Ozimo Pereira Gama Filho

Adjunct Professor at the Federal University of Maranhão

No conflict of interest

1. INTRODUCTION
2. HISTORICAL ASPECTS
3. ANATOMICAL FUNDAMENTALS
4. INDICATIONS
5. TYPES & TECHNIQUES
6. ADVERSE EVENTS
7. CUSTO RATIO x EFFECTIVENESS
8. CONCLUSIONS

SUMMARY

In the last decade, the use of gastrostomies has been widely indicated as the preferred form of access to the gastrointestinal tract for feeding in chronic conditions and during recovery from acute conditions such as trauma. Together with this increase in indications, new techniques have been developed that have made gastrostomies simpler and less risky. From the classical technique of Stamm performed by laparotomy, two new alternatives that do not require laparotomy emerged: percutaneous endoscopic gastrostomy (PEG) and fluoroscopy gastrostomy. Its main benefit is to avoid a laparotomy, with less associated postoperative pain and earlier return of gastrointestinal function. Although peg is currently widely accepted as the insertion technique of choice due to its simplicity and efficacy, there are patients who are not candidates for an endoscopic approach.   In this article we seek to clarify the indications, technical aspects and perioperative care of patients undergoing gastrostomy.

Keywords: Surgical Procedures; Ostomies; Gastrostomy.

Area of Knowledge: General Surgery

1. INTRODUCTION

The main indication   for enteral or parenteral feeding in the perioperative period is the provision of nutritional support to supply the metabolism of patients with inadequate oral intake. Enteral feeding is the preferred method in relation to parenteral feeding in patients with gastrointestinal dysfunction in the perioperative period due to the inherent risks associated with parenteral nutritional support, such as: infectious complications of the access routes, higher operational cost, and the inability to   parenteral nutrition to provide adequate enteral stimulation and subsequent involvement of the intestinal defense barrier [1,2].  In addition, enteral feeding may decrease the risk of bacterial translocation and corresponding bacteremia [3].   Gastric nutritional support is the most common type used. Access to insert the gastrostomy probe can be achieved using endoscopy, interventional radiologia, or surgical techniques (open or laparoscopic).   However, since its description in the 1980s [4], percutaneous endoscopic gastrostomy (PEG) is currently considered the method of choice for medium and long-term enteral support.

1.1 Objective: This article reviews the current knowledge about GOSTROSTOMIA in the medical literature, emphasizing the technical and perioperative aspects.

• HISTORICAL ASPECTS

In 876, Verneoil [5] successfully made the first gastrostomy in humans. Since then, several technical modifications have been suggested, such as witzel’s technique in 1891, in which a subseroso tunnel is made on the probe [6].   Stamm, in 1894 [7], described one of the most performed techniques today and in the history of surgical gastrostomy, which consists in the making of suture in a pouch to invaginate the probe inserted into the stomach [8]. In 1980, percutaneous endoscopic gastrostomy was described by Gauderer et al. [4] , which transformed the technique of making gastrostomy.

• ANATOMICAL FUNDAMENTALS

The stomach is a J-shaped dilated cylindrical organ that rests in the left epigastric and hypochodrial region of the abdomen at the level of the first lumbar vertebra. It is previously limited by the left hemidiaphragm, the left lobe of the liver and a triangular portion of the anterior abdominal wall. Subsequently, the pancreas, left kidney and adrenal delimit the stomach. The spleen is posterolaterally and the transverse colon is inferior. It is fixed at two points of continuity: gastroesophageal, superiorly and the duodenal, retroperitoneally.  Its ligament attachments also help  you in fixation to adjacent organs: gastrophemic (diaphragm), hepatogastric or minor omentum (liver), gastrosplenic or gastrolienal (spleen), and gastrocholic or omentum major (transverse colon). The anatomical regions of the stomach can be   distinguished as this: começa superiorly in the continuity of the abdominal part of the esophagus and dthe gastroesophageal junction, the cardiac part of the stomach. Soon below this portion, lies the bottom of   the stomach that expands to the left extending above thegastroesophageal junction, forming an acute angle with the distal esophagus known as cardiac notches. The body s andextends as a distensible reservoir and forms a medial edge called the smallest curvature to the right and a side edge called the largest curvature on the left. The gastric den of the stomach is not anatomically distinguishable, but it is estimated to be a region of the angular isis along the distal minor curvature to  a point along a lower line to the distal major curvature. It thus ends bymouthing r into the pyloric canal limited by the pyloric sphincter, a palpable thickened ring of muscle that is continuous with the first part of the duodenum.

