If a patient's oesophagus is obstructed, he cannot swallow food, so he starves. He cannot swallow saliva, so it drips from his mouth. You can feed him through an opening in his stomach, but this will not help him to swallow his saliva. This is such a disabling symptom, that there is little to be gained by prolonging his life merely to endure it. There is thus seldom any indication for doing a gastrostomy for inoperable carcinoma of the oesophagus or pharynx. The possible indications for it are given below. For many of them a jejunostomy is an alternative.
GASTROSTOMY INDICATIONS. (1) Strictures of a patient's oesophagus following corrosive poisoning, prior to referral for reconstruction. (2) A malignant stricture of his oesophagus or gastro-oesophageal junction, with no signs of advanced disease, and when you plan to insert a Celestin tube. (3) Operable oesophageal carcinoma to ''build him up' before referring him for resection. (4) Diseases of his pharynx or larynx which make swallowing impossible, but which can be cured (for example, retropharyngeal abscess or perforation from a fish bone). (5) Temporary postoperative drainage of his stomach, when a nasogastric tube is impractical. (6) Inoperable carcinoma of the oesophagus is seldom considered a suitable indication, see above and Section 32.24.
METHOD. Under local or general anaesthesia make a small upper median incision (9.2). Pick up the cut edges of his peritoneum and draw them apart. You will probably find that his stomach is small and tubular, so that the first thing that you see is is his great omentum or transverse colon. Pull this downwards and deliver the upper part of his stomach into the wound.
CAUTION ! Check that you really have found his stomach, and not his transverse colon by mistake!
Make a small stab wound beside the median incision and use a haemostat to pull a 12 or 14 Ch Foley catheter through it. Make the gastrostomy high on the anterior wall of his stomach, midway between its greater and lesser curves, and as far from his pylorus as you can. Hold his stomach with two pairs of Babcock's forceps, and draw it upwards and forwards into a cone. Make a small incision between the forceps, and push the catheter through this. Encircle it with 2 purse string sutures, and invaginate his stomach wall as you tie them.
CAUTION ! (1) Take the bites of the inner purse string suture through the full thickness of his stomach wall, so as to control bleeding. (2) The main dangers are haemorrhage and leaking. His gastrostomy must be as leak-proof as possible, so that his gastric juice does not enter his peritoneal cavity.
Anchor his stomach above and below the tube to his parietal peritoneum. Spigot the tube, and fix it to his skin with an encircling stitch.
Before he leaves the theatre instil some fluid (milk if possible) through it, to make sure it is patent, and to start giving him the food he so badly needs.