Adequate nutrition implies food availability (absence of starvation), its adequate intake and proper utilization by the tissues for growth and energy. Malnutrition can arise when any of the aforementioned factors are affected either singly or in multiples. Again food intake by way of enteral    nutrition   is   ensured    by    swallowing     (oral, pharyngeal and oesophageal phases) (Badoe et al., 2000). Diseases affecting these pathway(s) can lead to dysphagia or aphagia and ultimately to malnutrition if there is no intervention by parenteral route. Excessive tissue utilization and dumping syndrome (Emido et al., 2020)  including  cardiac  cachexia (Wolfman and Stefan, 2010) are other ways malnutrition can occur despite food availability and its intake enterally.

The primary indication for enteral and parenteral feeding is the provision of nutritional support to meet metabolic requirements for patients with inadequate oral intake. Enteral feeding is usually the preferred method over parenteral feeding in patients with a functional gastrointestinal tract (GIT) due to the associated risks of the intravenous route, higher cost and inability of parenteral nutrition to provide enteral stimulation and promote the gut defense barrier (Alverdy et al., 1985; Deitch et al., 1990). Patients in developing countries with dysphagia grade 2 according to Mellow and Pinka (Ahmed et al., 2020; Levy et al., 2020) from chronic corrosive oesophageal stricture among other causes, who present with significant weight loss are usually offered open or laparoscopic  gastrostomy or jejunostomy to enable enteral feeding and weight gain before oesophageal reconstruction with colonic flap is carried out to establish normal GIT (Eze et al., 2014; Ezemba et al., 2014). The reasons for open gastrostomy in such patients are two folds, that is, high cost of parenteral nutrition and that enteric feeding can decrease the risk of bacterial translocation and corresponding bacteremia (Grant, 1988).

In other related conditions, the GIT may be functional, yet patients may not be able to achieve oral intake. Since gastric or jejunal feeding is the most common type of enteral feeding, such patients are provided with gastrostomy via endoscopic route (PEG or PEJ) (De Oliveira, 2016). A variety  of indications for such procedures avail and include but not limited to cerebrovascular accident, amyotrophic lateral sclerosis, cerebral palsy, head injury, prolonged coma and head-neck cancer (Melchail et al., 2001; Park et al., 1992).

The primary goal of enteral nutrition either by gastrostomy or jejunostomy whether open or close is not only to improve the patient’s survival and nutritional status, but also to improve their quality of life which is not necessarily correlated with nutritional improvement (Baeten and Hoeffnagels, 1992). Also the long-term survival rate of some patients is low due to their underlying disease and this needs to be considered when undertaking the procedure (Blomber et al., 2012).

This is a retrospective study spanning 12 years (2010-2021) evaluating the indications for gastrostomy and jejunostomy in two tertiary hospitals in South East Nigeria. The study was performed using the data which were obtained from the surgical ward and operation registers including the hospitals’ medical record department database. The data obtained were patients’ demography, types of gastrostomy, profile and clinical spectrum of indications for gastrostomy or jejunostomy. Others were challenges and outcome. Inclusion criteria were all patients offered either open/laparoscopic or closed/endoscopic gastrostomy or jejunostomy (PEG/PEJ). Those offered nasogastric tubes (NGT) alone for enteral   feeding   were  excluded  from  the  study. The   data  were analyzed using SPSS version 20 (Chicago).

Table 1 displays the age ranges of patients with open gastrostomy or jejunostomy. The age range of 41-50 was the highest while the least was the 81-90. Table 2 displays the age range of patients with close gastrostomy. Here the age range of 71-80 was the highest. Table 3 shows the distribution of indications for open gastrostomy. Here corrosive oesophageal stricture was the highest followed by oesophageal carcinoma. Table 4 shows the distribution of indications for close gastrostomy. Cebrovascular accident was the highest while the least was encephalitis. Table 5 shows the distribution of indications for open jejunostomy. Chronic oesophageal stricture with severe stenosis of the pylorus was the highest followed by GEJ tumours with greater involvement of the stomach. There was no percutaneous endoscopic jejunostotomy (PEJ) in the series reviewed.

Table 6 shows the distribution of complications of gastrostomy (both closed and open) and management protocol. For open gastrostomy, skin excoriation was the highest followed by tube blockage. Complications in general are more with open than closed, perhaps in relation to adaptation of Foley’s catheter for gastrostomy tube.

Figure 1a to c shows the Foley’s catheter, gastrostomy and PEG tubes. Foley’s catheter: sizes 28, 30 or 32 French Gauge, constituted the most readily available and cheapest material in use in developing countries like ours for gastrostomy.

Challenges

1. High cost of gastrostomy or PEG tube

2. Non-availability (not readily available)

3. Deflation of balloon (urethral catheter) à frequent dislodgment

4. Lack of equipment

5. No technical know-how (pediatric anesthetists and endoscopic/laparoscopic experts).

The emerging trend in gastrostomy in the present setting is PEG. The indications and the age ranges of patients treated in the envisaged period are as highlighted in Tables 2 and 4. In this study group, CVA was the commonest indication followed by oropharyngeal carcinoma. In other studies (Badoe et al., 2000; Emido et al., 2020; WWW.MacheKnife3.org/Scoringsystem/ dysphagia html), many other indications were highlighted. The trend here is that PEG constitutes less morbidity and mortality than surgical gastrostomy. The implication is to use laparoscopic GT in cases where PEG is contraindicated like chronic oesophageal stricture or tracheosophageal fistula or atresia. Laparoscopic GT is emerging in our center and in time to come, it will replace open G-T.

The complications of G-T, whether open or closed, encountered in the present study were listed in Table 6. Among them, skin excoriation was the highest complication followed by blockage. Other complications including the management procedures were stated. The types of food ranged from liquid to semisolid diet. The liquid diet included  tea,  fruit  juices  while  semisolid  diet included pap, custard and blenderized yam, rice, potatoes, etc. The process of allowing some patients or family care givers to do the feeding at home frequently led to blockage because enough water was not applied. Those on temporary feeding GT or jejunostomy were fed mainly with tea and pap. In similar studies, complications noted were classified into major (aspiration pneumonia, bleeding, bowel perforation, buried bumper syndrome, necrotising fasciitis) and minor (wound infection, peritonitis, tube blockage, gastric outlet obstruction and dislodgement) (Sealock and Munot, 2018).  In the course of review of the records, there was no documented data of any mortality arising as a result of institution of open gastrostomy or jejunostomy and PEG, other than the primary pathology that necessitated the gastrostomy or jejunostomy.

In our institution, open gastrostomy constituted the majority (76.4%) for two reasons: (1) the commonest indications are chronic oesophageal stricture of which PEG is contraindicated and (2) laparoscopic gastrostomy is emerging. The emerging trend of PEG and laparoscopic gastrostomy will conform our institution to international standard. However, the adaptation of appropriate sizes of Foley’s catheter as gastrostomy tube will continue to benefit some indigent patients especially those with nonfunctional gastrointestinal tract like grade 4 Mellow and Pinka  dysphagia from chronic oesophageal stricture,  advanced oesophageal cancer and oesophageal atresia.

The authors have not declared any conflict of interests.