Esophagostomy tubes (E-Tubes)

Dr. Garret Pachtinger, DACVECC
VetGirlOnTheRun.com

In this VETgirl online veterinary CE blog, we review how to place an esophagostomy tubes (E-Tubes). These are a wonderful way of delivering enteral nutrition in anorexic cats.

E-Tubes are:

–        Easy to place

–        Have large diameters to feed through

–        Can be removed easily

–        Can be used in by the owners once the patient is discharged for home care

–        Have few serious complications,

Esophagostomy tube placement is performed under general anesthesia to allow intubation of the patient.

The patient is placed in right lateral recumbency and the left lateral and ventral cervical area is clipped and an aseptic preparation performed.

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Care is taken to identify the jugular vein

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For cats, a red rubber or silicone tube is used, ranging from 10-14 French.
The feeding tube is marked to length from the site of placement to the 7-8th intercostal space
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A curved hemostat (Kelly or Carmalt) is introduced per os into the proximal esophagus.

Pressure is applied to press the tip of the forceps against the skin caudal to the ramus of the mandible
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A stab incision is made through the skin and subcutaneous tissue over the tip of the forceps being careful to avoid the jugular vein
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The forceps is pushed through the small stab incision and the feeding tube is grasped.
The feeding tube is then pulled into the esophagus and out the mouth. The tube must be then turned around so it goes directly down into the esophagus. It should be manually pulled out through the mouth and turned directly back down the esophagus.
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The feeding tube is advanced to the previously marked position and secured using a purse string and Chinese finger trap suture.
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A lateral thoracic radiograph is taken to assess placement of the feeding tube into the distal esophagus.

E-Tube Rad

The diet we most commonly use: Hill’s A/D canned: Combine 1 can with 50 ml water (1.0 kcal/ml)

A feeding tube often remains in place for at least 3-6 weeks.  Guidelines for tube removal include:

Resolution / adequate treatment of the underlying disease where oral feeding would not be difficult or contraindicated:

  • A healed jaw fracture
  • Resolving hepatic lipidosis
  • Resolving pancreatitis
  • Severe oral ulceration / trauma
  • Etc

–       Improvement or normalization of bloodwork abnormalities

–       Appropriate voluntary, oral caloric intake

Most importantly, before the tube is removed, the voluntary caloric intake by the patient needs to be confirmed.  This often requires the veterinarian and owner to determine how much the cat is eating on their own each day.

–       Amount of food?

–       Type / Kcal of that food?

This will help ensure the tube is not removed prematurely before we can determine if the cat is eating enough on his or her own.  If the owner is feeding 100% RER via the feeding tube, the patient may not wish to eat due to a sense of being full.

Once comfortable with the improvement, the veterinarian may instruct the owner to decrease tube feedings and encourage more voluntary intake by the patient to assess the cat’s appetite.

Initially, the feeding tube caloric intake is decreased by 25-33%, allowing an opportunity for voluntary intake.  If the patient begins to eat, the following week, we then reduce the tube caloric intake by 50%, and monitor voluntary intake.  Each week, continue to reduce feeding tube caloric intake to assess voluntary, oral intake.

Once the patient shows a normal, voluntary intake of 75-100% RER, we can feel more comfortable removing the feeding tube.

During this time period, feeding tube site evaluation is important:

1)     Weekly, check the site for abnormalities. Feeding tubes should be checked for discharge, inflammation and infection.

2)     Along with a general examination and patient assessment including vital signs, tube bandages should be changed at least weekly.

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Once the tube is removed, it does not need sutures or any degree of surgical closing.  The stoma site closes up remarkably, often in 5-7 days.
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Over the first few days following tube removal, the site is kept covered with a clean bandage and triple antibiotic.

Trouble shooting: Tube clogging:

–       Not an uncommon occurrence.

–       Prevention is easier than unclogging when there is a problem.

