Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Gastrostomy Placement
We have determined that you would benefit from a gastrostomy. There are several reasons why we may be
offering this operation to you. The appropriate reason is indicated below.
____
1. Alternative to a nasogastric tube – there are situations where you may require drainage of your
stomach for a prolonged period. This will permit the stomach to be drained in a comfortable and
convenient fashion.
____
2. Feeding – you may not be able to take adequate nutrition or liquid by mouth, and this will permit
your doctors to supply your nutritional needs.
Description of the Procedure
There are two methods by which we may perform a gastrostomy placement, either Percutaneous
endoscopically assisted (PEG) or through a small incision in your abdomen.
_____ Percutaneous Endoscopically Assisted Gastrostomy (PEG)
A flexible gastroscope is passed through your mouth into your stomach, to assist placement of a
needle through the skin into the stomach. A wire is passed through the needle and pulled up through the
mouth with the gastroscope. A gastrostomy tube is then attached to the guide wire, and pulled through the
mouth into the stomach and into proper position, through the abdominal wall.
_______ Open Stamm Gastrostomy
A small incision is made in the mid-abdomen to expose the stomach. A tube is placed in the
stomach (sometimes making a portion of the stomach as a tube). The tube is then brought out through the
abdominal wall, the stomach is sutured to it, and the abdomen is closed.
________ Open Jane Gastrostomy
A small incision is made in the mid-abdomen to expose the stomach. A portion of the anterior
wall of the stomach is fashioned into a tube and brought our through the abdominal wall like a stoma. The
abdomen is closed. A tube need not be kept in the gastrostomy in order to keep it open.
Alternatives for Treatment
1. No tube – the gastrostomy tube is placed for comfort and supportive care. Without the tube, we expect
that your condition may deteriorate.
2. Nasogastric tube – this is a tube that goes through the nose into the stomach. It is uncomfortable, and
awkward to maintain in public. There are multiple problems that may arise with prolonged use of a
nasogastric tube.
Risks/Complications of Treatment
Treatment risks fall into two categories; those that could happen during any operation under anesthesia, and
those that are specific for a gastrostomy placement. In any medical treatment, it is impossible to predict all
the things that could go wrong. Fortunately, complications are the exception rather than the rule. Every
reasonable effort is made to avoid complications. The most common possible complications are as follows:
Possible complications of major surgery
1. Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood
transfusion is rare.
2. Infection – we take special care to prevent an infection, but it is always a possibility.
3. Reactions to medications – this could be many things, from a minor rash to possible death.
4. Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots, pneumonia,
sore throat, or potential death, in rare cases.
(see other side)
5. Injury to bowel or other internal organs – an injury to a portion of the bowel or other intraabdominal to repair the injury. This may require opening your abdomen to determine the problem.
6. Poor overall condition of patients undergoing this procedure brings increased risk of wound healing,
respiratory difficulties, infection, etc.
Anticipated Recovery/Expected Rehabilitation
Recovery is quite variable, depending on the individual. Most people can resume previous activities the day
after surgery, if this procedure is done as an outpatient. Inpatients tend to be quite ill, and a gastrostomy will
not effect that initially; it will facilitate care and hasten recovery. The gastrostomy may usually be use within
four hours of placement.
Consent for Treatment
I understand my need for a gastrostomy. I have read and understand the above explanation of the
operation required to create a gastrostomy. My surgeon has answered my questions, and I choose to
proceed with surgery.
I understand that every operation may yield unexpected finding. I give the surgeon permission to act
on his best judgment in deciding to remove or biopsy tissues that appear to be diseased, understanding
that complications may arise from that action.
I understand that while most people receiving a gastrostomy will benefit from the operation, I may
not. My condition may not improve, and it may worsen. No absolute guarantee can be made.
HIPPA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you
invite to attend the surgery will be informed of the surgical finding, your surgical status, and
anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may or
may not remember these important details.
PRINT NAME OF PATIENT __________________________________________________________________
SIGNATURE __________________________________________________________ DATE _________________
WITNESS ____________________________________________________________ DATE _________________
SURGEON ____________________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________
____ I waive the right to read this form, and do not want to be educated and informed of treatment
risks; nonetheless, I understand the need for this surgery and grant permission to the surgeon to
proceed on my behalf.
SIGNATURE _____________________________________________________ DATE _________________
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