Esophagostomy tubes (E-Tubes)
Dr. Garret Pachtinger, DACVECC
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.
- 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.
Care is taken to identify the jugular vein
A curved hemostat (Kelly or Carmalt) is introduced per os into the proximal esophagus.
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.
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
- 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.
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.
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