Gastrostomy is used to feed palliative patients with dysphagia. Currently, the preference is given to percutaneous puncture methods of gastrostomy, which do not require general anesthesia. Percutaneous puncture techniques are possible only if the patency of the upper parts of the digestive tract still exists for the «pull method» and can require additional X-ray irradiation in case of the «push method». These operations require expensive disposable kits, which affects the prevalence and availability of the technique. Therefore, the use of an alternative minimally invasive gastrostomy through minilaparotomy is justified. Minimal-invasive pressure gastrostomy is known for a long time, and in combination with small access, it can be successfully used to provide nutrition for palliative patients with dysphagia. Most patients with dysphagia have a thin anterior abdominal wall, which allows using minimal access. It is important to choose the right place of the incision so that access is in the area of the formation of the fistula. To obtain additional diagnostic information one can use a radiography of the abdominal cavity, which shows the gas bubble of the stomach, and other high-tech methods: ultrasound, spiral computed tomography, etc. At the same time such patients do not require general anesthesia, it is possible to perform the operation under a local anesthesia. The article provides a detailed description of the technique of minimal invasive laparotomy gastrostomy and two clinical observations of palliative patients who underwent this operation.
Complete care of a patient is important in palliative medicine. The necessity of nutrition support is determined by the severity of nutritive, trophic deficit, features of diseases which can cause (or which have already caused) protein-energy deficiency. Nutritive support is a multidisciplinary problem: it concerns not only a dietitian and an intensive care specialist but also a surgeon, a gastroenterologist, an oncologist, a dentist and other specialists who face patients unabled to satisfy their needs by physiological way. The feeding using gastral tube or gastrostomy should be special because oral cavity is switched off the nutrition. Efficiency of treatment rises while adapting enteral nutrition to specialties of digestion and metabolism in various types of pathology. Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction and in patients who are critically ill. Enteral nutrition is often used for children as well as for adults. Children may require enteral feeding for a wide range of underlying conditions, such as for malnutrition, for increased energy requirement, for metabolic disorders and also for children with neuromuscular disorders. Two main steps help to solve the problem of malnutrition: choosing the composition of formula and choosing the way to deliver the formula. This article gives a specification in using various feeding formulas according to different diseases and describes different ways to deliver the formula (from gastral tube to gastrostomy). If swallowing reflex is absent the formula should be delivered directly to stomach. The best way for a long-term or permanent nutrition support is feeding using gastrostomy. This article describes some surgical aspects of different types of gastrostomy from classical one to modern percutaneous endoscopic gastrostomy.
Nutrition is an important problem of palliative care. If oral feeding is not possible, percutaneous endoscopic gastrostomy (PEG) is the method of choice. The wide application of the procedure is limited by the cost of single-use sets produced in other countries. The aim of the study was to review methodic of the PEG and to find an opportunity to reduce its cost. A reusable device was developed for the application of the PEG with use of a Pétzzer catheter. Approbation of the device and methodic was carried out in experiment with 10 rabbits. In 2 cases animals died on the 5th and 6th day after the operation because of acute pneumonia and enterocolitis, complications from the operating wound and gastrostomy were absent. Remaining 8 rabbits were withdrawn from the experiment on the 10-13 day after the operation. In 3 cases purulent infection of the postoperative wound and formation of abscesses of abdominal cavity were revealed, while the gastrostomic fistula was without any signs of failure. In 5 cases were no complications. The gastrostomic fistula was placed next to laparotomic wound and was not complicated in all cases. All the described complications are considered to features of laparotomy and postoperative period in animals. The constructed analogue of the PEG allow significantly reduce costs and increase the economic efficiency of minimally invasive gastrostomy, reduce dependence on foreign materials. Encouraging results obtained in animal experiments allow testing of the technique in clinical settings.
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