Enteral Access Procedures
Pediatric Surgery NaT is a comprehensive reference for the general surgical care of children. Contains learning objectives, images, videos, and links to MOC CME and the medical literature. Explore these free sample topics:
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Where is the optimal place for a gastrostomy?
The gastrotomy for the gastrostomy tube is ideally placed toward the greater curvature of the stomach at the transition of the body and the antrum at a site that will reach the anterior abdominal wall without tension. The site should allow for the intraluminal portion of the gastrostomy tube to reside inside the stomach without obstructing the pylorus. Distal migration of the tube or balloon will occasionally occur.
When the stomach is very small every attempt should be made to place the gastrostomy at a safe location away from the gastroesophageal junction and the pylorus and toward the greater curvature.
The selection of a location on the abdominal wall should be inferior to the costal margin by a finger breadth or two. The location should allow for anticipated growth to prevent the feeding tube from encountering the rib cage. Usually, a site near the midclavicular line in the left upper quadrant is acceptable. It is critical to mark the site prior to inflation of the peritoneal cavity when the laparoscopic approach is used as the distention of the abdomen distorts the surface anatomy and could result in a site which is more superior than desired.
Anatomic considerations for percutaneous endoscopic gastrostomy placement must take into account the requirements for upper endoscopy as well as the safety of percutaneous access. For example, passage of a pediatric endoscope may not be an option in patients with oropharyngeal abnormalities or esophageal stenosis. Previous abdominal operations may increase the risk of interposed small bowel or colon between the stomach or bowel and the abdominal wall or limit the ability to perform laparoscopy. A limited abdominal computerized tomography or magnetic resonance scan may help to evaluate potentially complicating anatomic factors such as the relationship of the colon, small bowel and liver to the stomach.
Where is the optimal place for a jejunostomy?
A jejunostomy is best positioned at a site that will allow for a tension free attachment to the abdominal wall but that limits the chance of volvulus or internal hernia. The location of jejunal access should be reasonably proximal to allow for as much absorptive capacity of the bowel as possible. The enterotomy should be made on the antimesenteric border of the jejunum.