298 Section VII ■ Tube Replacement

Table 42.3 Complications and Complex Ostomies

Complication Interventions

Multiple stomas Customize pouch to fit around or accommodate stomas in bag; mucous fistulas

may be in or out of pouch.

Open incision or wound Two-piece pouches without starter hole may allow for easier customization.

Keep wound as clean as possible.

Use hydrocolloid wound dressing (e.g., DuoDERM, ConvaTec, Skillman, New

Jersey; Replicare, Smith and Nephew, London, UK; Memphis, TN) or calcium

alginate in wound bed covered with a piece of clear film dressing to protect

wound from stool.

Paste and powders may also be used to protect peristomal skin.

In some cases it may not be possible to apply a pouch; however, the skin must be

protected from caustic effluent, using a barrier such as Sensi-Care Protective

Barrier (ConvaTec, Skillman, New Jersey), or Calmoseptine Ointment

(Calmoseptine Inc., Huntington Beach, California).

Flush/retracted stoma Apply paste or moldable barrier around hole in wafer.

Use convex insert/convex pouch and belt to push skin back and allow stoma to

protrude.

Prolapsed stoma Notify surgeon if evidence of circulatory compromise.

Protect the stoma from injury. When using two-piece pouch with plastic flange,

the stoma could be pinched in the flange that secures the pouch to the wafer

when closed.

Adjust size of hole accordingly; cover exposed skin with moldable barrier or paste.

Peristomal hernia Use a flexible wafer and pouching system to adjust to contour of the skin.

Mushroom-shaped stoma Modify opening to accommodate size of “crown”; protect skin around base with

moldable barrier or paste.

Irritant dermatitis Ensure that hole is cut to fit properly.

Use paste/moldable barrier to protect from leakage.

Apply powder to open, weepy skin.

Assess for sensitivity to products.

Apply topical steroids if needed to decrease inflammation, pain, and itching.

Peristomal Candida

albicans

Appears as red, shiny, macular, papular rash that is pruritic.

Apply topical antifungal powder (e.g., nystatin) to skin. The powder should be

mixed with a small amount of water, painted smoothly on the skin with a cotton swab, and allowed to dry before placing the appliance. Continue to use

with each pouch change until rash resolves.

Dry skin completely when changing pouch.

Resize pouch so that no skin is exposed.

Dehydration, metabolic

acidosis, electrolyte

imbalance

Monitor intake and output carefully, especially for infants with ileostomy and/or

high output.

Assess lab values regularly. Infants can develop electrolyte imbalance rapidly.

Data from Borokowski S. Pediatric stomas, tubes, and appliances. Pediatr Clin North Am. 1998;45:1419; Craven DP, Fowler

JS, Foster ME. Management of a neonate with necrotizing enterocolitis and eight prolapsed stomas in a dehisced wound.

J Wound Ostomy Continence Nurs. 1999;26:214; Garvin G. Caring for children with ostomies and wounds. In: Wise B,

 

Chapter 42 ■ Neonatal Ostomy and Gastrostomy Care 297

fistula. Further discussion about pouching mucous fistula below in F8.

5. Trace hole size onto wafer. Cut hole(s) using small scissors or a seam ripper (Fig. 42.10). After cutting and

before removing the paper backing, check the fit

around the stoma and trim more if needed. Run a finger along the inside of the opening to make sure there

are no sharp edges; these can be cut or smoothed by

rubbing with the finger. It may be necessary to trim the

wafer to avoid umbilicus, groin, and so on. Cutting

small slits along the edges of the wafer may help the

barrier conform to the contour of the stomach.

6. Warm wafer in hands to promote flexibility and enhance

bonding to the skin. Avoid using a radiant heater to heat

the wafer because the amount of heat absorbed cannot

be controlled and may burn immature skin (2).

7. Press wafer to skin and hold for 1 to 2 minutes. Secure

the edges of the wafer down to the skin to improve

wear time. Avoid the use of high-tack adhesives. Pink

tape is a waterproof tape that contains zinc oxide; it is

very gentle and generally can be used safely. Other

low-tack alternatives are silicon tape or clear film

dressing.

