GASTROSTOMY (gastrostomia; Greek gaster a stomach + stoma of companies, an opening, pass) — operation of creation of artificial outside fistula of a stomach. The hl is applied. obr. for introduction of food directly in a stomach at disturbance of passability of a gullet or for its functional switching off. The idea of this operation belongs to V. A. Basov who in 1842 for the first time carried out it in an experiment on dogs. At the person G. it was for the first time executed in 1849 by the fr. surgeon Sediyo (Page E. Sedillot). Difficulty of creation of Hermeticism of gastric fistula served as the reason of development of a large number of methods. Vittsel for the first time achieved sufficient sealing of gastrostomy fistula (O. of Witzel), in 1891 the slanting channel which suggested to create of a front wall of a stomach by sewing together by serous and muscular seams of a wall of a stomach over a rubber tube, the end the cut plunges into its gleam. This method reliably entered surgical practice and still is the most widespread.
Indications: wounds of chest department of a gullet, existence of esophageal and tracheal or esophageal and bronchial fistula (functional switching off of a gullet); disturbance of passability of a gullet at its atresia, cicatricial strictures after chemical burns, at malignant tumors. Less often G. apply for the purpose of drainage at an acute gastrectasia and at heavy paresis went. - kish. a path (see. Intubation of intestines ).
Methods of operation and training of the patient
Special training of the patient for operation is not required. However before operation it is desirable to korrigirovat the sharpest disturbances of water and electrolytic balance during the short period. It can be made as under anesthetic, and under local anesthesia. Methods G. can be divided into two groups: creation of temporary gastrostomies (kanalovidny fistula forms) and constants (labelloid fistula of a stomach is created). Gastrostomies of the first type after extraction of a gastrostomy tube are closed independently, special operation is necessary for closing of a gastrostomy of the second type. G. across Vittsel, Kader, Skobelkin, a constant — G. on Toprovera, Doronina, Serebrennikov, Tavel, Sabaneev, etc.
Technology of operation
=== the Gastrostomy across Vittsel === belong to the most widespread methods of temporary G.
The abdominal cavity is opened with a left-side upper transrectal section (see. Laparotomy ). The front wall of a stomach is removed in a wound and on a longitudinal axis of a stomach stack a rubber tube on it. Sewing over a tube of a wall of a stomach serous and muscular seams, create the channel from a wall of a stomach; at the end of the channel open a wall of a stomach and immerse the end of a tube which together with a wall of the educated channel several additional seams is invaginated in a stomach in its gleam. Other end of a tube is removed outside, hem a wall of a stomach around the tube which is going out of the channel to a peritoneum and to a back wall of a vagina of a direct muscle. By an initial technique * offered by Vittsel, immerse the end of a tube directed towards the gatekeeper in a gastric cavity (fig. 1, a), immerse the end of a tube directed towards cardial department of a stomach in a stomach More often, and outside remove the end turned towards the gatekeeper (fig. 1,6); at the same time the end of a rubber tube is located in a zone of a gas bubble of a stomach and the level of gastric contents is below the end of a tube thanks to what the best conditions for Hermeticism of a gastrostomy are created. At G. by Vittsel's method operation for closing of gastric fistula when in it there is no need any more is not required; after removal of a tube the gastrostomy is closed independently.
A gastrostomy according to Kader
Imposing of gastric fistula, as well as at Vittsel's way, is combined with creation for a tube of the channel from a front wall of a stomach, but the direction of the channel and a tube perpendicular to a front wall of a stomach. The channel is created by consecutive invagination in a gleam of a stomach of front its wall by two-three purse-string seams. On the cone extended and removed in an operational wound from a front wall of a stomach impose (one over another) two, and at an opportunity three serous and muscular purse-string seams which remain not tightened; in a top of a cone the gleam of a stomach is opened and enter a rubber tube into the formed small opening, to-ruyu fixed a catgut seam to edges of an opening. After that at consecutive tightening and setting of purse-string seams the tube together with the site of the wall of a stomach adjoining to it is invaginated in its gleam. The direct channel from a wall of a stomach is as a result created. The wall of a stomach around a tube is hemmed to a parietal peritoneum and a back wall of a vagina of a direct muscle (fig. 2). This technique for many years competes with Vittsel's technique.
