Atlas of Procedures in Neonatology, 4th Edition
Thomas T. Sato
- Inability to swallow
- Neurologic or neuromuscular deficit leading to uncoordinated oropharyngeal swallowing
- Complex congenital malformations, including esophageal atresia or Pierre Robin sequence, not undergoing early correction
- Administration of supplemental feedings despite normal swallowing but inadequate oral intake
- Chronic disease states
- Requirement for unpalatable diet or need for consistent glucose source (i.e., glycogen storage disease)
- Presence of anatomic intestinal anomalies or functional intestinal dysmotility disorders that prevent normal enteral feeding
- Gastric decompression, particularly when respiratory compromise makes prolonged presence of nasogastric/ orogastric tube undesirable
- Chronic gastrointestinal decompression: duodenal atresia, gastric volvulus, gastric gas/bloat from antireflux procedure
- Emergency gastric decompression for inadequate mechanical ventilation secondary to gastric distention: tracheoesophageal fistula/esophageal atresia
The presence of treatable conditions that unduly increase operative risks, e.g., active infection or coagulopathy. These conditions should be treated aggressively prior to elective gastrostomy placement. Predictably, newborn infants with pure esophageal atresia or tracheoesophageal fistula with esophageal atresia have small stomach volumes (microgastria), making gastrostomy placement more difficult.
- Sterile neonatal laparotomy instruments
- 12- to 14- French (Fr) mushroom (de Pezzar or Malecot) single-lumen catheters, 14-Fr Ross balloon-type gastrostomy catheters, or similar size latex-free Foley-type silastic catheters
- 3-0 or 4-0 absorbable sutures on taper needles
- Local infiltrative anesthesia (0.25% bupivicaine at 1 mL/kg bodyweight)
Maintenance Care after Insertion
- Fixation device
- Modified feeding nipple, or
- Cotton gauze bolster dressing
- Stomadhesive (Squibb, Princeton, NJ, USA)
- 3-0 or 4-0 permanent suture on cutting needle
- Technique for Insertion
Neonatal gastrostomy placement often requires general anesthesia and frequently occurs as an adjunct to other abdominal operations. The technique varies according to individual surgeon preference, but the Stamm procedure described in 1894 is one of the most frequently used in premature infants and neonates (1). The gastrostomy should lie in the center of a triangle formed by the left costal margin, umbilicus, and xiphoid (Fig. 39.1).
Some data suggest that gastrostomy placement along the lesser curvature of the stomach may reduce the incidence of new-onset, postoperative gastroesophageal reflux (2,3). However, the small size of the neonatal stomach may make placement along the greater curvature more practical.
- After insertion of a nasogastric tube, sterile preparation of the skin, and delivery of intravenous antibiotics (typically a first-generation cephalosporin), enter the peritoneal cavity through either a transverse incision (Fig. 39.1) or a supraumbilical midline incision. Identify the stomach and elevate the anterolateral greater curvature of the stomach through the wound.
- Place two concentric, seromuscular purse-string sutures on the anterior greater curvature of the stomach body. Avoid injury to the gastroepiploic vessels (Fig. 39.2).
- Inner purse-string for hemostasis
- Outer purse-string for inversion of mucosa and fixing of stomach to abdominal wall
FIG. 39.1. Landmarks for gastrostomy. The primary horizontal incision is left supraumbilical. The gastrostomy tube will pass through the abdomen at a separate site in the center of a triangle formed by the xiphoid, umbilicus, and left costal margin.
- Make a stab wound through stomach wall (gastrotomy) in the center of purse-string sutures. With a stylet or grooved director inside the catheter, flatten the mushroom catheter head and introduce catheter through gastrotomy. Verify position of tube inside stomach.
FIG. 39.2. Site for concentric sutures for Stamm procedure. Entrance into stomach is on greater curvature midway between esophagus and pylorus.
FIG. 39.3. After the tube is secured inside the stomach and passed through a stab wound in the abdominal wall, the anterior wall of the stomach is sutured to the inner wall of the abdomen.
- Tie sutures sequentially. The inner purse-string suture secures the stomach around the catheter and provides hemostasis. The outer suture allows for inversion and water-tight seal of the stomach wall.
- At the identified exit site, make a stab wound through the abdominal wall (Fig. 39.1). A 3-mm dermal punch is often useful for this maneuver. Insert a curved hemostat through the abdominal wall exit site and expose the undersurface of the abdominal wall through the incision. Secure the stomach to the abdominal wall by placing three or four absorbable sutures through the gastric wall and the abdominal wall (Fig. 39.3).
