290 Section VII ■ Tube Replacement

placement), loss of the tube can be treacherous in that the

stomach can separate from the abdominal wall; therefore, the

surgical team should always be notified. Loss of the tube can

result spontaneous stoma closure if not reintroduced promptly.

1. Steps to reintroduce a gastrostomy tube

a. Replace within 4 to 6 hours to avoid stoma closure.

b. In the initial postoperative period prior to the formation

of a well-epithelialized tract, replace with a balloon-type

catheter (a button or a Foley-type catheter). For wellepithelialized tracts, mushroom catheter tubes or balloon-type gastrostomy tubes may be used for placement

c. Lubricate the catheter generously with water-soluble

lubricant, and insert gently.

If resistance is felt and/or the catheter does not

pass easily, stop and reassess.

(a) Attempt passing a flexible guidewire through

the tract.

(b) A catheter is inserted over the wire or the

stoma may be dilated by sequential dilators.

(c) Fluoroscopy can confirm gastric position.

(1) Inflate the balloon with 2 to 4 mL of water, then

pull firmly against the stomach wall.

(2) Secure with a fixation/external bolster device.

(3) Mark outside length of catheter to help detect

internal or external migration of the balloon.

(4) Prior to feeding, confirm placement of gastrostomy with water-soluble contrast study if replacement is difficult or uncertain or if performed

within 4 to 6 weeks of surgical placement.

2. Confirm intragastric position

a. For recent gastrostomy (initial postoperative period)

Instill 15 to 30 mL of water-soluble contrast

through the gastrostomy under fluoroscopic guidance to confirm accurate positioning.

b. For epithelialized gastrostomy tracts

(1) Aspirate for gastric contents and observe for fluctuation of the gastric fluids in the tube with respiration. Fluids should flow back to stomach

with gravity.

(2) If there is any doubt, obtain contrast study prior

to initiating feeding.

L. Discontinuation of Gastrostomy (16)

1. General principles

a. Remove gastrostomy tube and apply gauze dressing.

(1) Spontaneous closure usually occurs in 4 to 7 days.

(2) May also approximate the skin edges with surgical tape.

2. Persistent gastrocutaneous fistula

a. Granulation and epithelialization of gastrocutaneous tract (well-established tract).

(1) Remove gastrostomy tube.

(2) Cauterize the stoma granulation tissue and/or

epithelium with silver nitrate.

(3) Seal orifice with Stomahesive.

(4) Approximate the edges with surgical tape.

b. Persistent gastrocutaneous fistula (>4 to 6 weeks)

(1) Requires surgical closure

(2) If the skin is becoming macerated, replace the

gastrostomy and use protective skin ointment

prior to surgical closure.

M. Complications (1,15,17–19)

Gastrostomy placement can have serious complications. Early

recognition of such complications allows for prompt intervention and prevention of devastating sequelae. The complications associated with neonatal gastrostomy placement may be

characterized as intraoperative, early, or remote (late).

1. Intraoperative complications

a. Pneumoperitoneum

Some pneumoperitoneum is expected after the

laparoscopic and open placement but is most common with PEG placement.

b. Liver or splenic injury

c. Colonic placement

d. Hollow viscus injury

e. Injury to posterior wall of stomach on initial insertion or upon reinsertion (gastrostomy replacement)

f. Bleeding

2. Early complications (within the first 4 postoperative

weeks)

a. Most early complications are technical or mechanical in nature.

 

Chapter 41 ■ Gastrostomy 289

Tube feeds should be started slowly and advanced to the

goal rate over the next few days.

1. Maintain fixation of gastrostomy between stomach and

abdomen.

a. Prevent gastric distention.

b. Keep the gastrostomy balloon or flange pulled

snugly against the stomach wall by maintaining the

external bolster snug against the skin (take time to

recognize and record the gastrostomy level mark at

the skin) (Fig. 41.4).

c. Avoid pressure necrosis of the abdominal wall: the

external bolster should be snug enough to be gently

twisted around but not too tight.

d. Avoid inadvertent dislodgement of the gastrostomy

(i.e., patient restraints, minimize tension on the gastrostomy tube by providing secondary fixation points

on the skin or keeping the tube secure within the

diaper). Nursing staff and parents should be

informed of the type of gastrostomy tube inserted,

how much fluid has been placed in the retention

balloon, and anticipated time of first gastrostomy

tube exchange.

