Endoscopic Placement of Gastrostomy and Jejunostomy Tubes

Chapter 9 Endoscopic Placement of Gastrostomy and Jejunostomy Tubes



Jacqueline Whittemore, Joseph W. Bartges


Use of endoscopically placed gastrostomy and gastrojejunostomy tubes has increased in conjunction with the increased availability of endoscopy in veterinary medicine.


The benefits of nutritional support include improved patient immune function, wound healing, and survival. Compared with parenteral feeding, enteral feeding is associated with improved enterocyte health and reduced bacterial translocation. Appetite stimulants and force-feeding are often relied on for short-term enteral supplementation in hyporexic patients. Although potentially helpful in initially stimulating a patient’s appetite, pharmacologic stimulants provide little benefit in cases with chronic hyporexia or in patients with underlying disorders. Force-feeding uncommonly yields significant caloric benefit, may erode the human–animal bond, can generate food aversion, and may be associated with negative sequelae, including aspiration in the obtunded patient. Neither may be used in patients with dysphagia or motility disorders.


Compared with force-feeding and chemical appetite stimulation, feeding tubes improve maintenance of the human–animal bond, lessen the impact of patient appetite on dietary intake, and allow provision of the patient’s entire caloric needs. Depending on the type of tube chosen, additional benefits include the provision of long-term nutritional, fluid, and pharmacologic support; gastric decompression and suction; decreased pancreatic stimulation; and the ability to use commercial canned diets or soaked commercial kibble diets for cost savings. Generally, other factors being equal, clinicians should attempt to feed as high in the gut as possible.



Indications


Placement of gastrostomy and jejunostomy tubes should be considered for patients with significant hyporexia or anorexia, anatomic or functional disorders preventing adequate caloric intake, disease processes requiring ongoing (more than 7 days) nutritional or medical support, and cases in which bypass of upper portions of the gastrointestinal tract is indicated. Given the negative association between protein–calorie malnutrition and patient outcome, feeding tube placement should be considered as soon as a patient is identified as meeting one or more placement criteria. When anesthetizing patients for diagnostic procedures, clinicians should consider preemptive placement of feeding tubes if one or more of these criteria may be anticipated. Conversely, significant malnutrition, inflammation, and hypoproteinemia are associated with delayed wound healing and may compromise gastrostomy tract healing and fibrosis. In a patient with one or more of these risk factors or at high anesthetic risk, it may be prudent to feed the animal parenterally or via nasoesophageal or esophagostomy feeding tube until the patient is more stable. At that juncture, a percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic gastrojejunostomy (PEG-J) tube may be placed, and the relative risks of stoma site dehiscence or anesthetic arrest should be decreased.


PEG tubes have historically been reserved for patients with normal gastrointestinal motility that cannot or do not meet their caloric requirements. Dysphagic causes for tube placement include refractory anorexia, upper respiratory infection, head trauma, nasal or oral neoplasia, feline lymphocytic–plasmacytic gingivitis–stomatitis complex, cranial nerve deficits, cricopharyngeal achalasia, and esophageal disease (e.g., esophagitis, neoplasia, tear, or stricture). Common metabolic causes include hepatobiliary disease (e.g., hepatic lipidosis, cholangiohepatitis, or cirrhosis) and renal disease. Gastrointestinal causes include pancreatitis, inflammatory bowel disease, gastrointestinal neoplasia, and gastrointestinal foreign body. In several recent publications, PEG tubes have been successfully used to manage caloric needs of patients with idiopathic and secondary megaesophagus (see further on).