8. Change dressing to mucus fistula using a folded 2- ×

2-inch gauze piece and low-tack adhesive or secure

with diaper or tubular elastic dressing. If the drainage

from the mucus fistula is more than can be contained

in the gauze and is interfering with the pouch adhering

or the drainage may potentially contaminate wounds or

central line sites, then the mucus fistula can be

pouched. It is always preferable to pouch the mucus

fistula separately from the active stoma to keep the stool

from contaminating the bowel anastomosis or draining

into the vagina or bladder in the case of a patient with

high imperforate anus defect with fistula. It is advisable

to discuss with the surgeon before placing both stomas

in one pouch.

G. Emptying the Pouch

1. Supplies

a. Clean gloves

b. Diaper or syringe for withdrawing stool/effluent

c. 30- to 60-mL syringe for irrigating/washing the bag

d. Tap water

2. The pouch should be emptied when it is one-third to

one-half full. Gas must also be released or vented to

prevent pulling the adhesive wafer away from skin.

Neonates generally produce large amounts of gas,

related to increased intake with sucking and crying (2).

Effluent can be drained directly into a diaper or withdrawn from the bag with a syringe. Use of two or three

cotton balls placed in an open-end pouch can improve

wear time by wicking the effluent away from the barrier

and also may facilitate easy drainage of the pouch. It is

generally not necessary to wash the pouch, but it may

be necessary to add fluid to help loosen up thick or

pasty stool. For the hospitalized neonate, measurement

of ostomy output is usually indicated.

3. Close the pouch with an integrated closure device or

rubber band.

H. Complicated Stomas and

Peristomal Skin Problems (5,9)

Table 42.3 lists complications and interventions for treating

complex stomas and common stoma problems. Note that

many of items used are not generally recommended for use

on premature neonates or neonates <2 weeks of age, but in

situations of deterioration of the peristomal skin, they are

sometimes used cautiously to prevent further deterioration

and maintain an effective seal.

I. Vesicostomy Care

A vesicostomy does not require pouching; urine drains

directly into the diaper. Care is similar to general perineal

Fig. 42.9. Measuring the stoma.

Fig. 42.10. Cutting a hole in the wafer.

 

Moldable barrier Barriers that are adhesive and can be shaped to fill in uneven spaces; generally hold up very

well to corrosive effluent. Common types are Eakins Seals (ConvaTec, Princeton, New

Jersey), Barrier No. 54 (Nu-Hope Laboratories, Pacoima, California), and Adapt Rings

(Hollister, Libertyville, Illinois)

Caulking strips Similar to moldable barriers but come in narrow strips; they can be used to provide an extra

barrier between the edge of the stoma and the barrier. May come in contact with stoma;

soft enough that it does not injure the mucosa. Examples are Ostomy Strip Paste

(Coloplast, Marietta, Georgia), Skin Barrier Caulking Strips (Nu-Hope Laboratories,

Pacoima, California), and Adapt Strips (Hollister, Libertyville, Illinois)

Belt Elastic belt with tabs that fit to ostomy pouch of some two-piece appliances. Belt can help

maintain the appliance in place by holding it firmly to abdomen. Generally used as a last

resort when unable to obtain acceptable wear time.

296 Section VII ■ Tube Replacement

neonate is generally either an open-end pouch that allows

the passage of thick or formed effluent or a urostomy pouch

with a spout designed for drainage of urine or liquid effluent. The type of pouch and the need for accessory products

varies depending on the size of the child, the condition of

the peristomal skin, abdominal size and contours, and institutional preference. In general, it is best to keep the procedure simple and to use as few products as possible (2).

Special consideration needs to be given to the premature

infant whose skin is immature and fragile. Several companies manufacture pouches for neonates and premature

infants (Fig. 42.7). Neonatal units should have several varieties to choose from in order to meet each patient’s individual needs.

Supplies

1. Clean gloves

2. Warm sterile water or normal saline

3. Clean, soft cloth

4. 2 × 2-inch gauze

5. Appropriate-size pouch with closure device

6. Protective skin barrier and pouch

7. Other ostomy accessories as appropriate (Table 42.2

and Fig. 42.8).

