INTRODUCTION

Gastric tube placement is a common procedure for the delivery of supplemental or total enteral nutrition and for drainage in cases of distal obstructing masses. A number of approaches are available depending on the patient’s previous surgical history, comorbidities, and reason for requiring tube placement. Open gastrostomy placement by Stamm and Janeway techniques as well as percutaneous endoscopic gastrostomy (PEG) tube placement are addressed in this chapter. Most retrospective studies have shown little or no statistical difference in the complication rates between these procedures. The most serious complication reported is tube dislodgement, with all other complications falling into the minor category.¹ Reported overall complication rates range from 9% to 46%, in which a vast majority are minor complications.^1–5 Most steps discussed in this chapter are related to reducing risk of tube dislodgement in the early and late postoperative periods and reduction in risk of visceral injury during each procedure. Choosing to perform a Janeway gastrostomy with gastric stoma maturation can be the best choice in those cases in which early tube dislodgement is more likely, in cases of significant mental status changes, essentially avoiding all related and subsequent complications.

INDICATIONS

Open Gastrostomy Tube Placement

OPEN STAMM GASTROSTOMY

Upper Laparotomy

Intra-Abdominal Injuries with Midline Incision

To obtain access to and adequate exposure of the stomach, an upper midline is the standard incision of choice for an open gastrostomy tube placement. Occasionally, a left subcostal incision can be used. Complications related to laparotomy incisions are discussed in Section I, Chapter 7, Laparoscopic Surgery.

Mobilization of the Stomach and Lysis of Adhesions

Bowel Perforation

• Consequence

Leak from the injured stomach, small bowel, or transverse colon, leading to postoperative peritonitis. A minority of patients will have dense adhesions from previous surgery or a partially or completely intrathoracic stomach owing to paraesophageal hernia. The stomach will require adequate mobilization to allow the anterior portion along the greater curvature to approximate the anterior abdominal wall two fingerbreadths below the left costal margin without undue tension.

Grade 3/4 complication

• Repair

Two-layer suture repair of all full-thickness injuries. Single-layer suture repair of all serosal tears.

• Prevention

The position of the stomach must be fully visualized through an adequate fascial incision and any degree of herniation directly visualized. Sharp dissection should be used for lysis of adhesions and cautery avoided to reduce the risk of delayed thermal perforation.

Placement of the Pursestring Suture in the Anterior Stomach

Inadequate Suture Thickness

• Consequence

Tear of the gastric wall with pull-through of the suture. This can result in an immediate or delayed perforation in the stomach, allowing for potential leak if not repaired adequately. Suture that is visible through the serosal surface layer is too shallow, has a higher risk of tear, and should be replaced.

Grade 3 complication

• Repair

Two-layer repair and repositioning of the pursestring suture for a separate site of intended tube insertion.

• Prevention

Sutures should be placed to a seromuscular thickness by fully pronating the wrist and driving the needle perpendicular with an almost immediate supination of the wrist. If a seromuscular placement cannot be ensured, a full-thickness bite is adequate.

Gastrostomy in the Center of the Pursestring

Injury to the Posterior Wall of the Stomach

• Consequence

Immediate or delayed intra-abdominal leak through the posterior wall.

Grade 3/4 complication

• Repair

Two-layer suture repair from the posterior surface of the stomach requires exposure of the posterior stomach through a window into the lesser sac through the gastrocolic ligament.

• Prevention

Retract the anterior stomach wall with atraumatic forceps or Babcocks while creating the gastrostomy. The gastrostomy can also be made by opening the individual layers of the gastric wall, sequentially retracting each subsequent deeper layer. Avoid prolonged application of the cautery and using pressure on the tip of the cautery to create tension while making the gastrostomy.

Placement of the Gastrostomy Tube into the Stomach through the Anterior Abdominal Wall

Tube Damage/Inadequate Closure of Pursestring Sutures

• Consequence

Immediate or delayed failure of the balloon to retain inflation. Immediate or delayed leak from or around the tube. An early consequence of deflation of a balloon, if used, is bleeding from the gastrotomy owing to lack of tamponade. Leak from the tube early through a hole in the tube can result in extravasation of tube contents into the abdomen or along the abdominal wall tract leading to peritonitis or localized fasciitis, respectively.

Grade 1/2 complication

• Repair

After passing the tube through the tract in the abdominal wall, test a balloon, if used, or flush the tube with saline and look for a leak. A dilute solution of methylene blue can also be used if damage to the tube is suspected but unclear with saline flush.

• Prevention

After the tract in the anterior abdominal wall is made with a tonsil clamp use a broader Kelly clamp to pull the tube through the tract. Also clamp the entire tube rather than feeding the lumen of the tube onto one tine of the clamp to avoid damage to the tube as it is being pulled through the layers of the abdominal wall.

Suturing the Anterior Stomach to the Peritoneum around the Tube Tract and Insertion Site

Tension and Tearing of Stomach around Gastrostomy Site/Loss of Tube Tract

• Consequence

Leak around the tube insertion site. Slippage of stomach away from the anterior abdominal wall or tube from within the stomach. Early, this can lead to free intra-abdominal leak of gastric contents and inability to replace the tube by fluoroscopic guidance.

Grade 3 complication

• Repair

Fluoroscopic guidance to replace a slipped tube may be possible 3 to 5 days after placement. Seldinger technique can be used to identify the tract and determine whether access to the stomach is present. If access to the stomach cannot be verified, open exploration and replacement of the tube or repair of the original gastrotomy will be necessary.

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