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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_985_Библиотеки_им_академика_М_И_Перельмана.pdf
17114 CCF Color Photo Gallery
Fig. 14.48 Dermatitis, pouch opening too large
Fig. 14.51 Stoma stricture
a
Fig. 14.49 Ileostomy, parastomal squamous cell carcinoma from
chronic chemical irritation
Fig. 14.50 Ileostomy, parastomal cancer with island metastasis
Fig. 14.52 ( a ) Ileostomy stricture: “Bishop’s Collar” due to delayed
stoma maturation. ( b ) Ileostomy stricture revision. Stoma mobilization.
( c ) Ileostomy stricture revision. Excising the constricting scar tissue
b
c
172 V.W. Fazio et al.
Fig. 14.53 Parastomal abscess due to perforation caused by catheter
used for irrigation. Examination revealed marked tenderness, fl uctuance, and erythema. Note normal area ( arrow )
Fig. 14.56 Loop ileostomy prolapse. The pointer identifi es the second
lumen
Fig. 14.54 Paracolostomy abscess drained lateral to the appliance to
avoid interference with pouching by the drain
Fig. 14.55 Loop transverse colostomy, distal limb prolapse
Fig. 14.57 Ileostomy prolapse in pregnancy. The prolapse reverts to nor-
mal after delivery (pre-glove era, courtesy Rupert B. Turnbull, Jr., MD)
Fig. 14.58 Loop transverse colostomy prolapse, parastomal pressure
ulcer due to ostomy belt, incisional hernia
17314 CCF Color Photo Gallery
Fig. 14.59 Loop transverse colostomy, prolapse. The tip of the prolapse is becoming ischemic
Fig. 14.61 Paracolostomy hernia
a
Fig. 14.60 Paracolostomy hernia. Ectopic stoma site outside of the
rectus sheath
b
Fig. 14.62 Flush stoma ( a ), everted with pressure ( b )
174 V.W. Fazio et al.
Fig. 14.65 Ileostomy fi stula
a
Fig. 14.63 Psoriasis
Fig. 14.64 Candidiasis
Fig. 14.66 ( a ) Parastomal necrotizing fasciitis. ( b ) Necrotizing fascii-
tis debridement to viable tissue. ( c ) Parastomal necrotizing fasciitis.
Split-thickness skin graft needed
b
c
17514 CCF Color Photo Gallery
Fig. 14.67 Enterocutaneous fi stula
a
b
Fig. 14.68 Enterocutaneous fi stula managed using pouch with window
c
Fig. 14.69 ( a ) Loop ileostomy and wound dehiscence. ( b ) Open
wound packed with saline gauze dressing and covered with clear adhesive fi lm dressing. ( c ) Loop ileostomy surrounded with pectin paste,
powder, and wedges before pouch is applied
176 V.W. Fazio et al.
a
Acknowledgements Stoma images courtesy of Dr. Rupert B. Turnbull,
Jr., M.D.; Frank L. Weakley, M.D.; Victor W. Fazio, M.D.; Paula
Erwin-Toth, RN; James M. Church, M.D.; and James S. Wu, M.D.
b
Fig. 14.70 ( a ) Enterocutaneous fi stula: setting the stage for pouching
with cement, pectin paste, and wafer wedges. ( b ) Enterocutaneous fi s-
tula: custom-fi tted fi stula appliance
Stomas Via Percutaneous Endoscopy
Michelle D. Inkster and John J. Vargo II
1 5
I cannot see why the indications should not be as great to open
the intestinal canal to put nourishment in, as to open it to take a
foreign body out.