8. Scissors or seam ripper

9. Stoma-measuring device

F. Applying the Pouch: Routine/Simple

Ostomies (2,6,8)

1. Remove old pouch by gently lifting up the edges and

using water to loosen while pressing down gently on the

skin close to the edge to reduce traction on the epidermis. Adhesive remover should not be used on a neonate

<2 weeks of age. Limited use of adhesive remover, followed by thorough cleansing of the area to remove any

chemical residue, is recommended only when the

adhesive bond of the barrier to the skin is so strong that

the skin might be injured during removal (2).

2. Use damp soft gauze or paper washcloth to gently

cleanse the stoma to remove adherent stool or mucus. It

is common to have a little bleeding of the stoma when

it is cleansed.

3. Wash peristomal skin with water; pat dry. Soap is not

recommended because it may leave a chemical residue

that could cause dermatitis; furthermore, many soaps

contain moisturizers that can adversely affect the adherence of the barrier to the skin. It is also not advisable to

use commercial infant wipes, because most are lanolinbased and contain alcohol (2).

4. Measure stoma(s) using stoma measuring device (Fig.

42.9). The opening generally is cut 2 to 3 mm larger

than the stoma, to limit the skin exposed to effluent. In

tiny infants, in whom the mucus fistula may be immediately adjacent to the functional stoma, one pouch

Fig. 42.7. Examples of appliances for pouching a neonate. may be sized to fit over both the stoma and the mucus

Fig. 42.6. Barrier paste applied to wafer. Fig. 42.8. Examples of ostomy accessories.

Chapter 42 ■ Neonatal Ostomy and Gastrostomy Care 295

Fig. 42.5. One-piece ostomy appliance on small newborn

dwarfs this infant but provides longer wear time and holds larger

volume of output than the preemie pouches previously used.

skin and obtain acceptable wear time. In the rare

instance when a pouch cannot be maintained, it

may be necessary to leave the pouch off and protect

the peristomal skin with a protective barrier ointment that will adhere to denuded skin to allow the

skin to heal. The barrier ointment can be covered

with petrolatum-impregnated gauze; fluff gauze can

then be placed on top to absorb the effluent and

changed as needed. In some cases of severe skin

damage, some neonatal centers stop enteral feedings briefly to limit stool production and allow the

skin to heal (2). The more damaged the skin, the

more difficult it is to maintain a seal. It is best to

heal the skin, get a good seal, and then resume the

feeding.

d. Protect stoma from trauma. Measures include accurate sizing of the pouch opening to clear the stoma

as the size changes. If the infant’s movements cause

the inner edge of the barrier to rub against the

stoma, a moldable barrier between the stoma and

the wafer can be used to protect the stoma.

E. Equipment

A variety of pouches and ostomy care supplies are available

(Tables 42.2). One-piece pouches come with a barrier and

pouch attached as a single unit. Two-piece appliances have

a barrier and pouch separate, with a mechanism for attaching the pouch to the wafer. The type of pouch used for a

Table 42.2 Ostomy Accessory Products

Product Indications and Precautions

Barrier powder This product is used to dry moist and/or weepy skin. It can add extra adhesiveness to the

skin. It must be sealed by padding with a moistened finger and allowed to dry. In cases of

severely moist weeping skin, it may be necessary to apply powder and seal two or three

times to attain a dry peristomal skin surface. It adds an additional barrier over the skin to

protect from drainage. Apply in limited amounts and wipe off excess. Protect infant from

inhalation of aerosolized powder by using minimal amounts and wiping away gently; do

not blow powder away.

Paste Barrier product that is semiliquid because of addition of alcohol. Best if applied to barrier

and allowed to air for 1 to 2 minutes to allow the alcohol to evaporate (Fig. 42.6). Not

recommended for use on premature infants or term infants <2 weeks old.

