Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 22 • Percutaneous Gastrostomy Feeding Tube Placement 259

FIGURE 2 2–4

Proximal end

of guidewire

Distal end wire

of gastrostomy tube

Proximal end of

Gastrostomy tube

Guidewire

Trocar needle

Distal end

of wire loop

Guidewire

FIGURE 2 2–5

Gastrostomy tube

secured

FIGURE 2 2–6

260 Section IV • The Abdomen

STEP 4: POSTOPERATIVE CARE

◆ The PEG tube is placed to gravity for the remainder of the procedure day with 30 to 60 mL

of water or saline ﬂ ush performed every 4 hours. If no signs of infection, abdominal sepsis,

or ileus are seen the following morning, trickle feeds may be started and advanced as toler-

ated. The site should be kept clean and dry and the tube at approximately 3 to 5 cm

depending on patient girth. Pills should not be inserted into the tube, and only liquid med-

ications should be given.

◆ Removal: Most tubes are removed by gentle traction at the skin. If a balloon catheter type

has been inserted, the balloon should be deﬂ ated ﬁ rst. If the tube breaks and the inner disc

does not come out, endoscopic retrieval is necessary to avoid risk of bowel obstruction.

STEP 5: PEARLS AND PITFALLS

◆ Often patients are combative and accidentally dislodge tubes or break sterile ﬁ elds. In addition,

sedatives can disinhibit some patients. During the procedure, consider assistance or soft

restraints.

◆ If transillumination cannot be performed, stop the procedure. This is a contraindication

because adjacent viscera can be damaged.

◆ Early dislodgement may preclude replacement and require laparotomy. A Foley catheter can

be used to maintain the tract once epithelialization has occurred, if the tube is displaced

after that time. If a tube is reinserted, conﬁ rmation of placement should be made with a

gastrografﬁ n abdominal ﬁ lm.

◆ Excessive tension on the feeding tube can cause necrosis of the abdominal wall, site infec-

tion, and feed leakage. No gauze should be placed under the skin disc to help prevent this.

SELECTED REFERENCES

1. Eisen GM, Baron TH, Dominitz JA, et al: Role of endoscopy in enteral feeding. Gastrointest Endosc

2002;55:794-797.

2. Scott-Conner CEH (ed): The SAGES Manual: Fundamentals of Laparoscopy and GI Endoscopy. New York,

Springer, 1999, pp 462-469.

3. Duh Q-Y, McQuaid K: Flexible endoscopy and enteral access. In Eubanks S, Swanström LL, Soper NJ,

Leonard M (eds): Mastery of Endoscopic and Laparoscopic Surgery. Philadelphia, Lippincott Williams &

Wilkins, 2000, pp 133-143.

4. Angus F: The percutaneous endoscopy gastrostomy tube, medical and ethical issues in placement. Am

J Gastroenterol 2003;98:272-277.

5. Gopalan S: Enteral nutrition delivery technique. Curr Opin Clin Nutr Metab Care 2003;6:313-317.

261

STEP 1: SURGICAL ANATOMY

◆ The pylorus sits at the distal end of the stomach and is marked by thickening of the

circular smooth muscle layer, thus forming the pyloric sphincter, which acts as a valve

between the stomach and the duodenum and regulates gastric emptying. The pylorus

does not have independent blood supply; rather, it gets its blood supply from the vessels

that perfuse the distal stomach and proximal duodenum. Innervation of the pylorus is

through the terminal branches of the right and the left vagus nerves. Any injury to these

nerves or denervation of the pylorus will result in pylorospasm and delayed gastric

emptying.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Gastric drainage procedures such as pyloroplasties are indicated with truncal vagotomies

in the management of peptic ulcer disease (pyloric, prepyloric, and duodenal ulcers), in

selected patients who undergo transhiatal resection of the esophagus with gastric pull-

ups, and in children undergoing fundoplication for gastroesophageal reﬂ ux disease with

conﬁ rmed delay in gastric emptying. Three types of pyloroplasties have been classically

described, namely, the Heineke-Mikulicz pyloroplasty, which is the easiest to perform

and the most commonly used; the Finney pyloroplasty; and the Jaboulay pyloroplasty.

◆ Conﬁ rmation of the diagnosis of peptic ulcer disease or delay in gastric emptying should

be documented before the procedure with endoscopy, contrast studies, or technetium-99

sulfur colloid meals.

