Gastrostomy Techniques and Devices

0039-6109/92 $0.00

PEDIATRIC SURGERY

+ .20

GASTROSTOMY TECHNIQUES AND DEVICES Michael W. L. Gauderer, MD

Gastrostomy, initially performed more than 100 years ago, is one of the oldest abdominal operations in continuous use. 12 Some of the first patients on whom this gastric stoma was used were children who had swallowed corrosive materials. Gastrostomy is also closely associated with the early days of pediatric surgery, as it was commonly employed in conjunction with operations on the alimentary tract of newborns. 12 Fortunately, the incidence of esophageal lye strictures and the need for direct gastric access have decreased. Pediatric surgeons have also become more selective in the use of neonatal gastrostomies in the last two decades, largely because of advances in perioperative care. However, this relative decrease has been offset by a marked increase in the use of feeding gastrostomies for infants and children without associated surgical pathology. In most of these patients, the indication is inability to swallow, usually secondary to central nervous system disorders. This trend is even more pronounced in the adult population. Indeed, it has been estimated that the second most common indication for upper-tract endoscopy in hospitalized patients in the United States is placement of a gastrostomy.6

INDICATIONS FOR GASTROSTOMY IN PEDIATRIC PATIENTS

In infants and children, the three main indications for gastrostomy are long-term feeding,3, 9, 10, 12, 18, 19, 33 decompression, 12, 18, 19, 21, 30 or a combination thereof.4, 12, 18, 19,21 Additional uses include gastric access for esophageal bougienage,12 gastroscopy,12 and the administration of medications!' 12

From the Division of Pediatric Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio

SURGICAL CLINICS OF NORTH AMERICA VOLUME 72 • NUMBER 6 • DECEMBER 1992

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Feeding and Administration of Medications

The placement of a gastrostomy for enteral alimentation has two prerequisites: (1) the upper gastrointestinal tract must be functional; and (2) the need for enteral feedings must be long term, at least 3 to 6 months. If the intended period of use is shorter, the benefits of gastrostomy over nasoenteric feedings need to be demonstrated. Children benefiting from gastrostomy fall into two broad categories: (1) those unable to swallow and (2) those with inability to consume adequate nutrients orally. The first group is composed of primarily patients with neurologic disturbances. The second group includes patients with a variety of conditions wherein the central nervous system is intact. In our series of 283 children who underwent 288 percutaneous endoscopic gastrostomies, total or near-total inability to swallow was the main indication for the procedure in 206 (73%).10 Central nervous system lesions, primarily anoxic brain injury, were the most common defects observed. Other diagnoses included complex congenital oropharyngeal and laryngopharyngeal malformations, facial clefts, facial trauma, chromosomal and metabolic abnormalities, myopathies, and unclassified neurologic disorders. In 54 children (19%), a percutaneous endoscopic gastrostomy was employed for the administration of supplemental feedings, because oral intake was grossly inadequate despite a normal swallowing mechanism. Included were patients with failure to thrive, congenital heart disease, bronchopulmonary dysplasia, malignancy, esophageal dysmotility, biliary atresia, and acquired immunodeficiency syndrome. A percutaneous endoscopic gastrostomy was used in 16 children (5.5%) with complex bowel disorders (short-gut syndrome, Crohn's disease, malabsorption, intestinal pseudo-obstruction) to deliver enteral nutrients by continuous intragastric infusion. Five children (three with Alagille's syndrome requiring long-term cholestyramine and two with chronic renal failure receiving nonpalatable diets) had a percutaneous endoscopic gastrostomy to ensure compliance with these medications. In the remaining two children, percutaneous endoscopic gastrostomy was employed solely for gastric decompression l2 , 30 in one and to control bleeding from an operatively inserted Stamm gastrostomy9 in the other. Gastroesophageal reflux as a manifestation of foregut dysmotility is a common problem in neurologically impaired children both before 34 and after17, 22 the placement of a gastrostomy. Prior to considering the placement of a feeding stoma in these patients, the question, "gastrostomy only or gastrostomy plus antireflux procedure?" must be addressed. B, 34 A careful preoperative evaluation of these patients is indicated. 1 Since 1987, our evaluation includes an uppergastrointestinal barium study, esophageal manometry and 24-hour pH probe, and, in some patients, gastric emptying studies. Only patients with severe reflux, defined as inability to tolerate nasogastric feedings for a period of 4 to 6 weeks, undergo an antireflux procedure and a Stamm gastrostomy rather than a percutaneous endoscopic gastrostomy. Adjunct in Children with Surgical Lesions