Skin sealants Sealants use plasticizing agents to form a barrier on the skin that can protect from effluent

and also improve adherence of some adhesives. Most skin sealants contain alcohol and

are, therefore, contraindicated for use in preemies or term neonates <2 weeks old. One

skin sealant that does not contain alcohol is Cavilon No Sting Barrier Film (3M, St. Paul,

Minnesota). 

 

Fig. 42.1. A: End stoma. The end of the bowel is everted at the

skin surface. B: Loop stoma. Entire loop of bowel is brought to the

skin surface and opened to create a proximal, or functioning, end

and a distal, or nonfunctioning, end. The distal side is called a

mucus fistula because of the normal mucus secretions it produces.

C: Double-barrel stoma. Similar to a loop stoma, except the bowel

is divided into two stomas, a proximal and a distal stoma. The distal stoma functions as a mucus fistula. (Adapted from Gauderer

MWL. Stomas of the small and large intestine. In: O’Neil JA,

Rowe MI, Grosfeld JL, et al., eds. Pediatric Surgery. 5th ed. St.

Louis: Mosby; 1998:1349, with permission.)

Table 42.1 Conditions Necessitating

Ostomy in the Neonate

Disease/Congenital Anomaly Most Common Location of Stoma

Intestinal atresia Duodenum, ileum, or jejunum

Meconium ileus Ileum

Necrotizing enterocolitis Ileum or jejunum

Hirschsprung disease Sigmoid colon

Imperforate anus/anorectal

malformations

Colon

Volvulus Ileum or jejunum

Bladder exstrophy Bladder

294 Section VII ■ Tube Replacement

(2) Contact dermatitis: Most common type of peristomal skin complication seen, generally from

the leakage of fecal effluent on the skin.

b. Infection

(1) Bacterial

(2) Candidal

c. Mechanical trauma: Epidermal stripping, abrasive

cleansing techniques, or friction due to ill-fitting

equipment are the most common causes of mechanical injury to the perist-omal skin.

d. Hernia: A peristomal hernia appears as a bulge

around the stoma that occurs when loops of the

bowel protrude through a facial defect around

the stoma into the subcutaneous tissue (4).

D. Ostomy Care

1. Immediate postoperative care

a. Assess stoma for adequate perfusion.

b. Until there is output from the stoma, it is not necessary to apply an ostomy pouch

 Keep stoma protected and moist with petrolatum

gauze. When an enterostomy begins to produce, it is

preferable to pouch. The pouch will protect the

stoma, the peristomal skin, the suture line, and any

central lines in that area. Pouching allows for qualifying and quantifying output. Before applying

pouch, make sure to gently remove any residue

of petrolatum gauze, which will interfere with the

pouch adhesion.

c. Cover the mucus fistula with a moisture-retentive

dressing to keep it from drying out. When securing a

dressing on a neonate, use low-tack adhesives. There

is increased risk of skin tears in neonates, especially

when they are premature with delayed epidermal

barrier development. Avoid placing petrolatum

gauze over the pouching surface for the stoma, as it

can impede adherence.

2. Subsequent care

a. Regular assessment of the stoma

b. Protect peristomal skin from the effects of the effluent by pouching (Fig. 42.5). The effluent from a

small bowel stoma contains proteolytic enzymes

that can rapidly cause skin erosion. Ideally the

pouch should remain in place for at least 24 hours.

In some low-birthweight neonates, the pouch may

only last 12 hours. The average wear time is 1 to

3 days.

c. The pouch must be changed if there is any evidence

of leaking effluent under the skin barrier wafer.

Frequent pouch changes, however, can result in

denuded skin, especially in the premature infant

(2,4,7). In situations with frequent leaking and

pouch changes, expert help (certified wound ostomy

Fig. 42.3. Premature infant with double-barrel colostomy. continence nurse) may be required to preserve the

Fig. 42.2. Immediately postoperative loop ileostomy. Segment

of bowel on left is the exteriorized perforation from necrotizing

enterocolitis.

Fig. 42.4. End ileostomy and wound closure with retention

sutures posing a challenge for placing a pouch.