PEG-J tubes have been used less commonly in veterinary medicine. Common indications for the use of jejunostomy tubes include conditions predisposing animals to aspiration (e.g., regurgitation, vomiting, and significant obtundation), functional or mechanical obstructions (e.g., gastric stasis or atony, pyloric obstruction, and proximal small intestinal obstruction), significant gastric disease or gastrectomy, and pancreatitis. The use of gastrojejunostomy tubes in patients with pyloric outflow tract obstruction or small intestinal obstruction is dependent on the ability to successfully advance the jejunostomy tube. Endoscopic placement of nasojejunostomy tubes has been described; it may be a useful alternative for patients at high risk of stoma dehiscence that would otherwise benefit from jejunal feeding.



Megaesophagus and PEG or PEG-J Tubes


The use of PEG tubes in patients with megaesophagus remains controversial. In several recent reports, PEG tubes were successfully utilized to manage patients with megaesophagus that were unable to independently maintain adequate caloric intake. Three of four dogs with megaesophagus secondary to tiger snake envenomation received PEG tube placement as part of their case management.1 Two of these dogs survived to discharge and continued to be fed via tube until the megaesophagus resolved (30 and 36 days). Gastrostomy tube feedings were also successfully utilized in treatment of six other dogs with megaesophagus (etiology not stated), and a cat with megaesophagus after diaphragmatic repair.2,3 Megaesophagus was classified as idiopathic in three of four dogs receiving replacement low-profile gastrostomy tubes in one study.4 None of these dogs died or was euthanized as a result of complications from tube feeding. These dogs were maintained with the use of replacement low-profile tubes for 31, 1017, 723, and 1020 days. The first two dogs were still alive at the time the study was published; the other two died from non-tube–related causes.


Reports of successful long-term management of patients with megaesophagus are exciting, although placement of an endoscopic feeding tube is by no means a panacea. Because animals with megaesophagus often have aberrant gastric motility and associated gastroesophageal reflux, the use of gastrostomy tubes does not eliminate regurgitation or the risk of subsequent aspiration pneumonia. In cases of secondary megaesophagus that may be reversible, placement and use of PEG-J tubes may help mitigate the risks of gastroesophageal reflux and aspiration by introduction of food distally in the gastrointestinal tract. If the megaesophagus does not resolve or the patient does not tolerate the jejunostomy tube, it may be removed, and the patient may be fed through the coexistent PEG tube. Alternately, for patients with idiopathic or irreversible secondary megaesophagus, low-profile gastrostomy tubes may provide the best balance between patient quality of life and risks of aspiration.



Advantages of PEG Tubes


There are a number of specific advantages of PEG tubes over other feeding methodologies. These include but are not necessarily limited to


1. Decreased client time and cost associated with preparing feedings. In contrast to nasoesophageal and esophagostomy tubes, over-the-counter (OTC) canned diets and even soaked kibble diets may be administered with limited additional preparation (i.e., processing with a blender, straining, or other methods). Additionally, the ability to use OTC diets instead of prescription monomeric and elemental diets greatly reduces food costs.

2. Decreased client time spent administering feedings. Feedings can generally be administered more quickly via PEG tube compared with nasoesophageal, esophagostomy, and PEG-J tubes. In addition, clients administering PEG feedings generally record better patient feeding tolerance when compared with clients administering esophagostomy feedings.

3. Improved patient tolerance. Patients tolerate PEG tubes better than nasoesophageal and esophagostomy tubes. This is particularly true for patients with facial and nasal diseases.

4. Increased versatility. In addition to their usefulness for enteral feeding, PEG tubes may be utilized for administration of fluid therapy and medications and may provide access for gastric suction and decompression.

5. Improved tube life span. High patient tolerance, advances in gastrostomy tube manufacturing, and anatomic factors all contribute to greater indwelling life for PEG tubes compared with other tube types. Decreased bandaging requirements and conformational advantages of low-profile replacement tubes (discussed later) may further reduce the risk of unplanned tube removal and are associated with extended tube life spans.


