GASTROSTOMYFOR THE NEWBORN SURGICAL PATIENT*

A REPORT OF 140 CASES

BY

IRVING A. MEEKER and WILLIAM H. SNYDERFrom the Surgical Service of the Children's Hospital, Los Angeles, California, and the Department of Surgery,

School of Medicine, University of Southern California, Los Angeles, California

It is the purpose of this paper to relate ourexperiences employing prophylactic gastrostomy in140 consecutive newborn surgical patients born witha variety of life-endangering anomalies amenable tosurgical correction, and admitted to the Children'sHospital, Los Angeles, California, 1957 to 1961.The newborn surgical patient begins life exposed

to many complications not confronting a normalhealthy infant. Frequently, those congenitalanomalies in the neonatal period, which requireemergency surgery, affect either the abdominalviscera, the contents of the thorax, or both,with the result that, regardless of the success ofthe surgical procedure performed, these infantsexperience temporary periods of gastro-intestinalobstruction which in turn produce frequent vomitingof gastric contents. A delicate and meticulousprimary anastomosis of segments of the gastro-intestinal tract-with great disparity in calibre-maybe necessary to salvage an infant born with highintestinal obstruction. Leaks may develop atthe site of these anastomoses and lead to a surgicalcatastrophe. All such newborn infants, regardlessof their surgical pathology, may manifest par-ticularly precarious respiratory function in the firstfew days of life and this may be further jeopardizedby a prolonged or difficult anaesthesia. A dis-tended abdomen due to intestinal obstruction or thereduction of viscera from the thoracic cavity intothe abdomen, as in diaphragmatic herniae or theclosure of an omphalocele, causes increased intra-abdominal pressure and splinting of the diaphragms,thus interfering with respiratory exchange. Indeed,if this intra-abdominal pressure is sufficiently great,impairment of venous return to the right heartoccurs, resulting in circulatory collapse. Suchhazards may occur separately or in combinationduring the postoperative course in the newborn

* A paper read at a meeting of the British Association of PaediatricSurgeons held in Stockholm, September 1961.

infant surgical patient. Together these complica-tions account for a significant percentage of themortality encountered in infants who today maybe afforded life-saving surgical correction offormerlyfatal congenital anomalies.

Originally, gastrostomy was used for purposes offeeding patients with obstruction of the gastro-intestinal tract above the level of the stomach.Subsequently, such tubes were employed in adultsfor decompression of a denervated stomach follow-ing vagotomy and pyloroplasty for duodenal ulcer(C. B. McVay, personal communication; Farris andSmith, 1956). Gastrostomy has been employedcommonly in newborn surgical patients bornwith tracheo-oesophageal fistula and oesophagealatresia. The intention in these cases was to providenourishment and at the same time to protect theoesophageal anastomosis from rupture, allowingadequate time for healing before attempting oralfeedings. It soon became apparent to those caringfor these babies that a very significant advantagewas afforded by leaving the gastrostomy tube openin the early postoperative period so that retainedgastric content would drain through the tube andnot be retained and occasionally regurgitated acrossthe fresh oesophageal suture line, thus resulting inpulmonary aspiration of vomitus. Further, it wasan incidental finding that a gastrostomy tube leftopen vented swallowed air and decompressed thegastro-intestinal tract in these babies as shown inFig. 1. With this experience gained in the manage-ment of gastrostomy tubes, we began employingthem more frequently in place of nasogastric tubesin newborn infant surgical patients having a con-genital anomaly capable of correction, either in thechest or the abdomen. It was apparent that theywere far more effective than a long, slender-calibreLevine tube on continuous suction which mighteasily become plugged or adhere to the lining ofthe stomach when not irrigated frequently, thus

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160 ARCHIVES OF DISEASE IN CHILDHOOD

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FIG. la.-A 4 lb. 1 oz. (1-84 kg.) newborn infant afterduodeno-jejunostomy and gastrostomy for duodenal

obstruction.

FIG. lb.-A 6 lb. (2-72 kg.) infant following divisionof H-type tracheo-oesophageal fistula with gastrostomyand attached plastic bag containing 1,000 ml. of air

swallowed in the preceding six hours.

' :~~~~~~~~~~ .

FIG. 1c.-A 3 lb. 7 oz. (1 -5 kg.) infant with meconiumperitonitis and atresia of the ileum following restoration

of gastro-intestinal continuity and gastrostomy.

FIG. 1 d.-A 7 lb. 1 oz. (3 -2 kg.) infant after correctionof a right diaphragmatic defect, gastrostomy, and creation

of an intentional ventral hernia for decompression.

