Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

Using two Babcock clamps for traction, use forceps to stent mushroom catheter tip and place through enterotomy and advance tip 8 cm distally into intestine (Figure 21-4).

Secure purse string around catheter.

Mushroom

catheter

FIGURE 21–4

2 5 0 S E C T I O N I V • TH E A B D O M E N

Place multiple 3-0 silk interrupted sutures at 1-cm intervals for 6 to 8 cm proximal to enterotomy and incorporate bowel wall on both sides of catheter (Figure 21-5).

Tie sutures, thereby burying catheter within wall of intestine (see Figure 21-5, B).

Place several additional 3-0 silk sutures at 1-cm intervals in a Lembert fashion, incorporating enterotomy and continuing distally for 3 to 5 cm (see Figure 21-5, C).

Lembert sutures

Mushroom catheter

Purse-string

suture

A

B

C

FIGURE 21–5

Use several 3-0 silk sutures to anchor the antimesenteric wall of jejunum to peritoneum

(Figure 21-6).

Retract mushroom catheter to approximate antimesenteric jejunal wall with enterotomy to peritoneum, secure silk sutures.

Anchor sutures

Jejunum

Mesentery

Mushroom

catheter

FIGURE 21–6

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3. CLOSING

Close fascia with suture.

Close skin.

STEP 4: POSTOPERATIVE CARE

Routine: start feeds

STEP 5: PEARLS AND PITFALLS

Use of two Babcock clamps grasping edges of enterotomy in conjunction with forceps inserted into tip of mushroom catheter provides an excellent means for placing catheter through enterotomy.

Catheter should remain in place for at least 2 weeks to allow enterotomy tract and jejunum to heal securely to peritoneum.

Broad attachment of jejunal loop to peritoneum is advisable to minimize angulation of small intestine.

First place all the sutures from the antimesenteric edge of jejunum to peritoneum, and then retract the catheter to approximate the jejunum to peritoneum and secure ligatures. This sequence allows good visualization and space for placing sutures.

SELECTED REFERENCES

1. Zollinger RM Jr, Zollinger RM: Atlas of Surgical Operations. New York, Macmillan, 1983, p 92.

C H A P T E R 22

PERCUTANEOUS GASTROSTOMY FEEDING TUBE PLACEMENT (BY SURGEON

OR GASTROENTEROLOGIST)

Dennis C. Gore

STEP 1: SURGICAL ANATOMY

See Figure 22-1.

Transillumination site

Rib

Colon

Liver

Stomach

Scope

FIGURE 22–1

253

2 5 4 S E C T I O N I V • TH E A B D O M E N

STEP 2: PREOPERATIVE CONSIDERATIONS

Percutaneous endoscopic feeding tube placement is indicated for patients who have a functional gastrointestinal tract but are unable or unwilling to meet nutritional demands by mouth, in general for a period longer than 30 days (nasogastric or orogastric tubes are recommended for shorter-term use). In addition, the patient’s potential survivability should be good if adequate nutrition is achieved. Potential candidates include those with neurologic deficits, psychomotor deficits, pseudodementia with starvation, facial trauma, facial tumors that will not immediately threaten the patient’s life, and prolonged ventilation assistance, again with good survivability.

Placement can be done at bedside, in the endoscopy suite, or in the operating room.

Obtain informed consent. Often these patients cannot consent for themselves, so proper planning with family members is important.

Visualize the patient’s abdomen. Prior surgery may preclude proper placement. Adhesions may prevent transillumination (at which point the procedure should be stopped to avoid insertion into an overlying loop of bowel), or displacement of the stomach may cause placement too close to ribs or belt line.

If the patient has an oral or upper airway tumor, he or she may not be a candidate for endoscopy or passage of the scope.

Ensure there is no evidence of gastric outlet obstruction, in which case a jejunostomy feeding tube may be required.

Patients with excessive reflux or nonfunctional esophageal sphincters may not be good candidates for gastrostomy feeding tubes, which can increase risk of aspiration.

Some surgeons advocate one dose of preoperative antibiotic, such as a first-generation cephalosporin, but this is not universal practice.

Blood pressure, pulse oximetry, and electrocardiogram should be monitored in all patients during the procedure.

Place the video camera on the patient’s right to facilitate viewing during the procedure.

Two operators are required—one for endoscopy and one for feeding tube insertion.