The addition of a gastrostomy to the surgical correction of congenital or acquired lesions in pediatric patients should be considered only if it will substantially facilitate perioperative or long-term care. Examples of this situation in neonatal surgery include complex esophageal atresias, certain duodenal

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obstructions, abdominal wall defects in which long-term ileus is anticipated, and short gut syndrome. Among the indications in older children are severe esophageal strictures, complex foregut trauma, intestinal pseudo-obstruction, malignancy, and complex adhesive bowel obstruction. TECHNIQUES OF GASTROSTOMY

Three methods of constructing a gastrostomy are commonly used: 1. Formation of a serosa-lined channel from the anterior gastric wall around an in situ catheter; 2. Formation of a tube from full-thickness gastric wall to the skin surface, with a catheter introduced intermittently for feedings; 3. Percutaneous techniques, in which the introduced catheter holds the gastric and abdominal walls in apposition. In the first group, the catheter can be placed parallel to the stomach (Witzel technique),l2 perpendicular to the stomach (Stamm technique),l2 (see Fig. 1AF), or with the gastric wall not apposed to the abdominal wall (Dragstedt technique).12 In the second group, the gastric tube is constructed and then brought to the abdominal wall either directly (Depage, Beck-Jianu, Hirsch, and Janeway methods)12 or with interposition of a valve or torsion of the tube to prevent reflux (Watsudjii, Spivack techniques).12 In the third group, the catheter is placed without the use of a celiotomy (Gauderer-Ponsky technique)12,14 (see Fig. 2A-F). Depending on the method of introduction of the catheter, this percutaneous endoscopic gastrostomy can be performed using a pull (GaudererPonsky) technique, 13, 14 a push technique (Sacks et aF7), or the introducer technique (Russell et aP6). More recent attempts to gain direct long-term access to the stomach include percutaneous nonendoscopic gastrostomy using radiologic assistance 5 and minimally invasive techniques employing laparoscopy.29 Because of the possible increase in gastroesophageal reflux after the placement of a gastric stoma,17. 22 the use of a gastrostomy with antireflux properties has been suggested. 32 Table 1 provides a comparison of the three most commonly used types of gastrostomies. Stamm Gastrostomy

The essence of the Stamm gastrostomy is the utilization of concentric pursestring sutures around the gastrostomy tube, producing a serosa-lined invagination (Fig. 1). It is our preferred type of gastrostomy for the management of children with complex esophageal atresia or lye stricture or when used to complement other intra-abdominal procedures. For this open procedure, we prefer a de Pezzer-type catheter, 12 Fr to 20 Fr, depending on the child's size. For long-term feeding, the Stamm gastrostomy can be modified slightly to accommodate the initial placement of a skin-level stoma device, the gastrostomy "button. "16,31

Janeway Gastrostomy

The main appeal of the Janeway stoma is the absence of a catheter between feedings. The use of automatic stapling devices has greatly facilitated the

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Table 1. COMPARISON OF THE THREE MOST COMMONLY USED GASTROSTOMIES

Continuous catheter Celiotomy Need for endoscopy Need for abdominal relaxation during operation Procedure time Postoperative ileus Potential for bleeding Potential for wound dehiscence, hernia Potential for early catheter dislodgment Potential for gastric separation Potential for infection Potential for gastrocolic fistula Incidence of external leakage Permanent Passage of dilators for esophageal stricture Interferes with gastric reoperation (e.g., Nissen) Use in infants