FIG. le.-A 5 lb. (2- 3 kg.) infant after skin closure of an FIG. If.-A 4 lb. 4 oz. (1 .9 kg.) infant after approxima-omphalocele which ruptured in utero with gastrostomy tion of the skin around an omphalocele to the mucous

tube in place. membrane of an exstrophy of the bladder, with gastros-tomy.

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GASTROSTOMY FOR THE NEWBORN SURGICAL PATIENT

failing to decompress the stomach satisfactorily.In addition, damage to the naso-pharyngeal struc-tures from naso-gastric suction, particularly inpremature infants, was prevented by a gastrostomytube (no. 14 or no. 16 French) left open and draining.The indications for gastrostomy, the simple

technique for performing gastrostomy, the post-operative management of such tubes, and resultsobtained in a wide range of surgical conditions inthe newborn infant form the basis of this report.

Indications for GastrostomyAspiration of Gastric Content. Infants born with

various types of intestinal obstruction vomit copiousamounts of retained gastro-intestinal secretions. Itis apparent that when such infants, with a poorcough reflex, weak cry, and frequently immaturerespiratory function, aspirate gastric content, theremay be immediate obstruction of the extremelynarrow trachea and bronchi. Suctioning the oro-pharynx and induction of vigorous coughing maybe done too late to be helpful in clearing the airwayadequately before anoxia has taken its toll. Simplegastrostomy done at the time of surgery in a pre-mature infant with duodenal atresia (Fig. la) willmost effectively protect the child from possibleaspiration of vomitus and maintain an emptystomach and upper gastro-intestinal tract.

Reduction of Gastro-intestinal Distension. New-born infants, particularly those on 'nothing bymouth', cry vigorously, suck their fists, and swallowlarge quantities of air. A simple flat film of theabdomen of any newborn infant will normallydemonstrate many air-filled loops of bowel only afew hours after birth. This finding has beencorroborated in infant surgical patients on 'nothingby mouth' with gastrostomy tubes in place in whommore than 1,000 ml. of swallowed air has beencollected in six hours (Fig. lb). Without anadequate 'gastro-intestinal tract vent' in such infants,air rapidly fills and dilates loops of intestinesproximal to any obstruction present and this isa major factor accounting for abdominal distension.When these loops remain distended, they becomeatonic, fill the abdomen completely and are unableto move about; dense adhesions may form fixingthe bowel loops to themselves and to the parietalperitoneum potentiating intestinal obstructionalready present. A gastrostomy tube will ventswallowed air and secretions and prevent theirpassage into the lower intestinal tract. The airremaining in the distended loops ofbowel immediate-ly following gastrostomy and definitive surgery (onoccasion we also resort to decompression of the small

intestine by appendicostomy) is rapidly absorbed,the bowel becomes smaller and regains its tone.Free movement of the loops of bowel throughoutthe abdomen is possible, since no large dilatedredundant loops of intestine remain to 'kink onthemselves' producing further obstruction.

It can be anticipated that an infant with a mas-sively distended abdomen following appropriatesurgical intervention and gastrostomy will be relievedof gaseous distension in the first 12 to 24 hours, andthe contour of the abdomen may even become rela-tively scaphoid, as shown in Fig. 1 c, in a prematureinfant with meconium peritonitis. Frequent turningof the baby will constantly change the position ofthe collapsed loops of intestine and will help tominimize permanent adhesions, and reduce theincidence of subsequent obstruction.

Improvement of Respiratory Exchange. Whenmassive abdominal distension is present withincreased intra-abdominal pressure, as may occurin a diaphragmatic hernia after reduction of theabdominal viscera from the chest back into theabdomen (Fig. ld) or on closure of a massiveomphalocele (Fig. le), there may be splinting andsignificant immobilization of the diaphragms whichreduce respiratory exchange (Fig. 2) and compres-sion of the inferior vena cava which reduces venousreturn to the heart. If this situation is sufficientlysevere and persists for many hours, it results insignificant degree of tissue anoxia from pulmonaryinsufficiency and peripheral circulatory stasis. Incertain instances, a respiratory acidosis may beencountered with the arterial blood pH as low as7' 1. By venting swallowed air and gastro-intestinalsecretions in the immediate postoperative period,gastrostomy reduces the likelihood of these com-plications and assures the most ideal conditions foradequate respiratory exchange in a newborn infantrecovering from anaesthesia following a majorsurgical procedure, often affecting both theabdominal and thoracic viscera.

