Open Gastrostomy - Catalyst

Open Gastrostomy
Jeffrey R. Avansino, MD and Matthias Stelzner, MD
he principal concept of a gastrostomy was first de-
T scribed by Egeberg, a Norwegian army surgeon, in
1837, with the first operation being performed two years
later. 1'2 Since that time, many modifications and variations to the procedure have been added. 3-8 The purpose of
a gastrostomy is to create a fistulous connection between
the stomach and the outer surface of the abdominal cavity. Direct access to the lumen of the stomach can be
either temporary or permanent. A temporary gastrostomy
is based on a tract with a serosal lining. A permanent
fistula is a mucosal tract connecting the gastric lumen to
the skin that prevents spontaneous closure without catheter placement. Here we describe the operative techniques for a Stamm gastrostomy and a stapled tube gastrostomy.
Indications
Temporary gastrostomies are useful in patients in whom
prolonged nasogastric intubation is anticipated. A gastrostomy provides greater patient comfort and mobility
than a nasogastric tube with procedures resulting in delayed gastric emptying, such as pylorus-sparing pancreatoduodenectomy. Patients are at a decreased risk of
gastroesophageal reflux because the gastroesophageal
junction is not stented by a nasogastric tube. The absence
of a nasogastric tube also eliminates the risk of a sinus
infection, because the tubing does not compromise nasal
sinus ostia.
Temporary gastrostomies can be used to temporarily
feed patients who cannot ingest food, such as patients
with cancer of the oropharynx, larynx, or esophagus (Fig
1). Gastric nutrition is more physiologic than nutrition
delivered distally in the alimentary tract. Osmotic load is
decreased after mixing with gastric juices, and the alimentation provides mucosal protection by buffering the gastric acid.
Another form of temporary gastrostomy, percutaneous
endoscopic gastrostomy (PEG), is indicated for long-term
alimentation in patients with progressive neurologic disease and psychomotor retardation. This method obviates
the need for general anesthesia and laparotomy and reduces patient discomfort. However, it requires advancement of a gastroscope through the esophagus into the
stomach and thus cannot be used in patients with impassable pharyngeal or esophageal obstructions. Specific details of this procedure are discussed elsewhere in this
issue. Temporary gastrostomy procedures should generally be avoided in patients with massive ascites or severe
malnutrition, in whom tract formation is impaired, resulting in a potential leak. Gastrostomies placed in patients with gastric paresis and compromised swallowing
mechanisms can predispose to reflux, aspiration, and
pneumonia.
Permanent gastrostomies are used less frequently than
temporary gastrostomies. Elderly patients with unresectable esophageal or oropharyngeal cancers or other inoperable obstructions may benefit from this procedure. Permanent gastrostomies have the advantage of requiring a
feeding tube only when alimentation is being introduced.
Between feedings, the patient only needs to keep the external stoma covered.
Preoperative Preparation
The patient should receive a preoperative evaluation including appropriate laboratory evaluation (electrolytes,
complete blood count, prothrombin time, and partial
thromboplastin time), chest radiograph, and electrocardiogram. The patient is kept NPO for eight hours before
surgery and given maintenance fluids overnight.
Dehydrated and malnourished patients should be appropriately hydrated before gastrostomy procedures.
When a temporary gastrostomy is performed as a part of
another gastrointestinal surgical procedure, no special
preparation is required.
Anesthesia
i From the Department of Surgery, University of Washington, VA Puget Sound
Health Care System-Surgical Service, Seattle, WA.
Address reprint requests to: Matthias Stelzner, MD, Associate Professor of
Surgery, Department of Surgery, University of Washington, VAPSHCS-Surgical
Service (112), 1660 South Columbian Way, Seattle, WA 98108. E-mail:
stelzner@u.washington.edu.
Copyright 9 2001 by W.B. Saunders Company
1524-153X/01/0304-0007535.00/0
doi:10.1053/otgn.2001.27756
As an isolated procedure, the gastrostomy can be performed with local infiltration or field block anesthesia.
This is particularly advisable in patients with cardiovascular comorbidities, who would be at increased risk with
general anesthesia. No special considerations are required
in patients receiving a gastrostomy at the end of a longer
gastrointestinal resection (e.g., pancreatectomy).
Operative Techniques in General Surgery, Vol 3, No 4 (December), 2001: pp 251-257
251
252
Avansino and Stelzner
SURGICAL TECHNIQUE
1 A 56-year-old man presented with mild stridor and increasing complaints of dysphagia
and a weight loss of 50 pounds over the past six months. The patient's past medical history is
significant for radiation therapy to the neck as a child. The cross-sectional magnetic resonance scan of the neck shows a 6-cm large mass at the left thyroid lobe with invasion of the
larynx and displacement of the hypopharynx, larynx, and trachea and extension to the
esophagus. Biopsies of the mass confirmed the suspicion of an anaplastic thyroid carcinoma.
253
Open Gastrostomy
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9 .~X-%-~'.-.J
Site of gastrostomy
at greater curvature
of stomach
Line of incision in
abdominal wall
H
. .'"'"
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2 In preparation for a temporary gastrostomy, the patient is placed in
the supine position and prepped and draped in the standard sterile fashion. A transverse incision is made in the mid-left rectus abdominis region.
