Stamm Gastrostomy Research Articles

Neonatal Obstructive Jaundice Caused by a Malpositioned Gastrostomy Tube

Sebastian MV, Coley BD(AQ1) irst successfully performed more than 120 years ago by Verneuil [1], gastrostomy tube placement in the pediatric population is now common, performed most often for intestinal atresias, neurologic and swallowing disorders, and other conditions in which nutritional support is needed. As the procedure has become more common in the last 40 years, many types of complications have been documented, including tube obstruction and dislodgement, malpositioning of replaced tubes, stomal leak, and tube migration and prolapse with or without gastric outlet obstruction and intussusception [1–3]. A rare complication is obstructive jaundice caused by migration of balloon catheters into the duodenum [4–7]. We present such a case in a neonate. Case Report A 36-week-old preterm boy with a history of polyhydramnios was diagnosed with upper esophageal atresia with distal tracheoesophageal fistula. Fistula ligation was performed on day-oflife 1, but primary esophageal reanastomosis could not be performed. For enteric feeding, a surgical Stamm gastrostomy was performed and a 12-French self-retaining Malecot tip gastros-

Effects of Stamm Gastrostomy on Gastric Emptying Rate in Rats

Aim: Although frequency of gastroesophageal reflux (GER) increases after gastrostomy, the role of gastric emptying in GER has not been evaluated. In this study, we examined the effects of Stamm gastrostomy on gastric emptying rate in rats and whether Stamm gastrostomy induces GER or not. Methods: Sprague-Dawley rats were divided into three groups. Stamm gastrostomy was done in the first group (SG). Sham operation was carried out in group 2 and the 3rd group served as control. Gastric emptying was assessed using both liquid and solid meals in each group at postoperative 14th day. For solid meal emptying, after fasting of 16 h, the rats were fed for 3 h and gastric emptying rate was measured at the fifth hour. Methylcellulose was used for emptying of liquids and it was given after the animals were fasted for 16 h and gastric emptying rate was measured 30 min later. Histological evaluation for GER was performed in all groups. Results: GER was observed pathophysiologically in 5 of the 7 rats in SG group. Gastric emptying rates of liquid and solid meals were found to be similar in control, SG or sham groups. Conclusion: Surgical gastrostomy does not affect the gastric emptying of solid and liquid meals in rats. Other mechanisms should be considered in the development of GER observed following gastrostomy.

An unusual type of severe barotrauma owing to automobile tire biting in a child

The authors report a rare case of a barotraumatic pneumothorax and pneumomediastinum associated with esophageal perforation and orbital emphysema. A 4-year-old boy presented with sudden respiratory distress after blowout of a defective tire that he bit. Computed tomography scan showed right pneumothorax and bilateral orbital emphysema. A linear rupture has been detected in the cervical esophagus in esophagoscopy. Stamm gastrostomy and tube thoracostomy were performed, and broad-spectrum antibiotics have been introduced. Oral feeding started 23 days after blowout of tire, and the patient was discharged 50 days after injury.

Pyloric atresia: 15-year review from a single institution

Background: Pyloric atresia (PA) is a rare pathology. Calder presented the first pyloric atresia case in 1749 and Touroff, Sussman, Meltz, and their colleagues presented the first successful operation in 1940. PA has 3 types of anatomic variations: (1) type A, pyloric membrane or web; (2) type B, the pyloric channel is a solid cord; and (3) type C, in which there is a gap between the stomach and duodenum. Associated anomalies also have been described. Epidermolysis bullosa (EB) and intestinal anomalies occur most often with this condition. Methods: Charts of 16 cases of congenital PA, aged 1 to 30 days and admitted to our department between 1986 and 2001, were studied retrospectively in regard to sex, prenatal diagnosis, presence of polyhydramnios, time of admission, pathology, type of operation, associated anomalies, and mortality rate. Results: In the study group, the male to female ratio was 5:3, the mean birth weight was 2,312 g and the mean age of admission was 6.5 days. The distribution of the anatomic variations was type A in 9 (56.3%) and type B in 7 (43.7%) of cases. Associated anomalies were present in 7 cases (43.8%). Familial occurrence was a prominent feature of our series. Seven of 16 cases occurred in 3 families. We performed 9 web excisions together with Heineke Mikulicz (H-M) pyloroplasty, 5 atresia excisions and gastro-duodenostomy, and 2 H-M pyloroplasties alone. Stamm gastrostomy was supplemented in 3 cases. The overall mortality rate (n = 9) was 56.3%. Conclusions: Pyloric atresia can be managed succesfully if it is diagnosed early. In this group of patients, congenital anomalies or septicemia are the main causes of mortality.

