Chapter 20: Gastrostomy

INDICATIONS

Gastrostomy is commonly used as a temporary procedure to avoid the discomfort of prolonged nasogastric suction following such major abdominal procedures as vagotomy and subtotal gastrectomy, colectomy, and so forth. This procedure should be considered during abdominal operations in poor-risk or elderly patients prone to pulmonary difficulties or in whom postoperative nutritional difficulties are anticipated.

Gastrostomy is considered in the presence of obstruction of the esophagus, but it is most frequently employed as a palliative procedure in nonresectable lesions of the esophagus or as the preliminary step in treating the cause of the obstruction. A permanent type of gastrostomy may be considered for feeding purposes in the presence of almost complete obstruction of the esophagus due to nonresectable malignancy. The type of gastrostomy depends on whether the opening is to be temporary or permanent.

As a temporary gastrostomy, the Witzel or Stamm procedure is used frequently and is easily performed. A permanent type of gastrostomy, such as the Janeway procedure and its variations, is best adapted to patients in whom it is essential to have an opening into the stomach for a prolonged period of time. Under these circumstances, the gastric mucosa must be anchored to the skin to ensure long-term patency of the opening. Furthermore, the construction of a mucosa-lined tube with valve-like control at the gastric end tends to prevent regurgitation of the irritating gastric contents. This allows periodic intubation and frees the patient from the irritation of a constant indwelling tube.

PREOPERATIVE PREPARATION

If the patient is dehydrated, fluid balance is brought to a satisfactory level by the intravenous administration of 5% dextrose in saline. Because these patients may be malnourished, parenteral nutrition may be warranted. Blood transfusion should be given if there is evidence of symptomatic, physiologically significant secondary anemia or for a hemoglobin concentration of less than 7 g/dL. No special preparation is required for the temporary gastrostomy because this is usually performed as a minor part of a primary surgical procedure.

ANESTHESIA

Because some patients requiring a permanent gastrostomy are both anemic and cachectic, local infiltration or field block anesthesia is usually advisable. There is no special indication for anesthesia for a temporary gastrostomy because the procedure is usually considered technically minor and precedes closure of the wound of a major operation.

POSITION

The patient lies in a comfortable supine position with the feet lower than the head so that the contracted stomach tends to drop below the costal margin.

OPERATIVE PREPARATION

Prophylactic antibiotics are administered intravenously. The skin is prepared in the routine manner. Sterile drapes are applied according to the surgeon’s specifications, and then a time-out is performed.

INCISION AND EXPOSURE

A small incision is made high ...