◆ The Heineke-Mikulicz pyloroplasty is perhaps the most commonly performed because it is

technically simple, carries low morbidity and mortality, and of all pyloroplasties it takes the

least amount of time to complete.

CHAPTER

Pyloroplasty

Carlos A. Angel

262 Section IV • The Abdomen

STEP 3: OPERATIVE STEPS

1. INCISION

◆ After the antrum and duodenum are exposed, the pylorus is easily identiﬁ ed because it feels

thicker that either the stomach or duodenum, and the pyloric vein, which runs across the

pylorus transverse to the axis of the duodenum, serves as a clear landmark. A 3-cm full-

thickness incision is made along the axis of the pylorus equidistant from both the stomach

and the duodenum (Figures 23-1 and 23-2). Holding stitches are placed at the midpoint

of the incision on both the superior and inferior sides of the defect, and traction is used to

align the tissue perpendicularly with respect to its original axis (see Figure 23-2). Closure is

now performed in two layers. A running 3-0 absorbable suture layer is used to reapproxi-

mate the mucosa (Figure 23-3), and interrupted 3-0 silk seromuscular stitches are used to

complete the repair (Figure 23-4). Care must be taken to avoid excessive invagination of

the suture line. If tension is deemed to be excessive, mobilization of the duodenum with a

Kocher maneuver may be required.

3-cm incision in anterior pylorus

Duodenum

Antrum

FIGURE 23 –1

Duodenum

Interrupted seromuscular

Lembert sutures

Antrum

FIGURE 23 –4

Duodenum

Running closure

of the mucosal layer

FIGURE 23 –3

Duodenum

Longitudinal opening

of all layers

across pylorus

Antrum

FIGURE 23 –2

CHAPTER 23 • Pyloroplasty 263

264 Section IV • The Abdomen

2. DISSECTION, HEINEKE-MIKULICZ PYLOROPLASTY (STAPLED)

◆ A full-thickness 4- to 6-cm longitudinal incision is made along the axis of the pylorus,

and two holding stitches are placed as described previously. An additional stitch is

placed from the most proximal to the most distal point of the incision (Figure 23-5). As

these stitches are placed under traction, the longitudinal defect is converted into a trans-

verse defect. A terminal anastomosis (TA)-55 linear stapling device is applied, making

sure that all layers are involved and in such a manner that after its ﬁ ring the result will

be a transverse closure of the incision (Figures 23-6 and 23-7). After the stapler is

ﬁ red, excess pyloric tissue is removed with the scalpel, and subsequently the stapler is

released (see Figures 23-6 and 23-7). Careful inspection of the staple line is mandatory.

A stapled pyloroplasy such as the one described here requires a supple pylorus and

should not be chosen when the pylorus is scarred and nonpliable.

Duodenum

Antrum

Longitudinal incision

along the pylorus

(full thickness)

FIGURE 23 –5

CHAPTER 23 • Pyloroplasty 265

Removing excess

pyloric tissue

Antrum

Duodenum

Transverse closure

Antrum

FIGURE 23 –6

FIGURE 23 –7

266 Section IV • The Abdomen

3. CLOSING

◆ The incision is closed in layers using 2-0 polyglactin in a running fashion. The subcutane-

ous tissue is reapproximated with a running 3-0 polyglactin suture. The skin can be stapled

together or closed with a running subcuticular suture of 4-0 undyed absorbable monoﬁ la-

ment and adhesive strips.

STEP 4: POSTOPERATIVE CARE

◆ The patient should have already received a preoperative dose of a prophylactic antibiotic

such as cefazolin. Two additional doses are in order after the operation. Hydration will be

maintained with an intravenous infusion of a balanced dextrose and electrolyte solution.

Intravenous analgesics are used until the patient resumes enteral feeds. The decision to

decompress the stomach with a nasogastric tube is up to the individual surgeon, and the

current tendency is to use these tubes sparingly. Certainly, if the repair was deemed to be

tenuous, a nasogastric tube could prove to be very helpful. After 2 to 3 days (on average),

enteral feeds can be slowly and gradually resumed. The presence of bile in the gastric aspi-

rate does not necessarily represent a persistent postoperative paralytic ileus, because it

could be the result of the pyloroplasty itself and it should not be a reason for undue delays

in resumption of enteral feeds. Pain, abdominal distention, tachycardia, and guarding

should prompt the surgeon to order a contrast study to investigate for leaks in the

suture line.

