An artificial opening in the abdomen, which is surgically created, connecting the stomach to the anterior abdominal wall, allowing direct access to the internal organ. The operation to create such an opening is called gastrostomy and is one of the most common in the field of palliative medicine.
The main indication for the formation of a gastrostomy is the inability to eat food in the usual way. The cause of this condition can be various diseases that cause obstruction of the esophagus (tumors, scar formations, damage to the nervous system that prevents swallowing food, etc.). In addition, gastrostomy is performed:
- during bougienage, i.e. expansion of the esophagus due to the presence of scar formations,
- in preparation for surgical operations in the esophagus,
- for inoperable esophageal cancer and its treatment with radiation therapy.
Gastostomy can be permanent (in the above cases) or temporary - in case of chest injuries, preparation for a number of operations, fistulas.
Indications for gastrostomy
The upper part of the digestive canal consists of the oral cavity, pharynx and esophagus; a gastrostomy is applied in case of long-term disruption of the conductive function of each of these anatomical parts as a result of injury or illness. Adequate nutrition is of utmost importance for a sick person; without replenishing the increased losses of proteins, fats, carbohydrates, microelements and vitamins due to illness, one cannot hope for a quick recovery. Nutritional support using therapeutic nutrition is today considered a full-fledged element of therapeutic intervention for any disease and injury.
Successful treatment of some pathological conditions requires long-term exclusion of part of the digestive tube “from daily circulation” with the actual possibility of natural nutrition. The use of intravenous solutions is not able to replenish all the necessary nutrients, and a probe passed through the nose into the stomach with constant pressure causes ischemia of the mucous membrane, forming bedsores that are dangerous for rupture of the esophageal wall. The only alternative for adequate nutrition is a gastrostomy tube.
Indications for gastrostomy placement:
- from the oral cavity - this is, first of all, the inability to eat in case of common malignant processes in the floor of the mouth or tongue, during the effective postoperative recovery of extensive facial trauma, treatment of severe burns of the digestive tract;
- pathology of the pharynx - malignant tumors blocking its lumen, the condition after mutilating surgery for locally advanced carcinoma, scar narrowing after a severe burn, innervation disorders with the inability to swallow in neurological diseases;
- obstruction of the esophagus and the area where it passes into the stomach due to cancer or cicatricial narrowing after a burn, chronic fistulous tracts in the trachea and large bronchi complicated by aspiration pneumonia, as well as the need to “switch off from circulation” for full recovery during operations for injuries with rupture of the esophagus, inflamed diverticulum or fistulas, to perform reconstructive plastic interventions.
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Types of gastrostomy
Gastrostomy was invented in the early 19th century, but it was first used in humans 140 years ago, and since then dozens of modifications of the operation have been developed to minimize typical and frequent complications.
A generally accepted full classification of gastrostomy tubes has not been created; they are divided according to the duration of use:
- temporary, that is, used for curable processes and injuries, as well as for preparation for surgery and postoperative recovery, the most modern tactic is puncture of the stomach through the skin to install a thin tube;
- a permanent one is created during an operation that involves cutting the stomach wall with a scalpel and creating a large hole.
Permanent gastrostomy fistulas are formed by a surgeon from the anterior wall of the stomach, dissected and connected to the skin in a special way; their shapes are:
- tubular, when a tube is inserted into the canal created by the surgeon for permanent wear, and the canal itself is created from the mucous membrane or skin, often from the skin together with the mucous membrane, sometimes additionally overgrown with granulation tissue from the wound, or made from previously resected intestine and sutured to the opening in the stomach;
- labiform, when the external opening is surrounded by folds-valves from the gastric mucosa protruding above the skin; a tube is inserted into such a channel only during feeding.
At the Medicine 24/7 clinic, the patient is offered only optimal treatment, taking into account the characteristics of his pathology, his personal interest and wishes, because our specialists can do everything.
Installation of a gastrostomy tube
For complete nutritional support and taking into account the initial pathology, it is necessary to supplement the patient’s regular menu with special mixtures, but the main thing is to give the patient the opportunity to eat regular dishes to meet his needs if it is impossible to consume foods naturally. This is the main purpose of the gastrostomy - to feed, so the surgically formed canal should be:
- wide enough so that crushed food does not clog it;
- optimal in size to minimize chronic injury to the gastric wall;
- sealed, protecting against the passage of food masses past the stomach into the abdominal cavity;
- stable shape that prevents the hole from sticking together after accidental removal of the tube.
A gastrostomy is formed in three surgical ways:
- classic incision of the anterior abdominal wall and open abdominal intervention, creating a constant passage into the stomach;
- laparoscopically using endoscopic equipment;
- through the skin endoscopically.