2. Maintain gastrostomy immobility at the insertion site to

minimize the formation of granulation tissue.

a. Use careful fixation to maintain the perpendicular

position.

(1) This will decrease the amount of soft tissue

stretching at the stoma site.

b. Keep some slack in the tube when it is suspended.

 This prevents stoma tension and widening,

thereby decreasing the risk of stoma leak.

3. Prevent migration of gastrostomy

a. Proper fixation (Fig. 41.5)

If not fixed on the outside with a bolster or tape,

the gastrostomy tube may migrate through the pylorus or up into the esophagus.

b. Compare the length of external tube with the postoperative length (again checking and monitoring

the level at the skin).

c. Observe for signs of obstruction.

(1) Gastric distention

(2) Feeding intolerance, nausea/vomiting

(3) Increased drainage from oral gastric or gastrostomy tube

(4) Bilious drainage

(5) New-onset or increased gastroesophageal reflux

4. Minimize leak rate from the gastrostomy site

a. Maintain adequate fit of tube in stoma.

Long-term gastrostomy tubes may need to be

upsized if the stoma site increases in diameter.

b. Avoid local infection—continue meticulous wound

care.

Daily cleansing with soap and water starting

48 hours after placement.

5. Close follow-up after placement to screen for and

reduce risk of tube-related complications (see below).

K. Replacing Gastrostomy Tubes

Healing of gastrostomy sites requires 4 to 6 weeks for fibrosis to occur and create a well-epithelialized tract attaching

the stomach to the anterior abdominal wall and. This process may take several months with PEG tubes, as there is

generally no suture or fastener deployed to form a seal

between the stomach and the abdominal wall. During the

initial postoperative period (2 to 4 weeks postgastrostomy

Fig. 41.4. Latex bridge at gastronomy exit stabilizes tube perpendicular to skin, keeping stoma narrow to avoid leakage.

Rotating the bridge around the tube allows change in contact

points with the skin. Note how the flared end of the mushroom

catheter is pulled to keep the stomach apposed to the abdominal

wall.

Fig. 41.5. Modified feeding nipple. The elliptical hole at the

base allows air circulation and regular cleaning of the skin as

important factors in avoiding maceration of the site. (From

Kappell DA, Leape LL. A method of gastrostomy fixation. J Pediatr

Surg.1975;10:523, with permission.)

 

288 Section VII ■ Tube Replacement

frequently, a balloon retention tube (MIC-Key® or

AMT® button gastrostomy tube).

The purse-string is tied down to secure the gastrostomy tube in place.

7. The abdomen is reinsufflated and the laparoscope is

reinserted to confirm placement.

G. Laparoscopic Percutaneous

Endoscopic Gastrostomy

Laparoscopic gastrostomy may be difficult to place in neonates or children with thick abdominal walls. Some surgeons recommend the use of laparoscopic PEG. Other

indications for laparoscopic PEG include failed PEG

attempts, altered anatomy secondary to previous operations,

and when combined with another laparoscopic procedure

(11,13). It is basically a hybrid of the laparoscopic and percutaneous techniques to prevent hollow viscus and solid

organ injury and confirm accurate placement.

1. A laparoscope is inserted through a supra-umbilical

incision and the abdomen is moderately insufflated to 8

to 10 torr.

2. A standard PEG procedure as previously described is

completed under direct intra-abdominal visualization.

3. Additionally, in order to secure the stomach to the

abdominal wall, 2 to 4 T fasteners may be placed percutaneously through the gastric wall with laparoscopic

visualization.

H. Image-guided Percutaneous

Gastrostomy

A recent advance in minimally invasive gastrostomy placement utilizes fluoroscopy to guide percutaneous gastrostomy placement. Interventional radiologists typically perform this technique (14,15).

1. Insufflation of the stomach with an oro- or nasogastric

tube.