Sedation/anesthesia considerations: Often these patients can be comatose or altered in level of consciousness, so less sedation is required. Usually 1 to 2 mg of a benzodiazapine and a small dose of narcotic can relax the patient to allow passage of the endoscope, which may be eased if the patient can cooperate with swallowing. Topical spray to the oropharynx will facilitate endoscopy. The abdominal insertion site should receive local anesthetic.

Positioning/preparation: Patients are placed supine, often with the head of the bed raised at 30 degrees to prevent aspiration. A bite block is used in the mouth to prevent the patient from biting the scope or the surgeon. Suction should be available for secretions and to prevent risk of aspiration. The abdominal site is prepped widely with povidone-iodine (Betadine) or sterile soap, and sterile drapes are applied. The endoscopist should be at the patient’s head on the left and the assistant on the right by the patient’s abdomen.

STEP 3: OPERATIVE STEPS

In both methods currently used, at least two persons are needed to perform the procedure—one to perform the endoscopic visualization and the other to perform insertion of the tube under sterile technique. Both are performed using a prepackaged kit available from several manufacturers.

2 5 6 S E C T I O N I V • TH E A B D O M E N

1. INCISION

Sheath method (Russell technique) (rarely used): After the patient is adequately sedated and the abdomen is prepped in sterile technique, the endoscope is passed via the mouth into the stomach. The stomach is insufflated and transilluminated (see Figure 22-1). The lack of transillumination precludes safe placement (Figure 22-2). Once the light source is visible through the skin, an area is marked for insertion (the site should be 2 cm away from the costal margin) and lidocaine is injected. A no. 11 blade is used to make a small incision (0.5 mm) in the skin. A 14to 18-gauge needle is then passed through the incision with the tip identified on the video screen and endoscopy camera (Figure 22-3). The guidewire is then passed through the needle and identified inside the stomach and the needle is removed. The dilator and then the sheath are passed in turn over the guidewire. Once the sheath is confirmed within the stomach, the feeding tube is passed through the sheath into the stomach. Again after visualization of the tube, the balloon of the feeding tube is inflated inside the stomach.

No transillumination

Rib

Liver

Stomach

Scope

FIGURE 22–2

Distal end of wire loop

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Pull method (Ponsky): After the patient is adequately sedated and prepped using sterile technique, the endoscope is passed via the mouth into the stomach. Visualization and insufflation of the stomach is performed with transillumination (see Figure 22-1). After identification of an appropriate insertion site on the stomach (2 cm away from the costal margin), the area is marked and lidocaine is injected. A small incision is made (1 cm) with the no. 11 blade, and a 14to 18-gauge needle is passed through the incision into the stomach with visualization via the endoscope (see Figure 22-3). A braided suture is passed through the needle and encircled by a snare passed through the endoscope. Once the “rope” is securely entrapped, the needle is removed and the entire endoscope with snare and attached rope is withdrawn through the mouth (Figure 22-4). The feeding tube is then attached to the rope and lubricated well. The assistant then withdraws the rope from the stomach wall, and the tube is carefully guided through the patient’s mouth into the stomach and is pulled into position (Figure 22-5). Once the feeding tube has been drawn through the skin to approximately 4 cm, the endoscope is reinserted into the stomach to ensure proper seating of the feeding tube. A skin disc is placed to help hold the tube in position against the abdomen (Figure 22-6).

Push method (Sacks-Vine): After the patient is adequately sedated and prepped using sterile technique, the endoscope is passed via the mouth into the stomach. Visualization and insufflation of the stomach is performed with transillumination (see Figure 22-1). After identification of an appropriate insertion site on the stomach (2 cm away from the costal margin), the area is marked and lidocaine is injected. A small incision is made (1 cm) with the no. 11 blade, and a 14to 18-gauge needle is passed through the incision into the stomach with visualization via the endoscope (see Figure 22-3). A guidewire is passed through the needle and encircled by a snare passed through the endoscope. Once the guidewire is securely entrapped, the needle is removed and the entire endoscope with snare and attached guidewire is withdrawn through the mouth (see Figure 22-4). Once enough guidewire is visible through the mouth, the feeding tube is then fed over the guidewire and lubricated well. The feeding tube is then fed through the mouth and pushed over the wire. The assistant keeps tension on the guidewire and grabs the tapered end of the feeding tube as it emerges on the skin. Once the feeding tube as been drawn through the skin to approximately 4 cm, the guidewire is withdrawn and the endoscope is reinserted into the stomach to ensure proper seating of the feeding tube. A skin disc is then guided over the feeding tube to help secure its position against the skin (see Figure 22-6).

2. DISSECTION

Not applicable

3. CLOSING

Not applicable