Witzel, Stamm

Depage, Janeway

+ +

+

+

+

Short

Moderate

+ + +

+ + +

Percutaneous Endoscopic

+ + Very short

+ ±

±

+

+

± ±

+

+ +

+ + +

+ +

+

construction of the tube from the anterior gastric wall.!2 Although this gastrostomy has been applied to children,20 it has several disadvantages in this age group. The procedure is more complex, decreases gastric volume, renders subsequent operations on the stomach more difficult, and is prone to leakage. If continuous feedings are required, a Janeway gastrostomy offers no advantages over the two other modalities. A simplification of the technique employing a laparoscopically introduced stapler was recently described by Stellato. 29

Percutaneous Endoscopic Gastrostomy

The percutaneous endoscopic gastrostomy was initially developed for highrisk children with inability to swallowY It is based on the simple principle of sutureless approximation of the stomach to the abdominal wall by a catheter (Fig. 2). The procedure was adapted for adults/4 and an extensive experience with this type of gastrostomy has accumulated. 23, 25 We perform percutaneous endoscopic gastrostomy in the operating room. Older children and those able to tolerate endoscopy without compromise of the upper airway receive local anesthesia, with sedation as needed. In younger children, general endotracheal anesthesia is preferred, primarily because of anticipated difficulties with the airway management. A single dose of a broadspectrum intravenous antibiotic is given shortly before the procedure is begun. For the endoscopy, we use the smallest available pediatric gastroscope. Since 1988, we have employed a 15-Fr silicone rubber catheter designed for use in percutaneous endoscopic gastrostomy in children (Gauderer PEG; Bard Interventional Products, Tewksbury, Massachusetts) (see Fig 2A). The basic procedure has remained essentially unchanged since the initial publication!4 although

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technical details and refinements were recently described. !3 Figures 2B through 2£ highlight the key steps. While re-endoscopy might theoretically be unnecessary, we believe it adds safety to the procedure. After completed gastrostomy placement, the catheter is connected to a gravity drainage system for 12 to 24 hours (Fig. 2F). The abdomen is carefully examined to ensure that no signs of peritonitis have developed. Enteral feedings are then begun, starting with small amounts of dilute formula and advanCing to full volume over 1 to 2 days. Patients are discharged without wound dressing. The external cross-bar is adjusted to allow a little play. The children are seen for follow-up 1 to 2 weeks after discharge, when the skin-catheter interface is checked for the formation of granulation tissue. The percutaneous endoscopic gastrostomy catheter can be replaced with a gastrostomy button 3 to 6 months after the procedure, when a firm union has been established between stomach and abdominal wall (Fig. 3). Contraindications to percutaneous endoscopic gastrostomy are inability to perform upper-tract endoscopy safely or to identify transabdominal illumination and see an anterior gastric wall indentation clearly. Ascites, coagulopathy, and intra-abdominal infection, if severe, may render the procedure inadvisable. Percutaneous endoscopic gastrostomy has not been used for retrograde esophageal dilatation. We continue to prefer the original pull technique!' because we remain convinced that, at least in the pediatriC population, this method has several advantages over the other modalities. In the guidewire or push technique, v a rather large catheter with a stiff tube segment is used; in the introducer or poke technique/6 the stomach can be pushed away during insertion or the balloon may deflate prematurely; and in the nonendoscopic or radiographic procedures,' early dislodgment of rather thin catheters can occur. In the recent reviews of our experience with percutaneous endoscopic gastrostomy in children", 10 we analyzed the indications, safety, and effectiveness of the procedure. We also critically focused on its complications and their prevention. The two most serious complications encountered in 288 procedures were two deaths secondary to cardiac failure 24 hours after technically correct procedures and five gastrocolic fistulae 4 to 29 months postoperatively. The first three fistulae (4, 6, and 29 months) occurred early in the experience, whereas the last two (5 and 4 months) occurred after a change in the endoscopy team. On a careful analysis of the percutaneous endoscopic gastrostomy procedure in these children, who ranged in age from 4 months to 17 years, one or more basic principles of the technique proved to have been violated. Other complications included four minor tract infections, two operative catheter changes (both very early in the experience), one early and one late gastric separation, one celiotomy for suspected leak, and one episode of small-bowel obstruction secondary to impaction of the inner latex cross-bar in a Meckel's diverticulum after catheter removal. During the 12-year span of these procedures, three important trends emerged: (1) the indications for percutaneous endoscopic gastrostomy were expanded; (2) the number of high-risk patients increased; and (3) the average patient age decreased. At the same time, the complication rate gradually decreased. Indeed, there were no procedure-related complications in the last 5 years. GASTROSTOMY DEVICES

