Stomach: Gastrostomy

Surgical Gastrostomy

Laparoscopic Gastrostomy

  • Gastrostomy Placed Under Laparoscopic Guidance
  • Preformed Similar to Radiological Gastrostomy
  • Procedure:
    • Stomach is Anchored to the Wall with 3-4 T-Fasteners
    • Needle is Inserted at the Center of the T-Fasteners to Access the Stomach
    • A Guidewire is Passed through the Needle & the Needle is Removed
    • A Dilator is Passed over the Guidewire & Then Removed
    • The G-Tube is Then Passed Over the Guidewire & Wire is Removed
    • Finally the G-Tube is Secured with an External Bolster

Stamm Gastrostomy

  • Most Common Open Gastrostomy Procedure
  • Typically Used as a Temporary Procedure
  • Procedure:
    • Place a Purse-String Suture in the Mid Anterior Wall of the Stomach
    • Make an Incision in the Middle of the Purse String Along the Longitudinal Axis
    • G-Tube is Then Inserted into the Stomach 10-15 cm
    • First Purse-String is Secured
    • A Second Purse-String is Used to Invaginate the First Purse-String
    • A Separate Incision in Made Through the Abdominal Wall About 3 cm Below Costal Margin & 3 cm Left of Midline and The Tube is Brought Out
    • The Stomach is Then Gastropexied to the Abdominal Wall Around the Tube
    • Finally the G-Tube is Secured to the Skin

Witzel Gastrostomy

  • Procedure:
    • Place a Single Purse-String Suture in the Mid Anterior Wall of the Stomach
    • Make an Incision in the Middle of the Purse String Along the Longitudinal Axis
    • G-Tube is Then Inserted into the Stomach
    • Tube is Then Laid Against the Stomach
    • Additional Sutures are Placed to Imbricate the Gastric Wall Over the Tube
    • The G-Tube is Then Brought Through the Skin
    • Stomach is Gastropexied to the Abdominal Wall
    • Finally the G-Tube is Secured to the Skin

Janeway Gastrostomy

  • Mucosa Lined Permanent Procedure
  • Procedure:
    • A 5-6 cm Rectangular Flap is Made with Its Base Along the Greater Curvature
    • Edges of the Rectangular Flap are Approximated to Form a Tube
    • A G-Tube is Inserted Through the Approximated Flap
    • The G-Tube is Then Brought Out Through the Abdominal Wall
    • The Anterior Gastric Wall is Gastropexied to the Abdominal Wall

Percutaneous Endoscopic Gastrostomy (PEG)

General Considerations

  • Gastrostomy Tube Is Placed Through the Skin with Endoscopic Guidance/Assistance
    • Requires Both a Surgeon & Endoscopist
  • Compared to Surgical Gastrostomy Tube: Similar Morbidity & Mortality

Contraindications

  • Absolute Contraindications:
    • Massive Ascites
    • Unable to Pass Endoscope into Stomach
    • Interposed Organs (Liver or Colon)
    • Hemodynamic Instability
    • Sepsis
    • Uncorrectable Coagulopathy
    • Abdominal Wall Infection at Access Site
    • Past Total Gastrectomy
    • If Being Used for Feeding: Severe Gastroparesis or Gastric Outlet Obstruction
  • Relative Contraindications:
    • Esophageal Cancer (Compromise Future Gastric Conduit)
    • Hepatosplenomegaly
    • Peritoneal Dialysis
    • Portal Hypertension with Gastric Varices
    • Past Partial Gastrectomy

Classic “Pull Technique” (Ponsky)

  • Start with Endoscopy into Stomach to Ensure no Anatomic Obstacles & Insufflate
  • Gain Access Through Abdominal Wall
    • Choose Site on Abdominal Wall by Transillumination from Endoscope, Should Be About 2 cm Below Costal Margin
    • Confirm Site by Endoscopically Visualizing Gastric Wall Indentation While Finger Presses on Site
    • A Needle with Saline Syringe Under Negative Pressure is Inserted Through the Abdominal Wall into the Gastric Lumen
      • Stool or Air Bubbles Before Entering the Stomach Indicated Bowel Passage
      • OK to Retry if See Air Bubbles First
  • Pull Looped Wire Through the Mouth
    • Snare is Placed Around the Needle
    • Soft Looped Wire is Inserted Through the Needle & Then Grabbed with the Snare
    • Endoscope is Removed, Pulling the Wire through the Mouth
      • The Distal End Will Still Protrude from the Abdominal Wall
  • Pull PEG Tube Through the Abdominal Wall
    • Wire Loop is then Secured to the PEG Tube
    • The Wire is Then Pulled Back Through the Abdominal Wall, Pulling the PEG Tube with It
    • Needle is Removed Once the Tube Hits the Gastric Wall
    • PEG Tube is then Pulled Through the Abdominal Wall Until the Internal Bolster Rests Along the Gastric Wall
    • Endoscope Reinserted to Confirm Position
  • Place the External Bolster and Cut the Tube to Size
    • Bolster Should Lie 1-2 cm from the Skin
    • Snug but Not Too Tight (Will Necrose Stomach Wall)

