Gastrostomy Closure

Gastrostomy closure

Gastrostomy closure is a surgical or non-surgical operation of closing a gastrostomy site (hole cut in the stomach to feed the individual, usually through a gastrostomy tube) no longer necessary.

Indications

Closure is considered when:

• The patient is able to resume a normal oral intake.
• Gastrostomy feeding is not necessary anymore.
• Complications possibility is infection, granulation tissue, gastric leakage in the site of gastrostomy. 

Methods of Closure

Based on the type of gastrostomy, duration, and condition of a patient, closure can be surgical or non-surgical (spontaneous/primary closure).

Spontaneous Closure

• Generally occurs after removal of a temporary gastrostomy tube (<6 months).
• The perforation (hole) is usually self-healing in 24-48 hours. 
• The location is maintained clean and covered; there might be some slight leakage.

Surgical Closure

Indicated if:

• Stoma does not disappear with a removal of tubes (in long term gastrostomies).
• There is a big tract or complications.
• Patient is already having abdominal surgery.

Techniques:

Primary surgical closure

• The tract is excised.
• The gastric wall is lined (typically in layers (two); inner mucosa and outer seromuscular).
• Abdominal wall is closed in layers.

Laparoscopic closure

• Minimally invasive.
• It is particularly helpful when concomitant abdominal surgery is to be performed or to lessen the intensity of postoperative pain.
• Closure with the help of endoscopic methods or devices.
• Endoscopic closure devices can be employed in a few cases (e.g. PEG tubes).

Gastrostomy closure surgery

The following stepwise surgery of gastrostomy closure with some preparation, the procedure, and care after the operation will be detailed stepwise:

Procedure:

Preparation before surgery

• Patient workup: Assess nutrition, comorbid conditions and previous surgeries.
• Investigations: CBC electrolytes coagulation profile.
• Antibiotic prophylaxis: Single IV dose of antibiotic 
• NPO: Standard pre-op fasting (usually 6–8 h).
• Consent: Describe the risk (infection, leak, fistula, bleeding, hernia). 

Anaesthesia

• General anaesthesia is desirable.
• For high-risk patients with small tracts, local anaesthesia with sedation can be administered.

Surgical Technique

Step 1: Position the Patient 

• Half prone, with the upper abdomen open.

Step 2: Incision

• Incision of scar tissue around the gastrostomy stoma in an elliptical manner.
• Dissection is performed on the subcutaneous tissue in order to reveal the gastric wall.

Step 3: Gastric Tract Mobilization

• Circumferentially dissect the gastrostomy tract (the connective tissue line of the skin to the stomach). 
• Dissect the tract with attention to the surrounding tissues.

Step 4: Gastric Wall Closure

• The closure of two layers is desirable:
• Inner layer: Mucosa and submucosa are approximated with inverting absorbable sutures 
• Outer layer: Seromuscular layer, which is closed with interrupted absorbable or non-absorbable suture. 
• Ensure that it is closed, no leaking. 

Step 5: Abdominal Wall Closure 

• Close in layers the rectus fascia and the subcutaneous tissue. 
• Skin closure: Primary or skin stapling; occasionally, a small drainage is established in case of contamination.

Step 6: Dressing

• Sterile dressing on the wound.

Postoperative Care

• Follow-up: Vital signs, wound and evidence of stomach leakage.
• Diet: Usually nothing by mouth for 24 hours then gradual oral feeding as tolerated. 
• Pain treatment: Analgesics on demand.
• Pain management: Wound care: clean and dry, strip out sutures/staples 7-10 days.
• Antibiotics: in case of contamination risk.

Pediatric gastrostomy closure

The closing of gastrostomy tract in children is a procedure of surgically repairing a gastrostomy tract when the gastrostomy tube (to feed children over a long period) is not required any more, or when the gastrostomy has caused complications such as infection, continuing leakage, granulation tissue.

