Page 648 - Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice

Enteral Nutrition 635

endoscope is repositioned within the stomach to visualize
and confirm the presence of the cannula. The stylet is
Retaining
suture removed from the cannula and the end of a 1-0 or 2-
0 piece of suture material is passed through the cannula
Skin into the gastric lumen. The length of suture material
Body wall required can be estimated by measuring from the tip of
Gastrostomy
tube Stomach the animal’s nose to the greater trochanter of the femur.
The biopsy snare is passed through the biopsy channel of
Figure 26-10 Technique for securing gastrostomy tube. the endoscope and used to grasp the suture material.
Retaining suture and/or adhesive tape can be used. (Line drawing by
Dana Schumacher.) The biopsy instrument with the suture attached
should not be retracted through the biopsy channel of
the endoscope. While holding the biopsy snare in a closed
monofilament sutures placed in a mattress pattern positiontoretainthesuturematerial,theentire endoscope
through the seromuscular layer of the stomach and the is withdrawn from the stomach through the mouth. The
transverses abdominis muscle of the body wall. The cannula can then be removed from the abdominal wall,
gastropexy suture should be placed as close as possible being careful not to remove the suture. The suture end
to the feeding tube. The paracostal incision then is closed exiting from the mouth is passed retrograde through this
in a routine manner. The feeding tube should be capped cannula. An 18-gauge needle is passed through the feed-
and fixed to the skin using 3-0 nylon sutures through an ingtubejustbelowthebevelofthecatheter,andthesuture
adhesive tape butterfly or a 0 nylon antitension suture is passed through the needle and tied securely to the tube
(Figure 26-10). The tube then is incorporated into a light (Figure 26-11, A).
abdominal bandage to prevent removal by the patient. The gastrostomy tube is stretched and gently
Gastrostomy feeding tubes can be maintained in manipulated to feed the tapered end into the flared end
patients for months with good nursing care. Tubes should of the cannula, which guides the feeding tube back
remain in place for a minimum of 5 to 7 days, and prefera- through the gastric and abdominal walls. The cannula
bly 14 days, to allow firm adhesions (or a stoma) to form and feeding tube pass through the mouth, oropharynx,
between the stomach and peritoneum. Formation of the esophagus, and stomach, and exit through the gastric
stoma tract prevents leakage of food or fluid into the peri- and abdominal walls (Figure 26-11, B). The cannula is
toneal cavity. If prolonged feeding tube use is indicated, removed, and the gastrostomy tube is gently retracted
the original mushroom tipped catheter can be removed to pull the internal flange and mushroom tip securely
and replaced by a low profile tube to improve patient com- against the gastric mucosa. Replacement of the endoscope
fort. 92 When the gastrostomy feeding tube is no longer into the stomach allows visualization of the positioning of
needed, it may be removed with gentle but firm traction the tube. Anexternal flange can be placed around the feed-
and the wound left to heal by second intention. ing tube next to the skin to prevent separation of the stom-
PERCUTANEOUS ach from the abdominal wall, until a permanent adhesion
forms (Figure 26-11, C). The remaining end of the tube is
ENDOSCOPIC capped and fixed to the skin with an antitension suture.
GASTROSTOMY (PEG) A lightweight abdominal bandage or stockinette can
be used to protect the exit site from contamination
The patient is anesthetized (with a neuroleptanalgesic or (Figure 26-11, D). Complications associated with
general inhalant anesthetic) and placed in right lateral gastrostomy tubes include leakage around the feeding
recumbency. The left paracostal region is clipped and tuberesultinginperitonitis,necrotizingfasciitis,orsubcu-
the skin aseptically prepared for surgery. An oral speculum taneous abscessation. 11,14,25 This does not, however,
is placed in the patient’s mouth and a flexible endoscope, mean that tubes should be secured very tightly, which
with a biopsy channel, is passed through the mouth and can cause the same problems secondary to ischemia.
esophagus into the stomach. The stomach is insufflated Vomiting, regurgitation, gastroesophageal reflux, and
with air until distention of the left abdominal wall is visi- aspiration pneumonia may also occur, usually as a conse-
ble externally. This procedure displaces any abdominal quence of overdistention of the stomach during feeding.
viscera that were located between the stomach and left PERCUTANEOUS
body wall. The endoscope then is positioned so the
illuminated end is located within the stomach directly NONENDOSCOPIC
caudal to the last rib. GASTROSTOMY
A small stab incision is made through the skin at this
site. An 18-gauge intravenous cannula with a needle stylet Methods of blind placement (nonsurgical or
is placed through the skin incision and through the nonendoscopic) of gastrostomy tubes in dogs and cats
abdominal and gastric walls into the gastric lumen. The have been reported. 36,68 The technique is similar to that