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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter • Percutaneous Endoscopic Gastrostomy
Step7
Step8
Introduction of guidewire
e assistant passes a guidewire through the trocar. e guidewire is grasped by a snare that is
passed through the endoscope. e endoscope and guidewire are pulled out through the mouth
as one unit, as the assistant feeds more wire into the stomach (
. Fig.29.2
. Fig. 29.2).
Pull through
e tapered end of the lubricated PEG tube is secured to the guidewire then pulled through the
mouth into the esophagus and stomach by the assistant. is is called a “pull” PEG because the
assistant pulls the guidewire and PEG tube out through the abdominal wall. As the guidewire is
pulled, the tapered end of the PEG tube emerges from the incisional site. e PEG tube is pulled
until the bumper within the gastric lumen is snugly apposed to the gastric wall (
. Fig. 29.3).
. Fig.29.3
Section II • Esophagus, Stomach, and Duodenum
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Step9
Trimming and securing
e PEG tube is trimmed in length, and a feeding port is attached to the end aer anchoring the
tube to the anterior abdominal wall using an external stopper. e exact position of the stopper
will depend on the patient’s body habitus and other anatomical considerations, but generally
ranges from 2 to 5 cm.
Procedure: “Push” PEG
Although equally eective, this technique is less commonly performed.
Alternatively, Step7 is replaced with the following: e PEG tube assembly is advanced, dilator
end rst, over the portion of the guidewire exiting the mouth. Firm tension is maintained on both
ends of the guidewire as the PEG tube assembly is pushed through the mouth into the esophagus and
stomach. is is called a “push” PEG, because it involves pushing the PEG tube into the stomach and
through the abdominal wall. As the assembly is pushed, the tapered end of the PEG tube emerges
from the incisional site. e PEG tube is pushed until several centimeters remain beneath the skin.
Post-PEG Tube Placement Feeding
Feeding is generally commenced on the following day, aer the patient is examined.
PEG Tube Removal
is is advisable only for cases in which a well-dened tract has formed.
Indications
e PEG tube is no longer needed (reversal of original indication).
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e PEG tube is damaged/worn out.
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e PEG tube is clogged and cannot be ushed.
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Percutaneous Removal
Steps
Identify the type of PEG tube. e “mushroom” type has only one lumen whereas the balloon type
has two lumens on sectioning the tube.
Mushroom type
Clean the stoma and apply a topical anesthetic.
A sustained pull at 90° to the anterior abdominal wall will cause collapse of the bumper as it
“pops” out of the stoma.
Clinically signicant bleeding is uncommon and the stoma closes in 1 to 2days.
Balloon type
Deate the balloon using a syringe or by cutting the tube, allowing the water to leak out of the
balloon.
Once the balloon is deated, the tube can be pulled out with no resistance.
Endoscopic Removal
Indications
When percutaneous removal is not possible; for example, when the mushroom PEG cannot be
pulled out or the balloon PEG cannot be deated.
Chapter • Percutaneous Endoscopic Gastrostomy
Steps
Upper endoscopy is performed. e bumper is snared inside the stomach. Alternatively, a balloon
can be deated using a sclerotherapy needle.
e tube is cut from the outside using a pair of scissors or a scalpel.
e snared end is pulled out through the mouth along with the endoscope.
Reinsertion
Steps
A balloon-type PEG tube is inserted through the existing stoma and inated with water. e balloon end is pulled up toward the stomach wall and an external stopper is applied to position it
against the abdominal wall.
Standard Postoperative Investigations
Check for adequate approximation of the stomach to the abdominal wall, ensuring that a
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proper tract will form.
Postoperative Complications
Perforation of esophagus, stomach, or transverse colon
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Hemorrhage
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Cellulitis or abscess
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Peritonitis
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Gastric ulcer
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“Buried bumper syndrome” when the bumper is embedded within the stomach wall
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Gastric outlet obstruction due to distal migration of the bumper
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PEG tube clogging
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PEG tube being pulled out
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Tricks of the Senior Surgeon
A too rmly approximated stomach and anterior abdominal wall may lead to tissue necrosis or
“buried bumper syndrome.” Care should be taken to ensure that the PEG tube is snug but rotates
freely.
Conventional and Laparoscopic-Assisted Gastrostomy
Nathaniel Melling, Oliver Mann
Conventional Gastrostomy
Nowadays, surgical gastrostomy has been replaced in most instances by less invasive procedures
such as percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy
(PEJ). However, surgical gastrostomy still plays an important role in well-selected instances, such
as when transillumination of the stomach cannot be seen on attempted endoscopic percutaneous
gastrostomy, aer prior gastrectomy, when percutaneous access to the stomach is otherwise not
possible, or when there is ascites.