- With a hemostat, pull the gastrostomy tube through the abdominal wall exit site until the stomach is snug against the abdominal wall. Tie the previously placed sutures while placing gentle traction on the gastrostomy tube (Fig. 39.3).
- Secure the gastrostomy tube to the skin with a suture to prevent inadvertent removal. Document the length of the gastrostomy tube outside the abdomen. Close the abdominal incision in routine fashion.
- Fixation of Tube after Surgical Placement
Attention to gastrostomy tube fixation on the abdominal wall is critical to encourage proper gastrocutaneous tract formation and to prevent inadvertent removal or site irritation. The gastrostomy tube should be kept perpendicular to the abdominal wall to maintain the smallest possible orifice and to minimize leakage. A dressing that supports the gastrostomy tube in this position for 5 to 7 postoperative days is important. Once the dressing is removed and the wound healed, the gastrostomy tube may be secured to the abdominal wall with porous tape to avoid maceration of the skin.
Feedings may begin on the first postoperative day and increase as tolerated. Avoid clamping the gastrostomy tube with initial feedings. Use gravity suspension to prevent loss of gastric contents while allowing decompression of the stomach during drip feeding. Bolus gastrostomy feeding is generally started once the goal enteral feeding volume has been established using continuous drip.
Fixation of Gastrostomy to Abdominal Wall
- Catheter bridge (Fig. 39.4)
- Either latex or nonlatex catheters may be used.
- Cut a large, firm catheter at its wider end to a length of 3 to 4 cm.
- Cut opposing holes at the midpoint of the catheter bridge just wide enough to admit but not constrict the gastrostomy tube.
- Pull the gastrostomy tube through holes to create a tight seal on the catheter without constricting the lumen of the tube.
FIG. 39.4. Latex bridge at gastrostomy exit stabilizes tube perpendicular to skin, keeping stoma narrow to avoid leakage. Rotating the bridge around the tube allows change in contact points with the skin. Note how the flared end of the mushroom catheter is pulled to keep the stomach apposed to the abdominal wall.
- Insert distal end of catheter into gastrostomy site as described above. If using a Foley catheter, inject 2 to 4 mL of saline into balloon.
- Push catheter bridge snug against skin of abdominal wall.
Pull Foley catheter balloon or mushroom catheter flange against the stomach and abdominal wall.
- Gauze Bolster Dressing
- Fold gauze pad into bolster and use Steri-Strips or tape to affix bolster to abdominal wall next to the gastrostomy tube.
- Loop the gastrostomy tube over the bolster, maintaining the gastrostomy tube perpendicular to the abdominal wall.
- Secure gastrostomy tube to bolster and abdominal wall.
- Modified, soft, feeding nipple (4) (Fig. 39.5)
- Because it is critical to keep the site as dry as possible, there must be modification of the nipple for good circulation of air.
- Excise an elliptical window in flared base of nipple in circumferential direction 1 to 1.5 cm in length.
- Make 1-cm crosscut in tip of nipple.
- Slide nipple over gastrostomy tube until there is contact with abdominal wall.
- Adjust tension on tube to pull gastrostomy balloon or flange against gastric wall.
FIG. 39.5. Modified feeding nipple. The elliptical hole at the base allows air circulation and regular cleaning of the skin as important factors in avoiding maceration of the site. (From
Kappell DA, Leape LL. A method of gastrostomy fixation. J Pediatr Surg. 1975;10:523
, with permission.)
- Tape or suture nipple flange to skin. Clean skin around gastrostomy with cotton applicators and keep area under nipple dry to avoid skin maceration.
- Maintenance Care of Gastrostomy
- Maintain contact between stomach and abdominal wall.
- Prevent gastric distention.
- Keep gastrostomy balloon or flange pulled snugly against stomach wall.
- Avoid pressure necrosis of abdominal wall (Fig. 39.4).
- Avoid inadvertent dislodgement of gastrostomy.
- Keep tube immobile at insertion site to maintain stoma as small as possible.
- Use careful fixation to maintain perpendicular position.
Keep some slack in the tube when it is suspended.
- Prevent migration of tube through pylorus or esophagus by:
- Proper fixation
- Comparing length of external tube with postoperative length
- Observing for signs of obstruction, for example,
- Gastric distention, feeding intolerance
- Increased drainage from oral gastric or gastrostomy tube
- Bilious drainage
- New-onset or increased gastroesophageal reflux
- Minimize leak from gastrostomy site in long-term gastrostomies.
- Maintain adequate fit of tube in stoma.
- Avoid local infection.
- Treat leaking gastrostomy early.
- Remove tube for 24 hours to allow partial closure.