 

(2) Trauma to stoma caused by improper fitting

pouch. A wafer cut too close to the stoma can

injure the delicate tissue. Stomal lacerations

can occur as a result of the edge of the wafer

rubbing back and forth against the side of the

stoma (4).

b. Necrosis: Caused by ischemia and may be superficial or deep. Necrosis extending below the facial

level may lead to perforation and peritonitis, requiring additional surgical intervention (4).

c. Mucocutaneous separation: This condition is caused

by a breakdown of the suture line securing the stoma

to the surrounding skin, leaving an open wound

next to the stoma.

d. Prolapse: Telescoping of the bowel out through the

stoma. In infants, this condition is frequently related

to poorly developed fascial support or excessive

intra-abdominal pressure caused by crying.

e. Retraction: The stoma is flush or recessed below the

skin surface. This condition may result from insufficient mobilization of the mesentery or excessive tension on the suture line at the fascial layer, excessive

scar formation, or premature removal of a support

device (4).

f. Stenosis: The lumen of the ostomy narrows at either

the cutaneous level or the fascial level. Sudden

decrease in output may indicate stenosis.

9. Peristomal complications

a. Dermatitis

(1) Allergic dermatitis

C

B

A

 

a. A purple or dark brown to black stoma with loss of

tissue turgor and dryness of the mucous membrane

may indicate ischemia and possible stomal necrosis.

b. A pale pink stoma is indicative of anemia.

3. Size: The stoma shape (round, oval, mushroom, or

irregular) and diameter (length and width) in inches or

millimeters is noted. In the early postoperative period,

the stoma will be edematous. After the first 48 to

72 hours, the edema should resolve and result in a

reduction in size of the stoma, which should, however,

still remain everted from the skin surface. Stomas generally continue to decrease in size over 6 to 8 weeks

postoperatively. It is not uncommon for the stoma to

become edematous when exposed to air while changing the pouch; this edema generally resolves quickly

when the pouch is replaced.

4. Stomal height: The degree of protrusion of stoma from

the skin. Ideally, the surgeon will evert the stoma prior

to suturing it to the skin to produce an elevation, which

will promote a better seal with the ostomy wafer. With

the stoma elevated above the surface of the skin, the

effluent will be more likely to go into the pouch instead

of staying in contact with the skin (2). Eversion of the

stoma, referred to as maturing the stoma, is not always

possible in neonates, in whom blood supply may be

Chapter 42 ■ Neonatal Ostomy and Gastrostomy Care 293

tenuous, and in situations in which the bowel is markedly edematous (1,5).

5. Stomal construction: The ostomy may be an end, loop,

or double barrel (Figs. 42.1 and 42.3).

6. Abdominal location

7. Peristomal skin: Ideally the peristomal skin should be

intact, nonerythematous, and free from rashes.

However, frequently the stoma(s) is not separate from

the surgical incision (Fig. 42.4). There is often not

enough space on the baby’s abdomen for the surgeon to

create separate incisions. In addition, stomas are often

in close proximity to the umbilicus, ribs, or groin,

which may interfere with pouch selection and adherence (6).

8. Stomal complications

a. Bleeding

(1) Hemorrhage during the immediate postoperative period is caused by inadequate hemostasis

(4).

 

292

Linda C. D’Angelo

Dorothy Goodman

Neonatal Ostomy and

Gastrostomy Care

42

An ostomy is the construction of a permanent or temporary

opening in the intestine (enterostomy) or urinary tract (urostomy) through the abdominal wall to provide fecal or urinary diversion, decompression, or evacuation (1).

Gastrostomies (G tubes) are stomas that allow direct access

into the stomach and are used for feeding, medication

administration, and decompression. This chapter discusses

care of simple and complex ileostomies, colostomies, urostomies, and gastrostomies (see also Chapter 41). Tracheostomy

care is discussed in Chapter 37.

Enterostomies and Urostomies

A. Indications

Ostomies may be indicated in the neonate for a variety of

congenital or acquired conditions (Table 40.1). The stoma

is usually temporary, and reanastomosis of the bowel or urinary tract with closure of the stoma is performed during

infancy or early childhood (2, 3).