Evaluation of oesophageal atresia without fistula by three-dimensional computed tomography.

During the last decade, an increasing number of paediatric surgeons have chosen to perform a delayed oesophageal anastomosis for oesophageal atresia (OA) without tracheo-oesophageal fistula (TOF). The gap between the two oesophageal pouches is an important determinant in the surgical management of these patients. We describe a new method using spiral computed tomography (CT) to evaluate the gap between the proximal and distal oesophageal pouches. In our last four cases of OA without TOF, Stamm gastrostomy was performed soon after birth. At about 4 weeks of age, these patients underwent spiral CT with air inflation via the gastrostomy feeding tube with 3 mm slice thickness, pitch 1, and reconstruction interval every 1.5 mm. A three-dimensional reconstruction was done and measurements of the gap between the two segments were recorded. The procedure was repeated at monthly intervals until the optimal conditions for surgery were observed. All the babies thrived well on gastrostomy feeding. The gap distances were 2.4, 3.8, 4.2 and 5.9 cm respectively. Delayed primary oesophageal anastomosis was accomplished in three cases and gastric transposition was performed in another case at 12, 13, 14 and 16 weeks of age. The exact anatomical position the operation correlated well with the pre-operative three-dimensional CT results. this new technique is an easy and non-invasive method to assess the long gap in babies with oesophageal atresia without tracheo-oesophageal fistula. The radiological findings are also consistent with surgical anatomical situation during surgery suggesting that this investigation is useful in the pre-operative planning of oesophageal anastomosis or replacement.

Gastroesophageal Reflux Disease in Neurologically Impaired Children: The Role of the Gastrostomy Tube

We review our experience with gastrostomy techniques in neurologically impaired (NI) children, with or without a Nissen fundoplication. The records of 130 NI children who had a gastrostomy tube (GT) placed between January 1999 and October 2001 were reviewed. Data collected included: demographics, neurological status, operative time, time to first feed, postoperative stay, analgesic requirements, follow-up, mortality and complication rates. Open GTs were placed using the standard Stamm gastrostomy technique through a midline incision and were combined with a standard open Nissen fundoplication when indicated. Laparoscopic GTs were placed after institution of carbon dioxide pneumoperitoneum using a 2-port technique, a Mic-key G device of appropriate size and anchored to the anterior abdominal wall with 2 "U" stitches. The laparoscopic Nissen fundoplication (LNF) procedures were performed using a 5-port technique. Patients were divided into 4 groups: group I (n = 12) laparoscopic GT alone, group II (n = 44) open GT alone, Group III (n = 44) laparoscopic GT with LNF and Group IV (n = 30) open GT with Nissen fundoplication. Based on their similar characteristics, Groups I and II and Groups III and IV were compared together. Data were analysed using Student's t test, and internal review board approval was obtained. Patients ranged in age between 10 days and 17.7 years (mean 3.64 years). Their weight was between 1.2 and 63.4 kg (mean 12.8 kg). The compared groups showed similar characteristics with regard to age, weight, cause of mental impairment, and the reason for placement of the GT. The operative time for group III was significantly longer than that of group IV (P < 0.05). Time to first feed was significantly shorter for group I when compared to group II. The postoperative analgesic requirements were not statistically different. The overall short- and long-term complication rates were not statistically different when the related groups were compared, however, site-related complications and feeding problems were significantly less in group I compared to group II. Only 1 operative mortality occurred in group III. Follow-up showed less long-term morbidity and fewer complications with the laparoscopic GT compared to the open one as regard to admissions, surgery, and emergency department visits related to GT problems as well as frequency of GT change. Based on our experience, laparoscopic placement of a low-profile GT in NI children appears to be associated with less morbidity, permits earlier enteral nutrition, and has a cosmetic advantage. We believe that the laparoscopic technique should be the procedure of choice for GT placement in these children even when a Nissen fundoplication is deemed necessary.

