Overview
Definition:
An open feeding gastrostomy is a surgically created stoma through the abdominal wall and stomach for the long-term administration of nutritional support
This procedure bypasses the upper gastrointestinal tract, allowing direct access to the stomach for feeding
It is typically performed when nasogastric or orogastric feeding is not feasible or adequate, or when a longer duration of nutritional support is anticipated.
Epidemiology:
The incidence of gastrostomy placement varies widely based on patient population, indication, and local practice patterns
It is commonly performed in patients with neurological deficits, head and neck cancers, or other conditions leading to dysphagia or inability to maintain adequate oral intake
While percutaneous endoscopic gastrostomy (PEG) is more common for elective placements, open gastrostomy remains relevant for specific indications and in certain surgical settings.
Clinical Significance:
Adequate nutritional support is paramount for patient recovery, wound healing, and overall outcomes, especially in critically ill or debilitated patients
Feeding gastrostomy provides a reliable route for enteral nutrition, which is generally preferred over parenteral nutrition due to its physiological benefits and reduced infectious complications
Understanding open gastrostomy is crucial for surgeons managing patients requiring long-term nutritional support.
Indications
Nutritional Support:
Long-term need for enteral nutrition in patients unable to swallow or maintain adequate oral intake
This includes severe dysphagia due to stroke, neurodegenerative diseases (e.g., ALS, Parkinson's), or head and neck malignancies
Essential for patients requiring prolonged mechanical ventilation or with significant caloric deficits.
Gastrointestinal Obstruction:
Conditions causing obstruction of the upper GI tract, such as advanced esophageal cancer or complex upper GI fistulas, where passage of food via the normal route is impossible.
Gastric Decompression:
In select cases, a gastrostomy tube can be used for gastric decompression in patients with chronic gastric outlet obstruction where a formal surgical bypass is not immediately feasible or desired.
Prevention Of Aspiration:
In patients with severe reflux or aspiration risk, gastrostomy can be part of a management strategy, though specific tube types and surgical techniques may be tailored.
Preoperative Preparation
Patient Evaluation:
Thorough assessment of nutritional status, including anthropometric measurements, laboratory parameters (albumin, prealbumin, total lymphocyte count), and caloric requirements
Evaluation of comorbidities that may increase surgical risk.
Informed Consent:
Detailed discussion with the patient and/or family about the procedure, its benefits, risks (infection, bleeding, leakage, tube dislodgement), alternatives, and expected outcomes
Discussion of the type of gastrostomy tube to be used.
Bowel Preparation:
Standard bowel preparation with clear liquids and laxatives may be required, depending on the surgical approach and surgeon preference
Prophylactic antibiotics are administered intravenously before skin incision to reduce surgical site infection risk.
Nutritional Optimization:
Initiation of nutritional support (enteral or parenteral) preoperatively to improve the patient's nutritional status before surgery, if time permits
This can enhance wound healing and reduce postoperative complications.
Surgical Management
Operative Approaches:
Open gastrostomy can be performed using various techniques: **Direct Gastrostomy (e.g., Stamm procedure):** Involves manual fixation of the anterior gastric wall to the abdominal wall
**Witzel Gastrostomy:** Involves creating a Lembert tunnel for the tube within the gastric wall to create a more T-shaped tract, potentially reducing leakage
**Janeway Gastrostomy:** Primarily for creating a feeding stoma that is less prone to retraction, often used in conjunction with other procedures.
Procedure Steps Stamm:
Laparotomy or upper abdominal incision
Identification of the stomach
Pouch creation from the anterior gastric wall
Incision into the stomach
Insertion of the gastrostomy tube into the stomach lumen
Secure fixation of the gastric pouch to the abdominal wall with sutures (seromuscular and cutaneous)
Tube anchoring and dressing
Meticulous closure of the abdominal wall layers.
Tube Selection:
Choice of gastrostomy tube depends on duration of need and surgeon preference, ranging from Foley catheters to dedicated silicone gastrostomy tubes with internal bolsters
Tube size is selected based on patient anatomy and desired flow rate.
Abdominal Wall Closure:
Layered closure of the abdominal wall, ensuring secure fixation of the gastric stoma to prevent leakage
The tube is typically secured to the skin with a purse-string suture or adhesive device.
Postoperative Care
Wound Care:
Regular dressing changes to keep the stoma site clean and dry
Monitoring for signs of infection, erythema, or purulent discharge
Meticulous hygiene to prevent contamination.
Tube Management:
Initial tube flushing with sterile water or saline to confirm patency
Gradual initiation of enteral feeding as per protocol, usually within 24-48 hours postoperatively
Tube advancement may be considered after initial healing.
Nutritional Monitoring:
Regular assessment of caloric and fluid intake, tolerance of feeds, and monitoring of weight
Adjustment of feed rate and composition as needed
Laboratory monitoring for electrolyte balance and nutritional markers.
Pain Management:
Adequate analgesia to manage incisional pain and discomfort associated with the gastrostomy tube
Multimodal analgesia may be employed.
Complications
Early Complications:
Bleeding from the stoma site or into the gastric lumen
Peritonitis due to leakage of gastric contents around the tube or into the peritoneal cavity
Wound infection at the stoma site or abdominal incision
Tube dislodgement or obstruction
Injury to adjacent organs (e.g., colon, liver) during insertion.
Late Complications:
Stomal stenosis or stricture
Gastrocolic fistula formation
Gastric outlet obstruction due to tumor recurrence or scar tissue
Tube migration or retraction
Skin irritation or breakdown around the stoma site
Gastric distension or vomiting if feeds are initiated too rapidly or in excessive volumes.
Prevention Strategies:
Meticulous surgical technique with secure fixation of the stomach to the abdominal wall
Appropriate tube selection and placement
Careful initiation of enteral feeding
Regular stoma site care and patient education on tube management
Prompt recognition and management of any signs of complications.
Key Points
Exam Focus:
Indications for open vs
PEG gastrostomy
Stamm and Witzel techniques
common early and late complications
principles of postoperative nutritional management
DNB/NEET SS exams often test surgical decision-making and complication management.
Clinical Pearls:
In patients with significant ascites, consider the risk of increased intra-abdominal pressure and potential for leakage
Always confirm tube position radiographically if there is any doubt, especially after dislodgement
Regular flushing is key to preventing tube occlusion.
Common Mistakes:
Inadequate fixation of the stomach to the abdominal wall leading to leakage
premature initiation of enteral feeds
poor stoma care leading to infection or skin breakdown
failure to recognize early signs of peritonitis.