Definition and Overview
A gastrostomy is a procedure wherein an artificial opening is created and a tube inserted to connect the stomach to the skin. It is generally performed for two reasons: for feeding or decompression of the stomach and can be either temporary or permanent.
Who Should Undergo and Expected Results
Patients who are unable to feed by mouth need some form of nutritional access in order to survive. Initially, a nasogastric tube or an NGT (a tube inserted through the nose to reach the stomach) may be inserted. However, an NGT usually cannot be maintained for prolonged periods of time, and may clog or get dislodged. A gastrostomy provides a more secure form of access, which, at times, can be maintained permanently.
A gastrostomy is also essential in patients with upper gut obstruction, or a blockage in the upper portion of the gastrointestinal tract, which interferes with adequate oral intake. These include patients with obstructions in the esophagus, such as those with esophageal cancer and those with congenital defects of the mouth and esophagus, such as tracheoesophageal fistula or esophageal atresia. These patients can present with swallowing difficulties and aspiration of food into the respiratory tract during feeding. Elderly patients with dementia and stroke patients with significant neurological deficits who are unable to feed themselves may also need a gastrostomy. For patients who are unable to effectively take in food orally, blenderized feeding, special formulas, and medications may be given via the tube and delivered directly to the stomach.
Aside from the inability to feed, another reason for performing a gastrostomy is for the decompression of the stomach. This is usually done in patients with obstruction in the stomach or the small intestines. A blockage in these areas produces distention of the stomach, resulting in persistent vomiting. A gastrostomy can provide relief by draining the contents of the stomach.
How is the Procedure Performed?
There are several techniques for performing a gastrostomy. It may be inserted endoscopically or via traditional open surgery.
In percutaneous endoscopic gastrostomy or PEG, endoscopy is first performed. This is a procedure wherein an instrument containing a small camera is inserted into the mouth, down the esophagus, until it reaches the stomach to provide visual guidance. An anaesthetic will first be sprayed into the mouth to prevent coughing or gagging during the insertion of the scope. The camera is used to visualize the gastrointestinal tract, and will help determine the placement of the feeding tube. Once the location has been identified, a small incision will be made in the abdomen and the tube is inserted into it.
In an open surgical gastrostomy, an upper midline incision is performed. Once the surgeon gains access to the abdominal cavity, the location for the gastrostomy is selected. If adhesions are present, they are gently removed. A small circular suture (purse-string suture) is placed on the stomach, typically in two layers. An incision is then made in the middle of the circle where the tube is inserted. The balloon at one end of the tube is inflated and the purse-string sutures are tightened to secure the tube. The skin is then incised at the area where the tube will exit and the subcutaneous tissue is dissected, until the peritoneum is reached. The tube is then guided out through the skin and the stomach is anchored to the abdominal wall before the incision is closed.
PEG has several advantages over the open surgical technique. It is generally less expensive and can be performed faster. However, not all patients are good candidates for this procedure. Open surgical gastrostomy may be the better option for patients who are unable to undergo endoscopy safely, such as those with large, obstructing masses in the esophagus. Surgical gastrostomy may also be preferred for patients who have previously undergone esophageal or abdominal surgery, if thick adhesions are expected, or in special circumstances, such as in patients who have previously undergone colonic interposition surgery.
Possible Risks and Complications
Complications of a gastrostomy are generally minor. Tube dysfunction is common, usually due to blockage, especially if food particles are not sufficiently blenderized. In some instances, the tube may be inadvertently dislodged or pulled out. In such cases, the surgeon may elect to reinsert another tube.
Complications in the skin surrounding the tube may also occur. Minimal leaks around the tube are generally well-tolerated, but excessive peri-tubal leakage can lead to significant swelling and skin irritation. Infection may also occur, especially for permanent gastrostomies. For these cases, special wound care techniques may have to be utilized. Some pain is expected at the tube site, which is typically managed with pain medications after the procedure.
Serious complications, such as perforation of the intestines and other abdominal organs, are generally avoided if the procedure is performed properly. Other complications may include the development of fistulas and tumor seeding on the gastrostomy site.
Yarmus L, Gilbert C, Lechtzin N, Imad M, Ernst A, Feller-Kopman D. The Safety and Feasibility of Interventional Pulmonologists Performing Bedside Percutaneous Endoscopic Gastrostomy Tube Placement.Chest. 2013 Feb 7.
Jafri NS, Mahid SS, Minor KS, Idstein SR, Hornung CA, Galandiuk S. Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy. Aliment Pharmacol Ther. 2007 Mar 15. 25(6):647-56.