Page 647 - Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice

634 SPECIAL THERAPY

manipulated into the esophagus by retracting the tongue provides excellent exposure to the gastric fundus. They
and extending the end of the tube 180 (Figure 26-9, E). can be placed in conjunction with other abdominal

The surgeon should palpate the tube to be sure there are procedures through a ventral midline celiotomy. If an
no kinks, and visually examine the region to confirm that endoscope is available, it may be used to place the
the tube is placed caudal to the pharyngeal region. A lat- gastrostomy tube percutaneously. The patient is
eral and ventral-dorsal cervico-thoracic radiograph anesthetized with a general inhalant anesthetic and placed
should be taken to document correct placement. Once in right lateral recumbency. Endotracheal intubation is
in place, the tube is sutured (Ethilon or PDS suture) at recommended to ensure a patent airway and to prevent
the skin with a purse string around the tube and then a aspiration of gastric contents during manipulation of
Chinese finger trap method applied for three to four the stomach. The hair is clipped in the left paracostal
throws to prevent movement of the tube. A light bandage region from dorsal to ventral midline, and the skin asep-
should be applied over the tube and the tube should be tically prepared for surgery. A 4 to 8 cm curvilinear inci-
evaluated by a veterinarian for infection or movement sion is made in the skin caudal to the last rib and 2 to 4 cm
and rebandaged daily. ventral to the paravertebral epaxial muscles. 49
Esophagostomy tubes can be maintained for several Care must be taken to ensure that this incision is
weeks or months with good nursing care. A small amount located ventral enough to enter the peritoneal cavity.
of drainage may occur at the incision site; the area should The external and internal abdominal oblique and
be cleaned and bandaged daily or every other day as transversus muscles can be separated by blunt dissection
needed. Complications associated with esophagostomy or incised with a scalpel blade. The peritoneal cavity is
feeding tubes may include local infection and swelling opened and the greater curvature of the stomach
or cellulitis, coughing, and gastroesophageal reflux if identified. A small stab incision is made through the
the tube is improperly placed; vomiting and aspiration abdominal wall, cranial to the celiotomy incision and
of food if the animal is fed too much food rapidly; esoph- directly caudal to the last rib or between the last two ribs.
ageal erosion or esophagitis if the tube is too large or left The tip of a large-bore, mushroom-tipped Pezzer cathe-
in place too long; and premature displacement or occlu- ter (14 to 28 Fr) is passed through this incision into the
sion of the tube if not cared for adequately. 49,63 When abdominal cavity. Two stay sutures are placed in the gas-
tube feeding is no longer necessary, esophagostomy tubes tric fundus and used to retract the stomach into the
can be removed without sedation and discomfort. The celiotomy incision. A relatively avascular area near the
cervical wound is left to heal by second intention. greater curvature of the fundic region of the stomach
Esophagostomy feeding tubes offer several advantages should be chosen, and moistened laparotomy sponges
over other enterally-placed feeding tubes: they require used to isolate this region of the stomach for feeding tube
only a single surgical incision to place; they do not require placement. Two full- thickness purse-string sutures are
specialized or costly equipment such as an endoscope; placed concentrically through all layers of the gastric wall
they do not require sedation or anesthesia for tube using a 3-0 synthetic absorbable monofilament suture
removal; patients tolerate these tubes well; tubes can be material. The free ends of the sutures are tagged with for-
left in place for extended periods of time, and these feed- ceps. A No. 11 scalpel blade is used to make a small stab
ing tubes are easy for clients to manage in the home incision in the center of the inner purse-string suture.
environment. Care must be taken to prevent leakage of gastric contents
SURGICAL GASTROSTOMY OR from this stab incision. The mushroom tip of the catheter
is inserted into the gastric lumen, the inner purse-string
JEJUNOSTOMY TUBE VIA suture is gently tightened around the tube and tied, after
GASTROSTOMY TUBE which the second suture is tightened to minimize leakage
around the tube. Jejunostomy or enterostomy feeding
When nutrients cannot be introduced proximal to the tubes may be advanced through a gastrostomy tube dur-
stomach in patients with normal gastrointestinal func- ing open abdominal surgery to provide postpyloric feed-
tion, gastrostomy tube feeding is an excellent method ing without an increased risk of surgical dehiscence at the
of temporary or permanent nutritional support. 25,26 site. Percutaneous radiologic gastrojejunostomy (PRGJ)
8
Gastrostomy feeding tubes are specifically indicated in tubes have recently been described. However, at this
patients that are comatose or in those that require time their use is limited to specialty hospitals with fluoro-
bypass of the oral, oral pharynx, larynx, and esophagus scopic equipment. Specific indications for use of the
due to neurologic or neuromuscular diseases, dysphagia, enterostomy or jejunostomy feeding tubes may include
regurgitation, neoplasia, obstruction, inflammation, pancreatitis, pancreatic surgery, hepatobiliary surgery,
stricture, or following surgical procedures of the head proximal GI obstruction, neoplasia, or extensive gastro-
and neck. intestinal surgery.
Gastrostomy feeding tubes generally are placed The gastrostomy site is secured to the left abdominal
through a limited left paracostal laparotomy, which wall with approximately 4 to 6 synthetic absorbable