Gastric Perforation (Gastrotomy)/Necrosis

Twisting tubes: Gastrostomy tube issues

• Plain radiography
• This modality has been traditionally utilized to confirm proper placement of a gastrostomy button. Water-soluble contrast is instilled through the gastrostomy button and several images are taken to document the passage of contrast into the stomach and exclude contrast leakage outside of the stomach, and the examination usually shows contrast emptying into the small intestine.

Surgical Cystogastrostomy

• Open surgical drainage entails the creation of a cystogastrostomy or cystenterostomy. This can be accomplished laparoscopically through an anterior transgastric approach, which requires an anterior gastrotomy for access and a cystogastrostomy creation through the posterior gastric wall, or a posterior approach through the lesser sac.4 The procedure can also be performed through a lesser sac approach, which is technically easier and is associated with less intraoperative bleeding.

• Pancreatic pseudocysts that are not in close proximity to the stomach require the creation of a cystojejunostomy. The cystojejunostomy is sometimes created through a Roux limb of jejunum. Although the technical and treatment success rates for surgery are high, the procedure is associated with a 10% to 30% morbidity rate and a 1% to 5% mortality rate. The technique is invasive, associated with a prolonged hospital stay, and more expensive than the alternatives

Placement of the Gastrostomy Tube into the Stomach through the Anterior Abdominal Wall

• Consequence
• Immediate or delayed failure of the balloon to retain inflation. Immediate or delayed leak from or around the tube. An early consequence of deflation of a balloon, if used, is bleeding from the gastrotomy owing to lack of tamponade. Leak from the tube early through a hole in the tube can result in extravasation of tube contents into the abdomen or along the abdominal wall tract leading to peritonitis or localized fasciitis, respectively.

• Repair
• After passing the tube through the tract in the abdominal wall, test a balloon, if used, or flush the tube with saline and look for a leak. A dilute solution of methylene blue can also be used if damage to the tube is suspected but unclear with saline flush.

• Prevention
• After the tract in the anterior abdominal wall is made with a tonsil clamp use a broader Kelly clamp to pull the tube through the tract. Also clamp the entire tube rather than feeding the lumen of the tube onto one tine of the clamp to avoid damage to the tube as it is being pulled through the layers of the abdominal wall.