Gastrostomy
Bavana Ketha
Megan E. Beck
Kathryn M. Maselli
Thomas Sato
A. Alfred Chahine
A. Definition
Gastrostomy is the placement of a catheter in the stomach for a variety of indications.
Although usually performed in the operating room, it is essential that the NICU staff has a good understanding of what the procedure is and the optimal care of the tube, since it has become one of the most commonly performed surgical procedures in the neonatal population (1, 2). Surgical advances including endoscopy and laparoscopy have expanded the applications of gastrostomy while making placement quicker and safer (3, 4, 5).
B. Indications
1. Inability to swallow/dysphagia
a. Neurologic impairment resulting in uncoordinated swallowing.
b. Complex congenital malformations, e.g., esophageal atresia, Pierre Robin sequence, and chromosomal abnormalities.
2. Failure to thrive/need for supplemental feedings
a. Anatomic intestinal anomalies, i.e., short gut syndrome.
b. Functional intestinal dysmotility, i.e., gastrointestinal malabsorption.
c. Malignancy/tumor.
d. Chronic pulmonary disease, i.e., persistent pulmonary hypertension.
e. Congenital heart disease.
f. Glycogen storage disease (need for consistent glucose source).
g. Chronic kidney disease.
3. Frequent aspiration
a. Gastroesophageal reflux disease leading to pulmonary disease (in conjunction with a Nissen fundoplication).
b. Primary hypopharyngeal aspiration.
C. Relative Contraindications
Treatable medical conditions that increase operative risks, such as active infection or coagulopathy, should be treated aggressively prior to elective gastrostomy placement.
Pure esophageal atresia often results in small stomach volumes (microgastria), thus making gastrostomy placement more difficult. Ultimately, if the patient requires gastric transposition to treat long-gap esophageal atresia, a prior gastrostomy would make the repair contraindicated.
Short-term need for enteral nutrition for a period of weeks can be met through placement of a nasogastric tube instead.
D. Preoperative Workup
Prior to operative planning, it is important to make sure that the patient meets the proper anatomical and physiologic indications for gastrostomy. An upper gastrointestinal (UGI) study would reveal any anatomic malformations like malrotation or duodenal webs, but the utility of this has been recently questioned (6, 7, 8). Identifying neonates in need of concomitant procedures such as antireflux surgeries usually requires more extensive preoperative workups such as 24-hour pH probe to quantitate the extent of the reflux and a gastric emptying study to look for impaired gastric motility (6, 7, 9). However, in general, the clinical picture is usually all you need to determine if the infant would benefit from only a gastrostomy or whether he/she would need a fundoplication simultaneously. If an infant is tolerating gastric feeds without any evidence of aspiration or respiratory compromise, typically that infant will do well with only a gastrostomy. If an infant is requiring transpyloric feeding because of respiratory issues, then a concomitant fundoplication may be warranted. The routine addition of a fundoplication at the time of a gastrostomy in neonates with neurologic impairment is still controversial (10, 11).
E. Types of Gastrostomy
1. Open Stamm gastrostomy
Dr. Martin Stamm described the open gastrostomy procedure in 1894, which was frequently used in premature infants and neonates. The Stamm technique, however, is now being used with less frequency secondary to its invasive approach. Current indications include altered gastric anatomy, multiple previous abdominal surgeries, concurrent laparotomy for other procedures, and unstable patients. It is performed through an upper transverse abdominal or supraumbilical midline incision. The catheter is then brought out of the skin through a separate location about halfway between the umbilicus and the costal margin on the left side (Fig. 44.1). The catheters utilized in a Stamm gastrostomy include balloon, mushroom, and/or low-profile buttons.
 FIGURE 44.1 Anatomic landmarks for placement of a gastrostomy tube in a neonate. The tube will pass through the abdomen at a site in the center of a triangle formed by the xiphoid, umbilicus, and left costal margin. |
 FIGURE 44.2 A: Elements of a gastrostomy button. B: Gastrostomy button in left upper quadrant with feeding attachment secured. (Photo courtesy of Dr. Mariana Vigiola-Cruz.) |
2. Percutaneous endoscopic gastrostomy (PEG)
Developed in 1980 by Drs. Gauderer and Ponsky, PEG has become the primary method of gastrostomy in older children and adults but is rarely used in the neonatal period for several reasons. Neonates are at higher risk of bowel injury with PEG due to lack of direct visualization. Concomitant fundoplication cannot be performed with PEG placement and patients may go on to require additional intervention. They are also at greater risk of tube dislodgement due to the inability to perform simultaneous gastropexy with PEG placement. Moreover, endoscopy is not feasible in neonates less than 3 kg due to the endoscope’s size dimensions (1, 4, 12, 13).
3. Laparoscopic gastrostomy
Laparoscopic placement of gastrostomy tubes has become the method of choice for neonatal gastrostomy insertion (14, 15). Some believe that the laparoscopic gastrostomy technique has a lower complication rate than the PEG technique in neonates and small children (14, 15, 16, 17). It is a quick and safe technique requiring a short anesthetic and is usually very well tolerated. Most often, the tubes placed are primary button tubes that are easily maintained. They have a low profile on the outside and are held in place by a balloon inflated with a few milliliters of water (Fig. 44.2A,B). The catheters vary in width (12 Fr, 14 Fr, etc.) and length of the stem from the bottom of the flange to the top of the inflated balloon (0.8 cm, 1.0 cm, 1.2 cm, etc.) (Fig. 44.2A). The most commonly used size in the NICU is a 12-Fr, 0.8-cm button. A spare tube should always stay at the bedside and be given to the parents to keep at home.
4. Emergent percutaneous gastric decompression
The ability to decompress the stomach emergently is a life-saving measure that may be required in neonates
that have severe respiratory compromise or a high probability of gastric rupture secondary to the presence of extreme gastric distention.
that have severe respiratory compromise or a high probability of gastric rupture secondary to the presence of extreme gastric distention.
a. Indication
(1) The primary indication is massive abdominal distention from preferential ventilation of the stomach rather than the stiff lungs in a premature newborn with esophageal atresia and a tracheoesophageal fistula.
b. Procedure
(1) Prepare the abdomen with Betadine or chlorhexidine and then drape the skin in the upper left abdomen.
(2) If possible, utilize a light to transilluminate the abdomen to locate and verify the position of the distended stomach away from liver.
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