—The stomach is opened for purposes of exploration or for removal of foreign bodies, as may be needed, and then promptly and completely closed when the opening has permitted such diagnosis or removal, or after a diseased area in its interior has been exposed by incision. Such may be the procedure in certain cases of gastric ulcer, where the stomach is opened, its entire lining examined and the sharp spoon or cautery applied, with or without linear suture. The stomach is also opened for dilatation of its orifices as in cases of cardiospasm or pyloric stenosis, although the latter procedure has given way to anastomotic methods, which are more permanent in their results.
The stomach having been exposed, usually by a sufficiently long median incision, it is brought out and divided at a point of election, the incision being made of sufficient length to permit introduction of forceps or finger, or even of more or less eversion of its interior surface in order that it may be carefully inspected. The purposes of the opening having been achieved, it is closed as indicated above, with at least two layers of sutures. A perfectly clean wound will scarcely call for drainage. One which has been infected should be protected in this way.
Gastrotomy has also been done in order to permit of the retrograde division of strictures of the esophagus, when it has been impossible to pass even the smallest bougie from above. In these cases it has been occasionally possible after exposing the stomach to introduce a whalebone bougie which, passing upward, may follow the tortuous passage and be made to appear in the pharynx. To its upper end may then be attached, by strong silk, the small end of another bougie, and thus guide it downward as the first one is withdrawn. This procedure has been improved on by Abbe, who has thus been able to pull down from the mouth a stout piece of coarse silk, bringing it out through the stomach opening, and then, by a species of sawing manipulation, divide the tightest and densest part of an esophageal stricture sufficiently to permit of the passage of some other instrument. This having been accomplished the stomach wound is immediately closed.
Gastrostomy.
—This term implies making an opening into the stomach by which its cavity may be directly connected with the exterior abdominal surface, and the communication thus established maintained indefinitely. The procedure itself is necessary in cases of dense stricture or malignant disease of the esophagus, or the growth of such a tumor in its vicinity as shall occlude it, and thus cause slow starvation unless atoned for in some manner. In one instance recently, where I expected to do a gastrostomy, because the stomach itself had been so destroyed by powerful caustic that not only was the esophagus ruined as such, but the stomach decreased in size and motility, I found the stomach too immovable to permit of this procedure, and accordingly utilized the duodenum just beyond the pylorus, thus making essentially a duodenostomy; the indications, however, being the same as for gastrostomy. We have, in other words, to effect a permanent gastric fistula, the older method being to make the most direct possible communication between the stomach and the surface of the body, and then to introduce a tube, or resort to some similar expedient for preventing cicatricial contraction, and perhaps even subsequent closure. Silver tubes were formerly used, whose openings were corked and kept closed when the tube was not in use. In consequence of this foreign body with the irritation it produced there was always more or less leakage and discomfort. The more recent methods have been devised with an intent of making a tunnel rather than a direct opening, through which, as needed, a soft rubber tube may be introduced, whose walls shall collapse at other times and close themselves, if necessary, with a little assistance, by pressure, thus preventing leakage. Sometimes it is possible to attain this ideal. At other times a rubber tube is worn a greater part at least of the twenty-four hours.
Fig. 529
Gastrostomy: Witzel’s method. Tube in position; sutures ready to tie. (Richardson.)
Fig. 530