A Simplified Open Gastrostomy under Local Anesthesia

Revision of the standard gastrostomy is often necessary in patients with neuromuscular disorders. These patients pose many anesthetic risks that frequently preclude the use of general anesthesia, intravenous sedation, or endoscopy. Modification of the Stamm gastrostomy enables it to be performed comfortably and readily under local anesthesia. The modification proposed passes the gastrostomy tube through the omentum en route to the abdominal wall. This ensures a seal to the surgical site, eliminates the need for tacking sutures, and allows for a smaller midline incision. These factors greatly reduce the discomfort of the procedure allowing it to be easily accomplished under local anesthesia. This technique of open gastrostomy under local anesthesia has been used in more than 35 patients over the past 10 years with no documented leaks.

Stamm Gastrostomy for Postoperative Gastric Decompression in Gynecologic Oncology Patients

Objective. The aim of this study was to report our experience with Stamm gastrostomy for postoperative gastric decompression on a gynecologic oncology service.Methods. This was an observational study over the 9-year period ending in October 2000. A 24 French MIC gastrostomy with the Stamm technique was used. Criteria for a gastrostomy are outlined in the text and tubes placed for palliation were excluded. Patients were followed to determine length of open drainage, time to removal, related complications, and those who may have benefited.Results. A total of 167 patients had 174 nonpalliative gastrostomy tubes placed. Nine percent of the patients had related complications with a major complication rate of 2%. Overall, approximately one-third of the patients appeared to benefit from the gastrostomy tube.Conclusion. The results support the safety and efficacy of the MIC gastric tube in patients undergoing extensive gynecologic cancer surgery which is likely to impact the function of the gastrointestinal tract.

Limitations of percutaneous endoscopic gastrostomy in facilitating enteral nutrition in children: review of the shortcomings of a new technique.

Percutaneous endoscopic gastrostomy (PEG) insertion became the preferred technique for facilitating enteral nutrition in children unable to take adequate caloric intake orally once its advantages over the standard Stamm gastrostomy became apparent. It has taken longer for some of its limitations and shortcomings to be recognized. Problems encountered during PEG insertion include: inability to enter the stomach with the trocar, oesophageal laceration, colonic perforation, gastro-colo-cutaneous fistula, peritonitis, subcutaneous emphysema, external migration of inner flange, wound infection, peristomal excoriation, symptomatic gastro-oesophageal reflux requiring later fundoplication, intestinal obstruction and haemorrhage. Many of these complications can be avoided by attention to technique.

Is tube-feeding in disabled children associated with excess mortality?

Is tube-feeding in disabled children associated with excess mortality?

Open gastrostomy performed through the umbilicus.

A new variation of open gastrostomy placement is described in which a Stamm gastrostomy is performed via a supraumbilical incision around the circumference of the umbilicus. Access to the stomach is good and the cosmetic result is superior to that obtained with the conventional incision.

Initial experience with the changeable skin-level port-valve: A new concept for long-term gastrointestinal access

Background/Purpose: Experience with a new multipurpose system for long-term enteral access is reported. At the core of the concept is a changeable, skin-level “port” (SL port) that incorporates a valve accessible through a locking, right-angle feeding adapter. The new system allows conversion of a previously-inserted, long gastrointestinal catheter into a “button-type” skin-level device without removal of the long catheter, thereby eliminating pain, tract damage, and the risk of separation of the viscus from the abdominal wall. Methods: Sixty-four SL ports were used in 44 children (ages 2 weeks to 19 years). Conversion from long tube to skin-level device was performed 33 times, either immediately after the catheter placement or some time thereafter (percutaneous endoscopic gastrostomy, 18; Stamm gastrostomy, 6; laparoscopic gastrostomy, 7; jejunostomy, 2). Insertion as an assembled button-type device in an established tract was performed seven times. Twenty SL ports showing sings of leakage were replaced with an identical device without catheter removal. SL ports remained in place from 1 week to 15 months.

