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In selected patients, following multiple trauma or extensive abdominal operations, a decompression gastrostomy is easily performed during other operative procedures and may be helpful to avoid the use of an NG tube. In such cases, a simple tube gastrostomy is usually preferable to the more complex gastric mucosa-lined gastrostomy. Additionally, this can be combined with a separate feeding jejunostomy tube for simultaneous gastric decompression and enteral feeding directly into the small bowel.

One additional, although uncommon indication for gastrostomy, or more specifically percutaneous endoscopic gastrostomy, is for the treatment of chronic gastric volvulus. Particularly for high-risk patients in whom an open operation and/or general anesthesia is undesirable, PEG results in the fixation of the anterior stomach to the posterior abdominal wall with subsequent adhesion formation, which serves to prevent the

recurrence of gastric volvulus even after the catheter has been removed. Five types of gastrostomy are:

1. percutaneous endoscopic gastrostomy (PEG)

2. Stamm gastrostomy

3. Witzel gastrostomy

4. laparoscopic gastrostomy

5. permanent gastrostomy (Janeway)

Percutaneous Endoscopic Gastrostomy

Gauderer and Ponsky developed and modified an endoscopic technique to establish a tube gastrostomy without laparotomy with the use of local anesthesia. Grant has employed the technique with modifications. In most patients, sparingly used topical anesthesia and intravenous sedation (or no sedation in the poorly responsive patient) supplement local anesthesia. The lower chest and abdomen are sterilely prepared and draped. A pediatric gastroscope is introduced into the stomach, and the stomach then is insufflated with air and examined for abnormalities. A finger is pressed into the upper abdominal wall until an indentation in the gastric fundus, midway between the greater and lesser curvatures, is visible through the endoscope. This point marks the skin exit site, which should be at least 4 cm from the costal margin to minimize pain ( Fig. 4-1 ). A local anesthetic is infiltrated at this skin exit site, and an incision that is 0.5 cm larger than the gastrostomy tube's outer diameter is made. A trocar needle is passed into the stomach and visualized through the endoscope, a snare wire is passed through the endoscope to encircle the needle and is tightened, and the trocar is then removed. A braided wire is passed through the needle into the stomach, the needle is removed from the abdominal wall, and the snare is drawn tight over the wire. The endoscope and snare are withdrawn, pulling the braided wire through the patient's

Figure 4-1 Gastrostomy tube exit site. (From Gauderer, M.W.L., and Ponsky, J. L.: A simplified technique for constructing a tube feeding gastrostomy. Surg. Gynecol. Obstet, 152:82, 1980. By permission of Surgery, Gynecology and Obstetrics.)

Figure 4-2 Stamm method of gastrostomy, superimposing pursestring invagination. A, A tube is shown inserted through the anterior stomach wall, and pursestring sutures are placed about it. B, The cone of stomach has been invaginated, and the stomach wall is being sutured to the posterior layer of the rectus sheath, transversalis fascia, and peritoneum. Sutures to close the outer layers of abdominal wall are indicated. C, Sectional view of the gastrostomy.

Figure 4-3 Satisfactory method of performing a gastrostomy by the Witzel technique. 1, Position of the left rectus muscle-splitting incision. 2, Stomach exposed and held up with an Allis clamp. Catheter thrust in through gastric wall, and the opening is being closed with a pursestring suture. 3, Pursestring suture tied. Additional sutures of silk placed in gastric wall to form an oblique channel for the catheter. 4, Channel sutures tied, with the catheter embedded in the gastric wall. 5, Stomach being anchored to the peritoneum so that it will not pull away from the abdominal wall. 6, Parasagittal view of completed operation, showing the oblique implantation of the catheter in the stomach and abdominal walls. (From Ladd, W.E., and Gross, R.E.: Philadelphia, W.B. Saunders, 1941, with permission.)

Figure 4-5 Janeway gastrostomy. A, The stomach tube has been completed; the rubber tube is being stitched to it. B and C, The tube of stomach, brought to the skin surface through a left-rectus stab wound, is sutured to the skin margins of the wound.

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