Vol. 11.5. January Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1976 by The Williams & Wilkins Co.
URINARY DIVERSION: ADJUNCTIVE TUBE GASTROSTOMY DAVID L. FRO MANG AND DAVID M. DRYLIE From the Diuision of Urology, Department of Surgery, Uniuersity of Florida College of Medicine, Gainesuille, Florida
ABSTRACT
A series of 98 patients who had undergone construction of ilea! conduits is discussed. Of the 76 patients who had gastrostomy drainage 2 had complications related to the procedure. Complications occurred in 6 of the 22 patients who had nasogastric drainage. The advantages and of decompression tube gastrostomy and the nasogastric tube are discussed. We conclude that the tube has a definite place in and adult cases in which ileus may be expected. nasogastric
drainage with vomiting and There have been other complications from nasogastric tubes in the 21 adult patients who did not undergo gastrostomy. There were 3 cases of prolonged ileus with tube placement exceeding 10 days, 1 case of severe pneumonia and 1 gastric bleeding episode that required ice water lavage and antacid therapy. One paraplegic patient in the adult gastrostomy group died of sepsis from enteroenteric fistulas and recrudescent osteomyelitis. During a prolonged hospital course the patient suffered gastric bleeding thought to be secondary to stress ulceration. However, irritation of the gastric mucosa from the Foley catheter tip could not be ruled out as the initiating factor in the ulcer formation. One 14-month-old child had undergone cystectomy, appendectomy, construction of ilea! conduit and gastrostomy drainage. The patient had bleeding from the gastrostomy tube and dehiscence of the wound 3 days postoperatively. Nine days postoperatively a left subphrenic abscess developed to the intraperitoneal leakage of gastric fluid. The abscess was drained and the patient subsequently recovered.
Ureteroileocutaneous urinary diversion or an ilea] conduit is the primary method of diversion used at our hospital. Herein we report 98 cases of ilea! conduit urinary diversion using postoperative gastric decompression with a nasogastric tube or with tube gastrostomy. Use of the tube gastrostorny is discussed as an alternative to nasogastric intubation in these cases.
8
PATIENTS AND METHODS
The patients ranged in age from 4 months to 82 years and had undergone the construction of an ilea! conduit for a variety of clinical indications. Neurogenic bladder dysfunction was the most frequent indication for urinary diversion in the 40 pediatric patients. In these cases ureteral decompensation, vesicoureteral reflux, incontinence and chronic urinary tract infection dictated surgical intervention. In the 58 adults the most frequent diagnosis was carcinoma of the bladder but many patients were operated upon for a persistent vesicovaginal fistula and a neurogenic bladder. Basically, the ilea! conduit procedures were carried out as described by Bricker. 1 • 2 The ureteroileal anastomoses were modified in some cases as described by Albert and Persky. 3 A gastrostomy tube was placed during the operation in :-l7 of the 58 adults (64 per cent) and in 39 of the 40 children (98 per cent). We favored a combination of the Dragstedt technique,4 which places 3 layers of omentum between the stomach wall and parietal peritoneum, and the Stamm technique, 4 which approximates the stomach wall to the parietal peritoneum with suture. The omental barrier and suture approximation of the stomach to the lateral peritoneum prevent intraperitoneal gastric leakage and fistula formation when the tube is removed. In children and the small stomach size and relative lack of omentum require that the more formal Stamm procedure be used.' The nasogastric and gastrostomy tubes were connected to low, intermittent suction for 3 to 5 days. The tubes were clamped or removed when the patients had evidence of visceral motility, such as increased bowel sounds and the passage of flatus. The gastrostomy tubes were kept in place for a minimum of 10 days.
DISCUSS IOI\
Decompression of the stomach following an abdominal operation is desirable to prevent gastric and bowel distension resulting from an accumulation of swallowed air and upper gastrointestinal secretions.9 Decompression has been accomplished mainly by use of nasogastric tubes or temporary tube gastrostomy. Other methods such as jejunostomy have been proposed' but this discussion is limited to a comparison of gastrostomy and nasogastric tube drainage. Nasogastric tube drainage is the method most commonly used after urinary diversion procedures in which bowel anastomoses are accomplished. Most authorities advocate its use for a minimum of 4 days. 10, " Temporary tube gastrostomy should be considered more often following ureteroileocutaneous anastomoses and similar operative procedures. When compared to nasogastric drainage it has various advantages: 1) Enhanced patient comfort. When given a choice patients usually choose gastrostomy. Patients who have experienced both universally favor gastrostomy. Postoperative respiratory therapy is facilitated in those patients not encumbered with the nasogastric tube. 2) Decreased oral, pharyngeal and esophageal secretions. Gilles by and Puestow showed that the addition of nasogastric tubes increased gastrostomy drainage on the average of 750 ml. per 24 hours. 12 Increased nasopharyngea! secretions raise the for aspiration and its attendant
RESULTS
The number and variety of complications for the basic ilea! conduit procedure were similar to those of other series. s, 7 Prior to routine use of the tube gastrostomy 1 adult died of poor Accepted for publication June 20, 1975. Read at annual meeting of American Urolo,;ical Association, Miami Beach, Florida. May 11-LS, 1975.