• INDICATIONS

Gastrostomy is used in the following situations:

1. Gastric decompression: can be obtained by means of temporary gastrostomy, occasionally recommended, as a complement to large abdominal operations for which gastric stems, prolonged “adynamic ileus” and digestive fistulas are foreshadowed.
2. Nutritional Support: b.1 Temporary;  indicated when access to the digestive tract is temporarily impaired for recovery and maintenance of nutritional status (E.g. CEsophageal EC); b.2 Definitive;   as palliative therapy in patients with unresectable malignant neoplasia of the head and neck,  as wellas  n degenerative neurological diseases that lead  to irreversible disorders of deglutition.

However, the decision to perform a gastrostomy, as well as its route (surgical, radiological or endoscopic) should be individualizedaccording to the needs, diagnosis, life expectancy of the patient and the available hospital logistics. The objective is not only to optimize perioperative recovery, to improve survival and nutritional status of the patient, but also to  promote quality of life, which is not necessarily correlated with nutritional improvement only [9].  Therefore, the appropriate indication, like any other surgical intervention, must be clearly establishedand informed before it is performed.   Some of the absolute contraindications of gastrostomy are summarized in Table 1. In addition to absolute contraindication conditions,  other situations such as the presence of non-obstructive oromyctological oresophageal malignancy, hepatomegaly, splenomegaly, peritoneal dialysis, portal hypertension  with gastric varicose veins, and a history of partial gastrectomy are also considered relative contraindications.

ABSOLUTE CONTRA – INDICATIONS

Coagulopatia Severa (INR > 5, Plaquetas < 50.000 e TPT > 50s)

Hemodynamic Instability

Septic Shock

Refractory Ascites

Peritonitis

Dermatological infection in the upper abdomen

Carcinomatose Peritoneal

Interposition of organs that prevent gastric access

History of Total Gastrectomy

Stenosis or Pyloric Obstruction

Severe gastroparesis, in cases of indication for nutritional support

Absence of Informed Consent

• TYPES & TECHNIQUES

Currently there are three techniques for performing gastrostomy: radiological, through percutaneous gastrostomy by fluoroscopy, percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy.   Due to the didactic characteristics of this material, we will focus on endoscopic and surgical gastrostomy  , which becomes the main option in the following situations: 1) when the patient will already undergo a laparotomy due to some abdominal condition ; 2) impossibility of performing gastroscopy to perform gastrostomy  endoscopic percutaneous (PEG) ; 3) in  case of peg technical failure; 4) unavailability of resources for the preparation of PEG or percutaneous gastrostomy by fluoroscopy.

• ENDOSCOPIC PERCUTANEOUS GASTROSTOMY

The informed consent form must be obtained from patients or their legal representatives.   Patients should fast for a minimum of 8 hours and receive prophylactic antibiotics one hour before proceeding and intravenous administration of 1-2 g of cefazolin is recommended.  The technique introduced by  Gauderer et al [4] is the most used technique to insert the PEG gastrostomy probe. In this method, a guide wire is used, inserted in the distal gastric chamber through a needle puncture n to the anterior abdominal wall. This guide wire is then seized endoscopically with a handle and then removed through the esophagus and mouth. Subsequently, the guide wire is fixed to the end of the gastrostomy probe and then pulled from the mouth to the esophagus, stomach and then out to the abdominal wall, where it will be fixed.

• SURGICAL GASTROSTOMY

Surgical gastrostomy can be performed in two ways: 1) via laparotomy – the predominant form; and 2) laparoscopic approach.   The preparations are the same as the endoscopic pathway.