Dissection to the peritoneal cavity is performed with electrocautery. The
gastrostomy tube is brought out through a stab wound, about 5 cm
cephalad to the incision and inferior to the left costal margin. The stab
incision must be placed so that the underlying stomach can be attached to
the abdominal wall without tension.
254
Avansino and Stelzner
Greater curvature of stomach incised with electrocautery
3 The mid-anterior gastric wall is grasped with Babcock forceps and approximated to
the abdominal wall to estimate the amount of tension. Using electrocautery, a small,
full-thickness gastrotomy is made into the anterior wall at the transition between the
corpus and antrum. The pursestring sutures are then tied sequentially while invaginating
the gastrotomy opening.
j j
r
84
G~
4 A 16-20 French mushroom-tipped catheter is placed through the gastrotomy,
and the inner suture is tied. Subsequently the tube is pushed inward as the outer
suture is tied, producing an inverted valve of gastric wall, with a serosal lining for the
tube tract. After the gastric corpus is delivered into the operative field, two concentric
2-0 silk pursestring sutures are placed around the catheter entry site. One must make
certain that there is no submucosal bleeding, as this is a common complication of this
procedure.
255
Open Gastrostomy
~.~trn~tnmv
h ~h~ n~ ~lla~ through
abdominal
5 The temporary gastrostomy tube is pulled through the anterior wall with
a Schnitt or Kelly clamp. The gastric wall is affixed to the peritoneal surface
of the anterior abdominal wall with four 3-0 silk holding stitches. The suture
is passed through the peritoneum and posterior rectus sheath aponeurosis of
the abdominal wall and the serosa, muscularis, and submucosa layers of the
stomach. Care should be taken to create a tension-free attachment.
..................
ed and
iI wall
6 As shown here in cross-section, inversion of the gastric mucosa
about the gastrostomy tube and fixation to the abdominal wall creates
a seal. The gastrostomy tube is secured upward and attached to the
abdominal skin with a nonabsorbable 2-0 nylon holding suture and
tape.
256
Avansino and Stehner
7 Multiple variations of the permanent gastrostomy procedure exist. A
permanent gastrostomy can be easily constructed using a gastrointestinal
anastomosis (GIA) stapling device. We prefer the illustrated technique. The
stomach is exposed as described with the temporary gastrostomy. The
stomach is grasped with Babcock forceps, and the GIA stapling device is
fired across and then along the greater curvature. A gastric tube is created
based on the greater curvature. The cut edge is oversewn with 3-0 polyglyconate or 2-0 silk Lembert sutures to invert the staple line. The gastric tube
is brought through the abdominal wall similar to an enterostomy, and the
abdomen is closed. The tip of the gastric tube is amputated and attached to
the skin with absorbable suture, and a catheter is inserted.
257
Open Gastrostomy
Postoperative Care
When the gastrostomy is used for gastric decompression,
electrolytes are replaced and the tube is clamped and
discontinued when bowel function returns. If the stomach empties normally, the tube can be used for administration of alimentation and medication. Typically, a period of 24 hours is required before the gastrostomy can be
used for this purpose. The tube should be irrigated once
or twice a day to prevent occlusion. If the tube is inadvertently removed, then a Foley catheter or red rubber catheter should be placed in the tract to maintain patency
until a more permanent tube can be placed. After replacement of the feeding tube, a contrast study is obtained to
verify tube placement in the stomach.
Gastrostomy tubes may be removed as early as 3 - 4
days, because adequate peritoneal sealing occurs rapidly.
In a patient with wound healing problems, the tube
should be left in place longer. The tube is removed simply
by pulling it out. This is associated with minimal patient
discomfort. The tract closes spontaneously within a few
days in most patients. Very rarely, a gastrocutaneous fistula persists and operative closure becomes necessary.
REFERENCES
1. Maingot R: Aetiology, pathology, and diagnosis of carcinoma of the
stomach, in Maingot R (ed): Abdominal Operations (ed 6). New
York, NY, Appleton-Century-Crofts, 1974, pp 531-592
2. Walker LG Jr: L. L Staton, M.D. and the first successful gastrostomy in America. Surg Gyn Obstetr 158:387-388, 1984
3. Beck C, Carrell A: Demonstration of specimens illustrating a
method of formation of a prethoracic stomach. Ill MedJ 7:463-464,
1905
4. Janeway HH: Eine neue Gastrostomiemethode. Mfinch Med
Wochenschr 60:1705-1707, 1913 [In German]
5. Jianu A: Gastrostomie und Osophagoplastik. Dtsch Chir 118:383390, 1912 [In German]
6. Nyhus LM, McDade WC, Condon RE, et al: Further experience
with jejunal gastrostomy. Arch Surg 83:864-868, 1961
7. Verneuil A: Observation de gastrostomie pratiquee avec succes
pour un retrecessement cicatriciel infranchisable de l'oesophage.
Bull Acad Med Paris 25:1023-1038, 1876 [In French]
8. Webster MW Jr, Carey LC, Ravitch MM: The permanent gastrostomy. Use of the gastrointestinal anastomotic stapler. Arch Surg
110:658-660, 1975