–       Make sure that the diet is smooth in consistency and there are no chunks within the food with appropriate blending.

–       Flushing the tube before and after every use is best to avoid clogging.

–       If the tube clogs

  • Vigorous flushing may help dislodge a clog, but can also cause the cat to vomit/regurgitate.
  • Some advocate flushing the tube with Coca Cola – which can be placed into the tube and allowed to sit in the tube for 5-10 minutes, followed by vigorous flushing with water.
  • A flexible guide wire or long small diameter polypropylene catheter can also be considered (not by the client) to help try to relieve a clog.

P.S. When in doubt, we ideally no longer use these spring-loaded mouth gags (as demonstrated in this older video), so if you have them in your clinic, consider accidentally throwing them in the recycling bin. That’s because they have been associated with blindness. Check out this reference here.

Mouth gags

Copyright, VETgirl, LLC.

  1. Why do you have to place an E-feeding tube in the left side of the animal? Is it possible to do a right lateral approach, if not was is that contraindicated?
    Thank you

  2. Have you been using e-tubes in management of CKD when the kitty will not take in calories sufficient to control weight loss ?

    • Absolutely – especially if they have cardiac disease and can’t handle SQ fluids also. You can hydrate with oral water and feed a low protein slurry food.

    • Great question – E-tubes are just sitting in the esophagus. If you use a G tube, that’s in the stomach. There is some thought that leaving a tube in the stomach (e.g., a nasoesophageal vs. nasogastric) can “tickle” the stomach resulting in more vomiting, but a recent paper out of Michigan State proved it likely doesn’t make a difference. Hope that helps!

  3. I had a cat who briefly had an etube earlier this year and it was in the same location you show here. When another cat required an e-tube recently, i expected my vet to put it in the same location, so I ordered one of the collars you show in the pictures, only to find that the tube had been placed just under his left jaw almost. I was very surprised and assumed there was a standard, since the collars are sold assuming a placement similar to this one. Is there a best practice on this that might not be well understood in the vet community yet? This second tube came out last night and I’m taking him back to get it replaced. I’d like to explain to the doc why this site is a better idea, apart from the fact that it’s easier to inspect on a fluffy cat (safer for voicebox, etc). Thank you for putting this guide up.

  4. Thanks for the guide – to the point, great photos, although I suspect it deliberately forgot to mention about turning the tube around and pushing it down the esophagus after applying the trap suture (assuming that other vets like me read this).
    thanks also for the webinar you did with vet education earlier this year!

  5. Pingback: How to place an esophagostomy tube in a cat | VETgirl CE Blog

  6. Is it possible to push through the small stab incision and grasp the feeding tube and instead of pulling into the esophagus and out the mouth, should be pushed down further to direct the tube towards the stomach ?

  7. Hi, once the tube is removed does the cat need to fast until the hole in the esophagus has healed or can they just continue eating as they have done?

  8. Because these cats are usually very sick, what is your anesthesia protocol to minimize adverse effects while under anesthesia?

    • They do need anesthesia so a safe, reversible pre-med like an opioid and benzo + general anesthesia. With practice, this procedure should just take about 10-15 minutes.

  9. How would this operation be performed on a cat with Oral SCC who cannot open her mouth at all? We were told they could not use insert the anesthesia tube in through her mouth due to lack of vision into the mouth (would be none at all now) so is there any other way to do this? She’s just started to refuse food (a/d hills and nutripet gel) and I’m worried she won’t be able to get enough food! I also feel really conflicted about whether this operation is worth it or if it is cruel in her condition… she still loves life but cannot groom due to jaw restriction…

  10. I am removing an E-tube for the first time on Friday, do I need to have the pet alter their diet at all after removal? Do I literally just remove sutures and gently pull the tube out? I saw the part about the bandage and triple antibiotic ointment. Thanks!!!

    • Gently pull the tube and remove! I’m assuming the tube has been for at least 7-10 days first however.

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