Gastrostomy Retrograde Threading

Gastrostomy retrograde threading

Gastrostomy retrograde threading is a procedure utilized when inserting a gastrostomy tube- the tube or guidewire is laid forward through the stomach (retrograde) as opposed to laid backward through the mouth (down).

What is retrograde threading?

Retrograde threading involves inserting a tube or guidewire through a gastrostomy puncture in the stomach and advancing it out of the mouth or nose, or by railroading a feeding tube through the same path and outside the abdomen. It is, essentially, the backward (mouth-to-stomach) direction. 

When is it used?

The retrograde threading is particularly helpful when access to the esophagus or the mouth is challenging or impossible, e.g.:

• Esophageal atresia (without final repair)
• The presence of severe esophageal strictures.
• Post-esophageal surgery
• Unsuccessful or unsecure PEG insertion.
• Children with small or deformed anatomy pediatric patients.
• Neurocognitive disorder with aspiration risk.

Retrograde gastrostomy procedure

Retrograde gastrostomy is a surgical method whereby the feeding tube is passed through the stomach and outwardly as opposed to passing through the mouth and stomach. It is routinely applied to the pediatric surgical procedure and in patients with esophageal obstruction or challenging access to the upper-GI.

Preoperative preparation

• Nil orally according to age and condition.
• Prophylactic antibiotics
• Nasogastric tube (where possible) to decompose.
• General anaesthesia

Procedure:

Gastric and abdominal access

• Surgery through laparoscopic or open procedure.
• The stomach is located and pulled near the wall of the abdomen.
• On the anterior gastric wall, a small gastrotomy is made.

Introduction of guidewires retrogradely

• An endoscopic operation through the gastrotomy involves a soft catheter or guidewire.
• It is projected up to the esophagus.
• The guide wire will be removed via the mouth or nose.

Tube attachment

• The feeding tube (gastrostomy tube, PEG tube) is firmly bound to the oral tube of guidewire.

Retrograde pull-through

• The dissection on the gastrointestinal/abdominal side is performed with slow withdrawal of the guidewire.
• This draws the feeding tube up the esophagus and into the stomach. 

Tube fixation

• Internal retention device (balloon or bumper) is found in the stomach.
• The plate of external fixation is attached to the abdominal wall.
• Sutures may be done to gastropexy where required.

Postoperative care

• The feeding normally begins after 12-24 hours.
• Slow feed volume increment.
• Daily stoma cleaning
• Tie tube and ensure it is not removed accidentally.

Gastrostomy retrograde tube placement

Retrograde gastrostomy is the placement of a gastrostomy tube through the mouth or esophagus to the stomach (as an internal procedure), as opposed to through the skin (as an external procedure). It is widely used in cases in which the standard antegrade percutaneous gastrostomy is difficult due to anatomic, prior surgical or obstructive reasons. 

Indications

• Patients with difficult abdominal access
• Failed standard percutaneous endoscopic gastrostomy (PEG).
• Pediatric or neonatal patient in whom the usual PEG is not feasible. 
• Cases that mandate controlled placement to reduce complications.

Retrograde gastrostomy surgery

Retrograde gastrostomy is a surgical procedure in which a feeding tube is inserted into the stomach through the anterior abdominal wall, often under direct visualization. This is usually performed when the percutaneous or endoscopic approaches are contraindicated or failed. 

Procedure Overview:

Preoperative Preparation

• Patient fasting for 6–8 hours.
• General anaesthesia in either an adult or a child.
• Prevention with antibiotics against infection.
• Preoperative x-rays to determine the location of the stomach and the structures involved.

Surgical Access

• A small incision (typically left upper quadrant) is established on the upper abdomen.
• Careful identification and mobilization of the stomach is done to prevent any damage to other organs.

Retrograde Tube Placement

• A minimal gastrotomy (incision to the stomach) is done.
• The tube used to feed is implanted through inside the stomach through the stomach wall into the abdomen.
• Sutures or a retention device is used to attach the external end of the tube.

Securing the Stomach

• The stomach is fixed to the abdominal wall to ensure that there is no dislodgement and leakage of the tube (gastropexy).
• Function of tubes is assessed by injecting sterile saline or contrast.

Closure

• The tube is wrapped with closure of the gastrotomy site.
• Incision of the abdomen is done in layers.

Gastrostomy retrograde complications

Retrograde gastrostomy is considered to be a safe procedure, but like all surgeries or endoscopic procedures, there are risks involved. These complications can be classified as early (immediate/postoperative) and late (long-term).

Early Complications 

• Bleeding
• Infection
• Peritonitis
• Tube Dislodgement or Malposition
• Gastric Injury

Late Complications

• Tube Blockage or Occlusion
• Skin Irritation or Granulation Tissue
• Persistent Leakage
• Fistula Formation
• Buried Bumper Syndrome

Best hospital for retrograde gastrostomy India

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

Conclusion

During this procedure, a gastrostomy tube is placed through the abdominal wall and into the stomach for enteral feeding, via a retrograde gastrostomy. It is also valid in particular for patients in which percutaneous or endoscopic gastrostomy cannot be executed such as in patients with complex anatomy or with previous abdominal surgery or obstructions.  The operation may be done either surgically or endoscopically and enables one to see the stomach directly, minimizing future risks of damaging the surrounding organs. Although it is mostly safe, retrograde gastrostomy is associated with possible early and late complication such as an infection, bleeding, tube dislocation, leakage and uncommon occurrence of peritonitis or fistula. Correct surgical procedure, gastropexy, tube care, and follow-up are necessary to reduce risks to avoid failure with bilateral long-term utilization.

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FAQ

Is the procedure safe?

• Yes, it is usually not dangerous and in particular cases when it is done by skilled surgeons. Direct visualization minimizes the chances of damaging other organs.

When can feeding be started?

• Feeding can normally commence between 24 and 48 hours of surgery, after tube placement and functionality are verified.

What is the maximum length of stay of the tube?

• Gastrostomy tubes may last months or years with proper care. A follow up must be done regularly to monitor complications and tube activity.

Should retrograde gastrostomy be applied to children?

• Yes, it is usually favored in patients in pediatrics with complicated anatomy or unsuccessful percutaneous gastrostomy.