Traditionally, three types of catheters have been employed in the construction of Stamm-type gastrostomies: mushroom (de Pezzer), balloon (Foley), and

Figure 1. See legend on opposite page

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F Figure 1. A, Stamm gastrostomy: incision and catheter exit site. In the absence of previous celiotomies, other stomas, ventriculoperitoneal shunts, abdominal wall abnormalities, or other pertinent factors, the preferred approach in infants and children is a short transverse left-sided abdominal incision. Fascial layers are incised transversely and the muscle is retracted or transected. The catheter exit site is away from the celiotomy, the linea alba, and the costal margin. B, Gastrostomy site on the anterior gastric wall. The traction guy sutures and the first pursestring suture are depicted. The opening should be away from the gastric pacemaker at the level of the splenic hilum; away from the greater curvature because that site may be needed for the construction of a gastric tube for esophageal replacement; away from the fundus to allow for a possible fundoplication; and away from the antrum to prevent excessive leakage and pyloric obstruction by the catheter tip. C, The second pursestring suture has been placed. The lower guy suture pulls the stomach caudally, enhancing the exposure and allowing better gastric access. The gastrotomy has been completed and two guy sutures elevate the anterior gastric wall. The de Pezzer catheter is introduced using a simple stylet. D, The pursestring sutures are tied. A continuous monofilament suture, used to anchor the stomach to the anterior abdominal wall, has been partially placed. The catheter is brought out through the counter incision. E, The continuous monofilament suture placement permits a good watertight approximation of the stomach to the abdominal wall. In most cases, this suture obviates the need for the second pursestring suture shown in C. F, The completed procedure. The wound is closed with subcuticular stitches and adhesive strips. The catheter is secured with synthetic monofilament sutures. These are removed after a week and a small latex cross-bar is placed to prevent distal catheter migration. (From Gauderer MWL: Gastrostomy. In Puri P (ed): Operative Newborn Surgery. London, Heinemann Medical Books, in press; with permission.)

collapsable wings (Malecot). For initial placement, we prefer a de Pezzer catheter, as it is fairly easy to insert and has an adequate lumen and the head provides good intragastric retention. Foley-type catheters are easy to insert and may be useful when an early tube change becomes necessary. However, there are several disadvantages related to the balloon: it occupies a significant portion of the intragastric volume, predisposes the catheter to distal migration and intestinal obstruction, and may rupture prematurely, leading to dislodgment.

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Figure 2. A, Pediatric PEG catheter (15-Fr) demonstrating cross-shaped gastric retainer, markings on the shaft, and dilating tapered end with steel wire loop. The skin level retainer (external cross-bar), immobilizing ring, and catheter adapter with Luer-Lok cap are clearly seen. The catheter is 60 cm long, made of silicone rubber, and is cut to an appropriate length after the insertion. B, The gastroscope has been inserted and the stomach insufflated. Stoma site and gastric transillumination are depicted in the inset. As in the open procedure, the gastrostomy should be away from the rib cage to allow the placement of an incision should a fundoplication become necessary in the future. Gastric underinsufflation as well as overinsufflation should be avoided to minimize the possibility of accidentally pierCing the transverse colon. Small-bowel insufflation also should be avoided because this tends to push the transverse colon in front of the stomach. Digital pressure is applied to the proposed gastrostomy site, which usually corresponds to the area where transillumination is brightest. TranSillumination and clear visualization of an anterior gastric wall indentation are key points. Illustration continued on opposite page

Additionally, these tubes have a proportionally smaller main lumen because of the additional lumen needed to inflate the balloon. Improper inflation, while the balloon is in the esophagus or duodenum, can lead to rupture of these organs. 12 Malecot catheters are prone to early dislodgment, because the retaining wings are thin and very pliable. An attractive alternative to these catheters in infants is the use of T-tubes.

