Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)
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C H A P T E R 22 • Percutaneous Gastrostomy Feeding Tube Placement |
259 |
Distal end wire
of gastrostomy tube
Proximal end of
Gastrostomy tube Proximal end
of guidewire
Guidewire 
Trocar needle 
Guidewire
FIGURE 22–4
|
Distal end |
|
of wire loop |
Gastrostomy tube |
FIGURE 22–5 |
secured |
|
FIGURE 22–6
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STEP 4: POSTOPERATIVE CARE
The PEG tube is placed to gravity for the remainder of the procedure day with 30 to 60 mL of water or saline flush performed every 4 hours. If no signs of infection, abdominal sepsis, or ileus are seen the following morning, trickle feeds may be started and advanced as tolerated. The site should be kept clean and dry and the tube at approximately 3 to 5 cm depending on patient girth. Pills should not be inserted into the tube, and only liquid medications should be given.
Removal: Most tubes are removed by gentle traction at the skin. If a balloon catheter type has been inserted, the balloon should be deflated first. If the tube breaks and the inner disc does not come out, endoscopic retrieval is necessary to avoid risk of bowel obstruction.
STEP 5: PEARLS AND PITFALLS
Often patients are combative and accidentally dislodge tubes or break sterile fields. In addition, sedatives can disinhibit some patients. During the procedure, consider assistance or soft restraints.
If transillumination cannot be performed, stop the procedure. This is a contraindication because adjacent viscera can be damaged.
Early dislodgement may preclude replacement and require laparotomy. A Foley catheter can be used to maintain the tract once epithelialization has occurred, if the tube is displaced after that time. If a tube is reinserted, confirmation of placement should be made with a gastrograffin abdominal film.
Excessive tension on the feeding tube can cause necrosis of the abdominal wall, site infection, and feed leakage. No gauze should be placed under the skin disc to help prevent this.
SELECTED REFERENCES
1. Eisen GM, Baron TH, Dominitz JA, et al: Role of endoscopy in enteral feeding. Gastrointest Endosc 2002;55:794-797.
2. Scott-Conner CEH (ed): The SAGES Manual: Fundamentals of Laparoscopy and GI Endoscopy. New York, Springer, 1999, pp 462-469.
3. Duh Q-Y, McQuaid K: Flexible endoscopy and enteral access. In Eubanks S, Swanström LL, Soper NJ, Leonard M (eds): Mastery of Endoscopic and Laparoscopic Surgery. Philadelphia, Lippincott Williams & Wilkins, 2000, pp 133-143.
4. Angus F: The percutaneous endoscopy gastrostomy tube, medical and ethical issues in placement. Am J Gastroenterol 2003;98:272-277.
5. Gopalan S: Enteral nutrition delivery technique. Curr Opin Clin Nutr Metab Care 2003;6:313-317.
C H A P T E R 23
PYLOROPLASTY
Carlos A. Angel
STEP 1: SURGICAL ANATOMY
The pylorus sits at the distal end of the stomach and is marked by thickening of the circular smooth muscle layer, thus forming the pyloric sphincter, which acts as a valve between the stomach and the duodenum and regulates gastric emptying. The pylorus does not have independent blood supply; rather, it gets its blood supply from the vessels that perfuse the distal stomach and proximal duodenum. Innervation of the pylorus is through the terminal branches of the right and the left vagus nerves. Any injury to these nerves or denervation of the pylorus will result in pylorospasm and delayed gastric emptying.
STEP 2: PREOPERATIVE CONSIDERATIONS
Gastric drainage procedures such as pyloroplasties are indicated with truncal vagotomies in the management of peptic ulcer disease (pyloric, prepyloric, and duodenal ulcers), in selected patients who undergo transhiatal resection of the esophagus with gastric pullups, and in children undergoing fundoplication for gastroesophageal reflux disease with confirmed delay in gastric emptying. Three types of pyloroplasties have been classically described, namely, the Heineke-Mikulicz pyloroplasty, which is the easiest to perform and the most commonly used; the Finney pyloroplasty; and the Jaboulay pyloroplasty.