Indications

Children Closure is to be indicated when:

• The child is safe with nutrition through mouth.
• There is no longer any need of long-term gastrostomy feeding.
• Stoma leakage/infection is persistent.
• The gastrostomy tract does not close on its own, especially after long-term use (over 6-12 months). 

Gastrostomy closure recovery

The following is a step-wise review of gastrostomy closure recovery, including both adults and children, in both the surgical and spontaneous cases:

Recovery following Spontaneous Closure

• When it occurs: It typically happens following short-term gastrostomy tubes (<6 months).

Timeline:

• Stoma usually heals in 24-48 hours.
• Small leakages can take place within one or two days.

Care:

• Keep the site clean and dry.
• Apply sterile dressings if needed. 
• Watch for redness, swelling or pus. 
• Activity normal activity is usually able to resume instantly.
• Diet: Oral intake may be wise to proceed as tolerated.

Postoperative Recovery following Surgical Closure

• Persistent or large gastrostomy tracts, long-term gastrostomies, or complications need surgical closure to be done.

Postoperative Period Immediately

• Hospitalization: 1-3 days in the simple cases.
• Postoperative: Vital signs and wound were examined, gastric leakage, infection or hemorrhaging. 
• Management: Analgesics are given, usually IV. 

Diet:

• NPO (nothing by mouth) 24 hrs.
• Oral feeding is gradually reintroduced starting with fluids.
• Graduate to soft diet and then regular diet.

Wound Care

• Maintain an incision site free of infection.
• Alter the dressing according to the recommendation (typically, every day or as necessary).
• Staples or sutures can be taken off within 7-10 days depending on the healing.

Activity

• One can resume light activity immediately after the surgery.
• Restrict heavy lifting and straining of the abdomen 2 to 4 weeks.

Gastrostomy closure complications

The following is an elaborate breakdown of complications of gastrostomy closure, both spontaneous and incisional:

Common Complications

• Wound Infection
• Leakage of Gastric Contents
• Persistent Fistula
• Hemorrhage
• Hernia Formation

Less Common Complications

• Granulation tissue formation
• Delayed wound healing
• Abdominal pain or discomfort

Best hospital for gastrostomy closure India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Gastrostomy closure entails a safe and viable operation that can be conducted to close a gastrostomy that was created previously when the enteral feeding is no longer necessary or when complications emerge. The closure procedure (spontaneous vs. surgical) will be based on the time of a gastrostomy, the size of the opening, and the specifics of patients. Short term gastrostomies usually heal within 1-2 days on their own and therefore do not require much intervention. Long-term gastrostomies, persistent fistulas, or complicated stomas will need surgical closure which includes two-layered gastric wall closure and layered abdominal wall closure. Such recovery is typically easy. The intake through oral intake may restart in a few days and complete wound healing may take 12 weeks. It is necessary to provide proper postoperative care, watch against infection or leakage, and be concerned with nutrition to have optimal results.

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FAQ

How the procedure is done?

• Spontaneous closure: Temporary gastrostomy tracts may close spontaneously in 1–2 days.
• Surgical closure: The tract is excised and the stomach and abdominal wall closed in layers under general anaesthesia.

How Long Does Recovery Take?

• Spontaneous closure: It takes usually 1–2 days for the stoma to close.
• Surgical closure: Typical wound healing, 1 to 2 weeks, tissue healing 4 to 6 weeks.

When Can I Eat Normally?

• Oral intake can usually be restarted gradually at 24 hours if a surgical closure was performed.
• Begin with liquids, advance as tolerated to soft diet.

Is it Safe to Close the Gastrostomy in a Child?

• Yes. Closure of the pediatric gastrostomy is safe and effective, but children need to be monitored intently due to smaller tissues and potential underlying conditions.

Will the Stomach or Abdomen Look Normal Afterwards?

• Yes, with proper closure, the stomach and abdominal wall heal leaving normal anatomy.
• Most patients have no long-term problems returning to normal activities and feeding.