2. A needle is advanced into the distended stomach under

fluoroscopic visualization.

Contrast injection confirms intragastric positioning.

3. T fasteners (2 to 4) are advanced into the stomach to

secure it to the abdominal wall.

4. A second needle is then inserted in the center of the T

fasteners and again is confirmed by contrast injection.

5. A wire is advanced through the second needle and the

tract is dilated over the wire.

6. A balloon-type gastrostomy tube is inserted into the

stomach over the wire and positioning is confirmed

with contrast injection.

7. The T fasteners are tied externally over abdominal

bolsters.

I. Emergent Percutaneous Gastric

Decompression

The ability to decompress the stomach urgently is a lifesaving measure that may be required in neonates who have

severe respiratory compromise or a high probability of gastric rupture secondary to the presence of extreme gastric

distention.

1. Primary indication

a. Respiratory failure secondary to massive abdominal

distention that cannot be decompressed by either

an oro- or nasogastric tube. For example, premature

neonates with esophageal atresia and a tracheoesophageal fistula (prerepair) with massive gastric

distention from preferential ventilation of the compliant stomach rather than the stiff premature

lungs.

2. Procedure

a. Prepare the abdomen with Betadine or chlorhexidine and then drape the skin in the upper left abdomen.

b. If possible, utilize a light to transilluminate the

abdomen to locate and verify the position of the distended stomach away from liver.

c. Make a small skin weal with 1% lidocaine to provide

local anesthesia.

d. Using a 20- or 22-gauge catheter with needle stylet,

puncture the abdominal wall at the junction of the

left anterior rib cage and the lateral border of the

rectus abdominus muscle.

e. Advance the needle through the wall into the stomach.

f. Remove the needle and advance the catheter into

the stomach.

g. Attach a short IV extension tubing, three-way stopcock, and syringe.

(1) Aspirate only enough air to relieve tamponade

effect and improve ventilation.

(2) Avoid completely emptying stomach.

h. Secure the catheter and keep in place until surgical

evaluation is possible.

i. Secure with tape or suture if necessary.

J. Postoperative and Maintenance

Gastrostomy Care

Postoperative gastrostomy care begins immediately with

meticulous attention to wound care to prevent infection

and skin irritation. Initiation of feeds through the new

gastrostomy tube may begin within 12 to 24 hours postplacement. Certain complications, however, such as a

postoperative ileus, as seen in more complicated operations, may require further bowel rest prior to gastrostomy

feeding.

 

Chapter 41 ■ Gastrostomy 287

E. Percutaneous Endoscopic

Gastrostomy (PEG)

Developed in 1980 by Drs. Gauderer and Ponsky, percutaneous endoscopic gastrostomy (PEG) has become the

primary method of gastrostomy in children (1,4,10). Infants

and children require general anesthesia for PEG placement.

1. The gastrostomy site preparation and antibiotic prophylaxis are similar to the open technique.

Standard PEG kits include a drape for the abdomen.

2. A flexible endoscope is inserted through the oropharynx and guided down to the stomach.

3. The stomach is insufflated to approximate the stomach

to the abdominal wall.

4. An introducer needle is placed percutaneously into the

insufflated stomach under direct endoscopic visualization.

a. Transillumination of the stomach along the greater

curvature through the abdominal wall with the

endoscope can aid in introducer placement.

b. Proper gastrostomy site is about 2 cm inferior to the

left costal margin along the paramedian plane,

which can also be palpated and visualized by the

endoscope.

c. A looped guidewire is inserted through the introducer into the stomach and the proximal end is

captured with an endoscopic snare. The snared

guidewire is then pulled through the mouth with

the endoscope, with the distal end remaining externally on the abdomen.

5. A gastrostomy tube is attached to the proximal end of

the guidewire.

Simultaneously, a small nick (~8 mm) is made

with a scalpel at the site of the introducer to allow for

the gastrostomy placement.

6. The guidewire is gently pulled back from the abdominal end, guiding the gastrostomy tube through the oropharynx, esophagus, and into the stomach.

