What is the preferred technique for gastrostomy, Stamm or Janeway?

Stamm versus Janeway Gastrostomy

PEG (percutaneous endoscopic gastrostomy) should be preferred over both Stamm and Janeway surgical gastrostomy techniques for long-term enteral nutrition due to lower complication rates, reduced cost, shorter operating time, and better patient outcomes. 1, 2

Primary Recommendation: Avoid Both Surgical Techniques When Possible

Multiple ESPEN guidelines consistently recommend PEG as first-line over any surgical gastrostomy approach (including both Stamm and Janeway techniques) with Grade B evidence and strong consensus. 1, 2 The evidence demonstrates:

• Lower complication rates with PEG compared to conventional surgical gastrostomy 1, 2
• Reduced cost and operating time favoring endoscopic approaches 1, 2
• Better cost-effectiveness for long-term home enteral nutrition 1, 2

When Surgical Gastrostomy Is Necessary

If PEG placement fails or is contraindicated (e.g., endoscopically impassable tumors, anatomical abnormalities preventing endoscopic access), the hierarchy of alternatives is:

First Alternative: Percutaneous Laparoscopic Assisted Gastrostomy (PLAG)

PLAG demonstrates the lowest complication rate among all gastrostomy techniques in large observational studies and should be the preferred surgical approach. 1, 2, 3

• A comparative study of 224 patients showed 75% of PLAG patients were completely complication-free, compared to 0% in conventional surgical gastrostomy 3
• Gastric content leakage occurred in 66% of conventional surgical gastrostomy (Stamm/Janeway) versus 0% in PLAG 3
• ESPEN guidelines specifically recommend PLAG as a safe alternative when PEG is not suitable 1, 2

Janeway vs Stamm: When Conventional Surgery Is Required

If PLAG is unavailable and conventional surgical gastrostomy is necessary, Janeway gastrostomy offers specific advantages over Stamm technique in select populations:

Janeway Advantages:

• Creates a continent gastrostoma allowing intermittent feeding without continuous catheter presence 4
• Lower risk of tube dislodgement due to the formed gastric tube structure 5
• Preferred for patients with neurologic disease, agitation, or high dislodgement risk 5
• Suitable for permanent or palliative gastrostomy needs 5
• Mean operative time of 35 minutes in laparoscopic series 4
• Minimal nursing care requirements compared to Stamm 6

Stamm Characteristics:

• Historically the standard surgical technique until the 1980s 7, 8
• Higher complication rates, particularly gastric leakage and skin irritation 3
• Requires continuous catheter presence (non-continent) 4
• Associated with more nursing care needs 6

Clinical Decision Algorithm

1. First-line: Attempt PEG placement 1, 2

   • Lowest complications, cost-effective, shorter procedure time

2. If PEG fails or contraindicated: Perform PLAG 1, 2, 3

   • Lowest surgical complication rate (75% complication-free)
   • Zero gastric leakage in comparative studies

3. If PLAG unavailable and surgical gastrostomy required:

   • Choose Janeway if: 5, 6, 4
     • Patient has neurologic disease with agitation
     • High risk of tube dislodgement
     • Need for permanent/palliative access
     • Desire for continent stoma with intermittent feeding
   • Stamm may be considered if: 8
     • Simpler technique preferred by surgeon
     • Short-term access anticipated
     • Continuous feeding planned

Critical Caveats

• Both Stamm and Janeway are associated with significantly higher morbidity than PEG or PLAG, particularly gastric leakage (66% in conventional surgical gastrostomy) 3
• No patient in conventional surgical gastrostomy groups was completely complication-free in comparative studies 3
• The 2005 ESPEN guidelines explicitly state that PEG has replaced surgical gastrostomy (Witzel, Stamm, Janeway) which were associated with markedly higher complication rates 7
• Laparoscopic Janeway technique (when performed laparoscopically) shows better outcomes than open Stamm, with mean operative time of 35 minutes and minimal complications 4