O. K. Skobelkin developed the following modification of G. according to Kader. On a front wall of a stomach put a purse-string stitch, in the center to-rogo through a puncture of a gastric wall enter Pezzer's catheter with partially cut off (at the edges of the available openings) a head and her neck fixed around catgut thread. The ends of this thread sheathe edges of an opening in a wall of a stomach and fix to it a catheter. Tightening of earlier put purse-string stitch the catheter is invaginated in a gleam of a stomach, units after tightening of a seam do not cut off, and remove together with the end of a catheter outside through a puncture of an abdominal wall and for them densely tighten a stomach and fix to a front abdominal wall (rice, 3). Finish operation with fixing of a wall of a stomach to a parietal peritoneum in a circle of the catheter leaving a stomach. When need for a gastrostomy disappears, delete a catheter, and fistula is closed independently.
A gastrostomy on Toprovera
In a wound remove a front wall of a stomach in the form of a cone, On a cone put three parallel serous and muscular purse-string stitches which tighten and tie only after opening of a top of a cone and introduction to a stomach of a rubber tube that the gastric wall densely adjoined to a tube. The tube is taken out, and edges of the opened top of a cone hem to skin (fig. 4). After removal of a tube of a fold of a mucous membrane of a corrugated cone fill a gleam of the channel formed of it and interfere with an effluence of gastric contents outside, without complicating at the same time introduction of a tube during the feeding of the patient. In it advantage of this technique. G.'s lack on Toprovera is existence of labelloid gastric fistula which shall be closed in the operational way when passes need for a gastrostomy. At patients with inoperable cancer of a gullet or cardial department of a stomach at indications to imposing of a constant gastrostomy the technique saving them from constant carrying a rubber tube has advantages. However at long existence of the gastrostomy created on Toprovera, her Hermeticism often is broken owing to eruption of purse-string seams and their otkhozhdeniye in a gleam of a stomach. By other offered techniques are applied seldom; most of them or do not provide sufficient Hermeticism of gastric fistula, or are technically difficult and are followed by development of a number of complications.
Gastrostomy across Doronin provides creation of labelloid gastric fistula and the closing ring due to movement around fistula of rags of an aponeurosis of a direct muscle of a stomach.
Gastrostomy according to Frank. The cone formed of a front wall of a stomach is stretched through a hypodermic tunnel above edge of a costal arch.
A gastrostomy across Tavel. With a front wall of a stomach anastomose the end of an enteric transplant on a vascular leg, bring other end of a transplant to skin above a costal arch in the form of labelloid intestinal fistula. This method sometimes finds application at sharply reduced sizes of a stomach at its cicatricial wrinkling or cancer infiltration.
Gastrostomy according to Serebrennikov provides creation of the closing device in the cone formed of a front wall of a stomach by imposing of several purse-string seams (as at G. according to Kader) and invaginations separate seams of a wall of a stomach between purse-string seams in its gleam.
Gastrostomy across Marvedel. The slanting channel for a tube is formed in a submucosal layer of a front wall of a stomach.
Gastrostomy across Sabaneev. Bring the end of the tube created from the rag found in all thickness of a front wall of a stomach to a front abdominal wall.
At G. made for the purpose of drainage of a stomach, a small bowel or bilious ways it is reasonable to apply the «minimum» G.: to apply catheters of small diameter with the inflated cuff on the end entered into a stomach. The catheter is entered into a stomach through a puncture of an abdominal wall and a wall of a stomach. The cuff is inflated by introduction of a certain amount of liquid. At pulling up for a catheter the wall of a stomach nestles the inflated cuff on an internal abdominal wall (fig. 5). When need for drainage disappears, dismiss a cuff and delete a catheter; the fistular course is closed independently.
After G. executed by any technique for the first days for control of a condition of evacuation from a stomach a tube it is better to hold a postoperative current and leaving open, having lowered it in a vessel receiver. Feeding through a tube is usually begun on second day; at the same time enter into a stomach no more than 100 — 150 ml of nutritious mix every 2 — 3 hour. To 5 — to the 7th day pass to food with liquid and kashitseobrazny food 400 — 500 ml of 4 — 5 times a day. If G. make by force, at very weakened, exhausted and dehydrated patients, introduction on a tube to a stomach of nutritious mixes and liquid in the form of various solutions can be begun directly after operation with a drop way (75 — 100 drops in 1 min.) for days with several breaks for control overseeing by an oporozhnyaemost of a stomach at the open end of a gastrostomy tube; to second day it is possible to pass to fractional feeding by a usual technique.
the Majority of complications in the postoperative period is connected with insufficiently full-fledged Hermeticism of the created gastrostomy and with infiltration thereof between a wall of a stomach and a tube in the sewn-up operational wound of gastric contents with the subsequent its suppuration. Suppuration of a wound promotes development of leakage of a gastrostomy — to an effluence in a wound of the food entered into a stomach that leads to quickly progressing exhaustion and dehydration of the patient. At suppuration of a wound with the accompanying insolvency of a gastrostomy in early terms after operation there is a threat of an otkhozhdeniye of a gastrostomy from an abdominal wall with flowing of gastric contents in an abdominal cavity and development of peritonitis.