Protection from Evisceration. In certain newborninfants with anomalies of development of theabdominal wall, such as omphalocele with exstrophyof the bladder (Fig. lf), there may be little or nomuscle or fascia for use in a surgical repair. In anomphalocele with exstrophy of the bladder, onlyskin and thinned-out mucous membrane of theeverted bladder remain for closure of the abdominalwall. A gastrostomy tube will prevent abdominaldistension from swallowed air, relieve intra-abdominal pressure and tension on the epithelialsuture line, and permit wound healing of the pre-

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ARCHIVES OF DISEASE IN CHILDHOOD.::... ;,7 __,, ,,, ,! ^.;.'.e.C..

FIG. 2.-Radiographs of a newborn baby with a tracheo-oesophageal fistula and oesophageal atresia, Type III, showing (left) elevation of thediaphragms and interference with respiratory exchange, and (right) the same patient 24 hours later after 'open tube' gastrostomy. Note on

the right, the diaphragms are lower, there is better expansion of the lungs, and vastly improved air exchange.

carious abdominal wall closure. In other conditionswhere wound closure is precarious or eviscerationis feared, gastrostomy will be similarly effective.

Facilitation of Oral Feeding. In the majorityof infant surgical patients who have had operationsaffecting their gastro-intestinal tract, there is alwaysa temporary period of uncertainty as to how welland when a baby will tolerate the oral feedings thatare offered. With a gastrostomy tube in place,it is a simple matter to detect gastric retention andto drain the tube before each feeding, measure

any retained formula and be guided accordingly ininitiating oral feedings.

Technique of GastrostomySimple gastrostomy when performed as an isolated

intra-abdominal surgical procedure may be most easilyand satisfactorily accomplished by the technique des-cribed by Gross (1953). When gastrostomy is per-formed in conjunction with correction of a primaryunderlying surgical condition, it is performed throughthe laparotomy incision and the tube is brought outthrough a separate stab wound. The approximaterelationships of the gastrostomy tube, stomach andanterior abdominal wall stab wound may be plannedcarefully to avoid 'kinking'; curved clamps placed on theperitoneum, anterior rectus sheath and subcutaneoustissue will maintain these layers in normal anatomicalrelation. A finger is inserted beneath the abdominalwall in the appropriate position and a 4-5 mm. stabwound is made (Fig. 3a). As shown in Fig. 3b, twopurse-string sutures of 4-0 black silk are placed in theanterior wall of the stomach and a small incision madeonly large enough to permit the insertion of a no. 14 orno. 16 mushroom rubber catheter (Fig. 3b), with the

tip or face cut off to prevent plugging by milk curds andmucus in the stomach. The catheter is clamped andstretched over a small curved snap introduced into thestomach, and the purse-string sutures tied exactly asshown in Fig. 3c and 3d, so as to invert the edges ofthe stomach around the tube and prevent slippageof the tube into the stomach. In tying these sutures,the 'bell' or tip of the catheter should not be passedfurther into the stomach and downward into a positionwhere it might conceivably block the opening of thepylorus. To prevent this, the innermost purse stringis tied a second time directly around the rubber catheteras shown in Fig. 3d. A curved clamp is passed bluntlythrough the stab wound in the abdominal wall muscu-lature so as to impale the peritoneum on its tip (Fig. 3e).The outermost purse-string suture is passed through theperitoneum impaled on the tip of the curved forcep,and thereafter a knife is used to incise the peritoneumand permit the forcep to be passed through into theabdomen to grasp the end of the gastrostomy tube anddraw it out (Fig. 3f). The anterior surface of the stomachis pulled up firmly against the under-surface of theabdominal wall. Once this is achieved, the purse-stringsuture is tied approximating the seromuscular coat ofthe stomach to the peritoneum immediately adjacentto the stab wound.

Management of Gastrostomy TubesGastric Decompression and Reduction ofAbdominal

Distension. In the immediate postoperative periodbefore oral feedings are started, it is important todecompress the stomach to prevent abdominaldistension. This can be done best by irrigating the

FIG. 3.-Illustrations of the operative technique employed in estab-lishing a gastrostomy during exploratory laparotomy for correction

of the primary surgical lesion are shown opposite.

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GASTROSTOMY FOR THE NEWBORN SURGICAL PATIENT 163

FIG. 3c.-The arrow on the gastrostomy tube indicates that the tubeis being pulled upwards to ensure that the 'bell' has not descendedinto a position which will obstruct the pylorus. Once the 'bell' lies

FIG. 3a.-An outline of the body of a small infant showing approxi- immediately beneath the innermost purse-string suture, it is tied.mate position of the gastrostomy in relation to the underlyingstomach and the anatomy of the anterior abdominal wall. Threelarge curved clamps are applied to the peritoneum, anterior rectussheath, and subcutaneous tissue to maintain their normal anatomicalrelations, and these are held in the left hand while the index finger isintroduced through the small laparotomy wound and pushedanteriorly establishing a stab wound through which the gastrostomy

tube may be drawn.