The operation is performed under general anesthesia, and the gastrostomy is also closed. PEG does not require general anesthesia; local anesthesia is sufficient, but a special disposable set of instruments is required for endoscopy and simultaneous surgical procedures.
Gastrostomy: PROS and CONS
Often in our practice we encounter parents' fear of gastrostomy. Moms and dads think that placing a gastrostomy tube is a sign of the imminent death of their child. However, everything is exactly the opposite! Gastrostomy leads to prolongation of life and improvement of its quality. In this article we will try to dispel the myth of the gastrostomy tube as a tube of death.
A gastrostomy is an artificial opening connecting the anterior abdominal wall to the stomach.
Food or medications are given directly into the stomach through a gastrostomy tube, which is inserted into the gastrostomy tube.
Seriously ill children in need of palliative care sometimes cannot swallow. Their brain is so damaged that this skill has disappeared. If such children continue to be fed by the usual method through the mouth, there is a high risk of suffocation or reflux of food into the respiratory tract.
At the same time, children with disabilities often have decreased appetite. This is also very dangerous, as it leads to malnutrition (emaciation). Immunity decreases, which is why the child suffers from colds more often.
Gastrostomy solves both of these problems. A child can be fed regardless of his remaining skills and desires.
Parents prefer to refuse a gastrostomy tube in favor of a nasogastric tube.
However, long-term use of a nasogastric tube entails many complications, namely:
- bedsores;
- infections of the paranasal sinuses, eyes, ears from the side of the probe;
- reflux of stomach contents into the esophagus, oral cavity and lungs due to a partially open esophagogastric opening;
- aspiration pneumonia.
In this case, the rigid tube of the probe constantly injures the mucous membranes of the nose, throat and esophagus. This can cause erosions, ulcers or stomach bleeding. Gastrostomy eliminates these injuries.
In addition, placing a gastrostomy tube also has an aesthetic component - the gastrostomy tube is located under clothing. This allows the family to socialize more successfully, since many parents are embarrassed by protruding tubes and do not go outside with their child.
Contraindications:
A gastrostomy tube cannot be placed if:
- ascites;
- peritoneal dialysis;
- severe portal hypertension;
- severe hepato- or splenomegaly;
- high degree of obesity;
- anatomical defects as a result of previous surgery or inflammation.
Types of gastrostomy tubes:
- percutaneous endoscopic (PEG);
- balloon (long and low profile).
The choice of tube depends on factors such as: the length of time the child will have a gastrostomy tube; doctor's recommendations; family preferences and financial capabilities.
The advantage of a balloon tube is that anesthesia, as a rule, is given only once - during the initial installation. When replacing, general anesthesia and hospitalization are not required.
If you decide to install a gastrostomy tube for your child
The operation to install a gastrostomy tube is simple and lasts 15-20 minutes.
To install and replace a PEG, general anesthesia and hospitalization in a clinic are required. The balloon gastrostomy tube can be changed without anesthesia and at home. This is extremely important for palliative children.
Doctors recommend changing the balloon gastrostomy tube every 4-6 months. PEG – every 1.5-2 years.
Thus, a gastrostomy is a way out of a difficult situation when normal feeding is no longer possible or when the child has no appetite. Gastrostomy does not injure the body and does not cause complications. At the same time, if you have a gastrostomy tube installed, this does not mean that you can no longer feed your child through the mouth. If he has retained the ability to swallow food, nothing prevents you from combining and alternating gastrostomy and regular feeding as needed.
Gastrostomy: PROS and CONS (part 1) Gastrostomy: HOW TO CARE (part 2) Gastrostomy: HOW TO ADMINISTER MEDICATIONS (part 3) Gastrostomy: HOW TO USE - FOOD (part 4)
Complications of gastrostomy
In the immediate aftermath of surgery, usual surgical troubles in the form of mild and short-term pain are possible. The percentage of other complications is negligible.
A surgically applied gastrostomy, no matter during open or laparoscopic surgery, is fraught with a minor complication - inflammation of the skin around the hole due to leakage of caustic gastric juice. The use of ointments and pastes protects the skin well.
Regular and proper care of the tissues around the hole, timely consultation with a doctor when the first signs of inflammation appear, will prevent possible infection with the development of peristomal inflammation.
With a tubular gastrostomy, the plastic tube may fall out; of course, the patient is uncomfortable and even scared, but the doctor can easily return it to its place.
Theoretically, it is possible for a hernia to form in the anterior abdominal wall under a surgical scar; in real life, such a complication practically never occurs.