Prevention of these heavy complications during the first days of the postoperative period requires careful overseeing by an operational wound. The choice of the most full-fledged technique of the operation providing the maximum Hermeticism of a gastrostomy saves from the majority of postoperative complications. Nevertheless disturbance of Hermeticism of a gastrostomy and the subsequent complications are possible at any technique and faultless technology of performance of operation; they are caused by the general serious condition of patients and character of a basic disease. It convincingly is confirmed by numerous overseeing of G. made at cicatricial esophageal stenoses, the edge, as a rule, is not followed by complications and quickly normalizes a condition of patients; lethal outcomes at the same time meet as a rare exception. The same operation made at inoperable cancer of a gullet often is followed by early disturbances of Hermeticism of a gastrostomy with all subsequent complications which are the cornerstone of a high lethality at this group of patients reaching 20 — 40%. From the point of view of prevention of the complications developing in connection with insolvency of a gastrostomy patients with inoperable cancer of a gullet and the cardia should carry out this operation in earlier terms, without waiting for full impassability of a gullet.
The gastrostomy at children
the Gastrostomy at children is applied according to the same main indications, as at adults: for feeding, switching off of a gullet, a decompression went. - kish. path.
For feeding it is most often imposed at children with cicatricial narrowing or full impassability of a gullet as a result of its burn; further the gastrostomy can be used for bougieurage of a gullet.
At an atresia of a gullet bandaging of tracheosesophageal fistula is surely combined with existence of esophageal and tracheal fistula when at operation it is not possible to impose a direct anastomosis between pieces of a gullet, with.
The indication to G. for switching off of a gullet is its perforation during bougieurage, removals of a foreign body and other manipulations.
Decompressive G. is applied at some abdominal organs operations (malformations of intestines, peritonitis). At such patients through a gastrostomy it is possible to carry out an intubation of intestines that is a highly effective warning facility of postoperative complications (aspiration of gastric contents, paresis of a stomach and intestines, increase in intra belly pressure, eventration).
Method of the choice is the modified G. according to Kader. At children with cicatricial esophageal stenoses when long use of a gastrostomy is necessary, G.'s use across Vittsel is possible.
Technology of operation at newborns
Access — upper median laparotomy (see). After removal in a wound of a wall of a stomach on a front surface in an avascular zone is closer than it to big curvature an atraumatic needle put a purse-string stitch, diameter to-rogo shall not exceed 0,5 — 0,7 cm of Knaruzhi from the first seam at distance of 0,5 cm put the second purse-string stitch then the gleam of a stomach is opened and enter Pezzer's catheter or a tube, it is desirable from thermoplastic material. The inside purse-string weld is tightened, and the released thread is tied around a tube for its fixing. Then the tube is immersed in a stomach and tie an outside purse-string seam. The fabric ring formed between seams prevents the expiration of gastric contents.
The following stage of operation — fixing of a gastrostomy to an inner surface of a front abdominal wall. To the left of a section make an additional skin section length apprx. 1 cm. The styptic clip entered into a section stick out inside deep layers of a front abdominal wall and in this place remove thread from the tied outside purse-string seam. Then fabrics cut, remove a gastrostomy tube through a section outside and fix to skin. The stomach is in addition fixed to an abdominal wall four seams an atraumatic needle. The Laparotomny section is layer-by-layer sewn up tightly.
Postoperative maintaining patients variously also depends on the purpose of operation. After an establishment of gastric fistula for feeding food is begun in the first days. At newborns for this purpose the end of a tube is connected to system for drop injection. After decompressive G. a tube leave open. Each 3 hours wash out a tube. The followed contents and rinsing waters investigate for the accounting of losses of electrolytes which fill with parenteral administration of salt solutions.
With 8 — the 12th day when function is normalized went. - kish. a path, begin feeding through a mouth; the tube is deleted. Usually the gastrostomy is closed independently.
Complications do not differ from complications after G. at adults.
Bibliography: V. A basses. Notes on an artificial way to a stomach of animals, SPb., 1843; D about l ets to y S. Ya. and Isakov Yu. F. Children's surgery, p.1, page 385, M., 1970; Rusanov A. A. Cancer of a gullet, page 107, L., 1974; Yu htin V. I. Gastrostomiya, M., 1967; Bradley R. L. Feeding gastrostomy, Amer. J. Surg., v. 108, p. 743, 1964; W i t z e 1 O. Zur Technik der Magenfistu-lanlegung, Zbl. Chir., S. 601, 1891.
B. Rozanov; L. M. Kondratyeva (det.khir.).