B. Types of Ostomies

1. There are several types of intestinal stoma. The patient’s

condition, the segment of bowel affected, and the size

of the patient’s abdomen often determine the type of

stoma and its external location. Figure 42.1 depicts the

most common types of neonatal stoma (1).

2. Urostomies are urinary diversions constructed to bypass

a dysfunctional portion of the urinary tract. Ileal conduits and ureterostomies are rarely performed in the

neonatal period.

3. A vesicostomy is an opening directly from the bladder

through the abdominal wall and is a more common urinary diversion in the neonate. Urine flows freely

through the stoma from the bladder.

C. Ostomy Assessment

The neonate with a stoma needs careful observation and

assessment for a variety of potential complications (4).

Monitoring the infant for function of the ostomy is vital in

the initial postoperative period. Possible surgical complications are paralytic ileus, intestinal obstruction, anastomotic

leak, and stomal necrosis. The factors to be considered during evaluation of the stoma are listed below.

1. Type of stoma: The segment of bowel from which the

stoma is made.

2. Viability: A healthy stoma should be bright pink to

beefy red and moist, indicating adequate perfusion and

hydration (Fig. 42.2). The stoma is formed from the

intestine, which is very vascular and therefore may

bleed slightly when touched or manipulated, but the

bleeding usually resolves quickly. The stoma is not sensitive to touch because it does not have somatic afferent

nerve endings (4).

 

11. Zamakhshary M, Jamal M, Blair GK, et al. Laparoscopic vs. percutaneous endoscopic gastrostomy tube insertion: a new pediatric

gold standard?. J Pediatr Surg. 2005;40:859.

12. Akay B, Capizzani TR, Lee AM, et al. Gastrostomy tube placement in infants and children: is there a preferred technique?

J Pediatr Surg. 2010;45:1147.

13. Lantz M, Larsson MH, Arnbjornsson E. Literature review comparing laparoscopic and percutaneous endoscopic gastrostomies

in a pediatric population. Int J Pediatr. 2010;507:616.

14. Nah SA, Narayanaswamy B, Eaton S, et al. Gastrostomy insertion

in children: percutaneous endoscopic vs. percutaneous imageguided?. J Pediatr Surg. 2010;45:1153.

15. Fortunato JE, Cuffari C. Outcomes of percutaneous endoscopic

gastrostomy in children. Curr Gastroenterol Rep. 2011;13:293.

16. Ducharme JC, Youseff S, Tilkin R. Gastrostomy closure: a quick,

easy and safe method. J Pediatr Surg. 1977;12:729.

17. Gallagher MW, Tyson KRT, Ashcraft KW. Gastrostomy in pediatric patients: an analysis of complications and techniques. Surg.

1973;536:74.

18. Gauderer MW. Percutaneous endoscopic gastrostomy: a 10-year

experience with 220 children. J Pediatr Surg. 1991;26:288.

19. Gordon JM, Langer JC. Gastrocutaneous fistula in children after

removal of gastrostomy tube: incidence and predictive factors. J

Pediatr Surg. 1999;34:1345.

20. Curriano G, Votteler T. Prolapse of the gastrostomy catheter in

children. AJR Radium Ther Nucl Med. 1975;123:737.

21. Jolley SG, Tunnel WB, Hoelzer DJ, et al. Lower esophageal pressure changes with tube gastrostomy: a causative factor of gastroesophageal reflux in children?. J Pediatr Surg. 1986;21:624.