Indications and Contraindications
Indications
Contraindications
Locally non-resectable and/or metastatic obstructing tumor of the esophagus, gastroesoph-
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ageal junction, and proximal stomach
Tumor totally obstructing the esophagus preventing passage of the endoscope or even a
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guide wire for transtumoral endoluminal intubation
Contraindications for endoscopic treatment (“percutaneous endoscopic gastrostomy”), such
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as severe ascites
Severe unt for major surgery
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Neurological disorders (cerebral dysphagia)
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Resectable carcinoma
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Previous major gastric resection or gastrectomy (in this case, feeding tube jejunostomy is
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the treatment of choice)
Preoperative Investigation/Preparation for the Procedure
History: Previous upper abdominal surgery (i. e., gastric resection;
contraindication for [PEG])
Clinical investigation: Exclusion of further obstruction distal to the stomach such
as antral and pyloric strictures in cases of caustic burns.
Procedures
Temporary Tube Gastrostomy
(Synonyms: Witzel Procedure, Balloon Catheter Gastrostomy, Kader Procedure)
Step1
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_30, © Springer-Verlag Berlin Heidelberg 2016
Exposure
Opening of the peritoneal cavity is performed through the upper third of the le rectus muscle by
a vertical or horizontal incision or by a midline incision. Sharp transection of the skin and fasciae
should be followed by blunt division of the muscle.
e anterior wall of the body of the stomach can them be pulled anteriorly by clamps or
retention sutures.
Section II • Esophagus, Stomach, and Duodenum
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Step2
Step3
Step4
Preparation and incision of the gastric wall
A purse-string suture with a diameter of about 3 cm is usually placed at the anterior aspect of the
gastric body midway between the lesser and greater curvatures.
A gastrostomy is made in the center of the purse-string suture, and a tube is inserted with its
tip directed to the cardia. Aer the purse-string suture has been tested for leakage, the suture is
tied with some form of memory, either a Foley catheter, another form of balloon catheter, or a
Malecot catheter.
In cases of caustic burns, antral and pyloric stenoses should be excluded by intragastric digital
palpation of the distal stomach (. Fig. 30.1).
. Fig.30.1
Positioning of the catheter
When inserting a feeding catheter with a diameter of about 1 cm, the tip should be directed toward
the cardia.
Aer proper positioning of the catheter with a minimum distance between insertion site and
tip of the tube of 5 cm, the purse-string suture is tied.
Check for leaks at the site of the purse-string suture by lling the stomach with liquid.
Witzel Fashion
A Witzel-type gastro-gastric plication with single stitches aborally to the insertion site of the tube
and for a length of 8 cm distal to the insertion of the tube in the gastric wall is recommended
(. Fig. 30.2).
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. Fig.30.2
e gastric serosa is xed to the abdominal wall by drawing the stomach upward and sewing
the stomach to the abdominal wall in Stamm-like fashion where the tube exits the abdominal wall.
e tube is then xed to the skin.
Chapter • Conventional and Laparoscopic-Assisted Gastrostomy
Balloon Catheter Gastrostomy (Stamm fashion)
Step1
Access to the peritoneal cavity, exposure, and preparation of the anterior aspect of the stomach
as described previously.
Step2
Positioning of the balloon catheter and fixation
Aer exposure of the anterior wall of the stomach by clamps, a purse-string suture is prepared.
In the center of this suture, a small gastrotomy is made. If necessary, the incision is dilated gently
and the tube is introduced into the gastric lumen (
In cases of caustic burns, antral and pyloric stenoses should be excluded by intragastric digital
palpation of the distal stomach. Aer proper positioning of the catheter, the purse-string is tied.
Suciency of the suture line is tested by lling with liquid. Pulling the catheter to the abdominal
wall should not result in tension.
At least four seromuscular interrupted stitches then x the stomach to the abdominal wall in
Stamm-like Fashion.
en the balloon is inated and the tube pulled through an incision in the abdominal wall.
Note, if ascites is present, the tube can be Z-tracked through the abdominal wall via a long intramural track in attempt to hamper an ascitic leak at the insertion site (
. Fig. 30.3a).
. Fig. 30.3b)
Step1
Step2
. Fig.30.3
Permanent Stapled Continent Gastrostomy (Janeway Gastrostomy)
Access
Access to the peritoneal cavity and exposure of the stomach as described previously.