With PEG, the recovery period is shorter and easier, like the procedure itself; there are also fewer long-term complications; they are mainly associated with a thin probe installed in the stomach - blockage of the lumen with food masses or accidental damage to the structure.
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Gastrostomy: HOW TO CARE
Sometimes problems with the gastrostomy opening can occur. For example, gastric leakage or infection. And also with the tube itself - blockage, tube exit. Most often, such problems arise due to non-compliance with care rules or manufacturer's recommendations.
In this article you will learn how to properly care for a gastrostomy tube.
The skin around the stoma (gastrostomy opening) should be washed daily with warm water and soap. And also wipe under the external fixation device. Or a tube cap if your child has a low-profile gastrostomy tube.
You can take a regular bath or shower with a gastrostomy tube. After water procedures, you need to ensure dryness around the hole.
The new tube must not be immersed in water for three weeks after surgery!
In addition to soap and water, you can use a solution of an alcohol-free antiseptic (Miramistin, Octenisept) for treatment. BUT ONLY AS PRESCRIBED BY A DOCTOR!
You need to carefully monitor the condition of the skin around the stoma! The skin must be wiped with a cloth moistened with boiled water. Then dry and spray with an antiseptic like Miramistin. GAUSE WIPES CANNOT BE USED, as loose threads that get into the stoma can cause inflammation.
The gastrostomy tube should not be covered with a layer of napkins or adhesive tape - the gastrostomy tube should “breathe”. Otherwise, bedsores, infections or granulations may occur.
Hydrogen peroxide is not used to treat gastrostomy. It leads to granulations.
Granulation is granular tissue formed from wound healing.
To prevent the gastrostomy tube from becoming clogged, it should be flushed with water before and after each feeding or medication administration.
There is also a high likelihood of granulation tissue growing around the stoma. To avoid this, rotate the gastrostomy tube 360 degrees daily.
Every day, check whether the tube has sunk and whether the external fixation device is correctly installed (2-5 mm from the skin surface). Use the external marks to estimate the depth of the tube. In addition, every day after processing the gastrostomy opening and tube, check that the internal fixator or balloon is resting against the anterior abdominal wall (gently pull towards you until it stops), and then lower the external fixator to the desired mark.
The external fixation device must not be moved within 2 weeks from the date of surgery!
If compression occurs during this time or the child experiences discomfort, consult a doctor.
It is also worth contacting a specialist in cases where:
- the gastrostomy tube is immersed deep in the stomach (tightening the tube yourself is strictly prohibited!);
- compression, discomfort, and redness are observed while wearing additional clips for gastrospection (to prevent reflux, sometimes it is necessary to fix the stomach to the anterior abdominal wall);
- irritation, redness, and swelling appeared in the area around the stoma.
It is prohibited to use occlusive dressings over a gastrostomy tube!
They can contribute to the development of bedsores and granulations on the skin, as well as an increase in the number of bacteria.
If your child has a balloon gastrostomy tube, change the water in the balloon every week. In the hospital it is sterile water. At home – boiled, chilled. Check the volume of water in the instructions for this gastrostomy tube.
It is prohibited to fill the cylinder with other solutions. Only sterile or boiled water!
The tube should be changed every 4-6 months. If a gastrostomy tube has been placed recently, no manipulations need to be performed for another 2-3 weeks after surgery.
At the same time, we must not forget about the child’s oral hygiene, despite the fact that he eats through a gastrostomy tube. We brush our teeth 2 times a day. If necessary, use artificial saliva or mouthwash.
When oral nutrition is reduced, plaque quickly appears on the teeth. Poor oral hygiene can cause pain, inflammation in the nasopharynx and upper respiratory tract, and contribute to the development of infections.
What to do if the gastrostomy tube is blocked
If there is a partial blockage, flush the gastrostomy tube with warm water.
If that doesn't work, use soda or freshly squeezed pineapple juice.
If both approaches are ineffective: dilute pancreatin in water and inject it into the tube for 30-90 minutes.
If this does not help, the gastrostomy tube needs to be replaced.
To prevent such situations from happening, carry out prevention - rinse the tube with warm water before and after feeding in a volume of 20-40 ml.
If the tube still gets clogged, don’t panic. It will not harm the baby. If your child requires any medications that you administer through a gastrostomy tube (for example, anticonvulsants), consult your doctor. They can be temporarily administered to the child through a nasogastric tube or rectally.
Gastrostomy: PROS and CONS (part 1) Gastrostomy: HOW TO CARE (part 2) Gastrostomy: HOW TO ADMINISTER MEDICATIONS (part 3) Gastrostomy: HOW TO USE - FOOD (part 4)
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