Esophagostomy Feeding Tubes

Peer ReviewedProcedures Pro Surgery / Critical Care

Esophagostomy Feeding Tubes

Becca Hodshon, DVM, DACVS BluePearl Veterinary PartnersLouisville, Kentucky

nteral nutrition is indi-cated for conditions thatprevent oral food intake

or result in chronic caloricinsufficiency and is useful for fluid supplementation oradministration of medicationsin intractable animals. When the esophagus and stomach arefunctional, enteral feeding canbe provided via an esophagos-

tomy tube. Benefits include minimal cost; limited equipmentrequirements; and rapid, easy placement, especially in cats andsmaller dogs (see Benefits & Disad-vantages of Esophagostomy Tubes).Esophagostomy tubes are well toler-ated and do not interfere with eatingor drinking.

The main disadvantage is the neces-sity for general anesthesia. Whenplacing an esophagostomy tube in agiant breed or obese patient, whichcan be challenging, specialized per-cutaneous feeding tube applicators(ELD Tube Applicator, jorvet.com)may help. Esophagostomy tube feed-ing is contraindicated in patientswith persistent vomiting and is notusually recommended in animalsthat have undergone esophageal sur-gery or have esoph ageal disorders (eg, megaesophagus, esophageal strictures or neoplasia, esophagitis,esophageal stenosis from vascularring anomalies).

66 cliniciansbrief.com • February 2014

Karen M. Tobias, DVM, MS, DACVSUniversity of Tennessee

Compared with nasoesophageal and jejunostomy feeding tubes,esophagostomy tubes can be large enough to permit feeding ablenderized commercial canned diet. Unlike pharyngostomytubes, esophagostomy tubes do not cause pharyngeal or laryn-geal irritation or blockage. Unlike gastrostomy or jejunostomytubes, esophagostomy tubes can be removed any time afterplacement.

PlacementGeneral anesthesia with endotracheal intubation is recom-mended. Animals should be fully anesthetized to minimize riskfor gag reflex when the tube or instruments are passed throughthe pharynx. Pharyngeal stimulation can cause the patient to

Benefits & Disadvantages of Esophagostomy Tubes

Benefits

� Minimal cost

� Limited equipment needed

� Rapid, easy placement

� Well tolerated

� No interference with eatingor drinking

� Allows feeding of a blender-ized commercial canned diet

� No pharyngeal or laryngealirritation or blockage

� Can be removed any timeafter placement

Disadvantages

� General anesthesia necessary

� Possibly challenging to place in giantbreed or obese patients

� Contraindicated in patients with persist-ent vomiting

� Usually not recommended in patientsthat have:

– Undergone esophageal surgery

– Esophageal disorders (eg, megaesopha-gus, esophageal strictures or neoplasia,esophagitis, vascular ring anomaliescausing esophageal stenosis)

E

CB feb 14--prop esoph tube_CBR_ 1/27/14 5:47 PM Page 66

vomit, awaken, or bite reflexively. Large-bore tube selectionshould be based on the size of the patient; a 14- to 20-Frenchred rubber, silicone elastomer, or polyurethane tube can beused. Esophagostomy tubes can be placed in either side of theneck, depending on proximity of the esophagus, which can beevaluated during tube placement.

FeedingBlenderized commercial canned food is recommended foresophagostomy tube feeding. Canned recovery diets are lesslikely to clog the tube and have the highest caloric density butmay cause diarrhea. Food can be administered as bolus mealfeedings several times a day or, with liquid diets, as continuousinfusion. The resting energy requirement (RER) of the patientshould be calculated:

RER = 70 ¥ (body weight[kg]0.75)

Alternatively, RER for animals weighing more than 2 kg can becalculated:

RER = 30 ¥ (body weight[kg]) + 70

The patient should be fed approximately 25% to 30% of itscaloric requirement on the first day of feeding, with subsequentgradual increases of 25% to 30% of its caloric requirement perday.1-3 This may not always be necessary but is recommended to reduce risk for refeeding syndrome in patients with anorexiaor hyporexia for more than 3 to 5 days’ duration.1,3 Refeeding syndrome manifests as dramatic decreases in phosphate, mag-nesium, and potassium and can result in potentially fatal pul-monary, cardiovascular, neurologic, and neuromuscularabnormalities.