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/;

Figure 2 (Continued). C, After determining the appropriate site for the percutaneous endoscopic gastrostomy and making the skin incision, a Kelly-type hemostat is applied to maintain intragastric indentation. The scope is moved gently in small increments. The endoscopist then places the polypectomy snare around this "mound." The intravenous cannula is placed in the incision between the slightly spread prongs of the hemostat and then firmly thrust through abdominal and gastric walls, exiting through the tip of the "mound" into the loop of the polypectomy snare (inset). The snare is partially closed, but not tightened, around the cannula. D, The needle is removed and the looped steel wire is inserted through the cannula. The polypectomy snare is allowed to slide away from the cannula and is tightened around the wire. An alternate method is to retrieve the wire with an alligator or biopsy forceps. The wire is then pulled back with the scope through the stomach and esophagus, exiting through the patient's mouth. The guiding tract is thus established (inset). Illustration continued on following page

These soft catheters are available in several diameters and have a proportionally large lumen, and the transverse limbs can be cut to any desired length. A 10Fr to 12-Fr tube fits comfortably in a very small stomach, such as in patients with esophageal atresia without fistula. We have also found the T-tubes to be very useful in infant jejunostomies, because they permit easy atraumatic catheter changes without the use of an introducer. For insertion, one simply aligns the cross-bar with the main shaft. For a percutaneous endoscopic gastrostomy in children, we employ the

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Figure 2 (Continued). E, The percutaneous endoscopic gastrostomy catheter is attached to the guiding wire by interlocking the two steel wire loops. Traction is applied to the abdominal end of the wire, guiding the catheter through esophagus, stomach, and across gastric and abdominal walls. Notice the collapsed wings of the gastric retainer, minimizing the chance of esophageal injury. For diagrammatic purposes, a shortened catheter is shown. During the actual procedure, the tapered end exits through the abdominal wall before the gastric retainer enters the patient'S mouth, allowing complete catheter control during placement. Traction is continued until gastric and abdominal walls are in loose contact. The external cross-bar and immobilizing ring are slipped over the catheter and guided to the skin level. The inset demonstrates the completed procedure. Pressure from the retaining cross-bars on the mucosa or skin is avoided. The catheter is cut to the desired length, and the feeding adapter is attached. (Figure 2A-E from Gauderer MWL, Stellato TA: Percutaneous endoscopic gastrostomy in children: The technique in detail. Pediatr Surg Int 6:82-87, 1991; with permission.) F, Completed percutaneous endoscopic gastrostomy in a 4-month-old, 3-kg child with poor swallowing following premature birth, respiratory distress, intraventricular hemorrhage, and ventriculoperitoneal shunt placement. Sutures are not used, and the catheter is connected to a small clear plastic trap. A gauze pad and tape are applied and left in place for 1 to 2 days. When the dressing is removed, the external cross-bar and the retaining ring are checked and loosened if necessary. Notice the position of the VP shunt and the previous abdominal incision. In these children, care must be taken to avoid placing the percutaneous endoscopic gastrostomy catheter too close to the shunt tubing. Because some of these infants require either a gastrostomy or a gastrostomy and fundoplication, neurosurgeons should be encouraged to place the shunt tubing on the right side of the abdomen.

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Figure 3. Seventeen-month-old former premature child with severe bronchopulmonary dysplasia. A percutaneous endoscopic gastrostomy was placed 7 months earlier for feeding supplementation and the administration of medications. The 15-Fr catheter was removed and an 18-Fr gastrostomy "button" placed. The "button" is suited ideally for these children because it decreases complicagastrostomy-related tions and allows for greater independence for the child.