– Egeberg (a Norwegian Army surgeon) 1837 [
1 ]
Introduction
Although nutritional assessment has been an important part
of surgical training for many years, discussion about enteral
feeding was not included in the fi rst edition of this atlas,
which was devoted to elegant descriptions of the surgical
placement of stomas. The delivery of nutrition was changed
dramatically in 1979 with the introduction of endoscopic
methods of enteral tube placement by Gauderer and colleagues [ 2 ] . The concept, however, of creating a fi stula into
the stomach to feed patients enterally was fi rst proposed by
Egeberg in 1837 [ 3 ] . In the gut, protein malnutrition causes
gastric and intestinal mucosal atrophy, decrease in villus
height and crypt depth, changes in water and electrolyte balance, and changes in the production of fat-soluble vitamins
[ 4 ] . Delivery of nutrients to the gastrointestinal tract does not
provide any benefi t unless there is going to be adequate
absorption, therefore the decision to place a feeding tube
must be based on whether this intervention will actually
benefi t the patient.
Enteral nutrients provide improved motility – the nutrients
in a meal determine the motility response that dictates effi cacy of digestion and absorption [ 5 ] , improved blood fl ow in
the superior mesenteric artery [ 6 ] , decreased permeability,
M. D. Inkster (*)
Digestive Disease Institute, Cleveland Clinic Foundation ,
Cleveland , OH , USA
e-mail: inkstem@ccf.org
J. J. Vargo II
Department of Gastroenterology and Hepatology ,
Digestive Disease Institute, Cleveland Clinic Foundation ,
Cleveland , OH , USA
and increased immunoglobulin A (IgA) secretion [ 7 ] ,
decreased bacterial translocation [ 8 ] , improved mucosal
immunity and an improved mucous layer [
help to maintain the integrity of the gastrointestinal tract.
With enteral feeding, wound healing is improved in burn
patients [
tion is the preferred route for nutritional support [ 13 ] . Finally,
patients who are malnourished and who receive enteral feeding recover more quickly from surgery. For example, De
Gennaro reported that, for patients with colorectal cancer,
when the albumin level was less than 2.8 g/dL the postoperative complication rate rose to 70% with a mortality rate of
4% [ 14 ] . Many critically ill patients, however, are either too
ill or have too short a life expectancy to institute enteral feeding. For patients who have adequate nutritional status there is
no difference in outcome whether or not they receive enteral
nutrition [ 15 ] .
can deliver that nutrition started many years ago. The fi rst
enteral feedings have been attributed to Herodotus Euterpe
in ancient Egypt [ 16 ] . He noted that the Egyptians, next to
the Libyans, were the healthiest people in the world: “for
three successive days each month they purge the body by
means of emetics and clysters.” Hippocrates is also credited
with enteral feeding; in his treatise “On Ancient Medicine”
he expounds on different diets for different situations so that
those who are ill will suffer less because of the wrong diet
[ 17 ] . US President Garfi eld, on the other hand, was given
nutrient enemas every 4 h for 79 days before his death [ 18 ] .
This added nutrition did not prevent him from dying from
wound contamination.
have started with the Romans who would induce vomiting
during and after a banquet in order to make room for more
food and also to settle the stomach. Feathers and fi ngers were
used with good effect [
ach developed from bougies or sounds that were used for
blind extraction of foreign bodies. These tubes were designed
to clasp fi sh bones and extract them and were made from
11, 12 ] . In patients with renal failure, enteral nutri-
The development of nutritional concepts and devices that
The development of feeding tubes could be thought to
19 ] . Tubes for feeding into the stom-
9, 10 ] . All of these
V.W. Fazio et al. (eds.), Atlas of Intestinal Stomas,
DOI 10.1007/978-0-387-78851-7_15, © Springer Science+Business Media, LLC 2012
177
178 M.D. Inkster and J.J. Vargo II
perforated metallic tubes [ 20 ] , whale bone, lead, and silver
[
21 ] . When the patient could not swallow, Capivaceus and
Fabricious ab Aquapendente tried to fi nd solutions to this
problem. In 1568, Capivaceus [
introduced through the mouth into the esophagus. The upper
end was attached to an animal bladder into which the nutrient fl uid was inserted prior to expression [
Aquapendente devised a thin silver tube that he threaded
through the nostril to feed patients who had tetanus [ 25 ] . In
1790, John Hunter, the famous surgeon, is reported to have
given one of the fi rst orogastric feeds by using a syringe with
a hollow or fl exible tube made by a watchmaker of whale
bone and eel skin and that was long enough to extend into the
stomach so that the lungs would not be affected in persons
who had drowned [ 25 ] . Later he proposed that a feeding
tube could be passed into the stomach for patients who had
suffered a stroke and who were unable to swallow [
It is generally agreed that the fi rst gastroscope was
designed and used by Kussmaul in 1868. It was rigid and
stated to be “one of the most lethal instruments in the surgeon’s kit.” The fi rst fi ber-optic gastroscope was designed by
Heinrich Lamm in 1930, but his work languished during the
Second World War [
problem even though the endoscope was now more fl exible.