“Push Technique” (Sachs-Vine)

  • Initial Access Similar to “Pull Technique”
  • Pull a Guidewire Through the Mouth Instead of a Looped Wire
  • PEG Tube is Then Pushed Down Through the Mouth Over the Guidewire
  • Once Seen Emerging the Tube is Then Pulled Through the Abdominal Wall

“Introducer Technique” (Russel)

  • Endoscope Only to Insufflate & Observe
  • Initial Access Similar to “Pull Technique”
  • Guidewire Placed Through Needle & Needle Removed
  • Introducer with Outer Sheath Passed Over Guidewire Then Sheath and Introducer Removed
  • PEG Tube (Balloon Deflated) Passed Through Sheath
  • Sheath Then Pulled Away
  • Balloon Inflated & PEG Tube Appropriately Secured

PEG (Introducer Technique) 1

Complications

  • Infection
    • Most Common Complication
    • Give Prophylactic ABX
  • Dislodged Tube
    • Most Common Cause: Excessive Traction in Combative or Confused Patients
    • Initial Tx: Replace at Bedside
      • XR with Water-Soluble Contrast Through Tube to Confirm if < 2-4 Weeks or Any Concern for Intraperitoneal Placement
      • If Fails: OR Replacement (Emergent if < 2 Weeks)
      • *Some Advise Against Bedside Replacement if < 2-4 Weeks Old & Advise Letting the Tract Heal with New G-Tube Placement in a Few Days
  • Peristomal Leakage
    • More Likely with DM or Malnutrition with Poor Wound Healing
    • If Tract is Mature (> 4 Weeks) Can Remove Tube for 24-48 Hours to Allow Tract to Close Slightly
  • Tube Obstruction
    • Often Clogged with Tube Feeds or Medications
    • Prevention:
      • All Medications Should be Either Liquid Form of Dissolved in Liquid
      • Always Flush with ≥ 20-30 cc Saline/Water After Feeds or Medications
      • Never Use Bulking Agents Through the Tube
    • Tx: Flush with 60 cc Saline/Warm Water
      • Other Options: Pancreatic Enzymes, Specialized Gastrostomy Brush or Endoscopic Cytology Brush
  • Gastrocolocutaneous Fistula
    • During Initial Placement PEG Penetrates Through Interposed Colon Between Abdominal Wall & Stomach
    • Most Often Recognized After Removal & Replacement of the Original Tube
    • Presentation:
      • Sudden Onset Diarrhea – From Tube Feeds Entering Transverse Colon
      • Feculent Material in PEG Tube
      • Feculent Vomiting – From Retrograde Passage into Stomach
    • Diagnosis: UGI
    • Treatment: Removal of Feeding Tube to Allow Tract Healing
      • Laparotomy if Peritonitis or Signs of Leak

PEG Dislodged; Contrast Extravasation 2

Radiological Gastrostomy

Radiological Gastrostomy

  • Gastrostomy Tube is Placed Using Fluoroscopic Guidance in IR
  • Procedure:
    • First Insufflate Stomach Per a Nasogastric Tube
    • Stomach is Anchored to Wall with 3-4 T-Fasteners
    • Needle is Inserted at the Center of the T-Fasteners to Access the Stomach
    • A Guidewire is Passed through the Needle & the Needle is Removed
    • A Dilator is Passed over the Guidewire & Then Removed
    • The G-Tube is Then Passed Over the Guidewire & Wire is Removed
    • Finally the G-Tube is Secured with an External Bolster

References

  1. Toh Yoon EW, Kobayashi M. Percutaneous Endoscopic Gastrostomy in a Patient With Continuous Intrathecal Baclofen Infusion Therapy. Gastroenterology Res. 2017 Apr;10(2):132-134. (License: CC BY-NC-4.0)
  2. Soares da Silva MQ, Lederman A, Coelho da Rocha RF, Lourenção RM. Feeding tube replacement: not always that simple! Autops Case Rep. 2015 Mar 30;5(1):49-52. (License: CC BY-NC-3.0)