IS-Fr catheter depicted in Figure 2A. The original modification of a de Pezzer catheter14 can also be used. A 20-Fr, "adult"-type commercially available catheter is suitable for older children and adolescents. Children, particularly those with inability to swallow, tend to use their gastrostomies longer than adult patients, whose survival is often short. Two basic types of devices are available for the replacement of the initial tube: (1) long self-retaining catheters of latex or silicone rubber (de Pezzer, Foley, Malecot, T-tubes) and (2) short silicone rubber, skin-level, self-retaining devices with an intragastric mushroom- or balloon-type retainer. For long-term management, we prefer the gastrostomy "button" (see Fig. 3) (Bard Interventional Products, Tewksbury, Massachusetts; and Olympus Corp., Lake Success, New York). The button is a simple skin-level, nonrefluxing device designed for long-term enteral feedings. 16 These buttons are available in several sizes from 18 Fr to 28 Fr and lengths from 1.7 to 4.4 cm. They effectively avoid several of the problems commonly encountered with conventional tubes, namely internal or external migration, inadvertent removal, pivoting action leading to leakage, tissue reaction, discomfort, and psychological problems. Two significant advantages are the absence of fear of accidental dislodgment and the greater independence for the child. The intragastric portion of the button resembles the tip of a de Pezzer catheter; the outer portion consists of two flat wings, making it self-retaining. A one-way (in) valve at the gastric opening of the shaft prevents external reflux of intragastric contents. For

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feeding, the small cap at the skin level is opened and either a straight (bolus feeding) or right-angle (continuous feeding) hollow adapter inserted. The low opening pressure of the valve allows free passage of administered fluids. When feeding is completed, the tube is flushed with water, the adapter removed, and the cap closed. Our initial experience with five children was published in 1984. '6 An update, including experience and recommendations, followed 4 years later. IS Our present experience consists of 545 gastrostomy buttons in 224 children. The buttons are inserted in office procedures 3 to 6 months following the initial gastrostomy placement and changed as needed. Although some buttons have shown signs of malfunction after less than 3 months of use, this problem has become quite uncommon. Most buttons last approximately 1 year, and in several patients, the -same button remained functional for close to 3 years. When inserting a gastrostomy button, special care must be taken to follow the tract of the initial catheter, because misdirection can result in separation of the stomach from the abdominal wall. This mishap occurred in 3 of the 545 insertions in our series. The problem was recognized immediately in the first child and 24 and 10 hours postinsertion in the other two. The diagnosis was confirmed radiographically by contrast injection. The first two children (3.5 and 6 years old) had had a percutaneous endoscopic gastrostomy 3 years and 5 months earlier. The third child (9 months old) had a fundoplication and Stamm gastrostomy 2 months earlier. In the first youngster, the button was removed, and a Foley catheter was inserted and placed on gentle traction and gravity drainage. In the two other children, a small celiotomy was done, the button was properly positioned, and the partially separated stomach was reattached to the abdominal wall. All three children are well and continue to use a button. These complications underscore the need for skillful insertion and close postinsertion follow-up of any gastrostomy device. A "One-Step Button" (Olympus Corp.) has been introduced recently. This skin-level device is inserted using the percutaneous endoscopic gastrostomy technique. The approach is promising, but there is limited pediatric experience. We have successfully used this approach in four children. COMPLICATIONS OF GASTROSTOMIES

Although gastrostomies are generally regarded as basic and follow-up is not stressed in the surgical literature, gastrostomies have a long list of complications related to surgical technique, care, and catheters. 2, 9, 12, 18, 19, 21, 23, 28 Complications related to the operative technique include separation of the stomach from the abdominal wall causing peritonitis, wound separation, hemorrhage, infection, injury to the posterior gastric wall or other organs (colon, pancreas), placement of the tube in an inadequate position (greater curvature, antrum), prolonged ileus, gastric atony, failure of the gastrostomy to decompress or permit feeding, gastric torsion around the catheter, adhesive bowel obstruction, and gastric prolapse through the stoma. lit Most of these complications can be avoided by careful choice of the procedtre, considering it a major intervention and using meticulous technique, approximating the stomach to the abdominal wall, exiting the catheter through a counterincision, and avoiding tubes in the midline. Complications related to care include skin irritation, moniliasis, bacterial colonization of the stomach, tube plugging, inadequate feeding techniques, delay in catheter reintroduction, and trauma during catheter reinsertion with separation of the stomach from the abdominal wall. '2 Many of these problems