Van Heel was asked by the Dutch government to work on
periscopes for submarines in the 1940s and realized that light
leaked between the bare fi bers when they touched each other.
He solved the problem of poor image resolution by coating
the fi bers with plastic. He was then able to transmit images
through a 400 fi ber bundle up to a distance of half a meter
[ 27 ] . Basil Hirschowitz, a South African gastroenterologist,
then at the University of Michigan, used this concept to
“evaluate peering into the body” [ 27 ] . Techniques for deliv-
ering nutrition into the stomach were greatly advanced from
early attempts when, in 1937, an interpretable photograph
was taken with an external camera and, in cooperation with
the Eastman Kodak Company, a better light source was
developed that allowed increased light to operate in conjunction with the camera shutter [ 28 ] . Further development of
fi ber-optic endoscopes not only allowed visualization of the
stomach but also possibilities for advances in therapy, as the
endoscopist could now see into not only the stomach but also
the duodenum [ 29 ] .
Successful surgical gastrostomy tube placement was fi rst
performed by Verneuil in France in 1876 [ 30 ] . For many
years though, the enteral feeding method of choice was a
Stamm Gastrostomy tube, which was introduced in 1894
[ 31 ] . This surgical technique requires an incision through the
abdominal wall as far away from the pylorus as possible, lifting the stomach up past the omentum and using two pursestring sutures to anchor it to the abdominal wall. Leaking and
hemorrhage if the sutures are not tight enough are major
potential complications. This technique has persisted since
27 ] . Visual acuity remained a signifi cant
22 ] utilized a tube that was
23, 24 ] . In 1617,
26 ] .
its introduction with only slight modifi cation to allow for
jejunostomy. It was not until 1980 that the feeding tubes that
are now widely used were unveiled by Gauderer, Ponsky, and
Izant who had all been working in children’s hospitals and
who had devised a method to insert a feeding tube into the
pediatric stomach using endoscopy [ 32 ] . This procedure was
a safe way to introduce nutrition for children who had brain
damage and who had severe musculoskeletal deformities.
The concept was simple and possible because of the development of fi ber-optic endoscopes, an appropriate light source,
and advances in the design and availability of equipment that
was now readily available in any operating room. This technique has had some modifi cations since its introduction, but
the principles remain the same whether the tube is placed in
the stomach or the jejunum.
General Indications for a Feeding Tube
Delivery of nutrients can be via gastrostomy, cervical pharyngostomy, duodenostomy, and jejunostomy. The route chosen depends on whether there will be a need for short-term or
long-term access. Then the decision must be made as to
whether there are any contraindications to placement of a
feeding tube. Mechanical obstruction and dysmotility, for
example, can preclude using the gastrointestinal tract. During
times of critical illness, there is often a decrease in gastric
emptying and colonic motility but early use of the gastrointestinal tract can prevent dysmotility [ 5 ] . There is limited
long-term application for a tube that passes through the
esophagogastric junction as it can lead to aspiration with a
mechanically induced laxness of the lower esophageal
sphincter. Cervical pharyngotomy has limited usefulness as
well. Patients can be unwilling to have the latter placed
because they are not cosmetically acceptable, although there
are indications for this technique for selected patients.
