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Esophagostomy Feeding Tubes CB feb 14--prop esoph tube_CBR_ 1/27/14 5:47 PM Page 66 Procedures Pro Surgery / Critical Care Peer Reviewed Esophagostomy Feeding Tubes Becca Hodshon, DVM, DACVS Karen M. Tobias, DVM, MS, DACVS BluePearl Veterinary Partners University of Tennessee Louisville, Kentucky nteral nutrition is indi- Compared with nasoesophageal and jejunostomy feeding tubes, cated for conditions that esophagostomy tubes can be large enough to permit feeding a Eprevent oral food intake blenderized commercial canned diet. Unlike pharyngostomy or result in chronic caloric tubes, esophagostomy tubes do not cause pharyngeal or laryn- insufficiency and is useful geal irritation or blockage. Unlike gastrostomy or jejunostomy for fluid supplementation or tubes, esophagostomy tubes can be removed any time after administration of medications placement. in intractable animals. When the esophagus and stomach are Placement functional, enteral feeding can General anesthesia with endotracheal intubation is recom- be provided via an esophagos- mended. Animals should be fully anesthetized to minimize risk tomy tube. Benefits include minimal cost; limited equipment for gag reflex when the tube or instruments are passed through requirements; and rapid, easy placement, especially in cats and the pharynx. Pharyngeal stimulation can cause the patient to smaller dogs (see Benefits & Disad- vantages of Esophagostomy Tubes). Esophagostomy tubes are well toler- Benefits & Disadvantages of Esophagostomy Tubes ated and do not interfere with eating or drinking. Benefits Disadvantages The main disadvantage is the neces- I Minimal cost I General anesthesia necessary sity for general anesthesia. When I Limited equipment needed I Possibly challenging to place in giant placing an esophagostomy tube in a breed or obese patients giant breed or obese patient, which I Rapid, easy placement I can be challenging, specialized per- I Well tolerated Contraindicated in patients with persist- cutaneous feeding tube applicators ent vomiting I No interference with eating (ELD Tube Applicator, jorvet.com) I or drinking Usually not recommended in patients may help. Esophagostomy tube feed- that have: ing is contraindicated in patients I Allows feeding of a blender- – Undergone esophageal surgery with persistent vomiting and is not ized commercial canned diet – Esophageal disorders (eg, megaesopha- usually recommended in animals I No pharyngeal or laryngeal gus, esophageal strictures or neoplasia, that have undergone esophageal sur- irritation or blockage gery or have esoph ageal disorders esophagitis, vascular ring anomalies I Can be removed any time causing esophageal stenosis) (eg, megaesophagus, esophageal after placement strictures or neoplasia, esophagitis, esophageal stenosis from vascular ring anomalies). 66 cliniciansbrief.com • February 2014 CB feb 14--prop esoph tube_CBR_ 1/27/14 5:47 PM Page 67 vomit, awaken, or bite reflexively. Large-bore tube selection Tube obstruction with food or medications (common) can usu- should be based on the size of the patient; a 14- to 20-French ally be remedied by flushing warm water in and out of the tube red rubber, silicone elastomer, or polyurethane tube can be using alternating gentle pressure and suction. If unsuccessful, used. Esophagostomy tubes can be placed in either side of the carbonated water or a pancreatic enzyme slurry can be instilled neck, depending on proximity of the esophagus, which can be into the tube and allowed to sit for an hour before reapplying evaluated during tube placement. pressure and suction. Obstructions rarely require a guide wire to unclog the tube, which is more common if the tube has a blind Feeding end, a nonblenderized diet is fed, or administration of solid Blenderized commercial canned food is recommended for medications (eg, crushed tablets) has been attempted. To pre- esophagostomy tube feeding. Canned recovery diets are less vent clogs, tubes should be flushed with 10 to 20 mL of warm likely to clog the tube and have the highest caloric density but water before and after each feeding, depending on patient and may cause diarrhea. Food can be administered as bolus meal tube size. Straining blenderized food can help prevent tube feedings several times a day or, with liquid diets, as continuous obstructions, especially when small tubes are used. infusion. The resting energy requirement (RER) of the patient should be calculated: The risk for cellulitis and peristomal inflammation is increased if a purse-string suture is placed around the stoma. Inflamma- RER = 70 ¥ (body weight[kg]0.75) tion and infection around the stoma site generally resolve with tube removal and local wound therapy; stomas should always be Alternatively, RER for animals weighing more than 2 kg can be left to heal by second intention. Hemorrhage during tube place- calculated: ment (uncommon) may occur if a skin incision is made before the forceps tips are pushed through the esophageal wall and RER = 30 ¥ (body weight[kg]) + 70 subcutaneous tissue. The patient should be fed approximately 25% to 30% of its Esophageal