7. The tapered end of the gastrostomy is pulled through the

abdominal wall until the intragastric mushroom-type

flange fits snugly up against the abdominal wall (1).

8. An external bolster/immobilizing ring is slid over the

tube down to the abdominal wall to secure the gastrostomy in place.

9. The gastrostomy tube is cut to the desired external

length and a feeding adaptor is placed on the end of the

tube.

F. Laparoscopic Gastrostomy

Laparoscopic placement of gastrostomy tubes, one of the

most popular methods, has been described as safe and efficacious (11). Some believe that the laparoscopic gastrostomy technique has a lower complication rate than the

PEG technique in neonates and small children (12).

1. The gastrostomy site preparation and antibiotic prophylaxis are similar to the open technique.

a. Mark the costal margin and proposed gastrostomy

site.

b. Oro- or nasogastric tube decompression of the stomach.

2. A 3- to 5-mm 30-degree laparoscope is inserted through

an umbilical incision.

The abdomen is insufflated to 8 to 10 torr with carbon dioxide.

3. A small subcostal incision is made at the aforementioned proposed site.

A 5-mm trocar and then a laparoscopic grasper are

inserted.

4. Under direct visualization, the stomach is grasped

along the greater curvature and pulled toward the

abdominal wall.

The abdomen is desufflated, the trocar is removed,

and the stomach is pulled through the abdominal

wall.

5. A traction suture is placed and the stomach is secured

to the abdominal fascia in four quadrants.

Inner purse-string is placed.

6. A gastrostomy is created by stab incision or with cautery

and a gastrostomy tube is inserted. The gastrostomy

tube can either be a Pezzer-type tube, or more

Fig. 41.3. After the tube is secured inside the stomach and

passed through a stab wound in the abdominal wall, the anterior

wall of the stomach is sutured to the inner wall of the abdomen.

 

286 Section VII ■ Tube Replacement

D. Stamm Gastrostomy (Open)

Neonatal gastrostomy placement often necessitates general

anesthesia. Classically, the open, or Stamm, gastrostomy,

described by Dr. Martin Stamm in 1894, was frequently

used in premature infants and neonates (2). The Stamm

technique, however, is now being used with less frequency

secondary to its invasive approach. Current indications

include altered gastric anatomy, multiple previous abdominal surgeries, concurrent laparotomy for other procedures,

and unstable patients.

1. Sterile preparation of the skin, and delivery of IV antibiotics (first-generation cephalosporin) within the hour

prior to the skin incision.

2. Transverse abdominal or supraumbilical midline incision (Fig. 41.1).

3. Identify the stomach and elevate the greater curvature

of the stomach through the wound.

Choose a dependent portion of the anterior wall of

the stomach.

4. Place two concentric, seromuscular purse-string sutures

on the greater curvature of the stomach (Fig. 41.2).

a. The inner purse-string suture allows for hemostasis.

b. The outer purse-string suture inverts the gastric

mucosa while fixating the stomach to abdominal

wall.

c. Take care to avoid injury to the gastroepiploic vessels.

5. Make a stab incision through the stomach wall (gastrostomy) in the center of the purse-string absorbable

sutures.

a. With a stylet inside the catheter, gently direct the

catheter through the gastrostomy.

b. Verify position of the tube inside the stomach.

c. Inflate the balloon if present.

6. Tie sutures.

a. The inner suture secures the stomach around the

catheter while providing hemostasis.

b. The outer suture allows for mucosal inversion and a

watertight abdominal wall to stomach wall seal.

7. At a separate and previously identified exit site, make a

stab wound through the abdominal wall.

8. Insert a curved hemostat through the abdominal wall

exit site and into the intraperitoneal cavity.

9. Secure the stomach and abdominal wall to each other

with three to four absorbable sutures in a seromuscular

fashion.

10. With the hemostat, pull the gastrostomy tube through

the abdominal wall stab wound until the stomach is

snug against the abdominal wall.

11. Tie the previously placed inner and outer sutures while

placing gentle traction on the gastrostomy tube.

12. Secure the gastrostomy tube to the skin with a suture to

prevent inadvertent removal (Fig. 41.3).

Document the length of the gastrostomy tube outside the abdomen.