27
28
FROMANG AND DRYLIE
3) Decreased upper airway injury. Ulceration of the ala nasi, excoriation of the nasal septum and acute pharyngitis have been reported as complications necessitating premature tube removal. 13 4) Decreased gastric and duodenal injury. Ulceration and stricture formation as well as gastric and duodenal perforation have been reported as complications of nasogastric drainage. 13 5) Enhanced gastric drainage. Poor placement of the nasogastric tube and its small size may result in inadequate drainage. This is not observed with gastrostomy drainage. The advantages are accentuated in children and, therefore, gastrostomy tube drainage in children is to be preferred.•. 1 • Disadvantages of temporary tube gastrostomy are limited: 1) Necessity of opening upper abdomen. This has been considered a contraindication in those few patients in whom operative exposure was only infraumbilical. 2) Increased operating time. From 10 to 20 minutes are required to accomplish the gastrostomy. 3) Possible intraperitoneal leakage. This complication is minimized, as previously discussed, by use of the Dragstedt modification of the Stamm procedure. 4) Necessity of leaving the tube in place 10 days. With the possible exception of vague gastric discomfort, possibly caused by motility aberrations, no patient has complained of discomfort relating to the presence of the clamped gastrostomy tube. 5) Small and thin omentum in children. This probably dictates a more formal Stamm gastrostomy. When the advantages and disadvantages are compared, it seems that temporary tube gastrostomy is the preferred method for gastric drainage after urological operative procedures involving bowel anastomoses.
REFERENCES
1. Bricker, E. M.: Symposium on clinical surgery: bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 2. Bricker, E. M.: Substitution for the urinary bladder by use of isolated ilea! segments. Surg. Clin. N. Amer., 36: 1117, 1956. 3. Albert, D. J. and Persky, L.: Conjoined end-to-end uretero-intestinal anastomosis. J. Urol., 105: 201, 1971. 4. Cunha, F.: Gastrostomy; its inception and evolution. Amer. J. Surg., 72: 610, 1946. 5. Gallagher, M. W., Tyson, K. R. and Ashcraft, K. W.: Gastrostomy in pediatric patients: an analysis of complications and techniques. Surgery, 74: 536, 1973. 6. Engel, R. M.: Complications of bilateral uretero-ileo cutaneous urinary diversion: a review of 208 cases. J. Urol., 101: 508, 1969. 7. Cohen, S. M. and Persky, L.: A ten-year experience with ureteroileostomy. Arch. Surg., 95: 278, 1967. 8. Drylie, D. M. and Miller, G. H., Jr.: Ilea! conduit for urinary diversion with postoperative gastrostomy. Amer. Surg., 31: 102, 1965. 9. Smith, G. K. and Farris, J. M.: Re-evaluation of temporary gastrostomy as a substitute for nasogastric suction. Amer. J. Surg., 102: 168, 1961. 10. Campbell, M. F. and Harrison, J. H.: Urology, 3rd ed. Philadelphia: W. B. Saunders Co., p. 2330, 1970. 11. Glenn, J. F. and Boyce, W. H.: Urologic Surgery, 1st ed. New York: Harper & Row, Publishers, p. 628, 1969. 12. Gillesby, W. J. and Puestow, C. B.: Tube gastrostomy in abdominal surgery. Amer. Surg., 25: 927, 1959. 13. Farris, J. M. and Smith, G. K.: Evaluation of temporary gastrostomy-a substitute for nasogastric suction. Ann. Surg., 144: 475, 1956. 14. Holder, T. M., Leape, L. L. and Ashcraft, K. W.: Gastrostomy: its use and dangers in pediatric patients. New Engl. J. Med., 286: 1345, 1972.