- Replace mushroom catheter with Foley catheter, and pull balloon (inflated with 2 to 5 mL H2O) against abdominal wall to seal leak. Use catheter bridge or tape to secure tube.
- Apply Stomahesive around catheter to decrease excoriation and to encourage epithelialization. Change Stomahesive every 3 to 4 days, as long as seal remains.
- Maintain perpendicular position of gastrostomy tube.
- Keep tube unclamped.
- Maintain skin and stoma hygiene.
- Cleanse daily with soap and water; “crusty” exudate may be removed with half-strength hydrogen peroxide.
- Keep area dry. Change dressing after cleansing skin and whenever wet.
- Treatment of granulation tissue at gastrostomy site
- Silver nitrate: Apply daily for 3 to 5 days.
- 0.5% Triamcinolone ointment: Apply three times a day for 5 to 7 days.
- Cautery: May require local or general anesthesia
- Replacing Gastrostomy Tubes
- During the first 2 to 4 weeks after open gastrostomy placement, reoperation for replacement may be necessary.
- After formation of gastrocutaneous fistula, nonoperative placement is possible.
- To avoid stoma closure, replace within 4 to 6 hours.
- Use deflated Foley catheter for replacement prior to formation of well-epithelialized tract.
- If the catheter does not pass easily, a flexible guidewire may be placed through the tract and confirmed in gastric position by fluoroscopy.
- Lubricate catheter generously with water-soluble lubricant, and insert gently.
- Inflate balloon with 2 to 4 mL of water, and pull against stomach wall.
- Secure with fixation device.
- Mark outside length of catheter to help detect internal or external migration of balloon.
Prior to feeding, confirm placement of gastrostomy with water-soluble contrast study if replacement is difficult or uncertain.
- For replacement, use mushroom catheter tube or balloon-type gastrostomy tube in well-established tract.
- Carefully determine direction of tract.
- Lubricate catheter.
- Stretch tip of mushroom catheter with introducer.
- Apply gentle pressure to insert catheter. Avoid force, which may lead to traumatic separation of stomach from abdominal wall.
- Confirm intragastric position by one of the following methods.
- For recent gastrostomy
- Instill 15 to 30 mL of water-soluble contrast and obtain decubitus radiograph. Remove contrast.
- For well-established gastrostomy, aspirate for gastric contents. If there is any doubt, obtain contrast study prior to initiating feeding.
- Discontinuation of Gastrostomy Tube (5)
- Remove tube and apply gauze dressing.
- Allow spontaneous closure, usually 4 to 7 days, or
- Approximate skin edge with skin closure tape.
Persistent Gastrocutaneous Fistula
- Cause: Granulation and epithelialization of gastrocutaneous tract
- Remove tube.
- Cauterize granulation tissue or epithelium within stoma with silver nitrate sticks.
- Seal orifice with Stomahesive.
- Approximate edges with surgical tape.
- Persistent gastrocutaneous fistula of 4 to 6 weeks: Surgical closure required. If skin is becoming macerated, replace gastrostomy and use protective skin ointment prior to surgical closure.
- Percutaneous Endoscopic Gastrostomy
The use of percutaneous endoscopic technique has become well established for primary gastrostomy tube placement in infants and children. There are several techniques, performed either with or without endoscopy.
- Percutaneous endoscopic gastrostomy (PEG)
- “Pull” technique (6)
- “Push” technique (7)
- “Poke” technique (8)
- Nonendoscopic (9)
- Currently available instrumentation and fiber-optic endoscopes allow for the safe performance of percutaneous gastrostomy in selected neonates, infants, and children. Placement typically requires general anesthesia for airway protection and control. The original method of PEG described by Gauderer in 1980 involves four basic elements:
- Endoscopic gastric insufflation to approximate stomach to abdominal wall
- Percutaneous placement of an introducer into the stomach under direct endoscopic visualization
- Placement of a guidewire through the introducer and retrieval of the guidewire with an endoscopic snare; removal of the endoscope and the snared guidewire through the infant's mouth
- Attachment of a gastrostomy tube to the guidewire and pulling it through the infant's oropharynx, esophagus, and into the stomach. The gastrostomy tube is modified with a tapered end where it is pulled through the abdominal wall and an intragastric mushroom-type flange to keep it from pulling completely out of the stomach (10).
To provide prophylaxis against wound infection, a single intravenous dose of a first-generation cephalosporin or equivalent is recommended prior to PEG placement.
- Laparoscopic Gastrostomy Placement
Placement of gastrostomy tubes in infants using a laparoscopic approach has been described as safe, efficacious, and may have a lower complication rate than percutaneous endoscopic gastrostomy (11). This approach allows direct visualization of the stomach via a 3- or 5-mm laparoscope.