13. Close the abdominal incision in standard surgical fashion.

14. Anatomically, this will allow the gastrostomy tube to lie

in the center of a triangle formed by the left costal margin, umbilicus, and xiphoid (Fig. 41.1).

15. Tubes utilized in a Stamm gastrostomy include balloonand mushroom-tip catheters, and/or low-profile buttons

(e.g., Mic-Key buttons, Kimberly-Clark Worldwide,

Inc., Neenah, Wisconsin).

Fig. 41.1. Landmarks for gastrostomy. The primary horizontal

incision is left supraumbilical. The gastrostomy tube will pass

through the abdomen at a separate site in the center of a triangle

formed by the xiphoid, umbilicus, and left costal margin.

Fig. 41.2. Site for concentric sutures for Stamm procedure.

Entrance into stomach is on greater curvature midway between

esophagus and pylorus.

 

21. Lopez-Alonso M, Moya MJ, Cabo JA, et al. Twenty-four hour

esophageal impedance-pH monitoring in healthy preterm neonates: rate and characteristics of acid, weakly acid, and weakly

alkaline gastroesophageal reflux. Pediatrics. 2006;118(2):e299.

22. Omari TI, Davidson GP. Multipoint measurement of intragastric

pH in healthy preterm infants. Arch Dis Child Fetal Neonatal Ed.

2003;88(6):F517.

23. Gilbertson HR, Rogers EJ, Ukoumunne OC. Determination of a

practical pH cutoff level for reliable confirmation of nasogastric

tube placement. JPEN. 2011;35(4):540.

24. Crisp CL. Esophageal nasogastric tube misplacement in an infant

following laser supraglottoplasty. J Ped Nurs. 2006;21(6):454.

25. Kairamkonda VR. A rare cause of chylo-pneumothorax in a preterm neonate. Indian J Med Sci. 2007;61:476.

26. Agarwala S, Dave S, Gupta AK, et al. Duodeno-renal fistula due

to a nasogastric tube in a neonate. Pediatr Surg Int. 1998;14:102.

27. Halbertsma FJ, Andriessen P. A persistent gastric feeding tube.

Acta Paediatrica. 2010;99:162.

28. Misra S, Macwan K, Albert V. Transpyloric feeding in gastroesophageal-reflux-associated apnea in premature infants. Acta

Paediatrica. 2007;96:1426.

29. McGuire W, McEwan P. Transpyloric versus gastric tube feeding for

preterm infants. Cochrane Database Syst Rev. 2007;(3):CD003487.

30. MacDonald PD, Skeoch CH, Carse H, et al. Randomized trial of

continuous nasogastric, bolus nasogastric, and transpyloric feeding in infants of birth weight under 1400 g. Arch Dis Child. 1992;

67:429.

31. Flores JC, Lopez-Herce J, Sola I, et al. Duodenal perforation

caused by a transpyloric tube in a critically ill infant. Nutrition.

2006;22:209.

32. Latchaw LA, Jacir NN, Harris BH. The development of pyloric

stenosis during transpyloric feedings. J Pediatr Surg. 1989;24:823.

33. Hughes U, Connolly B. Small-bowel intussusceptions occurring

around nasojejunal enteral tubes—three cases occurring in children. Pediatr Radiol. 2001;31:456.

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)

 

284 Section VII ■ Tube Replacement

H. Complications (See also Oral or Nasal

Gastric Tubes, H.)

1. The risk of aspiration with transpyloric feeding does not

appear to be different from the risk with gastric feeding

(29).

2. Kinking or knotting of tube

3. Hardening of PVC tube with leaching of bioavailable

plasticizers (8)

4. Perforation of esophagus, stomach, duodenum (31)

5. Development of pyloric stenosis (32)

6. Possible interference with absorption of medications

7. Malabsorption and GI disturbance (29,31)

a. Risk of fat malabsorption with nasojejunal feeds

b. Dumping syndrome if hypertonic medications or

feedings instilled too rapidly

c. GI disturbance as characterized by abdominal distention, gastric bleeding, and bilious vomiting

8. Intussusception (33)

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