Creating a Continent Tubeless Gastrostomy

Ivan R. Rosado, MD, Phoenix, Arizona

Robert 6. Gilsdorf, MD, PhD, FACS, Phoenix, Arizona

Feeding gastrostomies are plagued with problems. The standard tube gastrostomy creates foreign body irritation, and the tube is constantly at risk of acci- dental removal especially in patients who are am- bulatory and receiving physical therapy or who are brain-injured and combative [1,2]. The feeding tube may migrate into the duodenum causing obstruction or it may erode into the peritoneal cavity producing peritonitis [3,4]. The tract is not always watertight and may leak gastric contents, producing painful peristomal irritation [5].

In 1913 the American surgeon H. H. Janeway de- scribed a gastrostomy using a tube made from the anterior wall of the stomach [6]. A similar gastros- tomy had been described in Europe 12 years earlier by the Belgian surgeon, Depage [7]. Spivak [8] in 1929 described a flap valve that was incorporated into the base of the gastric tube. Over the years the Janeway-Depage gastrostomy, even with its modi- fications, has not been well accepted because of the extent of surgery and the technical skill required plus the incontinence of the stoma that was created.

With the development of gastrointestinal staplers, it became possible to create a tube rapidly [9]. We found that this stapled gastrostomy still had prob- lems with leakage. To prevent leakage, we incorpo- rated a reverse intussusception valve at the base of the tube. Gastric secretions continued to cause per- istomal irritation, but by creating a small flush stoma we eliminated the problem. We are reporting our experience with a technique we developed to create a tubeless gastrostomy for long-term enteric nutri- tional support.

Material and Methods

Between August 1982 and January 1983, a tubeless gastrostomy was created in 23 patients aged 10 to 81 years. Eight had head injuries, 12 had cerebrovascular strokes, and 3 had head and neck disorders leading to aphago- praxia. The procedures were performed by either the senior author (RBG) or by a surgical resident with him in atten- dance. Twelve procedures were carried out with local an- esthesia and the remainder with general anesthesia.

From the Veterans Administration Medical Center, Phoenix, Arizona. Dr. Rosado is a Norwich-Eaton Fellow in the Phoenix Integrated Surgical Resi- dency Program, Phoenix, Arizona.

Requests for reprints should be addressed to Robert B. Gilsdorf, MD, 1010 E. McDowell Road. Phoenix. Arizona 85006.

Presented at the 35th Annual Meeting of the Southwestern Surgical Congress, Phoenix, Arizona, May 2-5, 1983.

820

A 6 cm midline epigastric skin incision was used (Figure 1). The midline fascia was opened 8 cm and the falciform mobilized to the right so the peritoneum could be entered from its left side. The stomach was delivered through the incision and an Allis clamp was placed 2 cm to the left of the incisura denoted by the nerve of Latarjet. Using the GIA stapler a narrow 5 cm gastric tube was made from that point to the base 3 cm from the greater curvature (Figure 2). The tube diameter was kept at 1.3 cm. The staple line was inverted with a running seromuscular suture of 3-O polyglycolic acid (Figure 3). The distal 2 cm of the staple line were inverted with interrupted Lembert sutures, be- cause these were frequently cut away in making the stoma. The staple line inversion was used to prevent hemorrhage and secondary ileus, but care was taken not to compromise the diameter of the tube. A valve was then created at the base of the tube (Figure 3). Six or seven sutures of nylon were placed radially around the tube to intussuscept 2 cm of it into the stomach. The sutures were not cut because they were used subsequently to anchor the stomach to the parietal peritoneum. A stoma exactly 1 cm in diameter was made 4 cm to the left of the incision. A tunnel through the anterior and posterior rectus fascia was made and dilated to admit the index finger (Figure 4). The lateral sutures used to create the valve were placed and tied before the tube was delivered through the tunnel. Thereafter, the medial stitches were placed. The tube was cut off flush with the skin, and the stoma was sutured with six to eight su- tures of 3-O chromic catgut, catching the full thickness of the gastric tube and just the subcuticular tissue of the skin. The tube was checked for patency and ease of cannulation before closure of the incision. Catheters were not left in the tube.