FIG. 3b.-Two concentric 4-0 arterial black silk purse-string sutures FIG. 3d.-The innermost purse-string suture has been tied again;have been placed in the anterior aspect of the stomach wall proximal this time, directly around the gastrostomy tube, silk to rubber, toto the pylorus. Note the insert drawing showing a no. 14 or no. 16 prevent the tube (note the arrow) from sliding inward into the stomachmushroom catheter with the end cut off, clamped and stretched and to ensure that the stomach wall will be invaginated, thus en-taut over a small forcep to facilitate introduction into a small opening hancing the leak-proof effectiveness of the second purse-string suture

in the stomach. being tied.

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ARCHIVES OF DISEASE IN CHILDHOOD

FIG. 3e.-A curved clamp passed through the stab wound previouslyestablished in the abdominal wall. The layers of the abdominalwall are held in normal anatomical relation to each other by thecurved clamps, while the outermost purse-string suture is passedthrough the peritoneum just above the point at which the abdominalwall is impaled on the forcep. Note these structures have not beenincised nor the clamp forced through the layers into the abdominal

cavity.

gastrostomy tube at least every three hours with7 ml. of normal saline, aspirating it, noting thecolour, and measuring the amount returned on eachoccasion. Between irrigations and aspirations, thetube should be left open in an inclined test-tube andallowed to drain freely with the volume and colourof the drainage fluid being recorded on the chart.Swallowed air will be seen to bubble out or 'vent'through the gastrostomy tube during episodes ofvigorous crying. The volume of gastrostomydrainage should be replaced with its approximateequivalent volume of appropriate fluid and electro-lyte.

Initiation of Feedings. Before administering thefeed, an empty asepto-syringe is inserted into thetip of the gastrostomy tube and suspended in anelevated position over the baby. This permitsoverflow of any retained gastric content into theasepto-syringe (a 'second stomach') so that thecontent will not be lost and ultimately can bemeasured. At the same time, it permits swallowedair to bubble out through the tube, thus preventing

FIG. 3f.-The peritoneum and abdominal wall structures have beenincised to permit the curved clamp to be pushed through the stabwound to grasp the gastrostomy tube and draw it outside the abdomen.The outermost purse-string suture is tied after the gastrostomy tubehas bee.n pulled upward to ensure accurate apposition of the gastricwal to the under-surface of the peritoneum in the region of the stab

wound

distension of intestinal loops beyond. Everythree to four hours the gastrostomy tube should bedrained and the amount of fluid obtained measured.When this becomes negligible (5 to 10 ml. everythree to six hours) and not significantly more thanthe volume of irrigations being given, it can beassumed that intestinal secretions are passing throughthe gastro-intestinal tract and that it is safe toproceed with feeding small amounts, 5 to 10 ml.,of clear fluid every two to three hours. The majorityof infants are fed by mouth whenever possible,since it is believed this may exert a favourableeffect on peristalsis. No formula or fluid is lostas long as the gastrostomy tube remains elevated.During the early phases of restoring alimentation,the tube is drained before each feed to note anyresidual formula or fluid that may have beenretained in the stomach. Thus, immediate detectionof any temporary failure to pass food from thestomach into the gastro-intestinal tract is possibleand overfilling of the stomach is avoided. As aresult, babies are neither fed too early in too largeamounts nor is intake withheld unnecessarily longonce their intestinal tract has demonstrated itscapacity to function.

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GASTROSTOMY FOR THE NEWBORN SURGICAL PATIENTRemoval of Gastrostomy Tube. Although gastro-

stomy tubes in adults are usually removed severaldays after insertion, we have adopted a rule ofwaiting 12 to 14 days before removing them frominfants. This does not lengthen the period ofhospital stay because the tube can be removedvery simply by pulling it out two weeks after opera-tion. When this is done, the small opening in theabdominal wall closes spontaneously. It isextremely rare for a fistula to develop at the site ofgastrostomy.

