Gastrostomy: Endoscopic, Laparoscopic, and Open
Jeffrey L. Ponsky
Melissa S. Phillips
Indications/ContraindicationsThe importance of nutritional support has been shown to decrease infectious complications, lead to better wound healing, and improve overall surgical outcomes. The most common approach for enteral access is through placement of a gastrostomy tube which can be placed through a percutaneous, laparoscopic, or open approach. Dysphagia and aspiration are common indications for gastrostomy tube placement and can result from multiple pathologies. Despite the approach taken, gastrostomy tube placement for nutritional support requires a functional gastrointestinal tract.
Neurologic disease: This is the most frequently encountered indication for gastrostomy placement. Underlying neurologic pathology may range from an acute onset cerebrovascular event to those with a more slowly progressive process such as multiple sclerosis or amyotrophic lateral sclerosis. Additional indications may include severe dementia, hypoxic encephalopathy, and meningitis.
Trauma: In addition to direct facial trauma, many people who undergo multisystem trauma require placement of a temporary gastrostomy for support during the recovery process. Patients with a high percentage of total body surface area burns may require supplemental nutritional support secondary to the induced state of catabolism.
Aerodigestive malignancies: The indication for gastrostomy may be a direct result of the patient’s primary malignancy, as would be the case in a nearly obstructing esophageal cancer or in dysphagia induced by a squamous cell carcinoma of the tongue. It may be, however, independent of the primary malignancy, being placed as a method for maintaining supplemental nutritional support during chemotherapy or to assure adequate caloric intake following a planned surgical resection.
Pediatric indications: Pediatric patients have additional indications, such as congenital malformations, enzymatic deficiencies, or congenital neurologic syndromes. Examples of these conditions include tracheoesophageal fistulas, cerebral palsy, and seizure disorders.
Decompression: Patients with unresectable malignant obstructions with a life expectancy greater than 4 weeks may be candidates for gastrostomy placement for decompression. Other indications include severe radiation enteritis, refractory gastroparesis, or for redirection of gastrointestinal flow, such as following a duodenal perforation.
Other indications: Gastrostomies have been used for refeeding of bile in patients with malignant biliary obstruction or for administration of intolerable medications. In patients who are unable to meet their caloric needs, such as those with inflammatory bowel disease or cystic fibrosis, supplemental tube feed support may also be indicated.
There are very few contraindications to gastrostomy tube placement although the approach for placement must be tailored to meet the specific needs of the patient. With the exception of a decompressive gastrostomy, an absolute contraindication for placement is a nonfunctioning gastrointestinal tract. Another specific contraindication is a limited life expectancy, generally accepted as less than 4 weeks. Patients in this situation should have a nasoenteric tube placed for temporary need given the cost and risks of a more permanent procedure. Patients with psychologically based eating disorders should also have a full evaluation including ethics consult before an invasive procedure is undertaken. Any patient with clinical decompensation, including fever of unknown origin or generalized sepsis, should undergo work up of this condition and gastrostomy tube placement should be delayed. Generally speaking, the percutaneous approach for gastrostomy is preferred in all patients without a specific indication for laparoscopic or open placement.
Percutaneous approach: Relative contraindications for the endoscopic approach include morbid obesity, massive ascites, portal hypertension, and a history of peritoneal dialysis. Anatomic variations, such as the presence of a hiatal hernia or previous operations, must be considered. These factors can be overcome in many circumstances by the use of a good technique and the skill level of the endoscopist. Any patient with peritonitis should not undergo a percutaneous approach to gastrostomy but should be treated with immediate surgical exploration.
Surgical approach: Laparoscopic or open gastrostomy is often reserved for patients who are not candidates for a percutaneous approach. This includes patients who have upper aerodigestive obstruction, commonly from malignancy, that does not allow the endoscope to pass. It may also be required for patients in whom there is a concern for interposed viscera (colon, liver, small bowel) between the gastric wall and the abdominal wall during a percutaneous attempt. In patients who have undergone a previous surgical intervention, an open approach may be required if significant intra-abdominal adhesions or postsurgical anatomy modifications fail to provide safe access to the stomach for gastrostomy tube placement.
