GASTROSTOMY

What is

A gastrostomy is the placement of a feeding tube in the upper abdomen, through which food, water and medicine are fed directly into the stomach.

It is the recommended method to prevent and treat repeated inhalations.

Generally

Unlike the levin nasogastric tube, the gastrostomy protects against reflux of food that has entered the stomach. Aspiration of food occurs when, usually for neurological reasons (Parkinson’s, Alzheimer’s, stroke, etc.), the epiglottis that seals the airway every time we swallow does not work properly, with the result that small or large amounts of food go down into the lungs with each swallow . Foods that pass through the epiglottis and down into the respiratory system are usually directed to the right lung. There are inflammations called bronchopulmonary foci. Initially the consequences are so mild that they are not easily noticed, or they are related to the progression of the underlying disease. Over time, the secretions inside the bronchi increase and this is the most common reason that the patient’s relatives seek medical help, that is, they ask for someone to aspirate these secretions with a machine. Gradually the oxygen in the patient’s blood decreases (low hemoglobin oxygen saturation) and finally a fever develops, as a manifestation of formal aspiration pneumonia. If the condition is not treated in time with a gastrostomy, the patient worsens and finally ends up with respiratory failure. Levine feeding, which is very common, gives only a partial solution to the problem, as it keeps the esophagus open and predisposes to regurgitation of food and, above all, is extremely uncomfortable for the patient. Gradually the oxygen in the patient’s blood decreases (low hemoglobin oxygen saturation) and finally a fever develops, as a manifestation of formal aspiration pneumonia. If the condition is not treated in time with a gastrostomy, the patient worsens and finally ends up with respiratory failure. Levine feeding, which is very common, gives only a partial solution to the problem, as it keeps the esophagus open and predisposes to regurgitation of food and, above all, is extremely uncomfortable for the patient. Gradually the oxygen in the patient’s blood decreases (low hemoglobin oxygen saturation) and finally a fever develops, as a manifestation of formal aspiration pneumonia. If the condition is not treated in time with a gastrostomy, the patient worsens and finally ends up with respiratory failure. Levine feeding, which is very common, gives only a partial solution to the problem, as it keeps the esophagus open and predisposes to regurgitation of food and, above all, is extremely uncomfortable for the patient.

Suctions

Aspiration of food occurs when, usually for neurological reasons (Parkinson’s, Alzheimer’s, stroke, etc.), the epiglottis that seals the airway every time we swallow does not work properly, with the result that small or large amounts of food go down into the lungs with each swallow .

Foods that pass through the epiglottis and down into the respiratory system are usually directed to the right lung. There are inflammations called bronchopulmonary foci. Initially the consequences are so mild that they are not easily noticed, or they are related to the progression of the underlying disease. Over time, the secretions inside the bronchi increase and this is the most common reason that the patient’s relatives seek medical help, that is, they ask for someone to aspirate these secretions with a machine.

Gradually the oxygen in the patient’s blood decreases (low hemoglobin oxygen saturation) and finally a fever develops, as a manifestation of formal aspiration pneumonia.

If the condition is not treated in time with a gastrostomy, the patient worsens and finally ends up with respiratory failure. Levine feeding, which is very common, gives only a partial solution to the problem, as it keeps the esophagus open and predisposes to regurgitation of food and, above all, is extremely uncomfortable for the patient.

Levine or gastrostomy?

Levine and gastrostomy are the two alternatives when the patient presents with repeated aspiration. Although much more widespread than the gastrostomy, the levine has significant disadvantages, the main one being the extreme discomfort of the patient. Patients are condemned to spend the rest of their lives with a foreign body in their nose and throat. They often remove it themselves and for this reason unfortunately in too many cases their hands are tied to the bed.

Gastrostomy: Will the patient tolerate it?

I am often asked how long a gastrostomy takes, and if a patient with, say, motor neuron disease, or debilitated or with an infection that has now just passed and has lost weight, if they can handle this procedure.

The answer is that the shorter the process of placing the gastrostomy tube, the easier it is for the patient to tolerate. For us, the average gastrostomy time is about five minutes. We’ve done gastrostomies in less than five minutes, some take a little longer. The average time is about five minutes. That is, measuring the time from the moment we approach the gastroscope to the patient’s mouth, until the moment we have finished the gastrostomy.

For such a short time, the anesthesiologists need to administer an infinitesimal dose of “intoxication”, simply so that the patient is not disturbed by the passage of the gastroscope.

How is it performed?

Gastrostomy used to be done with open surgery. Today the percutaneous endoscopic gastrostomy has completely replaced the old method and so now the open gastrostomy is no longer considered an acceptable method.

Gastrostomy is now performed with a minimally invasive method with the help of the gastroscope. The gastroscope, after proper preparation of the patient, is inserted through the esophagus into the stomach, where it offers a direct view of the inside of the organ. With the help of a fine needle, the gastrostomy tube is passed through the abdominal wall in the most atraumatic way, providing the possibility of administering food, fluids and medicines without the risk of aspiration.

