FEEDING TUBES

Karen Tobias, DVM, MS, DACVS

Professor, Small Animal Surgery
University of Tennessee

Enteral nutrition is recommended in patients that have not eaten for 3 or more days. Feeding the
gastrointestinal tract provides faster clinical improvement in patients with enteritis, peritonitis, and
pancreatitis. It also maintains enterocyte health and prevents villus atrophy. Enteral feeding stimulates
intestinal motility and decrease the risk of bacterial translocation.

Nasoesophageal and Nasogastric Tubes

Animals that are too debilitated to undergo anesthesia or that may require only a short period of
nutritional support (<7 days) are perfect candidates for naso-enteral feeding tubes. Tube sizes are usually
3 to 8 French in diameter, and the patient is therefore usually limited to a liquid diet. Additionally, caution
must be used when infusing crushed tablets and other medications, which could clog the tubes if not
ground finely or flushed through. Nasoenteral tubes are usually small enough in diameter that the tube
can be advanced all the way into the stomach. Large diameter tubes can permit gastroesophageal reflux
and secondary reflux esophagitis.

Sedation is usually not required for tube placement. One half to one ml of local anesthetic (0.5%
proparacaine or 2% lidocaine) is dripped into each nostril, and the patient’s head is tilted up to encourage
the local anesthetic to coat the nasal mucosa and nasopharynx. The tube is measured and marked so it
is the correct length. In dogs the tube is inserted in a ventromedial direction so it initially goes up and over
the “hump” in the rostral portion of the planum. To facilitate placement, the planum can be pushed
dorsally during the initial placement to encourage passage of the tube through the ventral meatus and
into the nasopharynx. In cats, the tube is inserted ventromedially without elevating the planum. After the
tube has been advanced caudally for 3 to 5 cm, the neck is flexed to encourage passage of the tube into
the esophagus. The tube can be secured to the side of the face or between the eyes and up over the
forehead with butterfly tape and sink staples or a finger trap pattern. Some clinicians use a small amount
of skin glue to secure the tube near the nostril.

Esophagostomy Tubes

For animals with anorexia or lesions of the oral cavity, esophagostomy tubes provide an excellent avenue
for supplying enteral nutrition. Esophagostomy tubes are quick, easy, and inexpensive to place. Unlike
gastrostomy tubes, esophagostomy tubes require no special equipment to place and can be removed at
any time after insertion. Compared to pharyngostomy tubes, they will not cause upper airway obstruction,
dysphagia, or pharyngeal irritation that stimulates vomiting. Large bore tubes can be inserted in most
patients, permitting infusion of a canned recovery diet. Although they are contraindicated in patients with
persistent or postprandial vomiting, patients with intermittent vomiting can often be fed successful by slow
continuous rate infusion through an esophagostomy tube. Esophagostomy tubes are difficult to advance
beyond the area of stenosis in animals with persistent right aortic arch or other vascular ring anomalies,
and are usually not place in animals with esophageal disorders.

Animals should be fully anesthetized during placement; when the instruments or tube pass through the
pharyngeal area, lightly anesthetized animals may awaken or reflexively bite down, potential injuring the
veterinarian. Many veterinarians intubate the patients so that the trachea will be protected during the
procedure; the endotracheal tube should be tied to the lower jaw, if possible, to keep it out of the way
during esophagostomy tube placement. Some veterinarians place mouth gags; however, these tend to
make placement more difficult.
Esophagostomy tube size is based on the size of the patient. In a cat, a 12 French red rubber catheter
may be sufficient; in dogs, tube sizes may range from 10 to 28 French. Tubes with blind ends may clog
more easily; the tube end can be removed with a slanted cut. The tube will be advanced in the
esophagus to the level of 5th to 8th intercostal space; long tubes should be cut off so that they won’t
inadvertently be advanced across the lower esophageal sphincter, which could result in gastric reflux with
subsequent esophagitis. The tube should be marked to indicate how far it should be fed down the
esophagus.

Although often inserted in the left side of the esophagus, esophagostomy tubes can also be placed
through the right side of the esophagus. The surgeon can determine the side on which the esophagus is
most superficial during initial placement of the forceps. The side of the neck is clipped and prepped. Long
curved forceps with fine tips are passed, closed, through the mouth and down the esophagus and
pressed outwards, pushing the esophagus up against the muscles and subcutis so the esophagus is
tented upward and forceps tips can be palpated. With the rings of the forceps in the palm of one hand, the
forceps are pressed through the esophagus while the opposite hand (positioned as a loose fist) applies
pressure against the neck around the tips until the tips pop through the muscles. [Alternatively, the
overlying tissues can be gradually incised and spread until the tips are visible.] The skin is incised to
expose the tips, which are opened to accept the tip of the tube. The tube is pulled through the skin,
subcutis, muscle, and esophagus and out the mouth. The tip is turned around and fed back down the
esophagus as far as possible, and then the tube end is carefully pulled out the neck until the portion of
the tube inside the esophagus unkinks, straightens, and is redirected caudally. The position is adjusted
based on the previous mark on the tube. The position of the tube is verified with a lateral radiograph, and
the tube is secured to the skin with a finger trap pattern or butterfly tape. No purse string should be used
around the stoma. The stoma is covered with a small nonadherent pad. Special neck wraps are available
to protect the stoma, hold the pad in place, and prevent premature removal of the tube. The tube can be
removed at any time after placement.

