1. Enteral access will be established ideally within 24 hours of admission to the Role 3 or higher Medical Treatment Facility (MTF).1-3,5,6

2. If the patient will be taken to the operating room within 24-48 hours of arrival for laparotomy procedure, a naso-jejunal feeding tube (NJFT) should be placed while the patient is in the operating room (OR). While in the civilian setting in intubated patients there is no difference in outcomes when comparing EN via the naso-jejunal versus gastric route, however enteral access distal to the stomach is recommended, particularly in those patients at risk for aspiration. Due to the intermittent nature of gastric feedings and the need for frequent holdings for patient aeromedical evacuation and/or procedures in the combat environment, it is emphasized that this is NOT the preferred initial method of feeding these patients. However if this is not practical, in many patients it is acceptable to initiate gastric EN. 1,3

3. If the patient is not a candidate for operative placement, use whatever means available to place a feeding tube. (e.g., endoscopic, fluoroscopic, etc.).

4. If unable to place a NJFT, consider the use of an Oro-Gastric (OG) or Naso-Gastric (NG) tube, with intent to discontinue enteral feeds 6 hours prior to transfer.

5. If prolonged enteral feeding (>4 weeks) is expected, then placement of a surgical feeding tube should be considered. A gastrostomy, jejunostomy, or combined gastro-jejunostomy should be considered prior to final closure of any open abdomen patient, and the risks versus benefits of each option along with the existing patient gastrointestinal anatomy will dictate the choice of surgical feeding access. 1-6