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285

Keith Thatch

Thomas Sato

A. Alfred Chahine

41 Gastrostomy

First performed over 150 years ago, gastrostomy is one of the

most commonly performed procedures by pediatric surgeons,

in the neonatal and pediatric population (1,2). Although

neonatologists do not usually perform gastrostomies, a range

of procedures are described to support the principles of good

gastrostomy care. Surgical advances, including endoscopy

and laparoscopy, have expanded the applications of gastrostomy while making placement faster and safer (3–5).

A. Indications

1. Inability to swallow/dysphagia

a. Neurologic impairment resulting in uncoordinated

swallowing

b. Complex congenital malformations (e.g., esophageal atresia or Pierre Robin sequence) not undergoing early correction.

2. Failure to thrive/need for supplemental feedings

a. Anatomic intestinal anomalies (i.e., short gut syndrome)

b. Functional intestinal dysmotility (i.e., gastrointestinal malabsorption)

c. Malignancy/tumor

d. Chronic pulmonary disease (i.e., persistent pulmonary hypertension)

e. Congenital heart disease

f. Glycogen storage disease (need for consistent glucose source)

3. Frequent aspiration

a. Gastroesophageal reflux disease (GERD) leading to

pulmonary disease

4. Nonpalatable diet or medications

a. Renal failure diet

b. HAART therapy for HIV

c. Cholestyramine for Alagille syndrome

5. Gastric decompression

a. Severe respiratory compromise necessitating longterm gastric decompression

b. Esophageal atresia with distal tracheoesophageal fistula with acute decompensation requiring emergency gastric decompression.

B. Contraindications

1. Treatable medical conditions that increase operative

risks (i.e., active infection or coagulopathy).

Treat aggressively prior to elective gastrostomy

placement.

2. Pure esophageal atresia

Small stomach volumes (microgastria), making

gastrostomy placement more difficult and potentially

contraindicated secondary to possible need for gastric

transposition to repair long-gap esophageal atresia.

C. Preoperative Workup

Prior to operative planning, it is important to make sure

that the patient meets the proper anatomical and physiologic indications for gastrostomy. For example, identifying

neonates in need of concomitant procedures such as

antireflux surgeries requires more extensive preoperative

workup.

1. Antireflux procedure workup (6–8)

a. Upper gastrointestinal (UGI) study (primary study)

Anatomic anomalies (e.g., malrotation, delayed

gastric emptying) alter operative planning.

b. 24-hour pH probe, especially in severely neurologically impaired neonates (9)

(1) Gold standard in establishing GERD diagnosis.

(2) DeMeester score—composite of

(a) Frequency and duration of episodes of pH ≤4

(b) Number of episodes lasting >5 minutes

(c) Duration of longest episodes

(d) Total percentage of time of GERD

(3) DeMeester score >14.7 correlates with pathologic GERD and need for antireflux surgery.

c. Gastric emptying study

If emptying is delayed, the use of a gastrojejunostomy tube to allow for gastric drainage and jejunal feeds might be considered.

d. Endoscopy (rarely utilized in neonatal population)