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can be prevented by avoiding occlusive dressings, flushing the catheter after each feeding, handling the catheters carefully, using atraumatic tube insertion, closely following each patient who has a stoma, and properly educating health care personnel, patients, and parents in the care of the gastrostomy. Complications related to catheters include formation of granulation tissue; leakage; discomfort; tube deterioration; inadvertent removal; internal migration leading to bowel obstruction; external migration of the catheter head leading to malfunction, abscess formation, or extrusion; esophageal and small bowel perforation (with Foley-type catheters); postural problems while lying on the abdomen or swimming; psychological problems; persistent gastrocutaneous fistula after tube removal; gastrocolic fistula formation; small-bowel volvulus around a malpositioned catheter; erosion of a gastrostomy tube through the stomach and diaphragm; abscess formation after removal; and retention of part of the tube leading to obstruction. 12 Solutions to these problems include excisioncauterization of granulation tissue, avoidance of too large a tube, proper tube immobilization, avoidance of Foley-type catheters, and use of a skin-level feeding device. One of the most serious long-term problems is severe gastrostomy leakage. Conservative measures are tried first. If these fail, the stoma can be relocated using a simple nonendoscopic variation of the percutaneous endoscopic gastrostomy technique. 7

SUMMARY Gastrostomies play an important role in the management of a wide variety of surgical and nonsurgical conditions of childhood. Many techniques and gastrostomy devices are available. In our experience, percutaneous endoscopic gastrostomy has proved safe and effective, and the gastrostomy button has eliminated most of the catheter-related problems. Candidates for gastrostomy, particularly children with foregut dysmotiIity, must be carefully selected, undergo preoperative studies aimed at determining the degree of gastroesophageal reflux, and have appropriate long-term followup. Attention to technical detail is essential to avoid operative complications. A good working relationship between the surgeon, gastroenterologist, nurse, and patient's family is essential to minimize long-term morbidity, particularly stoma-related problems. References 1. Boyle JT: Nutritional management of the developmentally disabled child. Pediatr

Surg Int 6:76--81, 1991 2. Campbell JR, Sasaki TM: Gastrostomy in infants and children: An analysis of complications and techniques. Ann Surg 40:505-508, 1974 3. Cohn R, Sunshine P: Gastrostomy in the premature and newborn infant. Arch Surg 96:933-935, 1968 4. CoIn D, Cywes 5: Simultaneous drainage gastrostomy and feeding jejunostomy in the newborn. Surg Gynecol Obstet 145:594-595, 1977 5. Cory DA, Fitzgerald JF, Cohen MD: Percutaneous nonendoscopic gastrostomy in children. AJR 151:995-997, 1988 6. Edmonson JM: History of the instruments for gastrointestinal endoscopy. Gastrointest Endosc 37:527-556, 1991 7. Gauderer MWL: A simple technique for correction of severe gastrostomy leakage. Surg Gynecol Obstet 165:170--172, 1987

