GASTROSTOMY

Operative Gastrostomy

Operative Indications

There are a variety of indications for placement of a gastrostomy. Generally, gastrostomies are used for gastric decompres-
sion or for external tube feedings. In many instances the gastrostomy can be performed percutaneously and endoscopical-
ly. However, in some instances that is not possible. An obstructing benign stricture or tumor of the esophagus or pharynx
may make esophagoscopy impossible. Prior intraabdominal surgery with scars and adhesions may make approximation of
the anterior gastric wall with the abdominal wall uncertain. Prior gastric surgery resulting in a small gastric remnant may also
eliminate the possibility of percutaneous endoscopic gastrostomy (PEG). In many instances the patient is explored for
other intraabdominal processes, and at the end a gastrostomy is performed as part of the operative procedure. Although
there are numerous techniques for operative gastrostomy, only one is shown here.

Operative Technique

The patient is explored through a short upper midline incision. The

stomach is identified and grasped along the greater curvature with two
Babcock clamps.
134 Atlas of Gastrointestinal Surgery: The Stomach

Concentric
purse string
sutures

Two concentric purse strings of 2-0

silk are placed (1). The site of the
gastrostomy is picked in the left
upper quadrant, and with the elec-
trocautery a small opening is made
through skin, subcutaneous tissue,
muscle, and fascia. From inside out a
Rienhoff clamp is passed through this
opening, and a No. 24 Silastic Foley
catheter is grasped and pulled into the

Anterior
abdominal cavity (2).
gastric wall
1

Linea alba

Silastic
Foley
catheter

2
 Operative Gastrostomy 135

Gastrotomy

Mucosa

Purse strings
secured

An opening is then made through the center of the two

Balloon
inflated
concentric purse strings using the electrocautery (3 and inset).
Once the gastric opening is made, the Silastic catheter is
inserted, and both purse strings are secured (4).

4
136 Atlas of Gastrointestinal Surgery: The Stomach

Four quadrant
sutures placed
The Foley balloon is filled with 10 mL of saline. The
Anterior
anterior gastric wall surrounding the gastrostomy site is
abdominal
wall
then sutured to the anterior abdominal wall with four
sutures. Each suture is placed in one of the quadrants
surrounding the gastrostomy tube in the stomach and
placed correspondingly around the exit site of the
gastrostomy tube in the anterior abdominal wall (5).
Once all four sutures are placed, the anterior gastric
wall is approximated to the anterior abdominal wall
by gently pulling the Foley catheter out onto the ante-
rior abdominal wall. All four sutures are then secured
(6 and 7). The gastrostomy tube is secured to the skin
with two 4-0 stainless steel wire sutures wrapped spiral-
Anterior
gastric wall
ly around the gastrostomy tube (7).
5

Wire sutures

Abdominal wall

Gastric wall

Foley
balloon

7
6
 Operative Gastrostomy 137

Alternate
catheters

Malecot
catheter

8 9

Extra side holes

in Foley catheter

This type of gastrostomy is very effective for feed-

ing. However, if it is to be used for decompression,
during creation of the gastrostomy, the Foley
catheter should have extra side holes cut into it and
be advanced into the gastric lumen for approximate-
ly 8 to 10 cm (8). In this configuration, it is very
effective in decompressing the stomach. In this
instance the Foley balloon should not be inflated
because peristalsis will tend to carry it into the
pylorus and cause obstruction. A variety of other
tubes can also be used for the gastrostomy (9). The
abdomen is irrigated with an antibiotic containing
10
solution and closed in layers.
Percutaneous Endoscopic Gastrostomy (PEG)

Operative Indications

Percutaneous endoscopic gastrostomy (PEG) provides a non-operative method of obtaining direct access to the stomach
for gastric decompression and enternal feeding. The advantages over operative gastrostomy are: (1) the avoidance of laparo-
tomy for operative placement of gastrostomy, and (2) the procedure can be performed easily under local anesthesia with
intravenous sedation. The indications are generally the same as for the open gastrostomy. In most series, patients with neu-
rologic disabilities or head and neck cancers predominate. Contraindications include the inability to pass a gastroscope
through an upper aerodigestive tract tumor or a benign or malignant esophageal stricture. Relative contraindications include
previous gastric surgery or prior abdominal surgery, which might be associated with extensive upper abdominal adhesions.

Operative Technique

Presently two techniques of PEG are commonly used: the “push” technique and the “introducer” technique. In all cases
the patient has fasted and the procedure is performed in an operating room, endoscopy suite, or intensive care unit.
Although an anesthesiologist is not necessary for all cases, absolute attention to airway management is required. The
abdomen is prepped and the patient’s mouth is swabbed with cleansing solution to minimize oral bacteria. Prophylactic
antibiotics should be administered before the procedure. The posterior pharynx is anesthetized with topical spray, and intra-
venous sedation is given.
Typically, two experienced operators are necessary, a surgical endoscopist and an assistant to perform the abdominal
part of the procedure. The gastroscope is passed into the stomach, and a complete endoscopic examination is carried out.
The stomach is fully insufflated with air, and the room lights are dimmed. The assistant identifies the site where the light of
the gastroscope most clearly transilluminates the anterior abdominal wall. Although this site is typically in the left upper
quadrant, it may be in the midepigastrium near the midline. Finger pressure at this site should produce an unmistakable
indentation of the gastric lumen seen by the endoscopist. Care should be taken to avoid placement at a site in the distal
stomach, near the pylorus, where the pyloric channel may be obstructed.