By: Patricia Smith, RN, B.S.N.
For more than 100 years, physicians have been surgically placing the Stamm gastrostomy to provide access for nutritional support or decompression. The Stamm gastrostomy and the Janeway Procedures require a laparotomy (open incision). In 1980, Gauderer, Ponsky, and Izant developed a technique known as the Percutaneous Endoscopic Gastrostomy (PEG). This method provided a simple and safe way for physicians to place a gastrostomy requiring minimal anesthesia and a shorter recovery time.
The Malecot, dePezer, Mushroom, and Foley catheters are the traditional gastrostomy tubes. These tubes are placed by any of the three methods described above. After the tube is placed, there is normally a small amount of surrounding redness because of the presence of the "foreign material" (a gastrostomy tube). The gastrostomy site may also drain a small amount of yellowish fluid. This fluid will dry and crust around the site. The area should be kept clean and dry to prevent infection and to promote healing.
For the first two weeks after surgery, the skin around the site can be cleaned with a mixture of one-half Hydrogen Peroxide and one-half water. Use this mixture to gently remove all the crusty material. After the initial two weeks, cleaning the gastrostomy site daily with mild soap and water during the child's bath is enough to keep the site healthy. Rotate the external anchor after cleaning the skin to prevent a skin breakdown due to pressure. It is not recommended to keep a dressing around the gastrostomy site. Dressings keep the area moist and may cause skin problems.
It is very important to keep the tube secure to prevent trauma to the site as well as to prevent accidental removal. Most of the gastrostomy tubes have an internal (inside the stomach) and an external (on the outside) anchoring device. The internal anchor keeps the tubing from falling out. The external anchor keeps the tube from being pulled into the stomach. The external anchor needs to be positioned against the skin firmly but not too tight. Positioning the anchor too tight will cause the site to become sore. If the anchor is too loose, gastric leakage or trauma to site may occur.
Children may chew the tubing or play with it. If a child is allowed to pull or tug at the tubing, they may be able to pull it out. You can prevent this by:
Choose a method that works best for you and your child.
With a Stamm or open gastrostomy insertion method, the tube will initially be held in place with a suture. Eventually an external anchor will need to be placed. Options for an external anchor are:
Look at the site for: leakage, bleeding, or skin problems. Report any problems to your doctor as soon as you notice them.
Granulation tissue can develop at the gastrostomy site and is a normal occurrence. Granulation tissue is the result of the foreign body (gastrostomy tube or button) which stimulates production of inflamed epithelial tissue. This tissue will be pink-red in color, moist, will bleed easily, and looks like the mucous membranes inside your mouth. Treatment of granulation tissue consists of chemically burning the tissue by topical application with Silver Nitrate (AgNO3) sticks. The granulation tissue has no sensation. Therefore, the treatment is pain free. It may take more than one application to eliminate the tissue, so parents can be taught the application of Silver Nitrate at home.
Daily care of your child's gastrostomy also includes flushing the catheter after each feeding or after medications. The flush is used to clear the tubing of residual formula or medicine. Recommended flushes are 5-10cc of water for infants and 15-30cc of water for children. In very small infants 3-5cc of air can also be used to clear the tubing.
While your child is being fed and for approximately 45 minutes after the feeding is completed, they should remain on their right side, upright in an infant seat, or in your arms. It is important to make feedings as much like family meal times as possible for socialization purposes. It is also recommended that a young child use a pacifier while being fed by a gastrostomy tube, to associate sucking with the full and pleasurable sensations of a normal feeding.
There are no restrictions in activity for a child with a gastrostomy tube. Your child should be able to crawl or sleep on their stomach. Taking a bath or swimming in a pool is also permitted. Be sure to completely dry the skin around the tubing or the button after bathing or swimming. If you are unsure of a planned activity, ask your doctor or nurse.
In 1984, Gauderer, Picha, and Izant developed a replacement for the dangling gastrostomy tubes. The "button" is a simple, skin-level device with a one-way valve. The buttons consist of an internal anchor, external anchor, one-way anti- reflux valve, and a connecting device. Currently all the gastrostomy buttons on the market can be classified into two categories: Obturated tubes and Nonobturated tubes.
Obturated tubes: These tubes have an enlarged tip (mushroom or Malecot style) that serves as an internal anchor. The tip must be stretched with a special introducer or obturator. Obturated tubes are inserted only by a doctor or a trained nurse.
Nonobturated tubes: Each of these tubes has an inflatable balloon tip that serves as an internal anchor. The balloon is inflated after the tube is inserted into the stomach. Nonobturated tubes can be inserted by medical personnel as well as by a care giver after proper instruction.
The button can be substituted six to eight weeks after the initial gastrostomy tube placement. The doctor or nurse will remove the tube in the office and then replace it with the button of your choice. The thickness of the abdominal wall is measured. This measurement, or length, and the diameter of the previous gastrostomy tube, are what is used to select the appropriate sized gastrostomy button.
The button should be rotated daily during routine skin cleansing. The care of the button site is the same as for the gastrostomy tube.
Wash the connecting device after every feeding with warm, soapy water and rinse thoroughly. Prompt flushing and rinsing prevents formula from drying and building up inside the tube. The connecting device is disposable but can be repeatedly used with replacement every two weeks.
As a parent you should view the gastrostomy tube as a "bridge" - a way to provide nutritional support for your child's growth and development until your child is able to resume normal feeding.
Patricia Smith, RN, B.S.N. has been with Rainbow Babies and Children's Hospital in Cleveland Ohio, since January 1985. For ten years, she worked as a Clinical Nurse on a surgical pediatric division. In February 1995, she began working with the Division of Pediatric Surgery as their Clinical Coordinator. Her responsibilities include management of all surgical patients with wounds, burns, colostomies/ileostomies, and gas-trostomies; fielding medical calls to the office; and coordinating multi disciplin-ary services. Her position as Clinical Coordinator is very rewarding as she interacts daily with many wonderful families and their children.