THE JOURNAL OF UROLOGY
Copyright © 1976 by The Williams & Wilkins Co.
URINARY DIVERSION: ADJUNCTIVE TUBE GASTROSTOMY DAVID L. FRO MANG AND DAVID M. DRYLIE From the Diuision of Urology, Department of Surgery, Uniuersity of Florida College of Medicine, Gainesuille, Florida
ABSTRACT
A series of 98 patients who had undergone construction of ilea! conduits is discussed. Of the 76 patients who had gastrostomy drainage 2 had complications related to the procedure. Complications occurred in 6 of the 22 patients who had nasogastric drainage. The advantages and of decompression tube gastrostomy and the nasogastric tube are discussed. We conclude that the tube has a definite place in and adult cases in which ileus may be expected. nasogastric
drainage with vomiting and There have been other complications from nasogastric tubes in the 21 adult patients who did not undergo gastrostomy. There were 3 cases of prolonged ileus with tube placement exceeding 10 days, 1 case of severe pneumonia and 1 gastric bleeding episode that required ice water lavage and antacid therapy. One paraplegic patient in the adult gastrostomy group died of sepsis from enteroenteric fistulas and recrudescent osteomyelitis. During a prolonged hospital course the patient suffered gastric bleeding thought to be secondary to stress ulceration. However, irritation of the gastric mucosa from the Foley catheter tip could not be ruled out as the initiating factor in the ulcer formation. One 14-month-old child had undergone cystectomy, appendectomy, construction of ilea! conduit and gastrostomy drainage. The patient had bleeding from the gastrostomy tube and dehiscence of the wound 3 days postoperatively. Nine days postoperatively a left subphrenic abscess developed to the intraperitoneal leakage of gastric fluid. The abscess was drained and the patient subsequently recovered.
Ureteroileocutaneous urinary diversion or an ilea] conduit is the primary method of diversion used at our hospital. Herein we report 98 cases of ilea! conduit urinary diversion using postoperative gastric decompression with a nasogastric tube or with tube gastrostomy. Use of the tube gastrostorny is discussed as an alternative to nasogastric intubation in these cases.
8
PATIENTS AND METHODS
The patients ranged in age from 4 months to 82 years and had undergone the construction of an ilea! conduit for a variety of clinical indications. Neurogenic bladder dysfunction was the most frequent indication for urinary diversion in the 40 pediatric patients. In these cases ureteral decompensation, vesicoureteral reflux, incontinence and chronic urinary tract infection dictated surgical intervention. In the 58 adults the most frequent diagnosis was carcinoma of the bladder but many patients were operated upon for a persistent vesicovaginal fistula and a neurogenic bladder. Basically, the ilea! conduit procedures were carried out as described by Bricker. 1 • 2 The ureteroileal anastomoses were modified in some cases as described by Albert and Persky. 3 A gastrostomy tube was placed during the operation in :-l7 of the 58 adults (64 per cent) and in 39 of the 40 children (98 per cent). We favored a combination of the Dragstedt technique,4 which places 3 layers of omentum between the stomach wall and parietal peritoneum, and the Stamm technique, 4 which approximates the stomach wall to the parietal peritoneum with suture. The omental barrier and suture approximation of the stomach to the lateral peritoneum prevent intraperitoneal gastric leakage and fistula formation when the tube is removed. In children and the small stomach size and relative lack of omentum require that the more formal Stamm procedure be used.' The nasogastric and gastrostomy tubes were connected to low, intermittent suction for 3 to 5 days. The tubes were clamped or removed when the patients had evidence of visceral motility, such as increased bowel sounds and the passage of flatus. The gastrostomy tubes were kept in place for a minimum of 10 days.
DISCUSS IOI\
Decompression of the stomach following an abdominal operation is desirable to prevent gastric and bowel distension resulting from an accumulation of swallowed air and upper gastrointestinal secretions.9 Decompression has been accomplished mainly by use of nasogastric tubes or temporary tube gastrostomy. Other methods such as jejunostomy have been proposed' but this discussion is limited to a comparison of gastrostomy and nasogastric tube drainage. Nasogastric tube drainage is the method most commonly used after urinary diversion procedures in which bowel anastomoses are accomplished. Most authorities advocate its use for a minimum of 4 days. 10, " Temporary tube gastrostomy should be considered more often following ureteroileocutaneous anastomoses and similar operative procedures. When compared to nasogastric drainage it has various advantages: 1) Enhanced patient comfort. When given a choice patients usually choose gastrostomy. Patients who have experienced both universally favor gastrostomy. Postoperative respiratory therapy is facilitated in those patients not encumbered with the nasogastric tube. 2) Decreased oral, pharyngeal and esophageal secretions. Gilles by and Puestow showed that the addition of nasogastric tubes increased gastrostomy drainage on the average of 750 ml. per 24 hours. 12 Increased nasopharyngea! secretions raise the for aspiration and its attendant
RESULTS
The number and variety of complications for the basic ilea! conduit procedure were similar to those of other series. s, 7 Prior to routine use of the tube gastrostomy 1 adult died of poor Accepted for publication June 20, 1975. Read at annual meeting of American Urolo,;ical Association, Miami Beach, Florida. May 11-LS, 1975.
