Gastrostomy tubes are commonly used devices that provide prolonged enteral support in patients who are unable to obtain sufficient nutrition orally. Simplified techniques for their placement and improved materials have made gastrostomies common in the outpatient setting. Emergency Physicians fill a valuable role in solving gastrostomy tube problems as many patients present to Emergency Departments with various gastrostomy tube complaints. This chapter reviews the methods and materials used in gastrostomies and the approaches to replacing displaced or malfunctioning 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 replacing tubes when appropriate.
Placement of Gastrostomy Tubes
Feeding tubes have been surgically placed in patients for more than a century. 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 64-1). They all require a laparotomy under general anesthesia and provide long-term access to the stomach for feedings or decompression while attempting to minimize the potential for gastric leakage.
Surgical gastrostomies. A. The Stamm technique. B. The Witzel technique. C. The Janeway technique.
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 gastrostomy tube using a double purse-string suture to invaginate the stomach about the feeding tube (Figure 64-1A). The Witzel technique places the gastrostomy tube through a seromuscular tunnel in the stomach wall (Figure 64-1B). The Janeway technique creates a formal tunnel from a gastric flap to envelop the gastrostomy tube and form a gastrocutaneous stoma (Figure 64-1C). Importantly, all three techniques involve suturing the stomach wall to the undersurface of the abdominal wall. This is significant because if a surgically placed gastrostomy tube is accidentally dislodged in the early postoperative period, the stomach wall remains attached to the abdominal wall and the chance of intraperitoneal contamination is decreased. These surgical gastrostomies are considered long-term, semipermanent stomas.
Modern endoscopic techniques have provided a less invasive option for the placement of percutaneous feeding tubes (also known as gastrostomy tubes, percutaneous endoscopic gastrostomies, or PEGs).7 Distinct advantages of endoscopically placed gastrostomy tubes over surgically placed tubes include relative ease of placement, avoidance of general anesthesia, smaller incision, and a lower morbidity rate.2,7,8 The disadvantages of endoscopic techniques include the inability to place tubes in patients with thick abdominal walls, a history of multiple previous operations, and the presence of abdominal wall hernias, as well as an increased risk of injuring overlying viscera during the “blind” placement of the PEG tube. Another disadvantage is the ...