Gastrostomy

One of the oldest gastric operations, gastrostomy was first performed in 1876. It is also one of the most commonly performed procedures, usually done for feeding purposes and less commonly for gastric decompression. A Foley, Pezzer, Malecot, or straight Robinson catheter may be employed. The most often used method now is percutaneous endoscopic gastrostomy (PEG), although a percutaneous procedure with fluoroscopic guidance also may be performed [46-49]. In the endoscopic technique, first described in 1979, a gastroscope is placed in the stomach and the stomach is fully inflated. The endoscopic light transilluminates the abdominal wall. An incision is made in the abdomen where the light is best seen. A needle is introduced into the stomach and a suture is passed through it, into the stomach. The suture is grasped with the snare of the endoscope and pulled out of the mouth. The end of the suture is tied to a modified 16F mushroom catheter. Traction is applied to the abdominal end of the suture and the tube is pulled down into the stomach and out of the abdominal wall [50].

The percutaneous fluoroscopic technique was first reported in 1981 [51], and the use of gastropexy devices (T fasteners) was described in 1986 [52]. Simply summarized, with this procedure the stomach is insufflated with air, usually via a nasogastric tube, and punctured under fluoroscopic guidance. A tract with serial dilatations is created over a guide wire, and the tube is then inserted. Although advocated by some, the use of T fasteners is controversial. The T fasteners provide a gastropexy that allows the tract to mature rapidly; moreover, peritonitis and intraperitoneal tube placement is avoided, and in case of tube dislodgment the tube can be easily replaced. The use of larger catheters, which are less likely to occlude, is facilitated by T fasteners. Details of this procedure are available elsewhere [47]. The fluoroscopic procedure is superior to the endoscopic one in terms of feasibility and can be performed in patients who have stenoses and/or tumors of the upper Gl tract (preventing the passage of an endoscope) and in obese patients (in whom transillumination of the abdominal wall is not possible). Intravenous sedation is also commonly avoided. Pull-type gastrostomy tubes (placed via an oral route) may also be inserted with radiological guidance [53].

In a small percentage of cases, a surgical approach may be necessary. In patients whose transverse colon and/or liver overlies the stomach or in those whose stomach is high in position under the ribs, the percutaneous methods are not possible. In patients with partial gastrectomies, the percutaneous techniques are more difficult and in some cases may not be successful. When gastrostomy is performed surgically, a gastropexy is done and the stomach is attached to the anterior abdominal wall with a few sutures. In patients who are likely to require long-term gastrostomy feeding, a permanent (Weasel) gastrostomy may be performed surgically. With the Weasel procedure, a seromus-cular tunnel is created between the stomach and anterior abdominal wall, and no gastropexy is done.

A variety of complications may develop after gastrostomy tube placement (Table 3.3) [54-56]. The complication rate is between 1% and

Table 3.3. Complications of gastrostomy.

Tube dislodgment or migration In peritoneal cavity In esophagus

Prolapsed into the duodenum or more distal bowel In stomach wall In anterior abdominal wall In colon

"Lost" (migration out of the stomach) Gastric outlet obstruction Small-bowel obstruction Bowel perforation Gastric ulcer Gastric volvulus Leakage into peritoneal cavity Peristomal leakage Gastric pneumatosis Hemorrhage Tube blockage Gastrocutaneous fistula

Gastrocolic fistula [percutaneous endoscopic gastrostomy (PEG) technique] Broken tubes Tube extrusion

Gastric perforation (PEG technique)

5%. An institutional evaluation and meta-analysis of the literature showed a higher success rate with radiological gastrostomy and less morbidity than with both PEG or surgery [57]. Complications are particularly common in the pediatric population [58-61]. Generally, tube position and complications are evaluated by injection of water-soluble material into the tube, although CT imaging can be helpful. The most common complication of gastrostomy is poor positioning of the tube, either from inadvertent misplacement or from migration. The tube may be identified in the peritoneal cavity, esophagus, colon, stomach wall, or anterior abdominal wall, or it may be prolapsed into the duodenum or more distal bowel (Figs. 3.46-3.52). The additional problem of bowel

Peg Tube Extravated Contrast
Figure 3.46. Gastrostomy tube in the peritoneal cavity. Supine view of the abdomen after injection of contrast into the gastrostomy tube shows malposition of the tube with the tip in the peritoneal cavity with extraluminal contrast.
Peg Tube Dye Peritoneal Space

Figure 3.47. Poor positioning of gastrostomy tube. Supine view of the abdomen after water-soluble contrast injection into the gastrostomy tube shows contrast within the stomach, with leakage of contrast into the peritoneal cavity. Portal venous gas is also identified secondary to ischemic bowel due to sepsis and hypotension.

Figure 3.47. Poor positioning of gastrostomy tube. Supine view of the abdomen after water-soluble contrast injection into the gastrostomy tube shows contrast within the stomach, with leakage of contrast into the peritoneal cavity. Portal venous gas is also identified secondary to ischemic bowel due to sepsis and hypotension.

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