5.2.1. GASTROSTOMIA At STAMM

After adequate asepsis and antisepsis, with the patient under anesthesia and in horizontal dorsal decubitus, the technical steps are as follows: 1. Median laparotomy (supraumbilical median incision); 2. Identification of the gastric body; 3. Stomach hold with Babcock tweezers (to evaluate the approach of the stomach to the peritoneum); 4. Suture in pouch (circular area of 2cm) – atraumatic absorbable thread; 5. Section of the stomach wall (0.5cm) – (incision with scalpel or Electrocautery in the center of the suture, of sufficient size, for the placement of a probe with 20 to 26 French); 6. Placement of the Gastrostomy probe in the extension of 5-6 cm, followed by suture closure in a pouch); 7. Tie the suture threads in a pouch around the probe; 8. Apply a second suture in a pouch 1cm above the first (seromuscular stitches); 9. Externalization of the probe by counter opening on the left flank; 10. Fix the stomach wall to the abdominal wall in 4 cardinal points (external ration with the two Kocher tweezers used for grip of the alba line and against traction by means of the index fingers of the wall of the left hipochondrio to approach the parietal peritoneum of the gastric wall); 11. Fixation of the probe to the skin (point with nonabsorbable wire); 12. Closure of the abdominal wall (synthesis of the wall with approximation of the alba thread by continuous suture with monofilament thread 1-0 or 2-0 and of the skin with separate points of nylon 3-0);  13. Dressing.

5.2.1 GASTROSTOMIA EM WITZEL

The initial technical steps from gastrostomy to Witzel are like those of gastrostomy to Stamm, including fixation of the probe to the stomach by a pouch suture. Then, the probe is placed on the gastric wall and a tunnel of 8-10 cm is made by seromuscular suture (continuous or with separate points of absorbable or nonabsorbable thread) covering it and externalization is performed by counteropening.

• ADVERSE EVENTS

According to the literature, the rate of complications for different procedures varies due to the heterogeneity of the samples evaluated. For surgical gastrostomy, the reported complication rates are between 1% and 35%, while for percutaneous radiological gastrostomy it is 3% to 11%, and for percutaneous endoscopic, 17%–32%, the main related adverse event is surgical site infection [10, 11].  Although considered a basic procedure, gastrostomy is associated with an extensive list of related technical complications, care and use of the probe. Serious problems related to the technique include separation of the stomach from the abdominal wall (leading to peritonitis), separation of wounds, hemorrhage, infection, lesion of the posterior gastric wall or other organs, and placement of the tube in an inappropriate place of gastric position. Separation of the stomach from the abdominal wall usually occurs due to inadvertent and premature displacement of the tube, particularly with balloon-like devices, or a rupture during a catheter change. It requires immediate attention, being treated with laparotomy, although in selected cases laparoscopic correction is possible. Most complications can be avoided with the careful choice of the type of procedure, from the appropriate ostomy device, considering it an important intervention and using meticulous technique with the proper approximation of the stomach to the abdominal wall and outflow of the probe through a counter-incision (in conventional procedures), thus avoiding probes in the midline or awfully close to the costal edge.

• COST VS. EFFECTIVENESS

A recent study [12] compared the cost associated with the different gastrostomy techniques, and the results of the evaluation showed variable the benefits of each of the individual percutaneous procedures, indicating that surgical gastrostomy was the onerous mais of the three modalities due to higher costs, complications, and recovery time, as well as the endoscopic technique presenting the cost effectiveness ratio.

• CONCLUSIONS

Despite the technique employed, the decision to performa gastrostomy is not based only on the patient’s survival expectancy, because the adequate indication provides a better quality of life even when the survival of the patient after the procedure is severely limited. Therefore, understanding of techniques, indications, complication rates is essential to guide the surgical team in the scope of multidisciplinary care, as well as the education of patients and their caregivers is vital to ensure the correct maintenance of the devices, thus ensuring adequate nutritional intake of the patient and minimizes complication rates.

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