Postoperatively, the patients continued receiving in- travenous feedings for 1 day. On the first postoperative day the stoma was cannulated with a 12 F. catheter, and bolus feedings of elemented diets were begun (Table I). These feedings were advanced over several days until eventually the patients were maintained with 5 feedings of complex liquid diet, all given during the day. A few patients were maintained with pureed regular diets. An adhesive bandage was applied over the stoma between feedings.

Results

Operative time ranged from 47 to 90 minutes. There were no deaths or surgical complications. Be- cause problems with reflux had been severe in two patients, a serosal tunnel jejunostomy was created at the time of gastrostomy.

Postoperatively, stoma1 necrosis occurred by the fifth day in two patients. In these two, a Foley cath- eter was inserted and the gastrostomy was used just

The American Journal of Surgery

Creating a Continent Tubeless Gastrostomy

Figure 7. A small epigasiric incision is made to deliver the s&m- sch. A narrow tube is made proximal to the incisura, using a GIA stapler.

Figure 3. A valve is created by imbricating the gastric tube into the stomach.

as a standard tube gastrostomy. One stricture of the stoma developed 4 months postoperatively, requiring incision of the scar band. Three patients resumed normal swallowing, so the gastrostomy was electively closed under local anesthesia on an outpatient basis. With 16 months of follow-up, none of the gastros- tomies has become incontinent and all continue to be used for total enteric nutritional support.

Comments

The continent tubeless gastrostomy eliminates the problems associated with conventional gastrostomy. Its management is simple and nursing care is mini- mal. There is no need for dressings or special cleaning agents for use around the tube because there is no persistent irritation; therefore, it is socially more acceptable and enables the patient to return to his home under the care of family members.

The technical aspects of creating a continent tubeless gastrostomy are uncomplicated. We found that most can be created using local anesthesia, and the procedure does not take much longer than con- ventional tube gastrostomy. Although the small

Figure 2. The staple line is oversewn.

Figure 4. A 1 cm stoma is created at the skin level after the stomach is fixed to the abdominal wall around the gastric tube.

midline incision requires a good assistant, the lack of postoperative ileus and the diminished risk of wound dehiscence make this inconvenience minor. Certain technical points are crucial. The blood supply of the gastrostomy tube must be protected; stitches should not be placed through the vessels at the base of the tube. Maturation of the stoma must be per- formed meticulously around its circumference to prevent the creation of a false passage outside the tube when cannulation is begun the following day. Finally, the stoma should be exactly 1 cm in diame- ter. A smaller stoma is prone to stricture and a larger one results in excess mucous leakage which can ultimately lead to peristomal irritation.

The feeding regimen has generally not been a problem. In an occasional patient abdominal dis- tention or early bloating sensation may develop, but these are alleviated by decreasing the volume of the feedings. Patients with reflux problems when nasal

TABLE I Feeding Schedule After Gastrostomy”

Day Schedule

0 No infusion 1 Elemental diet, 100 ml 2 hours every 2 Elemental diet, 200 ml every 2 hours 3 Complex liquid diet, 200 ml 2 hours every 4 Complex liquid diet, 240 ml 3 hours every 5 Complex liquid diet at 7 AM, 11 AM, 3 PM, 5 PM, and 9 PM

l The elemental diet consisted of Vivonex l-IN@.

Volume 146, December 1963 821

Rosado and Gilsdorf

feeding tubes were used did not have this problem when the gastrostomy was created. In neither of our two patients in whom we placed a concomitant jeju- nostomy because of this problem was it necessary. If reflux should become a problem, a small feeding tube can be inserted through the gastrostomy and allowed to pass into the small intestine before feedings are begun.

The continent tubeless gastrostomy need not be permanent. Closing the gastrostomy can be similar to removing a 1 cm lesion from the anterior abdom- inal wall. It is performed in the patient’s hospital room or in the office by merely removing the ellipse of skin containing the stoma. The gastric tube can then be oversewn and the skin closed above it.