Disadvantages of PEG Tubes


Although highly versatile and well tolerated in the majority of cases, PEG tubes do have some limitations with regard to placement and use. Limitations and disadvantages include


1. Specialized equipment and training is necessary. Nonendoscopically guided gastrostomy tube placement has been described and may provide a less expensive alternative in some cases. Limitations of blind percutaneous gastrostomy tube placement include the inability to visually examine the gastrointestinal tract for underlying disease and guide optimal tube placement.

2. General anesthesia is required. Although most PEG tubes can be placed in less than 25 minutes, general anesthesia is required. Patients that are poor anesthetic candidates may be better managed with parenteral or nasoesophageal feeding until they are more stable.

3. Stoma site disruption and premature tube dislodgement may be life-threatening. Unplanned removal of nasoesophageal and esophagostomy tubes is rarely associated with significant patient complications. In contrast, premature PEG tube removal or tube migration may be associated with gastric leakage into the abdomen and attendant peritonitis. Premature tube removal may be particularly deleterious in severely cachexic animals or those with marked hypoproteinemia or inflammation because these conditions directly impede wound healing and stoma development, which increases the risk of dehiscence and leakage. In cases with a high risk of poor wound healing, the use of parenteral or nasoesophageal feeding before PEG tube placement may improve patient outcomes.

4. Disease-related and conformational factors may preclude or negatively impact PEG tube placement. In patients with severe esophageal disease (e.g., stricture or mass effect), tube placement may need to be aborted if the endoscope cannot be advanced past the area of esophageal occlusion. In addition, appropriate gastric positioning may not be achievable in deep-chested dogs or excessively obese animals. In these cases, placement may lead to gastric malpositioning, outflow obstruction, excessive tension on the stoma site (leading to stoma dehiscence or unplanned tube migration/removal), or splenic laceration. When appropriate positioning cannot be achieved endoscopically, the procedure should be aborted and laparoscopically assisted gastrostomy tube placement or laparotomy should be considered.

5. Usefulness is limited in patients with significant gastrointestinal motility disorders. In cases with significant gastric atony or gastroesophageal reflux, a PEG-J tube or parenteral feeding may be more appropriate for feeding, although PEG tubes may still provide a benefit through gastric suctioning to decrease regurgitation, vomiting, and aspiration.

6. The feeding tube or kit itself is costly. Commercial gastrostomy tube kits, while more convenient and often better tolerated by patients than mushroom-tip latex tubes, are significantly more expensive. This cost may not be justifiable in cases in which the clinician anticipates the need for the tube will be relatively short-term.


Advantages of PEG-J Tubes


Although PEG-J tubes are less commonly placed in veterinary medicine, they offer a number of specific and compelling advantages and are probably underutilized. Advantages include


1. Increased flexibility in patient management. In comparison with surgically placed jejunostomy tubes, PEG-J tubes are placed in concert with a PEG tube. This means that the clinician gains all the potential benefits of a gastrostomy tube in addition to the benefits of a jejunostomy tube while only creating one transserosal defect (stoma) in the patient.

2. Decreased pancreatic stimulation. When PEG-J tubes are properly positioned, food enters the intestinal tract at the level of the proximal jejunum, causing minimal stimulation of the exocrine pancreas. This may offer significant benefits when necrotizing pancreatitis cases are being managed. When compared with parenteral nutrition (the other nutritional intervention with minimal pancreatic secretion), PEG-J feedings have the added advantage of providing trophic stimulation of enterocytes located aborally to the tube, which aids in maintenance of enterocyte health and minimizes the risks of bacterial translocation and secondary multiple organ dysfunction.

3. Decreased risks of reflux and aspiration. For patients with upper intestinal motility disorders, PEG-J feedings allow maintenance of a positive energy balance with decreased risks of gastric distension, esophageal reflux, and aspiration. These benefits are amplified by the ability to perform gastric suctioning through the indwelling PEG tube.