Feedings can be started once the patient is able to maintain a sitting position. Canned recovery diets are
easiest to use because they are unlikely to clog the tube. Calculated volumes should include any water
used to meet fluid requirements or flush the tube. Initially, small meals (5 to 15 mls in cats; 1 to 4 ml/kg in
dogs) are given every 3 to 4 hours until the animal has acclimated to the diet and volume; the volume is
gradually increased over 4 days. Constant infusions of liquid diet can also be used, starting at a few mls
per hour (trickle feeding) to test the animal’s response, and gradually increasing to 4 ml/kg/hour over 1 to
2 days. If patients show any signs of nausea, feedings are discontinued and a reduced volume of dilute,
warm, liquid diet is infused more slowly at the next feeding. Animals that have been anorexic for several
days or have lost a lot of weight should be evaluated for refeeding syndrome (low potassium,
phosphorus, and magnesium).

Tubes should be flushed with 5 to 10 mls of water before and after each use to prevent clogging. If the
tube clogs, it can often be unblocked with a blunt stylet (e.g., polypropylene urinary catheter), fresh
carbonated beverage, or a slurry of pancreatic enzymes. The bandage should be changed daily to allow
evaluation and cleansing of the stoma. Once the animal is eating voluntarily and can maintain adequate
nutrition, the tube can be pulled. The finger trap suture is cut, and the tube is occluded and gently pulled
from the stoma. The stoma is cleaned and bandaged daily until it has healed by second intention. Tubes
can be removed immediately after placement or left in for months. Tubes left in long term may degrade or
become brittle; because a fibrous fistula is present after several weeks, the old tube can be pulled and a
new one inserted immediately through the fistula.

Complications of esophagostomy tubes include inflammation, swelling of the head from overly tight
bandages, peristomal cellulitis, or clogging of the tube. Cellulitis is more common when the stoma has
been sutured with a purse string. Inflammation and infection around the stoma site will resolve with local
therapy and tube removal. Hemorrhage is rare as long as the tips of the forceps have been forced
through esophagus, muscle, and subcutis before the skin incision is made. Animals can vomit smaller,
soft tubes out of their mouths, so that the tube extends from the neck, through the pharynx, and out oral
cavity. This is unlikely to occur with larger, stiffer tubes. Tubes are difficult to place in some large dogs
because of limitations in forceps length. Percutaneous feeding tube applicators can also be used in place
of forceps.

Rarely, the esophagus is torn during tube placement, resulting in esophageal leakage, abscessation, and
possible sepsis. Tears may occur because the tissues are friable (e.g. very young animals), the forceps
are opened too wide while attempting to grasp the tube, or multiple attempts are made to pass the
forceps through the esophagus or pull the tube through the neck.

Surgically Placed Gastrostomy Tubes

Gastrostomy tubes provide a large port for feeding blendarized food. They also bypass the neck and
esophagus, which may be necessary when pathology is present in those areas. Because of it is minimally
invasive, percutaneous endoscopically placed gastrostomy (PEG) tubes are preferred. Surgical
placement of gastrostomy tubes is most often performed when the abdomen is to be opened for
exploration or other procedures. Benefits of surgical placement include better visualization (which avoids
inadvertent trauma to surrounding organs), improved adhesion (gastropexy) between the stomach and
body wall, and the ability to advance a smaller tube through the gastrostomy tube and into the intestine
(“J through G” tube) to provide direct enteral feedings in an animal that is vomiting. In the latter case, the
enteral tube can be removed from the gastrostomy tube once the animal has stopped vomiting so that
gastric feedings can be performed. In animals requiring long term feeding, the gastrostomy tube can be
replaced after one month with a low profile tube.

The appropriate portion of the body wall should be included in the surgical prep and draping. Unless the
tube is being placed to prevent gastric dilatation and volvulus, the tube will be positioned through the left
ventrolateral body wall and body of the stomach. A closed forceps is passed outward through the
peritoneum, muscle, and subcutis at the desired site of gastropexy, and the skin is incised over its tips.
The forceps is advanced and opened; the mushroom tip of the feeding tube (e.g., Pezzar or Malecot
mushroom tipped catheter) is grasped in the tips, flattened, and pulled through the body wall into the
abdomen. A purse string suture of 2-0 or 3-0 absorbable monofilament in placed in the stomach wall,
away from large vessels, and left loose. A stab incision is made through the stomach wall encircled by the
purse string suture; the mushroom tip of the feeding tube is flattened and inserted into the gastric lumen.
The purse string suture is tightened so that it apposes tissue around the tube without necrosing it and is
tied. Interrupted sutures are placed around the tube between stomach and body wall, starting dorsally, to
encourage adhesion formation (“pexy”). If desired, the omentum can be wrapped around the gastropexy
site for added protection against leakage; this is usually only necessary in animals with expected delayed
healing (e.g., those in renal failure or on high dose steroids). The tube is secured to the body wall with a
finger trap patter or butterfly tape. No purse string should be placed around the stoma. In cats and loose
skinned dogs, the original finger trap tissue bite should include muscle to prevent the tube from shifting
when the animal turns or stretches. Feedings can commence once the animal can be propped in a sternal
position.

Tubes are usually left in place for a minimum of 7 days while a fibrous tissue tunnel forms around the
tube and between the stomach and body wall. Removal before that time could result in gastric leakage
and peritonitis. As with esophagostomy tubes, the stoma is managed as an open wound until the site has
healed. Major complications of gastrostomy tubes include local cellulitis, leakage around the stoma (with
the potential for peritonitis or subcutaneous abscess formation), inadvertent tube removal (with the
potential for peritonitis), lack of fibrous tissue formation around the tube, or disruption of the fibrous tissue
tunnel during tube removal. Anecdotally, cats in renal failure have failed to develop these fibrous tissue
tunnels, or the tunnels have been disrupted, when the tube is pulled out a month or more after placement.