- The laparoscope may be inserted either through the umbilicus or via a left upper quadrant incision at the proposed gastrostomy tube site.
- CO2insufflation to 8 to 10 torr is generally sufficient to visualize the peritoneal cavity.
- The stomach is directly visualized, grasped, and traction sutures placed to elevate the stomach to the abdominal wall; the gastrostomy tube is inserted into the stomach and the stomach is sutured to the abdominal wall.
- Emergency Percutaneous Gastric Decompression
We describe an emergency percutaneous technique for gastric decompression that may be used as a life-saving measure when there is either respiratory failure or a high probability of gastric rupture in the presence of extreme gastric distention.
The primary indication for this type of procedure is for infants with massive abdominal distention causing respiratory failure that cannot be decompressed using an orogastric or nasogastric tube, for example, in infants with esophageal atresia and unrepaired tracheoesophageal fistula, requiring emergency transport to a definitive care facility:
- Prepare skin in upper left abdomen with Betadine.
- If possible, transilluminate abdomen to verify position of distended stomach away from liver.
- Make a small weal with 1% lidocaine to provide local anesthesia.
- Using a 20-gauge catheter with needle stylet, puncture the abdominal wall at the junction of the left anterior rib cage and the lateral border of the rectus abdominis muscle. Advance needle through wall into stomach.
- Remove needle and advance catheter into stomach. Attach short IV extension tubing, three-way stopcock, and syringe. Aspirate only enough air to relieve tamponade effect and improve ventilation. Avoid completely emptying stomach.
- Secure catheter and keep in place until surgical evaluation is possible.
- Complications (10,12,13,14 and 15)
The complications associated with gastrostomy placement in the neonate may be characterized as either immediate or long-term (late). Most immediate complications are technical or mechanical in nature.
Immediate Complications (in approximate order of frequency)
- Pneumoperitoneum (after PEG)
- Wound infection, dehiscence, ventral hernia
- Prolonged ileus, gastric atony, feeding intolerance
- Separation of stomach from anterior abdominal wall
- Intraperitoneal spillage, gastric leak, peritonitis
- Injury to posterior wall of stomach on initial insertion or reinsertion
- Perforation or injury to other organs
- Esophagus (16)
- Liver, spleen
- Inadvertent removal
- Internal or external migration (17)
- Intraperitoneal, extragastric placement
- Catheter deterioration
- Catheter fracture
- Balloon rupture
- Tube occlusion
- Persistent leak
- Wound breakdown
- Granulation tissue and skin irritation
- Infection, particularly Candida
- Loose gastrostomy with leakage
- Electrolyte imbalance
- New-onset or worsening gastroesophageal reflux disease (18)
- Persistent gastrocutaneous fistula following removal
- Adhesive bowel obstruction
- Prolapse of gastric mucosa
- Excessive leakage
- Gastric torsion around catheter
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- Stringel G.Gastrostomy with antireflux properties. J Pediatr Surg. 1990;25:1019.
- Seekri IK, Rescoria FJ, Canal DF, et al. Lesser curvature gastrostomy reduces the incidence of postoperative gastroesophageal reflux. J Pediatr Surg.1991;26:982.
- Kappel DA, Leape LL.A method of gastrostomy fixation. J Pediatr Surg. 1975;10:523.
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- Sachs BA, Vine HS, Palestrant AM, et al. A non-operative technique for establishment of a gastrostomy in the dog. Invest Radiol.1983;18:485.
- Russell TR, Brotman M, Norris F.Percutaneous gastrostomy. A new simplified and cost-effective technique. Am J Surg. 1984; 148:132.
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- Zamakhshary M, Jamal M, Blair GK, et al. Laparoscopic vs percutaneous endoscopic gastrostomy tube insertion: a new pediatric gold standard? J Pediatr Surg.2005;40:859.
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- Cywes S.Stomas in children. S Afr Med J. 1976;50:815.
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- Gauderer MWL.Percutaneous endoscopic gastrostomy: a 10-year experience with 220 children. J Pediatr Surg. 1991;26:288.
- Kenigsberg K, Levenbrown J.Esophageal perforation secondary to gastrostomy tube replacement. J Pediatr Surg. 1986;21:946.
- Currarino G, Votteler T.Prolapse of the gastrostomy catheter in children. AJR, Radium Ther Nucl Med. 1975;123:737.
- Jolley SG, Tunnel WB, Hoelzer DJ, et al. Lower esophageal pressure changes with tube gastrostomy: a causative factor of gastroesophageal reflux in children? J Pediatr Surg.1986;21:624.