What are the steps for open gastrostomy (gastrostomy) tube placement?

Open Gastrostomy Tube Placement: Step-by-Step Procedure

Open gastrostomy tube placement involves a surgical approach through a mini-laparotomy, typically performed under local or general anesthesia, and is reserved for patients who cannot undergo percutaneous endoscopic gastrostomy (PEG) due to oropharyngeal obstruction, head and neck cancer, or inability to tolerate endoscopy. 1

Pre-Procedural Preparation

Laboratory Assessment

• Obtain complete blood count and coagulation studies with target thresholds of platelet count >50,000/mL and INR <1.5 1
• Hold unfractionated heparin and oral anticoagulants prior to placement 1
• Resume oral anticoagulants with evening dose after placement; unfractionated heparin can be administered 2-6 hours post-procedure 1

Patient Positioning and Anesthesia

• Position patient supine 2
• Administer local anesthesia for high-risk patients (ASA IV) or general anesthesia for standard cases 2
• Ensure adequate sedation with anesthesia support, particularly in patients with severe dysmotility or esophageal varices 1

Surgical Technique

Incision and Access

• Make a minimal vertical midline incision (approximately 3 cm) just below the xiphoid process 2
• This mini-laparotomy approach significantly reduces operative time (mean 37 minutes vs 60 minutes for traditional Stamm gastrostomy) 2

Gastrostomy Site Selection

• Identify the anterior gastric wall 2
• Create a left lateral stab wound in the abdominal wall for tube passage 2

Tube Placement and Fixation

• Place double purse-string sutures in the gastric wall at the selected site 2
• Insert the gastrostomy tube through the lateral stab wound 2
• Secure the tube within the double purse-string sutures 2
• Pull the tube to approximate the gastric wall to the anterior abdominal wall 2

Key Technical Point

• In the simplified open technique, no sutures between the stomach and peritoneum are required, which distinguishes it from traditional Stamm gastrostomy 2
• Ensure at least 5 mm of free movement at the external fixation plate to prevent pressure necrosis 3

Post-Procedural Management

Immediate Care

• Begin tube feedings 3-4 hours after placement 1
• Medications can be administered immediately 1
• Monitor for prolonged ileus, which occurs in 1-2% of cases 1

Stoma Site Monitoring

• Perform daily monitoring of the exit site during the first week, specifically assessing for bleeding, erythema, secretion, or induration 3
• Avoid placing overlying gauze with tape or abdominal pads, as these retain moisture and injure surrounding skin 1
• Use foam dressing rather than gauze if leakage occurs (foam lifts drainage away from skin) 1

Tube Maintenance

• Flush the tube regularly with water before and after every feed or medication to prevent clogging 4
• Use large lumen tubes (at least 15 Charrière) to minimize clogging risk, particularly if the tube will be used for suction 3
• Replace percutaneously placed devices at 6-12 month intervals or sooner if tube breakdown occurs 1

Critical Contraindications and Considerations

Absolute Contraindication

• Mechanical obstruction of the small bowel is the only absolute contraindication (unless tube is for decompression) 1

Relative Contraindications

• Active gastrointestinal bleeding from peptic ulcer 1
• Hemodynamic and respiratory instability 1
• Large midline wounds, chest tubes, abdominal mesh, and ostomies complicate but do not preclude placement 1

Special Populations Requiring Modified Approach

Ascites:

• Drain ascitic fluid via paracentesis or intraperitoneal drain placement before procedure 1
• Consider T-tack gastropexy to improve tract formation and gastric-abdominal wall apposition 1

Ventriculoperitoneal Shunts:

• Place gastrostomy concurrently with VP shunt or before VP shunt placement rather than within 15 days after VP shunt placement 1
• Consider longer courses of perioperative antibiotics when placing in patients with existing VP shunts 1

Peritoneal Dialysis:

• Convert to or maintain hemodialysis for 6 weeks to reduce (but not eliminate) peritonitis risk 1

Common Complications and Management

Peristomal Infection

• Occurs in up to 30% of cases, though >70% are minor 1
• Risk factors include diabetes, obesity, poor nutritional status, chronic corticosteroid therapy, and immunosuppression 1
• Treat early infections with oral broad-spectrum antibiotics for 5-7 days 1
• Use intravenous broad-spectrum antibiotics with local wound care for systemic signs 1
• Surgical intervention required if peritonitis develops 1

Stomal Leakage

• Apply stoma adhesive powder or zinc oxide to prevent local skin irritation 1
• Treat local fungal infections with topical antifungal agents 1
• In refractory cases, remove tube for several days to allow stoma approximation, or place repeat gastrostomy at new site 1

Buried Bumper Syndrome

• Occurs in 0.3-2.4% of patients 1
• Presents with peritubal leakage, infection, or immobile gastrostomy 1
• Prevent by maintaining loose contact of outer bolster with skin (approximately 1 cm of play) 1

Advantages of Open Technique

The simplified open gastrostomy under local anesthesia is particularly advantageous for:

• Patients with severe neuromuscular diseases requiring continuous non-invasive ventilatory support 2
• High-risk patients (ASA IV) who cannot tolerate general anesthesia or sedation 2
• Patients with oropharyngeal obstruction preventing endoscopic access 1
• Patients with head and neck cancer where transoral approach risks tumor seeding 1