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8. Gauderer MWL: Feeding gastrostomy or feeding gastrostomy plus anti-reflux procedure? [editorial]. J Pediatr Gastroenterol Nutr 7:795-796, 1988 9. Gauderer MWL: Percutaneous endoscopic gastrostomy: A 10 year experience with 220 children. J Pediatr Surg 26:28S-294, 1991 10. Gauderer MWL: An updated experience with percutaneous endoscopic gastrostomy in children. Gastrointest Endosc Oin North Am 2:195-205, 1992 11. Gauderer MWL: Gastrostomy. In Puri P (ed): Operative Newborn Surgery. London, Heinemann Medical Books, in press 12. Gauderer MWL, Stellato TA: Gastrostomies: Evolution, techniques, indications, and complications. Curr Prob Surg 23:661-719, 1986 13. Gauderer MWL, Stellato TA: Percutaneous endoscopic gastrostomy in children: The technique in detail. Pediatr Surg Int 6:82-87, 1991 14. Gauderer MWL, Ponsky JL, Izant RJ, Jr: Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pediatr Surg 15:872-875, 1980 15. Gauderer MWL, Olsen MM, Stellato TA, et al: Feeding gastrostomy button: Experience and recommendations. J Pediatr Surg 23:24-28, 1988 16. Gauderer MWL, Picha GJ, Izant RJ Jr: The gastrostomy "button"-A simple, skin level, nonrefluxing device for long term enteral feedings. J Pediatr Surg 19:803-805, 1984 17. Grunow JE, AI-Hafidh AD, Tunell WP: Gastroesophageal reflux following percutaneous endoscopic gastrostomy in children. J Pediatr Surg 24:42-45, 1989 18. Haws EB, Sieber WK, Kiesewetter WB: Complications of tube gastrostomy in infants and children: 15 year review of 240 cases. Ann Surg 164:284-290, 1966 19. Holder TM, Leape LL, Ashcraft KW: Gastrostomy: Its use and dangers in pediatric patients. N Engl J Med 286:1345-1347, 1972 20. McGovern B: Janeway gastrostomy in children with cerebral palsy. J Pediatr Surg 19:800-802, 1984

21. Meier H, Willital GH: Gastrostomy in the newborn: Indications, technique, complications [English subtitle]. Z Kinderchir 34:82-86, 1981 22. Mollit DL, Golladay S, Seibert JJ: Symptomatic gastroesophageal reflux following gastrostomy in neurologically impaired patients. Pediatrics 75:1124-1126, 1985 23. Moran BJ, Taylor MB, Johnson CD: Percutaneous endoscopic gastrostomy [review]. Br J Surg 77:858-862, 1990 24. Ponsky JL, Gauderer MWL: Percutaneous endoscopic gastrostomy: A non-operative technique for feeding gastrostomy. Gastrointest Endosc 27:9-11, 1981 25. Ponsky JL, Gauderer MWL: Percutaneous endoscopic gastrostomy: Indications, techniques, and results. World J Surg 13:165-170, 1989 26. Russell TR, Brotman M, Norris F: Percutaneous gastrostomy, a new simplified and cost-effective technique. Am J Surg 148:132-137, 1984 27. Sachs BA, Vine HS, Palestrant AM, et al: A non operative technique for establishment of a gastrostomy in the dog. Invest Radiol 18:485-487, 1983 28. Shellito PC, Malt RA: Tube gastrostomy: Techniques and complications. Ann Surg 201:180-185, 1985 29. Stellato TA: Endoscopic intervention for enteral access. World J Surg, in press 30. Stellato TA, Gauderer MWL: Percutaneous endoscopic gastrostomy for gastrointestinal decompression. Ann Surg 205:119-122, 1987

31. Stellato TA, Gauderer MWL: Jejunostomy "button" as a new method for long-term jejunostomy feeding. Sllrg Gynecol Obstet 168:552-554, 1989 32. Stringel G: Gastrostomy with anti reflux properties. J Pediatr Surg 25:1019-1021, 1991 33. Vengusamy S, Pildes RS, Raffensperger JL, et al: A controlled study of feeding gastrostomy in low birth weight infants. Pediatrics 43:815-820, 1969 34. Wesley JR, Coran AG, Sarahan TM, et al: The need for evaluation of gastroesophageal reflux in brain-damaged children referred for feeding gastrostomy. J Pediatr Surg 16:866-871, 1981

Address reprint requests to Michael W. L. Gauderer, MD Division of Pediatric Surgery Rainbow Babies and Children's Hospital 2101 Adelbert Road Oeveland, OH 44106