leakage through esophageal wall tears (also uncom- caloric requirement on the first day of feeding, with subsequent mon) can occur in very young patients with friable tissue, if gradual increases of 25% to 30% of its caloric requirement per multiple attempts have been made to pass the tube or an exces- day.1-3 This may not always be necessary but is recommended sively large stoma is in the esophageal wall. Esophagitis and to reduce risk for refeeding syndrome in patients with anorexia vomiting may occur if the tube passes through the lower or hyporexia for more than 3 to 5 days’ duration.1,3 Refeeding esophageal sphincter. syndrome manifests as dramatic decreases in phosphate, mag- nesium, and potassium and can result in potentially fatal pul- Patients rarely vomit and dislodge the tube, allowing the end to monary, cardiovascular, neurologic, and neuromuscular protrude from the mouth (more common with smaller, soft abnormalities. tubes). The patient can then bite through the tube, resulting in a gastric foreign body. Tube dislodgement requires replacement Gastric capacities for cats and dogs are 5 to 10 mL/kg during under general anesthesia; immediate replacement through the food reintroduction, but capacities as high as 45 to 90 mL/kg existing stoma is possible if the tube has been in place long have been measured after complete realimentation.2,3 With enough for fibrous tissue formation. bolus feeding, the daily volume of food is divided into 4 to 6 feedings according to estimated stomach capacity. Daily fluid Aspiration pneumonia is a potential complication of enteral tube requirements should be calculated based on amount of water in feeding. Risk factors include absence of a gag or cough reflex, or added to the canned diet and used to flush the tube. impaired mental status, neurologic injury, mechanical ventila- tion, presence of laryngeal disease (especially after arytenoid Complications lateralization surgery), and previous aspiration pneumonia. In Complications, usually minor, may include tube obstruction, patients at high risk for aspiration pneumonia, gastrostomy or swelling of head and neck from an overly tight bandage, peri - jejunostomy tubes should be considered over esophagostomy stomal dermatitis or cellulitis, inflammation, and stomal infec- tubes. To reduce aspiration risk, feeding should not start until the tion and abscessation.4,5 patient has fully recovered from anesthesia and can be kept in a sternal position. MORE February 2014 • Clinician’s Brief 67 CB feb 14--prop esoph tube_CBR_ 1/27/14 5:48 PM Page 68 Procedures Pro What You Will Need I Clippers, 4% chlorhexidine scrub, gauze or roll cotton (for aseptic prep) I Sterile gloves I Sterile Huck towels and towel clamps (optional) I Sterile needle holders I Mayo suture scissors I Curved Carmalt (medium and large dogs) or Kelly (cats and small dogs) forceps with long jaws and fine tips I Scalpel blade I 14- to 20-French red rubber, silicone elastomer, or polyurethane tube I Tubing adapter and injection cap (to permit capping of tube) I 0 or 2-0 nylon suture I Nonionic iodinated radiographic contrast (eg, iohexol) I Triple antibiotic ointment I Nonadherent dressing and bandage material I Fabric, washable esophageal feeding-tube collar (eg, Kitty Kollar, kittykollar.com; optional) Step-by-Step I Esophageal Tube Placement Step 1 Step 2 Place the anes- Premeasure the thetized patient tube from the in lateral recum- midcervical bency and clip esophagus to and aseptically the level of the prepare the 5th–8th inter- lateral cervical costal space. region. Step 3 Author Insight To ensure appropriate place- Cut the tip of the tube to remove any ment, use a permanent blind end and to ensure appropriate marker to indicate where length. Alternatively, if the tube does the tube will be level with not need to be shortened, elongate the skin when properly the side-hole opening to help prevent positioned. Alternatively, clogging. The tube should be long have a second tube of the enough so that the proximal end same length available. exiting the neck can be gently curved away from the head. 68 cliniciansbrief.com • February 2014 CB feb 14--prop esoph tube_CBR_ 1/27/14 5:48 PM Page 69 Step 4 Insert Carmalt (medium and large dogs) or Kelly (cats and small dogs) forceps through the oral cavity and into the cervi- cal esophagus with the tips facing outward. Choose forceps that are long and narrow enough to pass caudal to the hyoid apparatus. Step 5 Tilt the forceps (ie, lower the handle toward the table) so the tips (arrow) are pressing the esophagus outward and dorsal to the jugular vein, and palpate the neck to determine where the esophagus is most superficial. Placing a sandbag or towel under the neck may facilitate passing and tilting the forceps and aid in isolation of the esophagus against the skin. Step 6 Using the palm of the dominant hand, apply steady pressure to ity of carotid artery and vagosympathetic trunk to the esopha - the forceps rings (A), making sure not to insert fingers into the gostomy tube), and other neurovascular structures aside to pre- rings.
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