside abdomen into the stomach. The surgeon then pushes a fine wire through the opening and attaches it to the endoscope. With wire attached, the doctor pulls the scope back up through your esophagus and out of your mouth. The endoscope then gets unattached, the new PEG tube is attached to the wire, and the wire gets pulled back down the esophagus into the stomach and out of the incision. External pieces, such as the bumper that prevents the tube from getting pushed into your stomach, will be added to the tube along with bandages around the site. You will wake up sore from the procedure. This is expected (you did just get a stab wound from the surgeon!) and will last a few days, but typically heals very quickly.

There are generally two methods that are used in order to prevent the PEG tube from being pulled out of the stomach. The two systems that prevent dislodgment of the tube are the 'pigtail' or 'balloon' type tubes. With the pigtail system, a small wire within the tube is pulled from the exterior end of the tubing causing the portion within the stomach to curl up, giving it the 'pigtail' name. The second system employs a very small balloon at the end of the tube, which gets inflated with sterile water within the stomach after insertion. Both are effective ways to prevent dislodgment of the tube.

Gastric tubes need changing at different frequencies, depending on the type of tube, how much care you give it, and luck. Usually, tubes secured using a balloon have to be changed more often (in some cases, every few weeks) because of balloon degradation. These types of tubes are generally easier to change, with no anesthesia or distress. The balloon can be deflated through a special water port by your doctor, a nurse or even yourself. Then, the tube is pulled out of the stomach with minimal discomfort. A new tube gets pushed in through the same incision, and the balloon is inflated through the water port to hold the tube in place.

Non-balloon PEG tubes could easily last two to three years, or more, before needing to be changed. Removal of the old tube requires cutting the wire that created the pigtail, allowing the tube to slip out easily from the stomach. A new tube is inserted through the same incision and the pigtail wire curled externally to secure it. NOTE: once the PEG tube is removed, a new tube needs to be placed as soon as possible because the hole into your stomach begins to close up and heal over almost immediately.

PEG tubes come in various diameters measured using the 'Fr' scale, which stands for 'French'.  Catheters are also measured using this scale, where 1 Fr = .33mm. So, the bigger the Fr number, the larger the diameter of your tube. Most adult PEG tubes run between 16 and 24 Fr.

A more "low profile" option to consider is getting a button, rather than a PEG tube. The button sits right up against the skin, so it wouldn't show beneath your clothes when you're out in public. When eating, you need an extension tube that plugs into the button, allowing you to conduct normal tube feedings. Buttons do look nicer and are easier to wear than the bulky PEG tube, however it can be difficult for some patients to plug in the extension set. Also, buttons have more moving, non-replaceable parts, like valves, that can fail, so buttons tend to need replacing more often than tubes. It all comes down to personal preference on whether you decide to use a tube or a button.

Two other types of tubes that are a bit more uncommon for oral cancer patients are J tubes and nasal tubes. J, or jejunal, tubes run straight into the small intestine. They become necessary when the patient is unable to fully digest food in their stomach. The J tube could be percutaneous, meaning it comes straight out of the jejunem via an incision, like the PEG. Alternatively, they can run alongside the G tube (what's called a GJ tube) through the same incision into the stomach. While the G tube stops in the stomach, the J tube keeps going into the small intestine. Any patient unable to swallow who has a J tube will also need a G tube because most medicines are absorbed in the stomach and the G tube also makes it possible to vent gases and aspirate stomach contents. Plus, free water is often given through the G tube.

Another type of feeding tube system is the nasal tube. These are uncommon for oral cancer patients, but they may be used if you need nutrition for a short period of time. Nasal tubes are generally very thin and travel up through one of your nostrils, down the esophagus, and into the stomach (NG tubes) or all the way to your small intestine (NJ tubes). These tubes are usually held in place just with a bit of surgical tape on the face. Nasal tubes are actually one of the oldest types of feeding tubes--commonly used since as early as the 18th century.

The placement of the nasal tube is a very simple procedure; often done by nursing staff rather than doctors. Typically the patient is given nasal spray to numb the sinuses and back of the throat. The tube is lubricated, guided up the nostril and down until it reaches the top of the esophagus. At this point, the patient is commonly asked to swallow to help guide the tube down the right passage, and it's pushed the rest of the way to the stomach. The tube gets held in place with tape and it's ready for food. Nasal tubes can feel strange and uncomfortable and take some getting used to. Patients often report that the tubes make their throats sore (even creating callouses and tenderness in the area), feel invasive, and obtrusive. Also, patients feel much more conspicuous with a tube on their face and the tubes can get accidentally pulled out easier. For these reasons, NG and NJ tubes are generally short-term methods to get nutrition.