How does it stabilized?

Once the gastrostomy tube is passed through the abdominal wall, the doctor places a round fitting that secures the tube against the skin, preventing it from moving inward. The gastrostomy tube is then cut, and the fitting, to which the syringe or feeding device is attached, is placed on the cut end.

What care is needed

Many people ask how they should care for the gastrostomy site. With sterile gloves and gauze using saline? oxygen? betadine? another antiseptic? The answer is simple: What is a gastrostomy? An orifice of the body, through which the stomach communicates with the skin. So is the mouth. How do we wash our mouth? With WATER. Without any sterilization. We handle the mouth of the gastrostomy in exactly the same way. With WATER, without sterile gloves and sterile gauze. As also something analogous is the anus. A small opening through which the intestine communicates with the skin. We wash him with water without any antiseptic. So just as we handle any orifice of the body (ears, nose, mouth, anus, urethra or vagina), so we handle the gastrostomy. No difference. The gauze that is recommended to be placed under the tray of the gastrostomy tube which is in contact with the skin, takes the place of the underwear. Just as we wear clean and dry underwear and change it daily or as often as needed, we also change the gastrostomy gauze to keep the area around the stoma clean and dry.

Replacement of the gastrostomy tube

The gastrostomy tube does not need regular replacement, except when it wears out. The first placed can even last a year. The first tube that is placed is replaced when needed either by traction to the outside, or with a gastroscope from the inside.

Subsequent tubes have a second lumen through which an internal fixation balloon (like Folley catheters) is inflated. So subsequent replacements of the gastrostomy tube are very simple.

It is possible to replace the gastrostomy tube with one identical to the one that was placed the first time. The advantages are:

• The length of the tube is long and easier to handle.
• It does not need frequent replacements. 
• There is no way that it will leave its position on its own, as it does not have a balloon inside (which can break), but an internal retaining disc. 

Reinsertion of the same tube as the original one requires a gastroscopy. 

Flat valve (button) gastrostomy

The flat gastrostomy valve is intended for patients who for some reason have gastrostomies but are otherwise healthy enough to be socially active.

E.g. someone who in the summer would like to put on their t-shirt and go outside, not wanting to see the gastrostomy tube under them. 

Gastrostomy feeding

Gastrostomy feeding is done in two ways:

• With a feeding syringe
• Through a special device with gravity.

In this video we present how feeding with a syringe is done. Aiming at the amount that the patient should take in a day, we administer small amounts at intervals of less than an hour.

In other words, we simulate feeding someone who never sits at the table, but often takes small amounts of food. This is the ideal way to feed a patient, so that the possibility of regurgitation and aspiration is greatly reduced.

Passed foods or feeding solutions?

In a patient who has a gastrostomy, what food do we give? The foods we take every day when we sit at the table have only one advantage and too many disadvantages.

The only advantage is:

• The taste

Disadvantages:

• Saturated fats
• Animal and plant hormones
• Antibiotics
• Preservatives
• Pesticides.

Because taste is a very important factor for the quality of our lives, we often sacrifice a part of the healthy nature of the food on its altar, adding a few saturated fats (the skin from the chicken, the butter in the kourabies, the frying), a few carcinogenic hydrocarbons (grilling on coals), etc. Even when we cook perfectly “healthily” for a patient, it is impossible to avoid the cholesterol and saturated fats hidden between the fibers of clean meat, hormones and antibiotics freely given to animals production and the pesticides that producers use in toxic quantities in order not to risk their income.

When we give a patient food through a tube (levain or gastrostomy), the advantage of taste is lost and so we only have the disadvantages of prepared food.

Thus, it is absolutely recommended for gastrostomy patients to be given special nutrient solutions, which have ALL the ingredients necessary for life (proteins, fats, carbohydrates, vitamins, trace elements, minerals) in the RIGHT PROPORTIONS, guaranteed without a trace of pesticides, preservatives, hormones, antibiotics and others harmful substances.

There are many pharmaceutical companies that produce such solutions, they are all of excellent quality, with small differences between them, based on which we make our choices for each patient.

In order not to lose the advantage of taste, I recommend that traces of his favorite flavors be administered to the patient’s mouth, regardless of their nutritional value (snacks) or their possible unhealthy character (alcoholic), since with such small amounts even the harmful properties are important, nor can suctions be induced, while at the same time complete nutrients are administered to the patient in the correct quantity and quality from the stoma.

Gastrostomy and suctions

We do the gastrostomy to prevent aspiration.

As we have said, in the neck, at the level of the larynx, the airway separates from the passage through which the food descends to the stomach. Therefore we have to make sure that food and liquids do not go down to the airway and that is why we do gastrostomies.

The question is: Does gastrostomy completely prevent aspiration?