Gastrostomy tubes are indicated when patients cannot
maintain adequate nutrition with oral intake and where there is
an expectation that the patient will survive to achieve longterm clinical benefi t from the intervention [ 33 ] . For example,
patients with head and neck cancer are candidates for longterm nutritional support, especially when surgery is expected
to be extensive and chemotherapy and radiation therapy are
planned. Benefi ts include improved tolerance compared with
nasogastric tubes, ease of use, patient and caregiver satisfaction, reduction in aspiration pneumonia, and cost-effectiveness.
Gastrostomy tubes are also placed for long-term decompression,
for example, when the patient has a mechanical obstruction
due to a malignancy or intractable gastroparesis. The percutaneous endoscopic gastrostomy (PEG) tube is placed to suction
and can improve the quality of life for the patient. Because a
chronic nasogastric tube does not need to be placed, care of the
patient is also simplifi ed.
17915 Stomas Via Percutaneous Endoscopy
Table 15.1 Indications and contraindications for a feeding tube
Indications Contraindications
Amyotrophic lateral sclerosis
Burns Coagulopathy
Crohn’s disease Intestinal dysmotility
Decompression Marked hepatomegaly
Delivery of medication Portal hypertension
Hypoxic encephalopathy Sepsis
Long-term enteral feeding
Macroglossia secondary to amyloidosis Ascites
Respiratory failure Esophageal obstruction
Tracheoesophageal fi stula Intestinal obstruction (feeding)
Absolute
Relative
Morbid obesity
Peritoneal dialysis
Peritoneal metastases
Previous gastrectomy
Comorbid conditions may delay placement of a percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic
jejunostomy (PEJ) tube. For example, severe malnutrition
where the albumin level is below 2.8 g/dL may lead to failure
of the site to heal and wound infection may occur [ 34 ] . The
presence of severe gastric ulceration may lead to signifi cant
bleeding after the procedure. Appropriate patient selection is
part of the preoperative evaluation and is an important part of
the process (see Table 15.1 ).
Indications for a Jejunostomy Tube
For individuals in whom there is signifi cant risk of regurgitation of stomach contents into the cervical esophagus or ineffective gastric emptying or gastroparesis, jejunostomy tube
placement may be a good alternative. Jejunostomy tubes
were initially placed surgically, requiring laparotomy and
general anesthesia. Shike described direct PEJ placement in
1987 in patients who had undergone gastrectomy [ 35 ] .
Mellert in Germany described direct PEJ in 39 patients in
1994 who had undergone either partial or total gastrectomy
for cancer, esophageal perforation, severe trauma, or who
had esophageal fi stulae [ 36 ] . His group showed that endoscopic placement was not only feasible but also exposed the
patient to less procedural risk.
Techniques
PEG Tube Placement
There are two techniques that are commonly used for PEG
tube placement: the “push” technique of Ponksy [
“pull” technique of Sacks-Vine [ 38 ] . The patient’s abdomen
must fi rst be examined to evaluate for an appropriate area for
37 ] and the
the gastrostomy site. Extensive scars from prior surgery may
make it diffi cult to place the tube in the best site within
the stomach. Feeding is usually withheld for 8 h prior to
the procedure to ensure an empty stomach. A prophylactic
antibiotic that will cover gram-negative organisms is given
intravenously just before the procedure.
The patient is placed in reverse Trendelenburg position at
about 45°: this allows the stomach to be in a dependent position within the abdomen. One operator is at the head of the
patient to perform the gastroscopy while the second performs
the actual tube placement. An esophagogastroduodenoscopy
(EGD) is performed and the best site for tube placement is
selected by the second operator palpating the abdomen with
gentle pressure while the fi rst operator illuminates the stomach
with the gastroscope (Fig. 15.1 ). The stomach is fully insuf-
fl ated to appose the stomach with the anterior abdominal wall.
The safety of the site is verifi ed [
39, 40 ] by using the safetrack
technique. The abdomen is draped and prepared in the usual
sterile fashion. A syringe containing several milliliters of local
anesthesia is introduced just beyond the skin at the selected
point. Under constant view by the endoscopist, the needle of
the syringe is advanced while negative pressure is maintained
within the syringe. The endoscopist should see the end of the
needle enter the lumen at the same time as his/her partner sees
air bubbles in the barrel of the syringe. If air bubbles are seen
before the needle enters the stomach, the needle has passed
through another air-containing structure such as the colon or
small bowel. In this event, the needle is withdrawn and another
site is selected.