Confirmation of the diagnosis of peptic ulcer disease or delay in gastric emptying should be documented before the procedure with endoscopy, contrast studies, or technetium-99 sulfur colloid meals.
The Heineke-Mikulicz pyloroplasty is perhaps the most commonly performed because it is technically simple, carries low morbidity and mortality, and of all pyloroplasties it takes the least amount of time to complete.
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STEP 3: OPERATIVE STEPS
1. INCISION
After the antrum and duodenum are exposed, the pylorus is easily identified because it feels thicker that either the stomach or duodenum, and the pyloric vein, which runs across the pylorus transverse to the axis of the duodenum, serves as a clear landmark. A 3-cm fullthickness incision is made along the axis of the pylorus equidistant from both the stomach and the duodenum (Figures 23-1 and 23-2). Holding stitches are placed at the midpoint of the incision on both the superior and inferior sides of the defect, and traction is used to align the tissue perpendicularly with respect to its original axis (see Figure 23-2). Closure is now performed in two layers. A running 3-0 absorbable suture layer is used to reapproximate the mucosa (Figure 23-3), and interrupted 3-0 silk seromuscular stitches are used to complete the repair (Figure 23-4). Care must be taken to avoid excessive invagination of the suture line. If tension is deemed to be excessive, mobilization of the duodenum with a Kocher maneuver may be required.
Antrum
Duodenum
3-cm incision in anterior pylorus
FIGURE 23–1
C H A P T E R 23 • Pyloroplasty |
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Antrum
Longitudinal opening of all layers across pylorus
Duodenum
FIGURE 23–2
Running closure
of the mucosal layer
Duodenum
Interrupted seromuscular
Lembert sutures
FIGURE 23–3
Antrum
Duodenum
FIGURE 23–4
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2. DISSECTION, HEINEKE-MIKULICZ PYLOROPLASTY (STAPLED)
A full-thickness 4- to 6-cm longitudinal incision is made along the axis of the pylorus, and two holding stitches are placed as described previously. An additional stitch is placed from the most proximal to the most distal point of the incision (Figure 23-5). As these stitches are placed under traction, the longitudinal defect is converted into a transverse defect. A terminal anastomosis (TA)-55 linear stapling device is applied, making sure that all layers are involved and in such a manner that after its firing the result will be a transverse closure of the incision (Figures 23-6 and 23-7). After the stapler is fired, excess pyloric tissue is removed with the scalpel, and subsequently the stapler is released (see Figures 23-6 and 23-7). Careful inspection of the staple line is mandatory. A stapled pyloroplasy such as the one described here requires a supple pylorus and should not be chosen when the pylorus is scarred and nonpliable.
Longitudinal incision along the pylorus (full thickness)
Antrum
Duodenum
FIGURE 23–5
C H A P T E R 23 • Pyloroplasty |
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Antrum
Removing excess pyloric tissue
FIGURE 23–6
Transverse closure
Antrum
Duodenum
FIGURE 23–7
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3. CLOSING
The incision is closed in layers using 2-0 polyglactin in a running fashion. The subcutaneous tissue is reapproximated with a running 3-0 polyglactin suture. The skin can be stapled together or closed with a running subcuticular suture of 4-0 undyed absorbable monofilament and adhesive strips.
STEP 4: POSTOPERATIVE CARE
The patient should have already received a preoperative dose of a prophylactic antibiotic such as cefazolin. Two additional doses are in order after the operation. Hydration will be maintained with an intravenous infusion of a balanced dextrose and electrolyte solution.
Intravenous analgesics are used until the patient resumes enteral feeds. The decision to decompress the stomach with a nasogastric tube is up to the individual surgeon, and the current tendency is to use these tubes sparingly. Certainly, if the repair was deemed to be tenuous, a nasogastric tube could prove to be very helpful. After 2 to 3 days (on average), enteral feeds can be slowly and gradually resumed. The presence of bile in the gastric aspirate does not necessarily represent a persistent postoperative paralytic ileus, because it could be the result of the pyloroplasty itself and it should not be a reason for undue delays in resumption of enteral feeds. Pain, abdominal distention, tachycardia, and guarding should prompt the surgeon to order a contrast study to investigate for leaks in the
suture line.
