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Gastrostomy tubes are used to provide prolonged enteral support in patients who are unable to obtain sufficient nutrition orally. They are an adjunct to the supportive care of many chronically ill patients. A few of the indications for feeding tubes include nervous system disorders (stroke, spinal cord injury, dementia, coma), swallowing dysfunction (neuromuscular diseases), obstructive lesions (esophageal cancer, oropharyngeal trauma), and chronic debilitating disorders (severe malnutrition, advanced cancer, respiratory failure). Simplified techniques for their placement and improved materials have made gastrostomies commonplace in acute and chronic health care settings. Repair and replacement of problematic gastrostomy tubes are best handled in an expedient manner. Primary Care and Emergency Physicians fill a valuable role in solving gastrostomy tube problems. This chapter reviews the methods and materials used in gastrostomies and the approaches to replacing displaced or malfunctioning gastrostomy tubes.

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There are many different procedures that may be used to place feeding gastrostomies and dozens of commercially available gastrostomy tubes. Familiarity with the basic techniques used to create gastrostomies and the characteristics of common gastrostomy tubes is helpful in solving problems with their function and selecting appropriate replacement tubes.

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Placement of Gastrostomy Tubes

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Formal surgical techniques for the placement of feeding tubes have been used for more than a century. Sedillot is given credit for having performed the first open human gastrostomy in 1845.1 However, the first postoperative gastrostomy survival was not reported until 30 years later.2 The evolution of techniques in surgical gastrostomy has a colorful history, with many contributors.1–3 Three main procedures that remain in use today are the Stamm (described in 1894), the Witzel (described in 1891), and the Dupage and Janeway (described in 1913)1–6 (Figure 53-1). Operative gastrostomies require a laparotomy and general anesthesia. They all share the common goal of providing long-term access to the stomach for feedings or decompression while attempting to minimize the potential for gastric leakage.

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FIGURE 53-1
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Surgical gastrostomies. A. The Stamm technique. A double purse-string suture invaginates the stomach about the feeding tube. B. The Witzel technique. The feeding tube is directed away from the gastric puncture through a seromuscular tunnel. C. The Janeway technique. A full-thickness tube fashioned from the greater curvature of the stomach envelops the feeding tube.

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Each of the techniques attempts to create a leakproof interface between the stomach, the feeding tube, and the anterior abdominal wall. The Stamm gastrostomy secures the stomach to a feeding tube using a double purse-string suture to invaginate the stomach about the feeding tube (Figure 53-1A). The Witzel technique places the feeding tube through a seromuscular tunnel in the stomach wall (Figure 53-1B). The Janeway technique creates a formal tunnel from a gastric flap to envelop the feeding tube and form a gastrocutaneous stoma (Figure 53-1C). ...

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