4. Decreased mechanical complications and improved patient comfort. Compared with surgically placed jejunostomy tubes, PEG-J tubes are better tolerated by patients. In addition, larger diameter jejunostomy tubes may be utilized, which decreases the prevalence of mechanical issues like kinking, coiling, and clogging. In cases in which the PEG-J tube is inadvertently dislodged or removed, replacement or repositioning may easily be performed through the PEG tube and does not require creation of an additional stoma. The ability to manage two tubes through one stoma (thus minimizing sites for possible dehiscence) provides an additional advantage in patients predisposed to poor wound healing due to cachexia, hypoproteinemia, peritonitis, generalized inflammatory disorders, concurrent endocrine disease, or immunosuppression. The decreased number of enterostomy sites, compared with separate placement of gastrostomy and jejunostomy tubes, has been associated with a significant decrease in life-threatening complications like peritonitis and premature tube dislodgement.


Disadvantages of PEG-J Tubes


Widespread use of jejunostomy tubes has been historically limited by mechanical and logistic challenges. Changes in tube placement and management practices have rendered some of these concerns moot. In addition to the limitations noted for PEG tubes, additional limitations and disadvantages of PEG-J tubes include


1. The need for continuous rate infusion (CRI) feeding. The use of a CRI feeding protocol has been recommended so that vomiting and diarrhea are minimized when patients are fed through jejunostomy tubes. This drastically limits home use of jejunostomy tubes and generally increases the level of care and treatment costs of in-hospital feedings. The need for CRI feeding to minimize vomiting and diarrhea has come into question. In one retrospective study of 47 dogs and cats with surgically placed jejunostomy tubes, 6 animals received feedings via jejunostomy tube at home, which suggests that bolus feeding was utilized in at least some of these animals without noted ill effects.5 More recently, bolus feedings of commercial canned foods via PEG-J tubes successfully maintained body weight in 12 healthy dogs and 5 cats for 14 days without medical (i.e., diarrhea or abdominal cramping) complications.6 It is possible that the improved tolerance of bolus feedings may partially relate to the decreased velocity of food entering the intestines as a result of increased luminal tube diameter. Ongoing investigation of bolus jejunal feedings in clinical patients is indicated.

2. The need for monomeric diets. Because the PEG-J tube bypasses a large portion of the intestinal tract, use of monomeric liquid diets has been recommended. Monomeric diets are relatively expensive, costing approximately four times as much as prescription recovery diets (e.g., Hills a/d, Royal Canin Recovery RS, or Eukanuba Recovery). The successful use of commercial diets in the aforementioned study without medical (diarrhea, abdominal cramping) or mechanical (clogging of the tubes) complications is particularly encouraging.


Advantages and Disadvantages of Nasojejunostomy Tubes


To our knowledge, there have been no reports evaluating the use of nasojejunostomy tubes in either a clinical or research veterinary setting. Advantages include decreased pancreatic stimulation and lack of an enterostomy site. Limitations include increased esophageal reflux (because the feeding tube traverses the lower esophageal sphincter), poor patient tolerance, increased mechanical difficulties due to decreased tube diameter and increased length, and the need for CRI feeding and liquid diets. In addition to patient removal due to intolerance, the small diameter of the tubes makes them prone to dislodgement secondary to vomiting.



Contraindications


Contraindications to endoscopic feeding tube placement include high anesthetic risk; refractory coagulopathy; refractory vomiting (nasojejunostomy and PEG tubes); significant obtundation (PEG tubes); significant malabsorptive intestinal disease, motility derangement, or obstruction aboral to the anticipated tube location; and an inability to achieve successful orientation and apposition of the stomach and body walls due to patient conformation, splenomegaly, peritoneal effusion, gastric neoplasia, or gastropexy (PEG and PEG-J tubes). An additional relative contraindication would be the potential for the patient to benefit diagnostically or therapeutically from laparotomy.



Equipment


Aside from a flexible endoscope, equipment needs vary depending on the tube type and whether to use a commercial tube placement kit. Commercially available kits are more expensive than homemade kits but often offer greater flexibility with regard to tube material and conformation. In addition to the feeding tubes themselves, commercial kits include most of the necessary equipment for tube placement and usage. If long-term usage of the tube is not anticipated or required, the added cost of a commercial kit may not be indicated.