Creation of the gastric tube
For creation of a permanent reverse gastrostomy, the greater curvature is used. e le gastroepiploic vessels represent the vascular pedicle of the tube. Aer ligation of the right gastroepiploic
vessels at the site of the beginning of the tube, the gastrocolic and, if necessary, gastrosplenic ligaments are transected at a safe distance from the le vascular pedicle without compromising the
integrity of the gastroepiploic arcade.
e apex of the gastric tube is situated at the middle third of the greater curvature. e le
gastroepiploic vessels are the vascular pedicle of the gastrostomy.
A sucient length of the tube is achieved by two to three applications of a linear stapler, depending on the thickness of the abdominal wall. Inversion of the GIA suture lines is performed
by interrupted or running sutures (
. Fig. 30.4).
Section II • Esophagus, Stomach, and Duodenum
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Step2 (continued)
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Step3
. Fig.30.4
Attention should be paid not to compromise the tube’s blood supply at its superior aspect.
e gastric tube is pulled through a narrow incision in the abdominal wall in the le upper
abdominal quadrant as one would for an ileostomy. Opening of the gastric tube and sewing of
the mucosa to the skin as a permanent stoma are performed ush with the skin so as to minimize
the eects of gastric secretions that may induce peristomal dermatitis. Stomaplast around the
stoma is applied to protect the skin from peristomal problems (
. Fig. 30.5).
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Chapter • Conventional and Laparoscopic-Assisted Gastrostomy
Step3 (continued)
. Fig.30.5
Postoperative Instructions
Liquid diet feeding 6 to 12hours following surgery.
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Feeding with pureed foods as soon as evidence for postoperative abnormalities of gastro-
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duodenal clearance has been excluded.
Postoperative Complications
Postoperative obstruction due to stomal edema
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Leakage of the gastrotomy or suture line disruption
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Peritonitis
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Intragastric and intraperitoneal bleeding
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Gastric wall or stomal necrosis
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Tricks of the Senior Surgeon
The continence of the gastrostomy can be enhanced by drawing the tube upward and bring-
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ing it to the surface near the costal margin.
Avoid linking and narrowing of the stomal tube due to oversewing of the staple lines and/or
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anchor sutures of the tube to the posterior abdominal wall. Both may compromise the blood
supply of the gastrostomy from the left gastroepiploic vessels.
z Acknowledgments
e authors acknowledge the contribution of Asad Kutup and Emre F. Yekebas in the previous
edition.
Laparoscopic-assisted Gastronomy
Nathaniel Melling, Oliver Mann
Laparoscopic-assisted gastrostomy is an excellent minimally invasive procedure for patients who
are unable to swallow and unable to undergo a PEG. e original conventional method was
devised as a feeding tube by Bronislaw Kader in 1896 and modied for the minimally invasive
approach in the 1990s.
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4
Section II • Esophagus, Stomach, and Duodenum
Indications
Contraindications
Indications and Contraindications
See above section on conventional gastrostomy
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Severe Ascites
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Previous gastric or major upper abdominal surgery (in this case laparoscopic exploration
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can be tried)
Preoperative Investigation/Preparation for the Procedure
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Step1
See above section on conventional gastrostomy
Procedure
z Access via
3-trocar technique (2 × 10 mm and 1 × 5 mm)
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Pneumoperitoneum (12 mm Hg)
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10 mm subumbilical trocar
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10 mm trocar in le lower quadrant
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5 mm trocar in right upper quadrant
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Exposure
Exposure and exploration, adhesiolysis if necessary (. Fig. 30.6).
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. Fig.30.6
Chapter • Conventional and Laparoscopic-Assisted Gastrostomy
Step2
Three full-thickness stitches
Using a straight needle, which is brought into the abdomen through the skin of the le upper
quadrant, a triangle is created by three full-thickness stitches which allow the catheter system to
be introduced under laparoscopic control (stitches: skin-abdominal wall-stomach-abdominal
wall-skin) (. Fig. 30.7).
. Fig.30.7
Step3
Insertion of the guidewire
A 1 cm incision is made in the center of the triangle created by the three sutures which are held
under tension. Under laparoscopic vision the anterior stomach wall is punctured by an 18-gauge
needle exactly in the center of the triangle. rough the needle a guidewire is inserted into the
stomach and a 26Fr dilator with a peel-away sheath is pushed over the guidewire into the stomach
percutaneously (. Fig. 30.8).
. Fig.30.8