Preoperative PlanningAs mentioned in the “Indications” section, each patient should undergo evaluation as to which type of gastrostomy tube will offer the best benefit. The level of invasiveness increases with the different approaches from percutaneous to laparoscopic to open. The most common approach taken is a percutaneous endoscopic gastrostomy (PEG) which can be performed under sedation in an endoscopy suite.
All patients undergoing gastrostomy placement should have coagulation values and platelet levels checked. Subcutaneous heparin administration for deep venous thrombosis (DVT) prophylaxis is not a contraindication; however, full anticoagulation may need to be held temporarily. Any patient requiring general anesthesia should have the risks of this evaluated and an appropriate evaluation, such as cardiac clearance or consultation for a difficult airway, performed.
Any patient who has undergone previous surgical intervention should have evaluation to detail the postsurgical anatomy before undertaking gastrostomy placement. Old operative notes should be obtained and will help with determining the best treatment approach. In patients who have undergone imaging of the abdomen for other reasons, these studies should be evaluated to assess for the feasibility of a percutaneous approach.
SurgeryAll patients undergoing gastrostomy placement should be prepared by fasting for 8 hours prior to the procedure. Intravenous access should be obtained in all patients. Patients should receive preprocedural antibiotics as this has been shown to decrease the risk for peristomal infection. Antibiotic coverage should be directed to skin flora and should be administered within 30 minutes of the procedure.
Operative Technique for Percutaneous Endoscopic Gastrostomy
Placement of a PEG was first described in 1980. Since its description, multiple modifications for placement have been developed. These can be broadly divided into procedures that introduce the gastrostomy orally, such as the “pull” or “push” techniques, and those that introduce the gastrostomy through the abdominal wall under endoscopic guidance, such as the introducer technique.
Positioning and sedation: The patient is placed in the supine position and step-wise administration of intravenous medications, commonly a combination of narcotic and benzodiazepine, is given until adequate sedation has been obtained. Patient factors may necessitate the use of general anesthesia and should be evaluated before the procedure is undertaken.
Upper endoscopy: Following the placement of a bite block, a standard gastroscope is passed through the mouth. The esophagus, stomach, and duodenum are then examined for any evidence of pathology. Specifically, one must take care to assure that there is no evidence of poor gastric emptying or of duodenal obstruction before PEG placement.
Site selection: Finding the appropriate site for PEG placement is important as poor technique in this step can lead to inadvertent viscus injury. Attempts should be made to identify transillumination of the gastroscope when viewing the external abdominal wall. Next, the abdominal wall should be palpated under endoscopic visualization, watching for a one-to-one movement of the abdominal wall with finger indentation as seen by the gastroscope. Most important in the opinion of the authors is the use of the “safe tract” technique to confirm placement (Fig. 35.1A). A syringe is filled with local anesthesia, available in most kits, and the needle is introduced through the anterior abdominal wall while negative pressure is applied to the syringe. Endoscopically, the expected site is carefully monitored for the presence of the needle (Fig. 35.1B). If air is aspirated before the needle is seen in the gastric lumen, significant concern for interposed viscera is present. If this occurs, a new site should be selected. If the “safe tract” technique is unable to confirm a safe location, the percutaneous approach should be aborted and other techniques of gastrostomy considered.
Obtaining access: After an appropriate location has been chosen, an introducer needle with a plastic catheter is introduced through the anterior abdominal wall (Fig. 35.2A). This catheter is grasped using an endoscopic snare while the needle is removed (Fig. 35.2B). A guidewire is then passed through the catheter and the endoscopic snare is relocated onto the guidewire. The guidewire is then advanced through the abdominal wall while the snare, other end of the guidewire, and endoscope are removed through the patient’s mouth.Related posts:
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