Seminar on Stamm, Janeway & PE
gastrostomy
Presenter: Dr Biswajit Deka
1st yr PGT
Moderator : Dr S B Choudhury
Asstt. Professor
Department of surgery,SMCH
Indication
• Need for feeding
• Decompression
• Gastric acess
Stamm gastrostomy
• Temporary procedure
• The mid anterior gastric wall is grasped with a
Babcock forceps,& the ease with which the
gastric wall approximates the overlying
peritoneum is tested.
• A purse-string suture using nonabsorbable
suture is placed in the mid anterior wall of the
stomach.
• An incision is made in the centre of the purse
string at right angles to the long axix of the
stomach
• It reduces no of arterial bleeders
• Incision made with electrocautery,scissors,or
knife
• A mushroom catheter of avg. 18 to 22F is
introduced into the stomach for 10 to 15 cm
• A foley type catheter may also be used
• The purse string suture is tied
• The gastric wall about the tube is then inverted
by a 2nd purse-string suture or interupted
Lembert’s stiches
• The gastric wall should be inverted about the
tube to ensure rapid closure of the gastric
opening when the catheter is removed
• A point is then selected some distance from the
margins of the operative incision & the costal
margin for the placement of the stab wound &
subsequent passage of the tube through the
anterior abdominal wall.
• The position of the catheter end should be
checked
• The gastric wall is then anchored to the
peritoneum about the tube by 4/5 non
absorbable suture
• The gastric wall must not be under undue
tension at the completion of the procedure
• The gastrostomy tube is snugged upward and
then secured to the abdominal skin with a non
absorbable suture.
Stamm Gastrostomy
Janeway Gastrostomy
• Permanent procedure
• The surgeon visualizes the relation of stomach
to the anterior abdominal wall & with Allis
forceps outlines a rectangular flap.
• Its base plcaced near the greater curvature to
ensure an adequate blood supply.
• The flap is made somewhat larger than would
appear to be necessary
• The gastric wall is divided between the allis
clamps near the lesser curvature & a
rectangular flap is developed by extending the
incision on either side toward the allis clamp on
the greater curvature.
• After pulling the flap, the catheter is placed
along the inner surface of the flap
• The mucous membrane is closed with
continuous suture, then submucosa and serosa
is closed preferably by interrupted
nonabsorbable suture
• When this cone shaped entrance to the
stomach has been completed about the
catheter,the anterior gastric wall is attached to
the peritoneum at the suture line with non
absorbable suture.
• A gastric tube canbe constructed with a
stapling instrument.
Closure
• After the pouch of gastric wall is lifted to the
skin surface,the peritonem is closed about the
catheter.
• The catheter may be brought out through a
smal stab wound to the left of the major
incision.
• The layers of abdominal wall are closed about
this and the mucosa is anchored to the skin.
• Catheters are anchored to the skin with
adhesive tap in addition to a suture that has
included a bite in the catheter.
Janeway Gastrostomy
Percutaneous Endoscopic
Gastrostomy-PEG
Indications:
• Need for feeding
• Decompression
• Gastric acess
Contraindications
• Inability to pass the endoscope safely
• Inability to identify the trans-abdominal
lumination of the lighted endoscope tip within
the dilated stomach
• Ascites
• Partially corrected coagulopathy
• Intra abdominal infection
Pre-operative preparation
• NPO
• Gastric decompression- nasogastric tube
• Single dose i/v antibiotic given 1 hr prior to
the procedure
– Because the peroral passage of the special
catheter may contaminate the abdominal wall
tract created as the catheter is brought out
through the stomach
Anaesthesia
• Topical anaesthesia for oropharynx
• Local anaesthesia for abdominal site
Position :
supine on the table with the head slightly
elevated.
Operative preparation
-smallest possible gastroscope used
- after the endoscope is passed safely into the
stomach,the skin of the abdomen & lower chest
is prepared with antiseptic solutions and drapes
applied.
Procedure
• During the placement of the gastroscope any
pathology may be evaluated.
• Stomach fully inflated with air
• This displaces the colon inferiorly & places the
anterior gastric wall against the abdominal wall
• A suitable zone selected& Endoscopist places the
lighted gastroscope end firmly upward at this
point – this is usually between the costal margin
and the umbilicus
• The operating room lights are dimmed & the
transilluminated site is identified & marked.
• The endoscope is backed away from the
anterior gastric wall & the appropriateness of
the site is verified as external palpation with a
finger indents the chosen area.
• LA is injected & a 1cm skin incision is made
• The endoscopist visualizes the site as a 16G
smoothly tapered iv cannula/needle is
introduced into lumen of the stomach.
• A long large silk or nylon suture is passed
through the hollow outer cannula after
withdrawing inner needle
• The silk is grasped with a polypectomy snare
passed through the endoscope and then all are
withdrawn through the patient’s mouth
• A de pezzer catheter with the inner crosspiece
(a cut section of tubing) or a special PEG
catheter is secured to the long suture
• The catheter must have a tapered end that will
enclose the open end of the de pezzer catheter
• The whole assembly is covered with a sterile
water soluble lubricant
• Gentle, steady traction on the abdominal end
of the long suture pulls the tapered end of the
assemblt down the esophagus & then through
the gastric & abdominal wall
• The endoscope is reintroduced and the
positioning of the special catheter of crosspiece
is verified
• An external crosspiece or collar is applied and a
non-absorbable suture is used to secure the
catheter & crosspiece to the skin without
pressure or tension that might necrose the skin
• The small skin incision is left open and topical
antiseptic may be applied.
PEG
Post-operative care
• The gastrostomy catheter is opened for
decompression and gravity drainage for a day
• Then feeding may start in a sequencial manner
beginning with small ,dilute volumes
• The catheter may be changed in a periodic manner
or may be converted to a silastic prosthesis after 4
weeks or more when the gastrostomy incision has
solidly healed & the stomach has fused to the
anterior abdominal wall.This prosthesis is stretched
and thinned over an obturator and inserted into the
open gastrostomy tract
Thank you...