Gastrostomy Tubes



Construction Materials


Gastrostomy tubes may be manufactured from rubber, latex, silicone, or polyurethane. In human medicine, the use of rubber or latex tubes has been supplanted by silicone and polyurethane tubes. Long-term use of rubber and latex tubes is complicated by tissue reactions to the tubes, changes induced by chronic gastric acid immersion (hardening), and colonization by fungal organisms. Tube failure due to Candida colonization has been reported in a cat. Silicone tubes are softer than other tubes and thus better tolerated by patients, but their use in human medicine is limited by difficulties in performing gastric aspiration due to luminal collapse and limitations in luminal diameter. Polyurethane tubes are generally more resilient and are available in larger luminal diameters.



Placement Style


PEG tubes are generally designed for one of two placement techniques (pull versus push). The majority of PEG tubes are initially placed by the pull method. Tubes installed with the use of the pull method are pulled through the mouth into the stomach with a long suture and then outward through the gastric and body walls. The tube has, or is modified to have, a tapered end with an attachment mechanism or loop so it can be smoothly pulled through the gastric wall (Figure 9-1). With the push method, the tube is pushed over a guidewire from the mouth into the stomach and out through the body wall. The proximal end of the tube is tapered to push across the stomach and body walls and is fenestrated for passage of the guidewire.


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Figure 9-1 A, Custom percutaneous endoscopic gastrostomy (PEG) kit for veterinary use (Medical Innovations Corp., a division of Ballard Medical Products, Draper, Utah). The kit includes an 18F pull PEG tube with a custom-attached bumper, a looped placement wire, an introducer needle with over-the-needle catheter, a retention disk, and a feeding adaptor. B, Close-up of the feeding adaptor. C, Endoscopic view after placement of the internal bumper of the PEG tube shown in A. Note that the inner bumper needs to be pulled closer to the gastric mucosa for proper placement.



Anatomy


Retention of the PEG tube in the stomach is dependent on the tube’s internal bumper or retention disk. The anatomy of the bumper varies by manufacturer and placement technique (Figures 9-2 through 9-4). Bumpers are designed to balance the risk of accidental dislodgement against the risk of gastric necrosis and the invasiveness of tube removal or replacement. Bumpers that offer a decreased risk of accidental dislodgement generally require endoscopic removal, whereas those that may be removed through the body wall by applying traction with or without the use of a stylet are more susceptible to premature removal. When selecting a PEG tube for placement, the clinician must weigh the patient’s temperament and the anticipated need for tube removal or replacement against the patient’s size, anesthetic risk, and the client’s finances.


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Figure 9-2 Internal bumper of a percutaneous endoscopic gastrostomy (PEG) tube (Ballard Medical Products, Draper, Utah) after placement.


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Figure 9-3 Internal bumper of a percutaneous endoscopic gastrostomy (PEG) tube (C. R. Bard Inc., Covington, Ga.) after placement.


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Figure 9-4 Internal bumper of a percutaneous endoscopic gastrostomy (PEG) tube (Biosearch Medical Products Inc., Somerville, N.J.) as seen endoscopically after placement in a cat.



Sizes


Tubes with luminal diameters of 18F to 24F are commonly utilized in dogs and cats. Clinicians are encouraged to use larger diameter tubes whenever possible, particularly if PEG-J placement or replacement with a low-profile gastrostomy button is desired or anticipated. When using mushroom-tip or Pezzer catheters, it is particularly important to select a large-bore tube with a rigid tip to minimize the risk of premature dislodgement.



Additional Materials


Components of a homemade kit are displayed in Figure 9-5. The majority of these materials are included in commercial feeding tube kits. See Box 9-1 for a checklist of materials necessary for PEG tube placement.