STEP 5: PEARLS AND PITFALLS
Performance of this procedure in a scarred and nonpliable pylorus can potentially be plagued by complications. Poor selection of pyloroplasty technique will result in undue tension of the repair. On the other hand, excessive tension can also result in a supple pylorus from extending the initial incision too far proximally into the stomach and distally into the duodenum.
Complications: Alkaline reflux, alkaline gastritis, and dumping syndrome can be seen after any pyloroplasty. Failure of the operation with delayed gastric emptying is the result of excessive invagination of one or both suture lines. Excessive tension of the suture line when performing this procedure in a pylorus that is acutely inflamed or ulcerated may result in disruption of the suture line, intestinal leaks, and intra-abdominal sepsis.
SELECTED REFERENCES
1. Economou SG, Economou TS: Atlas of Surgical Techniques. Philadelphia, Saunders, 1996, pp 224-227. 2. Mercer DM, Robinson EK: Stomach. In Townsend CM, Beauchamp RD, Evers MB, Mattox KL (eds):
Sabiston Textbook of Surgery, 18th ed. Philadelphia, Saunders, 2008.
C H A P T E R 24
FINNEY PYLOROPLASTY
Carlos A. Angel
INTRODUCTION
Finney, in 1902, described a gastric emptying procedure consisting of a horseshoe-shaped incision through the pylorus followed by a transverse repair in layers. In essence, Finney pyloroplasty is a side-to-side anastomosis of antrum and duodenum that, unlike the Jaboulay pyloroplasty, does not exclude the pyloric area. This procedure involves an extensive Kocher maneuver of the duodenum and can be performed with a classic handsewn two-layer technique as illustrated later, or using a gastrointestinal anastomosis (GIA) linear stapler to approximate antrum and duodenum with a single stab incision through the pylorus and closure of the defect with a terminal anastomosis (TA)-55 linear stapler.
STEP 1: SURGICAL ANATOMY
The pylorus sits at the distal end of the stomach and is marked by thickening of the circular smooth muscle layer, thus forming the pyloric sphincter, which acts as a valve between the stomach and the duodenum and regulates gastric emptying. The pylorus does not have independent blood supply; rather, it gets its blood supply from the vessels that perfuse the distal stomach and proximal duodenum. Innervation of the pylorus is through the terminal branches of the right and left vagus nerves. Any injury to these nerves or denervation of the pylorus will result in pylorospasm and delayed gastric emptying.
STEP 2: PREOPERATIVE CONSIDERATIONS
Confirmation of the diagnosis of peptic ulcer disease or delay in gastric emptying should be documented before the procedure with endoscopy, contrast studies, or technetium-99 sulfur colloid meals.
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STEP 3: OPERATIVE STEPS
1.INCISION
The operation can be performed through a limited midline supraumbilical laparotomy. The skin incision is made with the knife, and the rest of the layers are divided with electrocautery, taking care to stay in the midline and paying close attention to hemostasis. Once the peritoneum is opened, the surgeon’s fingers or a malleable retractor is used to protect the intestines from enterotomies.
2.DISSECTION
After mobilization of the duodenum, the midpoint of the pylorus is grasped and lifted with a Babcock forceps. A seromuscular suture line 5 cm long with interrupted 3-0 silk is placed to approximate the antrum and duodenum. These stitches should be placed as posteriorly as possible to diminish the tension on the anterior suture line (Figure 24-1). A horseshoeshaped incision involving all layers of the anterior wall of the antrum, pylorus, and duodenum is made. Hemostasis is achieved with electrocautery (Figure 24-2). A continuous 3-0 absorbable stitch is used to reapproximate the mucosa, beginning posteriorly and finishing anteriorly (Figures 24-3 and 24-4). The anastomosis is completed with 3-0 silk interrupted seromuscular stitches (Figure 24-5).
Pylorus
Grasped with
Babcock forceps
Antrum
Duodenum
MC
FIGURE 24–1