The gastrostomy tube (G-tube) is a commonly used device that provides prolonged enteral support in patients who are unable to obtain sufficient nutrition orally. Indications for enteral feeding tube placement include prolonged neurogenic or mechanical dysphagia, prolonged mechanical ventilation, and poor intake. Relatively common complications related to enterostomy tubes encountered in the Emergency Department include tube dislodgement, tube occlusion, leakage around the tube, and skin changes (e.g., hypergranulation, ulceration, erythema, and infection).1,2 Some less common problems include buried bumper syndrome, peritonitis, gastric outlet obstruction, gastro-colo-cutaneous fistula, and stomal herniation.1-5 Some of the complications may require replacing G-tubes.6 Simplified techniques for their placement and improved materials have made gastrostomies common in the outpatient setting. Emergency Physicians fill a valuable role in solving G-tube problems as many patients present to Emergency Departments with various G-tube complaints. This chapter reviews the methods and materials used in gastrostomies and the approaches to replacing displaced or malfunctioning G-tubes.
ANATOMY AND PATHOPHYSIOLOGY
Familiarity with the basic techniques used to create gastrostomies and the characteristics of common G-tubes is helpful in solving problems with their function and replacement.
The choice of access route (i.e., gastrostomy, gastrojejunostomy, or jejunostomy) and the choice of placement technique (i.e., surgical, endoscopic, or radiologic) often depend on individual patient issues and the treating physician (e.g., specialty, experience, and preference). 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) (Figure 82-1).7-12 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 G-tube using a double purse-string suture to invaginate the stomach about the feeding tube (Figure 82-1A). The Witzel technique places the G-tube through a seromuscular tunnel in the stomach wall (Figure 82-1B). The Janeway technique creates a formal tunnel from a gastric flap to envelop the G-tube and form a gastrocutaneous stoma (Figure 82-1C). All three techniques involve suturing the stomach wall to the undersurface of the abdominal wall. The stomach wall remains attached to the abdominal wall, and chance of intraperitoneal contamination is decreased if a surgically placed G-tube is accidentally dislodged in the early postoperative period. These surgical gastrostomies are considered long-term or semipermanent stomas.