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Figure 9-5 Components of a homemade gastrostomy kit. From left to right, in the front row: No. 11 scalpel blade, 22F Bard Urologic Catheter (C. R. Bard, Inc., Covington, Ga.). From left to right, in the back row: Retention suture, over-the needle catheter, disposable pipette tip, catheter tip adaptor, syringe port cap. Not displayed: sterile lube, gauze squares, and orthopedic stockinette.


(Photo taken by Greg Hirshoren, © 2009 The University of Tennessee.)



BOX 9-1 Equipment Checklist for Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement by the Pull Method



▪ Surgical scrub and drapes

▪ Endoscope and endoscopic snare or retrieval forceps

▪ Scalpel blade

▪ Over-the-needle catheter

▪ Inexpensive suture material or fishing line for tube retrieval

▪ Disposable pipette tip for use as dilator and sheath

▪ Large-bore needle

▪ Sterile lube

▪ Feeding tube
▪ If a mushroom-tip catheter is utilized, the catheter administration tip will need to be cut at an angle to create a beveled edge. Set aside the catheter tip portion for later use as an external flange.

▪ If a commercial kit is used, many of the following materials may be included in the kit.

▪ Catheter tip adaptor

▪ Syringe port cap

▪ Nonabsorbable suture

▪ Gauze squares

▪ Orthopedic stockinette

Note: Equipment is listed in the order of use.



Low-Profile Gastrostomy Tubes


Low-profile gastrostomy tubes or buttons (PEG-B) offer a number of advantages over traditional tubes. The compact and self-retaining designs (Figure 9-6) generally eliminate the need for external dressings and retention sutures, which improves patient tolerance, aesthetics, and ease of management. The presence of a one-way valve minimizes reflux of food during administration, while alternate attachments facilitate gastric sampling and suction.


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Figure 9-6 Low-profile gastrostomy tubes: On the left is a tube with a mushroom-tip internal bumper (Passport Low Profile Gastrostomy Device, Cook Medical, Bloomington, Ind.). On the right is a tube with an inflatable balloon internal retention device (MIC-KEY Low Profile Gastrostomy Feeding Tube, Kimberly-Clark, Roswell, Ga.).


(Photo taken by Greg Hirshoren,© 2009 The University of Tennessee.)



One-Step Gastrostomy Tubes


Although low-profile gastrostomy tubes have historically been used as replacement tubes, several commercial one-step low-profile gastrostomy button (OSB) kits (Figure 9-7) are available for primary placement. Because of their aesthetic benefits, large luminal diameters, and ease of use, OSBs are increasingly being utilized as the tube of choice in human medicine. Initially, placement of OSBs was associated with a high prevalence of peri-PEG cellulitis, button migration, and secondary peritonitis. These complications have been decreased with changes in tube design and may be minimized further through careful selection of the appropriate OSB shaft length and creation of an adequately large skin incision. In a recent study in children, equivalent complication rates were noted for OSBs and traditional PEG tubes, but tube life and feeding tolerance were much higher in the OSB group.7


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Figure 9-7 A, Percutaneous positioning of a one-step low-profile gastrostomy tube (EndoVive Low Profile Percutaneous Endoscopic Gastrostomy kit; Boston Scientific, Natick, Mass.) before flange release. B, Deployment of external flanges of a one-step low-profile gastrostomy tube (EndoVive Low Profile Percutaneous Endoscopic Gastrostomy kit; Boston Scientific) using the ripcord. C, One-step low-profile gastrostomy tube (EndoVive Low Profile Percutaneous Endoscopic Gastrostomy kit; Boston Scientific) shown with variably sized silicon spacers.


(Photos taken by Greg Hirshoren, © 2009 The University of Tennessee.)

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Sep 10, 2016 | Posted by in SMALL ANIMAL | Comments Off on Endoscopic Placement of Gastrostomy and Jejunostomy Tubes

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