Gastric capacities for cats and dogs are 5 to 10 mL/kg duringfood reintroduction, but capacities as high as 45 to 90 mL/kghave been measured after complete realimentation.2,3 Withbolus feeding, the daily volume of food is divided into 4 to 6feedings according to estimated stomach capacity. Daily fluidrequirements should be calculated based on amount of water inor added to the canned diet and used to flush the tube.

ComplicationsComplications, usually minor, may include tube obstruction,swelling of head and neck from an overly tight bandage, peri -stomal dermatitis or cellulitis, inflammation, and stomal infec-tion and abscessation.4,5

Tube obstruction with food or medications (common) can usu-ally be remedied by flushing warm water in and out of the tubeusing alternating gentle pressure and suction. If unsuccessful,carbonated water or a pancreatic enzyme slurry can be instilledinto the tube and allowed to sit for an hour before reapplyingpressure and suction. Obstructions rarely require a guide wire tounclog the tube, which is more common if the tube has a blindend, a nonblenderized diet is fed, or administration of solidmedications (eg, crushed tablets) has been attempted. To pre-vent clogs, tubes should be flushed with 10 to 20 mL of warmwater before and after each feeding, depending on patient andtube size. Straining blenderized food can help prevent tubeobstructions, especially when small tubes are used.

The risk for cellulitis and peristomal inflammation is increasedif a purse-string suture is placed around the stoma. Inflamma-tion and infection around the stoma site generally resolve withtube removal and local wound therapy; stomas should always beleft to heal by second intention. Hemorrhage during tube place-ment (uncommon) may occur if a skin incision is made beforethe forceps tips are pushed through the esophageal wall andsubcutaneous tissue.

Esophageal leakage through esophageal wall tears (also uncom-mon) can occur in very young patients with friable tissue, ifmultiple attempts have been made to pass the tube or an exces-sively large stoma is in the esophageal wall. Esophagitis andvomiting may occur if the tube passes through the loweresophageal sphincter.

Patients rarely vomit and dislodge the tube, allowing the end toprotrude from the mouth (more common with smaller, softtubes). The patient can then bite through the tube, resulting in agastric foreign body. Tube dislodgement requires replacementunder general anesthesia; immediate replacement through theexisting stoma is possible if the tube has been in place longenough for fibrous tissue formation.

Aspiration pneumonia is a potential complication of enteral tubefeeding. Risk factors include absence of a gag or cough reflex,impaired mental status, neurologic injury, mechanical ventila-tion, presence of laryngeal disease (especially after arytenoid lateralization surgery), and previous aspiration pneumonia. Inpatients at high risk for aspiration pneumonia, gastrostomy orjejunostomy tubes should be considered over esophagostomytubes. To reduce aspiration risk, feeding should not start until thepatient has fully recovered from anesthesia and can be kept in asternal position.

February 2014 • Clinician’s Brief 67

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Step-by-Step � Esophageal Tube Placement

Place the anes-thetized patientin lateral recum-bency and clipand asepticallyprepare the lateral cervicalregion.

Step 1

Premeasure thetube from themidcervicalesophagus to the level of the5th–8th inter-costal space.

Step 2

Cut the tip of the tube to remove anyblind end and to ensure appropriatelength. Alternatively, if the tube doesnot need to be shortened, elongatethe side-hole opening to help preventclogging. The tube should be longenough so that the proximal endexiting the neck can be gently curvedaway from the head.

Step 3 Author Insight Toensure appropriate place-ment, use a permanentmarker to indicate wherethe tube will be level withthe skin when properlypositioned. Alternatively,have a second tube of thesame length available.

What You Will Need

� Clippers, 4% chlorhexidine scrub, gauze or roll cotton (for aseptic prep)� Sterile gloves� Sterile Huck towels and towel clamps (optional)� Sterile needle holders� Mayo suture scissors� Curved Carmalt (medium and large dogs) or Kelly (cats and small dogs) forceps

with long jaws and fine tips� Scalpel blade� 14- to 20-French red rubber, silicone elastomer, or polyurethane tube� Tubing adapter and injection cap (to permit capping of tube)� 0 or 2-0 nylon suture� Nonionic iodinated radiographic contrast (eg, iohexol)� Triple antibiotic ointment� Nonadherent dressing and bandage material� Fabric, washable esophageal feeding-tube collar (eg, Kitty Kollar, kittykollar.com;

optional)



Insert Carmalt (medium and large dogs)or Kelly (cats and small dogs) forcepsthrough the oral cavity and into the cervi-cal esophagus with the tips facing outward.Choose forceps that are long and narrowenough to pass caudal to the hyoid apparatus.