Once the correct site has been identifi ed and confi rmed,
the skin is infi ltrated with local anesthetic. A transverse
incision is made through the abdominal wall. The introducer needle is pushed through the incision into the gastric
cavity (Fig.
15.2 ) and a guidewire is threaded through the
needle, grasped with the endoscopic snare, and pulled out
through the patient’s mouth. The PEG tube is looped
through the thread – “blue through,” lubricated well, and
the PEG tube is pulled back through the patient’s mouth
into the stomach. The tube is then pulled out through the
skin incision by the second operator (Fig. 15.3 ) until
the button is snug against the gastric wall. It is anchored on
the outside with a bumper (Fig. 15.4 ). The mushroom but-
ton decreases the likelihood of tube migration and keeps
gastric contents from leaking onto the skin because of the
antirefl ux valve [ 41 ] .
The stomach and small bowel should not be overdistended, as overfi lling of the stomach and small bowel may
“lift” the transverse colon and increase the probability of
colon injury [ 42 ] . Colonic injury usually presents with peri-
tonitis. Gastrocolic fi stula results from interposition of the
colon between the anterior abdominal wall and the stomach.
Patients are often asymptomatic except for transient fever or
ileus. The problem is usually discovered months after PEG
180 M.D. Inkster and J.J. Vargo II
Fig. 15.1 The fi rst operator
illuminates the gastric wall from
the inside with the endoscope.
The second operator places a
fi nger on the outside of the
abdomen and palpates gently to
produce a bulge in the stomach
wall that is visible on the inside.
Illustration © CCF
tube placement when the original tube is removed or manipulated [ 43 ] . Extensive tension of the external bolster against
the abdominal skin should be avoided to prevent buried
bumper syndrome (see Fig. 15.5f ) [ 44 ] . Epithelialization can
cover the internal stoma with gastric mucosa and result in
complete closing of the orifi ce. Fatal cases have been
reported. A buried bumper should be removed even if the
patient is asymptomatic because of the risks of tube impaction in the abdominal wall and gastric perforation. The PEG
tube should not migrate if the external bumper is properly
positioned. The PEG tube can be dislodged into the pylorus
and cause gastric outlet dysfunction. If the PEG tube is a
Foley catheter type, defl ating the balloon and withdrawing
the tube should provide relief.
In obese patients, placement of a PEG feeding tube is often
considered impossible because of an inability to transilluminate the abdominal wall. Inadvertent puncture of the transverse colon, or even puncture of the left lobe of the liver, can
occur. Kirby [ 45 ] , however, was able to place PEG tubes
endoscopically in obese patients with a body mass index up to
63 kg/m 2 . Gastrostomy tubes were placed successfully in 130
of 134 obese patients with a 0% procedure-related mortality.
Of 355 patients evaluated, 14 did not receive a PEG tube. Four
procedures were aborted because of paucity of anatomical
landmarks and failure to illuminate the abdominal wall.
Peristomal infections are the most common complications
of PEG tube placement; although in patients who are compromised neurologically, aspiration pneumonia is more common [ 46 ] . Because systemic infections can occur and are
often underinvestigated, antibiotics are given prior to the
procedure. One gram of cefazolin administered intravenously
prior to the procedure reduces the rate of infection, although
the reduction is variable depending on the study reported.
Pneumoperitoneum is common after placement of a PEG
tube and can persist for several weeks [ 47 ] . This is a benign
condition but can result in diagnosis of a perforated viscus
when those involved are unaware of this association. See
Table 15.2 and Fig. 15.5a–g for common complications of
PEG tube placement.
Pharyngostomy
Klopp described cervical pharyngostomy in 1951 in a patient
who had cancer of the cervical esophagus with complete
obstruction [
48 ] . The tube was placed through an open neck