The answer is no”. When we give something inside the stomach, we have made sure that the introduction of these substances is done in absolute safety, so that nothing goes to the airway. But what the stomach will do is its own business. Logically, the stomach, which has an inlet and an outlet, will process its contents to push them to the outlet and not allow anything to rise up. But this is not certain. Very often the stomach has a different “opinion” from us: It makes deductions. All of us have had reductions, if we have eaten something that our stomach does not accept well, while we are still sitting or standing, a sourness rises to our throat. But having our senses and the ability to react, we re-swallow this liquid or react accordingly and nothing goes to the lungs.

So, there is a case, even in a patient with a gastrostomy, that the stomach makes upward reductions and causes suction of gastric fluids.

How can we prevent this? The simplest way is the one I recommend feeding the gastrostomy patient. That is, with small amounts and constantly checking to make sure that the patient has digested the previous amount, before administering the next one. To summarize the aspiration issue: If we normally feed a patient with dysphagia by mouth, we have a high probability, almost a certainty, that some of that food will go to the lungs.

If the patient has levain, the possibility of aspiration is reduced, but it still exists, since in addition to the factor of antiperistalsis, i.e. the opposite movements of the stomach that push the gastric contents upwards, we also have the factor of the foreign body that keeps the stomach open esophagus along its entire length. Thus, around the levain, acid content can rise into the esophagus and from there to the lungs and cause both microbial and chemical pneumonia (due to the acid).

When we do gastrostomies, the possibility of aspiration decreases, as there is no longer the foreign body that keeps the esophagus open. Unfortunately, however, this possibility does not become zero, as it is left to the proper functioning of the stomach to promote through peristaltic movements the content towards the intestine and not to allow the reflux of content towards the esophagus.

What is said to feed the patient, and to remain semi-sitting for three hours after the last meal, is of doubtful effect, for, as we have said, it may happen to all of us, while we are sitting, standing, or walking, that acid contents rise up to the neck. We are not horizontal, we are upright. Again antiperistalsis does this. How much more can he do it to the patient who is fed through a gastrostomy and is in a semi-sitting position at an angle of 30-45 degrees on the bed.

Of course, if we give the patient a large amount of food and immediately lay him down in a horizontal position, this possibility becomes much greater. If we have him in an elevated position the probability decreases, NOT ZERO. What I recommend is small amounts and frequent checks to make sure the stomach is empty before administering the next small amount.

For almost certain prevention of aspiration, the gastroestomy method is recommended.

Gastroenterostomy

What is it and when is it indicated? We have said in other discussions that when we administer something to the stomach, it depends on the “philotimos” that the stomach has, whether this “something” will take it in the right direction which is the intestine and not turn it towards us esophagus and throat, with a very high probability of being led to the lungs, where it will cause both chemical and microbial pneumonia.

When we observe this, the only completely safe and indicated solution is gastroenterostomy.

Through the already existing gastrostomy tube, we pass a second, very thin one, which with a special technique we direct endoscopically into the small intestine. In this way, we have the absolute certainty that not a single drop of the administered solutions has a chance to turn towards the duodenum and the stomach, so that it has a chance to go up towards the esophagus and be absorbed. Even the liquids produced by the stomach itself, we have the ability to drain them, so that they too cannot rise towards the esophagus and the lungs. We have absolute certainty.

Gastrostomy control

When a gastrostomy is present, it is very important that caregivers check the contents of the stomach before any administration. It goes without saying that the same applies in the case of feeding through a nasogastric tube (Levain). This must be done because in some cases the stomach shows reluctance to push its contents towards the intestine. In normal individuals, this prolonged gastric filling is perceived by the brain and the individual avoids further food intake. However, patients who are fed through a gastrostomy are usually unable to express their potential gastric load. If the caregivers do not realize this and administer the next meal, simply because the time has come, then the patient will experience vomiting and then regurgitation with very serious consequences.

Feeding frequency and amounts

How should a patient who has a gastrostomy be fed?

The recommended way to avoid reflux to the esophagus and from there to the lungs is to administer small amounts at frequent intervals. Most of them give complicated instructions like “so many syringes of food and then so many syringes of water” etc. They are instructions only to cause anxiety and headache.

We do not measure food with syringes . The correct way is to set as a goal an amount of food that it is desirable for our patient to take in in a 24-hour period and to spend this amount, little by little, until the evening, provided that we constantly check the stomach, to make sure that it digests the amounts we administer.

We can compare this method to someone who, while never sitting at a table to eat, constantly nibbles, not caring how much time passed between one “nibble” and another. Thus, by giving small amounts to the stomach, we have a greater chance that it will manage them easily and correctly, i.e. by advancing them quickly to the intestine. Thus, the possibility of making anti-peristaltic movements and of gastric contents rising towards the esophagus with the risk of aspiration is significantly reduced.

If, despite all this, we find that the stomach cannot handle even these small amounts, we do not administer the amount that we had initially set as our goal. In such a case, we may try some drugs that have gastro-intestinal properties, or resort to the gastroenterostomy method.

The gastroenterostomy method consists of inserting a thinner tube through the gastrostomy tube, which is placed deep into the small intestine. By administering food and fluids through such a tube, we are absolutely sure that nothing can back up into the stomach and thence to the esophagus and lungs.

Is the patient taking enough food?