Summary

Standard tube feeding gastrostomy is associated with a myriad of problems among which leakage of gastric contents is the most serious. Over the years many methods of creating tubeless gastrostomy have been unsuccessful because of the extent of surgery required and the persistent leakage of gastric fluids. By using gastrointestinal staplers to create a gastric tube and by incorporating a reverse intussusception valve at its base, we created a continent tubeless feeding gastrostomy in 23 patients aged 10 to 81 years. Eight had head injuries, 12 had cerebrovas- cular strokes, and 3 had head and neck disorders leading to aphagopraxia. Twelve of the procedures were performed with local anesthesia and the re- mainder with general anesthesia. The GIA stapler was used to create a 5 cm gastric tube after which circumferential stitches were placed to intussuscept 2 cm of the tube into the stomach to create a valve. A 1 cm stoma was created at skin level. Operative time was 47 to 90 minutes, and there were no opera- tive deaths or complications. Stoma1 necrosis oc- curred in two patients so they were converted to a standard tube gastrostomy by leaving a Foley cath- eter in place. After 16 months of follow-up, one stricture developed at 4 months and two were elec- tively closed under local anesthesia. None is incon- tinent. The tubeless continent feeding gastrostomy is convenient for both patients and nursing staff and should replace the standard feeding gastrostomy when long-term nutritional support is needed.

References

1. Wasiijew BK, Ujiki, GT, Beal JM. Feeding gastrostomy: compli- cations and mortality. Am J Surg 1982;143:194-5.

2. Shackelford RT, Zuidema GD. Surgery of the alimentary tract,

2nd ed, vol. II. Philadelphia: WB Saunders, 1981:332. 3. Sherman ML, Cosgrove JJ, Dennis JM. Gastrostomy tube mi-

gration. Am Surg 1973;39: 122-3. 4. Torosian MH, Rombeau JL. Feeding by tube enterostomy. Surg

Gynecol Obstet 1980; 150:9 18-24. 5. Thorek M. Modern surgical technique vol. 3. Philadelphia: JB

Lippincott, 1938:1280-95. 6. Janeway HH. The relation of gastrostomy to inoperable cancer

of the esophagus with a description of a new method of per- forming gastrostomy. JAMA 1913;61:93-5.

7. Depage A. Nouveau procede pour la gastrostomie. J Chir et Ann Sot Belge Chir 1901;1:715-8.

8. Spivack JL. Eine neue methode der gastrostomie. Beitr z klin Chir; 1929;147:308-18.

9. Moss G. A simple technique for permanent gastrostomy. Surgery 1972;71:369-70.

Discussion

Carey P. Page (San Antonio, TX): All experienced surgeons are conversant with the potential complications of creating a primary feeding enterostomy. Often these patients have not only serious neurologic disease or ad- vanced cancer, but also serious malnutrition, making them less than ideal candidates for any surgical procedure. Drs. Rosado and Gilsdorf have addressed the important issue of a safe, effective route of access for long-term nu- tritional support in a group of patients incapable of eating for one reason or another. Certainly we have fallen short in this endeavor in the recent past with the use of standard, large tube feeding enterostomies.

I should like to pose several questions to the authors. (1) What is the overall complication rate in their patients? Specifically, what about some of the malnutrition-related complications such as wound infection and healing prob- lems? (2) What is the mean survival time of the patients in whom they are creating this type of primary feeding access? (3) What feedback have they received from chronic care facilities regarding the continent tubeless gastrosto- my? (4) Do these investigators share my skepticism re- garding the long-term benefits of a competitive technique for feeding access; that is, the endoscopy/percutaneous gastrostomy?

Ivan Rosado (closing): There is one point that perhaps I did not stress enough. We do not recommend this gas- trostomy as the primary method of support in malnour- ished patients. In the severely malnourished patient, other means would be more appropriate. We have limited our procedure to patients who are not severely malnourished but require long-term nutritional support. We like our patients to have an albumin level of 3 g/100 ml or above before doing the procedure.

The feedback from the nursing homes about the nursing care of our patients has been good. The gastrostomy is easy to use and there have been no nursing care problems. I do not have any follow-up data regarding survival because the study is still too early. We have no experience at this time with endoscopically placed gastrostomy.

822 The American Journal of Surgery