STEP 5: PEARLS AND PITFALLS

◆ Performance of this procedure in a scarred and nonpliable pylorus can potentially be

plagued by complications. Poor selection of pyloroplasty technique will result in undue ten-

sion of the repair. On the other hand, excessive tension can also result in a supple pylorus

from extending the initial incision too far proximally into the stomach and distally into the

duodenum.

◆ Complications: Alkaline reﬂ ux, alkaline gastritis, and dumping syndrome can be seen after

any pyloroplasty. Failure of the operation with delayed gastric emptying is the result of

excessive invagination of one or both suture lines. Excessive tension of the suture line when

performing this procedure in a pylorus that is acutely inﬂ amed or ulcerated may result in

disruption of the suture line, intestinal leaks, and intra-abdominal sepsis.

SELECTED REFERENCES

1. Economou SG, Economou TS: Atlas of Surgical Techniques. Philadelphia, Saunders, 1996, pp 224-227.

2. Mercer DM, Robinson EK: Stomach. In Townsend CM, Beauchamp RD, Evers MB, Mattox KL (eds):

Sabiston Textbook of Surgery, 18th ed. Philadelphia, Saunders, 2008.

267

INTRODUCTION

Finney, in 1902, described a gastric emptying procedure consisting of a horseshoe-shaped

incision through the pylorus followed by a transverse repair in layers. In essence, Finney

pyloroplasty is a side-to-side anastomosis of antrum and duodenum that, unlike the Jaboulay

pyloroplasty, does not exclude the pyloric area. This procedure involves an extensive Kocher

maneuver of the duodenum and can be performed with a classic handsewn two-layer technique

as illustrated later, or using a gastrointestinal anastomosis (GIA) linear stapler to approximate

antrum and duodenum with a single stab incision through the pylorus and closure of the defect

with a terminal anastomosis (TA)-55 linear stapler.

STEP 1: SURGICAL ANATOMY

◆ The pylorus sits at the distal end of the stomach and is marked by thickening of the circular

smooth muscle layer, thus forming the pyloric sphincter, which acts as a valve between the

stomach and the duodenum and regulates gastric emptying. The pylorus does not have

independent blood supply; rather, it gets its blood supply from the vessels that perfuse the

distal stomach and proximal duodenum. Innervation of the pylorus is through the terminal

branches of the right and left vagus nerves. Any injury to these nerves or denervation of the

pylorus will result in pylorospasm and delayed gastric emptying.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Conﬁ rmation of the diagnosis of peptic ulcer disease or delay in gastric emptying should

be documented before the procedure with endoscopy, contrast studies, or technetium-99

sulfur colloid meals.

Finney Pyloroplasty

Carlos A. Angel

CHAPTER

268 Section IV • The Abdomen

STEP 3: OPERATIVE STEPS

1. INCISION

◆ The operation can be performed through a limited midline supraumbilical laparotomy. The

skin incision is made with the knife, and the rest of the layers are divided with electrocau-

tery, taking care to stay in the midline and paying close attention to hemostasis. Once the

peritoneum is opened, the surgeon’s ﬁ ngers or a malleable retractor is used to protect the

intestines from enterotomies.

2. DISSECTION

◆ After mobilization of the duodenum, the midpoint of the pylorus is grasped and lifted with

a Babcock forceps. A seromuscular suture line 5 cm long with interrupted 3-0 silk is placed

to approximate the antrum and duodenum. These stitches should be placed as posteriorly

as possible to diminish the tension on the anterior suture line (Figure 24-1). A horseshoe-

shaped incision involving all layers of the anterior wall of the antrum, pylorus, and duode-

num is made. Hemostasis is achieved with electrocautery (Figure 24-2). A continuous 3-0

absorbable stitch is used to reapproximate the mucosa, beginning posteriorly and ﬁ nishing

anteriorly (Figures 24-3 and 24-4). The anastomosis is completed with 3-0 silk interrupted

seromuscular stitches (Figure 24-5).

Antrum

Pylorus

Duodenum

Grasped with

Babcock forceps

FIGURE 24 –1