The gastric hepatic ligament is opened to allow access to the right crus of the diaphragm. The short gastric arteries can be divided with the harmonic scalpel. Great care is taken to maintain a 2-cm distance from the gastroepiploic arcade. The harmonic scalpel is used to open the gastrocolic ligament. The assistant standing to the patient's left will maintain the camera and provide countertraction for the surgeon. The liver retractor is used to retract the left lobe of the liver so the underlying esophageal hiatus is visualized. Sellke MD, in Sabiston and Spencer Surgery of the Chest, 2016 Laparoscopic Mobilization of the Gastric Conduit, Pyloroplasty, and Formation of a Jejunostomy Tube.įour 5-mm ports and one 10-mm port are placed as they would be in preparation for a laparoscopic Nissen fundoplication. This is easily remedied (see procedural description in section on Complications and Fig. Note that a migrated tube, with the balloon or tube obstructing the gastric outlet, is a common cause of gastric distention, persistent vomiting, or signs of intestinal obstruction. If the patient has signs of a complication (e.g., infection, ileus, intestinal obstruction), surgical consultation is warranted. IN THE TUBE SKINIf it appears that a skin incision was used to place the tube, it is unlikely that the patient has an easily removable tube. The major concern is that a new tube may be misplaced (i.e., into the peritoneal cavity). If the tube is nonfunctioning yet still in place, the clinician must make a judgment regarding the risk versus benefit of removal and replacement, versus an attempt at unclogging the tube (see the subsequent discussion on unclogging). The only real concern of placing a gastric tube into the jejunum is that the balloon will produce intestinal obstruction if it is fully inflated. Some type of tube must be placed to stent the stoma, or the stoma will quickly close (in a matter of hours) and the patient might require a more complicated procedure to regain access. When in doubt, pass a Foley catheter without balloon inflation, tape it to the skin, and refer the patient to a consultant or the original referring clinician. If no surgical scar is seen at the stoma site, the tube is almost certainly a G tube or a G tube that terminated in the jejunum. If only a stoma exists, one may request that the nursing home describe or send the prior tube to the ED. Unfortunately, old records or nursing home personnel rarely give specific information that is helpful to the emergency clinician. The clinician has a few options when faced with the task of replacing a feeding tube. Always inflate the balloon with saline and use a bolster to prevent migration of the tube. A call from a nursing home indicating that a tube has been pulled out should be answered with the advice that a Foley catheter be used immediately to keep the stoma open. They may be used temporarily but should be replaced with specialized feeding tubes when feasible ( Fig. They clog easily and the balloon disintegrates in stomach acid. Note that on cross section this original long tube has no balloon or port to inflate a balloon but has a mushroom end that is removed by traction.įoley catheters are not ideal as long-term feeding tubes. An original tube is not usually a Foley or balloon-tipped tube. These can be confused with tubes that have two entrances to one lumen (one for continuous feeding and the other for medications) and tubes that have a second lumen leading to an inflatable balloon. Some tubes have two lumens, one terminating in the stomach for decompression and the other in the small bowel for feeding. A de Pezzer (mushroom) tube, a Corflo tube (CORPAK MedSystems, Buffalo Grove, IL), or a Foley G tube is designed only for intragastric termination. Tubes are kept in place by either a modified end (such as a mushroom tip) or an inflatable balloon. G tubes are available in various types ( Fig. Contrast-enhanced studies and fluoroscopy usually provide such information ( Fig. External inspection may or may not reveal where a feeding tube should terminate. Nevertheless, the emergency clinician should attempt to ensure that the terminal end of a replaced tube is in the same viscus as the original was. The clinician cannot always determine the location of the original feeding tube by simply looking at a patient who arrives in the ED for replacement of the tube. Roberts MD, FACEP, FAAEM, FACMT, in Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, 2019 Gastroenterostomy and Jejunostomy TubesĪ nursing home patient with a nonfunctioning or displaced feeding tube represents a common ED scenario.
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