Gastrostomy: operative or nonoperative?

Open gastrostomy by mini-laparotomy: a comparative study

BACKGROUND

Gastrostomy tube feeding is the best option for long lasting nutritional support in patients with dysphagia caused by obstructive tumours of the mouth, pharynx, larynx and ooesophagus or neuromuscular diseases. However, these severely compromised patients often present severe respiratory risks, precluding the use of general anesthesia, sedation or even endoscopy. A simplified open gastrostomy (SOG) under local anesthesia has been in practice in our institution, especially for patients with severe neuromuscular diseases and continuous non-invasive ventilatory support. In this study, we try to compare the surgical outcomes of this technique, with the classical Stamm gastrostomy (SG).

MATERIAL AND METHODS

This simplified technique uses a minimal vertical midline incision (3 cm), just below the xyphoid process, under local anesthesia. The gastrostomy tube is passed by a left lateral stab wound, inserted in a double purse-string in the gastric wall and pulled to the anterior abdominal wall. No sutures between the stomach and the peritoneum are placed. We retrospectively analyzed the clinical records of 63 consecutive gastrostomies performed upon a 3-year period, 23 of which were by SOG.

RESULTS

The SG was performed mainly in oncological patients, and SOG in patients with neuromuscular diseases (p < 0.001). In the SOG group, 95,4% (n = 22) of the patients were ASA IV, compared with 74,4% (n = 29) in SG (p = 0,03). The mean operative time was shorter in the simplified technique (37 vs 60 min; p = 0,01). All the surgeries in the SOG group were performed exclusively with local anesthesia and in the Stamm procedure, 47,5% required invasive ventilatory support (p < 0.001). There were no significant differences regarding in-hospital morbi-mortality (p = 0,18). The patients were able to receive adequate nutritional support, and the overall satisfaction of the patients and family/caregivers is very good.

CONCLUSION

The simplified mini-laparotomy gastrostomy is a safe and effective alternative to other approaches. The association of local anesthesia with a minimal surgical offense and a short operative time render its effectiveness, even in high-risk patients.

Percutaneous endoscopic gastrostomy to set up a long-term enteral feeding route in children: an encouraging result

Percutaneous endoscopic gastrostomy (PEG) is now accepted as the preferred technique to establish long-term enteral feeding. A total of 30 pediatric patients (21 males and 9 females, aged from 5 months to 14 years) underwent PEG in the National Taiwan University Hospital from December 1994 to February 2001. The underlying diseases of the patients receiving PEG were neurological dysfunction ( n=26), gastrointestinal disease ( n=2) and metabolic disorders ( n=2). All patients received intravenous sedation and PEG was performed successfully. Prophylactic antibiotic treatment was given for 1 day. Tube feeding began 48 h after the placement. The Z-score of weight before and 6 months after PEG was -1.54+/-1.74 and -0.98+/-1.46, respectively, which is significant (paired t-test, p<0.0001). Accelerated weight gain was found after PEG. Complications of PEG in our patients included local wound infection ( n=15), gastrocolic fistula ( n=1), pneumoperitoneum ( n=1), dislodgement of tube ( n=6) and tube occlusion ( n=2). Of these patients 12 received button replacement after PEG and the gastrostomy tube was discontinued in 2 patients when they resumed adequate oral intake. Removal of PEG was performed in 2 patients due to complications of gastrocolic fistula and severe dislodgement. Our results encourage the use of PEG as a long-term route for nutritional supply.

Role of endoscopy in enteral feeding

This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. A previous guideline related to this topic (ASGE Publication No. 1017, Gastrointest Endosc 1998;48:699-701). Since that time, new information has become available that requires an update of this statement and its recommendations. In preparing this update, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from the recommendations of expert consultants. When inadequate data existed from well-designed prospective trials, emphasis was given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance from these recommendations.

Percutaneous endoscopic gastrostomy in the elderly: complications (review)

Due to varying disease processes, the elderly may have limited oral access to their otherwise intact gastrointestinal tract. In such individuals, the intact gastrointestinal tract must be accessed in other ways. Until the early 1980s, choices were limited to temporary solutions such as the nasogastric tube or to long operative procedures such as the operative gastrostomy tube. The introduction of percutaneous endoscopic gastrostomy (PEG) allowed a quick, safe, and cheap procedure as an option. While PEG tubes have been used to help many of the elderly with their nutritional needs, they are not without risks. Below is a review of the literature concerning PEG complications in the elderly.