A Method for Gastrostomy
Fixation
By David A. Kappel and Lucian L. Leape
G
ASTROSTOMY, frequently indicated in pediatric surgery, and often of major therapeutic importance. is not without hazard, although the complications can be minimized by careful attention to technical details and appropriate tube care. Most serious complications result from leakage about the gastrostomy tube;’ intraperitoneal leak may be fatal, but external leakage leads to wound breakdown, infection, dislodgement of tube, etc. The importance of a and is probably the most critical fact.or proper dressing has been emphasized.‘-5 in preventing complications. Recently, we have adopted a new method of fixation which is of particular advantage in the small neonate. TECHNIQUE A standard Stamm gastrostomy is performed using a No. 14-18 French mushroom (Pezzer) catheter. The stomach is sutured to the anterior abdominal wall so there is good serosal- peritoneal fusion. The skin wound is closed with fine nylon sutures. A standard-sized disposable nipple is then used for fixation of the tube. It is modified by excising an elliptical window in the widened base of the nipple and by enlarging the hole in the tip with a cruciate incision so that it will fit the gastrostomy catheter. The nipple is then slipped over the catheter after first coating the undersurface of the flange and the corresponding area of skin around the gastrostomy site with skin adhesive (as for ostomy appliances). The nipple is seated in place to maintain the gastrostomy tube perpendicular to the skin. Tension of the tube is then adjusted so that the flange of the mushroom catheter is snug against the interior of the stomach, holding it against the anterior abdominal wall. The tube is then taped to the end of the nipple, and the nipple itself is taped to the skin. The use of a nipple for fixation maintains the tube perpendicular to the skin and prevents motion, the most common cause of leakage. The elastic property of the nipple allows the surgeon to adjust the tension applied to the catheter to hold it against the gastric wall, while avoiding possible pressure necrosis from excessive tension. The window cut in the side of the nipple permits care for the site with cotton tip applicators through the window, visualization to permit necessary adjustments, and also prevents moisture accumulation and maceration of the skin. The need for frequent dressing changes is eliminated. DISCUSSION Gastrostomy is a useful adjunct in many pediatric surgical problems, vided complications of its use can be avoided. If the tube is maintained
From the Department the Department
of Surgery.
of Pediatric
Surgery,
University Tufts-New
of Kansas Medical England Medical
Address for reprint requests: David A. Kappel. M.D., Medical
Department
Center,
Kansas City,
proim-
Kansas and
Center, Boston. Mass. of Surgery.
lJniversit_v of Kansas
Center, Rainbow Blvd. at 39th St., Kansas City, Kansas 66103.
‘a 1975 by Grune & Stratton,
Inc.
Journal of Pediatric Surgery, Vol. 10, No. 4 (August), 1975
523
KAPPEL AND LEAPE
524
Fig. 1.
The method
of gastrostomy
fixation.
mobile and perpendicular to the skin, and on mild tension, leakage can be minimized. We have found the use of a disposable nipple of value, especially in premature newborns in whom tissues are thin and dressings often cumbersome. ACKNOWLEDGMENT We gratefully
acknowledge
the suggestions
of Mrs.
Anna
Marie
Stuckey
in the evolution
of
this idea.
REFERENCES 1. Connar RG, Sealy WC: Gastrostomy its complications. Ann Surg 143:245, 1956 2. Beck RA, Allen JE: An improved tomy dressing. Arch Surg 94:904, 1967 3. Holder
TM,
Leape
LL,
Ashcraft
and
gastros-
KW:
Gastrostomy: Its use and dangers in pediatric patients. N Engl J Med 286: 1345, 1972 4. Prioleau WH, Othersen HB Jr: Fixation of gastrostomy tube. Am J Surg I l5:433, 1968 5. Richards JT. Othersen HB Jr: Gastrostomy fixation in infants. Surg Gynecol Obstet 124:122, 1967
Fixation
By David A. Kappel and Lucian L. Leape
G
ASTROSTOMY, frequently indicated in pediatric surgery, and often of major therapeutic importance. is not without hazard, although the complications can be minimized by careful attention to technical details and appropriate tube care. Most serious complications result from leakage about the gastrostomy tube;’ intraperitoneal leak may be fatal, but external leakage leads to wound breakdown, infection, dislodgement of tube, etc. The importance of a and is probably the most critical fact.or proper dressing has been emphasized.‘-5 in preventing complications. Recently, we have adopted a new method of fixation which is of particular advantage in the small neonate. TECHNIQUE A standard Stamm gastrostomy is performed using a No. 14-18 French mushroom (Pezzer) catheter. The stomach is sutured to the anterior abdominal wall so there is good serosal- peritoneal fusion. The skin wound is closed with fine nylon sutures. A standard-sized disposable nipple is then used for fixation of the tube. It is modified by excising an elliptical window in the widened base of the nipple and by enlarging the hole in the tip with a cruciate incision so that it will fit the gastrostomy catheter. The nipple is then slipped over the catheter after first coating the undersurface of the flange and the corresponding area of skin around the gastrostomy site with skin adhesive (as for ostomy appliances). The nipple is seated in place to maintain the gastrostomy tube perpendicular to the skin. Tension of the tube is then adjusted so that the flange of the mushroom catheter is snug against the interior of the stomach, holding it against the anterior abdominal wall. The tube is then taped to the end of the nipple, and the nipple itself is taped to the skin. The use of a nipple for fixation maintains the tube perpendicular to the skin and prevents motion, the most common cause of leakage. The elastic property of the nipple allows the surgeon to adjust the tension applied to the catheter to hold it against the gastric wall, while avoiding possible pressure necrosis from excessive tension. The window cut in the side of the nipple permits care for the site with cotton tip applicators through the window, visualization to permit necessary adjustments, and also prevents moisture accumulation and maceration of the skin. The need for frequent dressing changes is eliminated. DISCUSSION Gastrostomy is a useful adjunct in many pediatric surgical problems, vided complications of its use can be avoided. If the tube is maintained
From the Department the Department
of Surgery.
of Pediatric
Surgery,
University Tufts-New
of Kansas Medical England Medical
Address for reprint requests: David A. Kappel. M.D., Medical
Department
Center,
Kansas City,
proim-
Kansas and
Center, Boston. Mass. of Surgery.
lJniversit_v of Kansas
Center, Rainbow Blvd. at 39th St., Kansas City, Kansas 66103.
‘a 1975 by Grune & Stratton,
Inc.
Journal of Pediatric Surgery, Vol. 10, No. 4 (August), 1975
523
KAPPEL AND LEAPE
524
Fig. 1.
The method
of gastrostomy
fixation.
mobile and perpendicular to the skin, and on mild tension, leakage can be minimized. We have found the use of a disposable nipple of value, especially in premature newborns in whom tissues are thin and dressings often cumbersome. ACKNOWLEDGMENT We gratefully
acknowledge
the suggestions
of Mrs.
Anna
Marie
Stuckey
in the evolution
of
this idea.
REFERENCES 1. Connar RG, Sealy WC: Gastrostomy its complications. Ann Surg 143:245, 1956 2. Beck RA, Allen JE: An improved tomy dressing. Arch Surg 94:904, 1967 3. Holder
TM,
Leape
LL,
Ashcraft
and
gastros-
KW:
Gastrostomy: Its use and dangers in pediatric patients. N Engl J Med 286: 1345, 1972 4. Prioleau WH, Othersen HB Jr: Fixation of gastrostomy tube. Am J Surg I l5:433, 1968 5. Richards JT. Othersen HB Jr: Gastrostomy fixation in infants. Surg Gynecol Obstet 124:122, 1967