27
28
FROMANG AND DRYLIE
3) Decreased upper airway injury. Ulceration of the ala nasi, excoriation of the nasal septum and acute pharyngitis have been reported as complications necessitating premature tube removal. 13 4) Decreased gastric and duodenal injury. Ulceration and stricture formation as well as gastric and duodenal perforation have been reported as complications of nasogastric drainage. 13 5) Enhanced gastric drainage. Poor placement of the nasogastric tube and its small size may result in inadequate drainage. This is not observed with gastrostomy drainage. The advantages are accentuated in children and, therefore, gastrostomy tube drainage in children is to be preferred.•. 1 • Disadvantages of temporary tube gastrostomy are limited: 1) Necessity of opening upper abdomen. This has been considered a contraindication in those few patients in whom operative exposure was only infraumbilical. 2) Increased operating time. From 10 to 20 minutes are required to accomplish the gastrostomy. 3) Possible intraperitoneal leakage. This complication is minimized, as previously discussed, by use of the Dragstedt modification of the Stamm procedure. 4) Necessity of leaving the tube in place 10 days. With the possible exception of vague gastric discomfort, possibly caused by motility aberrations, no patient has complained of discomfort relating to the presence of the clamped gastrostomy tube. 5) Small and thin omentum in children. This probably dictates a more formal Stamm gastrostomy. When the advantages and disadvantages are compared, it seems that temporary tube gastrostomy is the preferred method for gastric drainage after urological operative procedures involving bowel anastomoses.
REFERENCES
1. Bricker, E. M.: Symposium on clinical surgery: bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 2. Bricker, E. M.: Substitution for the urinary bladder by use of isolated ilea! segments. Surg. Clin. N. Amer., 36: 1117, 1956. 3. Albert, D. J. and Persky, L.: Conjoined end-to-end uretero-intestinal anastomosis. J. Urol., 105: 201, 1971. 4. Cunha, F.: Gastrostomy; its inception and evolution. Amer. J. Surg., 72: 610, 1946. 5. Gallagher, M. W., Tyson, K. R. and Ashcraft, K. W.: Gastrostomy in pediatric patients: an analysis of complications and techniques. Surgery, 74: 536, 1973. 6. Engel, R. M.: Complications of bilateral uretero-ileo cutaneous urinary diversion: a review of 208 cases. J. Urol., 101: 508, 1969. 7. Cohen, S. M. and Persky, L.: A ten-year experience with ureteroileostomy. Arch. Surg., 95: 278, 1967. 8. Drylie, D. M. and Miller, G. H., Jr.: Ilea! conduit for urinary diversion with postoperative gastrostomy. Amer. Surg., 31: 102, 1965. 9. Smith, G. K. and Farris, J. M.: Re-evaluation of temporary gastrostomy as a substitute for nasogastric suction. Amer. J. Surg., 102: 168, 1961. 10. Campbell, M. F. and Harrison, J. H.: Urology, 3rd ed. Philadelphia: W. B. Saunders Co., p. 2330, 1970. 11. Glenn, J. F. and Boyce, W. H.: Urologic Surgery, 1st ed. New York: Harper & Row, Publishers, p. 628, 1969. 12. Gillesby, W. J. and Puestow, C. B.: Tube gastrostomy in abdominal surgery. Amer. Surg., 25: 927, 1959. 13. Farris, J. M. and Smith, G. K.: Evaluation of temporary gastrostomy-a substitute for nasogastric suction. Ann. Surg., 144: 475, 1956. 14. Holder, T. M., Leape, L. L. and Ashcraft, K. W.: Gastrostomy: its use and dangers in pediatric patients. New Engl. J. Med., 286: 1345, 1972.