 

b. Presentation may be subtle: recognition requires a

high index of suspicion.

c. Symptoms range from early feeding intolerance to

worsening abdominal pain/peritonitis and signs of

systemic infection.

d. Common early complications

(1) Wound infection, dehiscence

(2) Prolonged ileus, gastric atony leading to feeding

intolerance

(3) Gastric separation from anterior abdominal wall

(4) Intraperitoneal spillage/gastric leak leading to

peritonitis

(5) Early tube dislodgement

(6) Early tube occlusion

(7) Gastric outlet obstruction

3. Remote (late) complications

a. Common remote complications

(1) Dislodgement

(a) Inadvertent removal

(b) Internal or external gastrostomy migration

(20)

(2) Catheter deterioration

(a) Tube erosion/fracture

(b) Balloon rupture

Chapter 41 ■ Gastrostomy 291

(3) Tube occlusion

(4) Granulation tissue formation

(5) Persistent leak

(a) Wound breakdown

 i. Granulation tissue and skin irritation

 ii. Infection

iii. Enlargement of tract leading to loose

gastrostomy with leakage

iv. Skin ulceration

(b) Electrolyte imbalance

(c) Malnutrition

(6) New-onset or worsening GERD (21).

(7) Persistent gastrocutaneous fistula (post removal)

(8) Prolapse of gastric mucosa

(a) Bleeding

(b) Excessive leakage.

(9) Gastric torsion around catheter

b. Prevention

(1) Requires meticulous hygiene and appropriate

perpendicular positioning to avoid trauma to the

skin and subcutaneous tissues

(2) Parental education is essential to long-term care

and prevention of complications.

4. Treatment of Common Complications

a. Gastrostomy leak—treat early

(1) Remove tube for up to 24 hours to allow partial

tract closure.

(2) Replace mushroom catheter with a balloon-type

catheter.

Secure tube by pulling the balloon (inflated

with 2 to 5 mL of water) against the abdominal

wall.

(3) Apply Stomahesive around catheter.

(a) Decrease excoriation.

(b) Encourage epithelialization.

(c) Change Stomahesive every 3 to 4 days to

maintain seal.

(4) Maintain perpendicular positioning of gastrostomy tube.

(5) Do not clamp the gastrostomy tube.

(6) Maintain skin and stoma hygiene

5. Cleanse daily with soap and water.

Consider half-strength hydrogen peroxide for areas

of fibrinous exudate.

6. Frequent dressing changes to maintain a dry site.

a. Granulation tissue at gastrostomy site

(1) Silver nitrate

(a) Apply daily for up to 3 to 5 days.

(b) Avoid spilling the liquefied silver nitrate

onto normal adjacent skin since this will

cause a chemical burn.

(2) 0.5% Triamcinolone ointment

Apply three times a day for 5 to 7 days.

(3) Cautery

May require local or general anesthesia.

References

1. Gauderer MW, Stellato TA. Gastrostomies: evolution, techniques,

indications, and complications. Curr Probl Surg. 1986;23:657.

2. Stamm M. Gastrostomy by a new method. Med News (NY).

1894;65:324.

3. Jones VS, La Heir ER, Shun A. Laparoscopic gastrostomy: the

preferred method of gastrostomy in children. Pediatr Surg Int.

2007;23:1085.

4. Gauderer MW. Percutaneous endoscopic gastrostomy-20 years

later: a historical perspective. J Pediatr Surg. 2001;36:217.

5. Charlesworth P, Hallows M, Van der Avoirt A. Single-center experience of laparoscopically assisted percutaneous endoscopic gastrostomy placement. J Laparoendosc Adv Surg Tech A. 2010;

20:73.

6. Valusek PA, St. Peter SD, Keckler SJ, et al. Does an upper gastrointestinal study change operative management for gastroesophageal reflux? J Pediatr Surg. 2010;45:1169.

7. Wheatley MJ, Wesley JR, Tkach DM, et al. Long-term follow-up

of brain-damaged children requiring feeding gastrostomy: should

an anti-reflux procedure always be performed? J Pediatr Surg.

1991;26:301.

8. Cuenca AG, Reddy SV, Dickie B, et al. The usefulness of the

upper gastrointestinal series in the pediatric patient before antireflux procedure or gastrostomy tube placement. J Surg Res. 2011;

170:247.

9. Soares RV,Forsythe A, Hogarth K, et al. Interstitial lung disease

and gastroesophageal reflux disease: key role of esophageal function tests in the diagnosis and treatment. Arq Gastroenterol.

2001;48:91.

10. Gauderer MW, Ponsky JL, Izant Jr. RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg.

1980;15:872.