Morbidity in neurologically impaired children after percutaneous endoscopic versus Stamm gastrostomy

Neurologically impaired children frequently require a feeding gastrostomy. Few reports are available comparing the incidence of postoperative complications and symptomatic gastroesophageal reflux after endoscopic versus operative Stamm gastrostomy in this group of children. We undertook a retrospective study of 63 consecutive neurologically impaired children requiring a feeding gastrostomy, with an average of 23 months of follow-up. No child had symptomatic gastroesophageal reflux. Thirty children had a percutaneous endoscopic gastrostomy and 33 had a Stamm gastrostomy, depending on the preference of the surgeon. The two groups were comparable in age range, cause of neurologic impairment, and indication for gastrostomy. Minor complications occurred in 30%. All three major complications occurred after Stamm gastrostomy, including two postoperative deaths. Symptomatic gastroesophageal reflux developed in 60%. The incidence of fundoplication after gastrostomy was 10% in the percutaneous endoscopic gastrostomy group and 39% after Stamm gastrostomy ( p < .025). Morbidity was lower after percutaneous endoscopic gastrostomy than after Stamm gastrostomy in this group of neurologically impaired children. Fundoplication for symptomatic gastroesophageal reflux was infrequent after percutaneous endoscopic gastrostomy and significantly more common after Stamm gastrostomy. Percutaneous endoscopic gastrostomy is recommended as the initial procedure in neurologically impaired children without symptomatic gastroesophageal reflux who require a feeding gastrostomy. (Gastrointest Endosc 1995;42:41-4.)

Experiences with stamm gastrostomy in children: C. Deindl and M. Barba. Chirurg 64:813–818, 1993

Experiences with stamm gastrostomy in children: C. Deindl and M. Barba. Chirurg 64:813–818, 1993

Pyeloduodenal fistula: A previously undescribed complication of stamm gastrostomy

A variety of complications have been described after placement of a Stamm gastrostomy in infants and children, including gastric volvulus, pancreatitis, jaundice, gastroduodenal mucosal intussusception with gastric outlet obstruction, and even aortogastric fistula. However, this is the first report of pyeloduodenal fistula after Stamm gastrostomy in a 4 1 2 - month-old boy. The child successfully underwent nonoperative therapy; he was treated by withdrawing the gastrostomy tube (Foley catheter) from the renal pelvis, bowel rest, and total parenteral nutrition. After the case presentation is a brief review of this rare entity, with its clinical presentation and pathophysiological differences between adult and pediatric cases. Various treatment options, both operative and nonoperative, are also described.

Lesser curvature gastrostomy reduces the incidence of postoperative gastroesophageal reflux

Gastrostomy is frequently required in children with neurological impairment and feeding disability. In some centers, concomitant (prophylactic) antireflux procedures are often performed due to the increased risk of occurrence of significant gastroesophageal reflux (GER) after isolated operative or percutaneous endoscopic gastrostomy placement. This has been documented in both experimental and clinical settings. A recent clinical study suggests that placement of a gastrostomy in a lesser curvature location rather than on the greater curvature of the stomach may decrease the incidence of postoperative GER. The purpose of this study is to evaluate this clinical impression. Under ketamine anesthesia and sterile technique, 30 cats underwent laparotomy and placement of a Stamm gastrostomy tube; 15 (group A) were located on the greater curvature of the stomach and 15 (group B) on the lesser curvature of the stomach. Each animal was evaluated postoperatively for the occurrence of GER using upper gastrointestinal contrast study, nuclear medicine gastric scintigraphy (technetium 99m), pH probe/Tuttle test, and lower esophageal sphincter (LES) manometrics. Contrast esophagram with barium demonstrated GER in 3 animals in group A and none in group B ( P < .05). The pH/Tuttle test was positive in 4 animals in group and none in group B ( P < .05). 99mTc gastric scintigraphy (over a 30-minute period) demonstrated GER in 7 cats in group A and in only 1 cat in group B ( P < .05). LES manometric pressures were similar among both groups. This study suggests that a gastrostomy placed in the lesser curvature may reduce the incidence of postgastrostomy GER and obviate the need for a concomitant antireflux procedure in patients with a severe feeding disability but without demonstrable GER during preoperative assessment.