Step 4

Tilt the forceps (ie, lower the handletoward the table) so the tips (arrow) arepressing the esophagus outward and dorsalto the jugular vein, and palpate the neck todetermine where the esophagus is mostsuperficial. Placing a sandbag or towelunder the neck may facilitate passing andtilting the forceps and aid in isolation ofthe esophagus against the skin.

Step 5

Using the palm of the dominant hand, apply steady pressure tothe forceps rings (A), making sure not to insert fingers into therings. With the nondominant hand, make a fist and applydownward pressure over the tips of the forceps to force themthrough the esophageal wall and musculature of the neck. Thispushes the jugular vein (B), carotid artery (arrow; note proxim-

ity of carotid artery and vagosympathetic trunk to the esopha -gostomy tube), and other neurovascular structures aside to pre-vent trauma. On palpation, the forceps tips are indistinct untilpushed through the esophageal wall and cervical musculature.

Step 6

A BMORE

Author Insight Theesophageal wall can beinadvertently caught andtorn if the box locks ofthe forceps open and thetips separate before theypenetrate the skin. Theclamps must remainfirmly closed until thetips protrude through theskin incision.


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With a scalpel blade, incise the skin overthe forceps tips. Place a palm on the han-dle rings and push the forceps tips throughthe incision. Open the tips just enough tograsp then clamp the tube end.

Step 7

Pull the tube end rostrally through theneck and out through the oral cavity. Leaveseveral centimeters of the proximal tubeend protruding from the incision. At thispoint, the distal tip of tube will be facingrostrally and the proximal end will be facing caudally.

Step 8

Redirect the distal tip of the tube throughthe oropharynx (A) and gently advancethe tube as far as possible into the esoph-agus using fingers or forceps tips. Avoidencircling the endotracheal tube or itsgauze tie with the esophagostomy tube.Once the tube has been advanced as dis-tally as possible, retract the proximal end through the skin incision several cen-timeters until the tube is redirected in arostro caudal position (B). Adjust the tubeto the premeasured appropriate lengthand cap the end.

Step 9

A

B

Author Insight If thetube end is large, it canbe cut at an angle to moreeasily clamp the forcepsto pull the tube end backthrough the skin andesophageal wall.


B


Secure the tube to theskin with 0 or 2-0nylon in a finger trappattern. A purse-stringsuture should not beused. In cats, include abite of deep muscle orthe periosteum of theatlas wing to preventtube migration fromneck movement.

Step 10

Ensure the tube is properly positioned via lateral radiography (A). If placement is uncertain, infuse a small amount of nonionic contrast material to differentiate the esophagostomy tube from the endotracheal tube or jugular catheter (B). If the tube is in the trachea, the portion running in the proximal cervical region will be visibly ventral to the esophagus on radiography (C).

Step 11

A

C

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Inadvertent tube insertioninto the trachea; note theposition of the proximalesophagus (arrow)compared with theesophagostomy tube(arrowhead). The jugularcatheter is in the ventralneck.

Author Insight Esophagostomy tubes frequently fold asthey are advanced through the oropharynx and into the esoph-agus. If the proximal end of the tube is retracted from the neckwhile the folded section is pushed down toward the esophagus,the folded section is gradually pulled out of the esophageal per-foration and will palpably unfold, allowing the tube to reorientitself with the proximal end facing rostrally. The proximal endof the tube can then be redirected and the tube advanced far-ther down the esophagus.


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Step 13

Replacement of a blocked esophagostomy tube attempted with an awake patient resulted in collapseof the stoma, inadvertent placement of the tube (arrow) into the mediastinum, and subsequent mildpneumothorax.

See Aids & Resources, back page, for references & suggested reading.

Step 12

Once tube position is verified,bandage the neck to cover thestoma site. The bandageshould be changed daily forthe first week and as neededthereafter.

The tube can be left in as long as it is needed (eg, months); sutures may need to be replacedmonthly to keep the tube secure. The tube can be replaced if a blockage or degradationoccurs or if the end connected to the adapter splits. If the tube has been in place longenough for formation of a fibrous stoma (ie, 7 days or more), it can be replaced as neededthrough the stoma. The patient should be anesthetized for tube replacement, and tubeposition should be confirmed with radiographs.

Once the esophagostomy tube is no longer needed, anchoring sutures should be removedand the tube clamped and removed. The site should be bandaged and left to heal by secondintention, which usually occurs within a week of tube removal. � cb


Esophagostomy Feeding Tubes

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