Suction on Gastrostomy Tube Contraindicated.Intermittent low suction has been applied to thesegastrostomy tubes on occasion much as one woulddo with a Levine tube. However, this has resultedin intermittent obstruction of the tube, failure todrain the stomach adequately, and a markedreduction in general effectiveness. From theseobservations, it is apparent that the best resultsare achieved by leaving a gastrostomy tube openat all times and not resorting to suction of any type.However, in certain cases, i.e. premature infantswith tracheo-oesophageal fistula and oesophagealatresia, we have placed the gastrostomy tube onwater-seal drainage initially (E. B. Scott, personalcommunication), never on suction, before thetracheo-oesophageal fistula was closed.

ResultsA statistical analysis of the survival rates obtained

in these 140 infant surgical patients (Table 1) in

GASTROSTOMY INTABLE 1

140 NEWBORN INFANT SURGICALPATIENTS

Pre- Sur- Full- Sur-Site mature vived term vived

Diaphragmatic defects 1 0 16 14Tracheo-oesophageal fistulaand oesophageal atresia 25 2 41 31

Duodenal obstruction 5 5 14 14Jejunal-ileal obstruction 5 4 14 10Colon obstruction .. I 1 7 7Omphalocele .2 2 7 3Biliary atresia .0 0 2 2

Total .39 14 101 81

whom prophylactic gastrostomy was employed,revealed that, if the 25 premature infants withtracheo-oesophageal fistula and oesophageal atresiaare excluded, a long-term survival rate of 80% wasachieved for all cases in this group treated withgastrostomy regardless of the nature of the surgicalcondition or the size of the patient or associatedcongenital anomalies. The survival rate of full-term babies in this group recorded in Table 1slightly exceeded 80%. Finally, again excluding

the 25 premature infants with tracheo-oesophagealfistula and oesophageal atresia, the survival rate ofpremature infant surgical patients in whom gastro-stomy was employed was 86%.A somewhat similar analysis was made by

Forshall and Rickham (1960) in Liverpool afterthey had established a Neonatal Surgical Unitspecializing in the management and treatment ofinfant surgical patients. Their findings in com-parable surgical conditions revealed a survivalrate of 67% for comparable cases, excluding pre-mature infants with tracheo-oesophageal fistula andoesophageal atresia. Their survival rate for com-parable full-term infants was 79%, and finally theirsurvival rate for premature infants excluding thosewith tracheo-oesophageal fistula and oesophagealatresia was 58%.

Interpretation of these two contemporary seriesseems to suggest the following conclusions: thesurvival rate of full-term infant surgical patients isgreatly increased by consistently utilizing prophy-lactic gastrostomy in a hospital without a NeonatalSurgical Unit and offsets the great advantagesafforded by a Neonatal Surgical Unit specializingin the total care of such infants. In view of Forshalland Rickham's survival rate of 58% of prematureinfants, excluding those with tracheo-oesophagealfistula and oesophageal atresia compared with ourrate of 86%, it appears reasonable to presume thatroutine prophylactic gastrostomy offers particularadvantages to these diminutive infants not affordedby a Neonatal Surgical Unit.

In conclusion, it is apparent that gastrostomy inno way reduces mortality in premature infantswith tracheo-oesophageal fistula and oesophagealatresia and that another approach to the manage-ment of this anomaly in the premature infant mustbe considered if survival rates are to be improved.In contrast, survival -of premature infants withsurgical conditions other than tracheo-oesophagealfistula and oesophageal atresia is significantlyhigher when gastrostomy is performed in conjunctionwith the primary corrective surgical procedure.Finally, the statistics suggest that gastrostomyemployed in full-term infant surgical patients com-pensates in part for the advantages afforded by aNeonatal Surgical Unit.

Complications have been negligible with nobleeding from gastric mucosa, perforation of thestomach, or stoma leakage. On rare occasions, inextremely debilitated babies in negative nitrogenbalance, soft tissue erosion around the tube hasbeen encountered, but in each instance has healedafter tube removal or improvement of the infant'sgeneral condition.

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166 ARCHIVES OF DISEASE IN CHILDHOOD

SummaryElective gastrostomy is recommended as an

adjunct to major abdominal and thoracic surgicalprocedures required in certain newborn surgicalpatients. The indications, technique of performinggastrostomy, and the postoperative managementof such tubes are described in detail. One hundredand forty consecutive cases of prophylactic gastros-

tomy in newborn surgical patients are presentedwithout complications incident to gastrostomy.

REFERENCESFarris, J. M. and Smith, G. K. (1956). An evaluation of temporary

gastrostomy-A substitute for nasogastric suction. Ann. Surg.,144, 475.

Forshall, I. and Rickham, P. P. (1960). Experience of a neonatalsurgical unit. Lancet, 2, 751.

Gross, R. E. (1953). The Surgery of Infancy and Childhood, p. 147Saunders, Philadelphia.

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