Successful management of esophageal strictures without resection or replacement

Esophageal resection or replacement has become the standard therapy for severe esophageal strictures chiefly because less aggressive methods generally have failed. We hereby report our experience with 12 consecutive infants and children who have been managed successfully by means of Stamm gastrostomy and string-guided esophageal dilatation, coupled with endoscopically guided four-quadrant intralesional steroid injection, protected by Nissen fundoplication when gastroesophageal reflux has been demonstrated. In six patients, the stricture(s) were caused by ingestion of lye. In five, they were associated with repair of esophageal atresia. In one, the etiology was never determined. The strictures averaged 3.5 cm in length (range, 1 to 10 cm); the severity of the lesions was indicated by the fact that, in all instances, patients were completely intolerant of solids, and was confirmed fluoroscopically by demonstration of significant luminal narrowing. A mean of 4.3 steroid injections (range, 1 to 8) was required to obtain complete remission of symptoms; there have been no complications except in one lye ingestion patient who developed a tiny perforation following the initial dilatation, which responded to antibiotics alone. All patients remain symptom-free; the mean length of follow-up is 6.2 years (range, 1 to 11 years). We conclude that string-guided esophageal dilatation, when coupled with endoscopically guided steroid injection, is a safe and reliable method for treatment of severe esophageal strictures, which should obviate the need for esophageal resection or replacement in most patients. Moreover, even if treatment should ultimately fail, a procedure of lesser magnitude than esophageal replacement will likely be possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Sloughing of the proximal colon segment in retrosternal colonic esophagoplasty and lengthening of the distal colonic stump

A case of esophageal atresia with tracheoesophageal fistula is described. When the female neonate was 5 days old a right thoracotomy with division of the fistula was performed and a stamm gastrostomy was established because of a long gap between the esophageal stumps. These procedures were followed by elongation of the upper esophageal stump by bougienage. Severe respiratory complications later necessitated a left cervical esophagostomy. Retrosternal, isoperistaltic interposition of the right colon was performed for esophagogastric reconstruction when the baby was 20 months old. The proximal segment of the retrosternal colonic conduit sloughed postoperatively at the level of the sternal angle. This complication was treated by re-exploration of the anterior mediastinum through a midline sternotomy. Dissection and elongation of the distal colonic stump were done. Elongation of the colonic stump became feasible by partially excising the proximal anterior taenia coli and creating relaxing, transected incisions of the seromuscular layers of the distal anterior taenia coli. This maneuver provided additional length and permitted stretching of the colonic segment. Thus, an easy, new retrosternal esophagogastric reconstruction was feasible when the child was 30 months old.

Changes in lower esophageal sphincter pressure (LES) after stamm gastrostomy: D.F. Canal, D.W. Vane, S. Goto, et al. J Surg Res 42:570–574, (May), 1987

Changes in lower esophageal sphincter pressure (LES) after stamm gastrostomy: D.F. Canal, D.W. Vane, S. Goto, et al. J Surg Res 42:570–574, (May), 1987

The effect of various types of gastrostomy on the lower esophageal sphincter

Previous studies have demonstrated a cause and effect relationship between standard Stamm gastrostomy (SG) and subsequent gastroesophageal reflux (GER). To further investigate this clinical problem, three additional types of gastrostomy were evaluated in regard to their influence on the lower esophageal high pressure zone (LEHPZ). Twenty-three male cats were entered in the study weighing 2.6 to 3.6 kg. Baseline manometric studies of the LEHPZ were determined after ketamine anesthesia. In group I (n = 9), Witzel gastrostomy was performed over a 12 Fr catheter without fixation of the stomach to the anterior abdominal wall. In group II (n = 7), percutaneous gastrostomy was performed without fixation of the stomach to the anterior abdominal wall. In group III (n = 7), percutaneous gastrostomy was performed but the stomach was firmly fixed to the abdominal wall. LEHPZ pressures were then repeated 2 weeks postoperatively. Mean preoperative LEHPZ pressure for group I was 16.2 +/- 3.72 mmHg, group II was 16.5 +/- 6.91 mmHg, and group III was 18.3 +/- 5.59 mmHg. Mean postoperative pressure for group 1 was 14.7 +/- 4.26 mmHg, group II was 16.5 +/- 5.77 mmHg, and group III was 10.8 +/- 3.97 mmHg. LEHPZ pressure was similar preoperatively and postoperatively in groups I and II but was significantly decreased postoperatively (P less than .01) in group III. Contrast studies demonstrated maintenance of the angle of His in group 1 and II and alteration of the angle of His in group III. Gastrostomy associated with fixation of the stomach to the anterior abdominal wall results in decreased LEHPZ pressures. This predisposes the subject to GER.(ABSTRACT TRUNCATED AT 250 WORDS)