Esophagostomy tubes and the dental patient (Proceedings)

Esophagostomy tubes are an option when long term nutritional support is necessary. Patients requiring the placement of an esophagostomy tube are those that are not able to take in food orally. In veterinary dentistry, this works out well for patients with full or caudal mouth extractions, maxillary or mandibular fractures, oral or nasal neoplasia. Placement of the esophagostomy tube is contraindicated in vomiting patients and in patients with esophageal disorders such as esophagitis, esophageal strictures, megaesophagus, or those patients that have undergone esophageal surgery.

Choosing the Tube

The best tube for this procedure is the red rubber catheter. In the cat 12-16 fr. works best and in the dog 12-24 fr.

Placing the Esophagostomy Tube

Patients must be under general anesthesia for this procedure. It is best done right after the dental procedure is completed. Place the patient in lateral recumbency.

Supplies needed are a large Kelly or Carmalt forcep, appropriate size red rubber catheter, Luer slip catheter plug, 1" tape, non-absorbable suture material, scalpel blade, permanent marker, cast padding, needle holders, thumb forceps, clippers and scrub.

Clip the entire lateral cervical region from the ventral midline to near dorsal midline. Surgically prep the area.

Cut the distal rounded tip of the tube or widen the lumens of the side vents to facilitate the food administration and remove the possibility of any food impaction in the tube. Measure the feeding tube by placing the tip at the 7th or 8th intercostal space. The other end should be marked with a permanent marker at the midcervical area where the tube will exit the skin.

Insert the Kelly or Carmalt forcep into the mouth and into the proximal cervical esophagus. Turn the tip of the forcep toward the lateral aspect of the patient so that the instrument can be seen and palpated through the side of the neck.

Place 2 fingers on either side of the protruding forcep tip. Using a scalpel blade, make an incision just large enough for the tip of the forcep to pass through and be opened large enough for the catheter to be grabbed by the forcep.

Once the catheter has been grabbed by the forcep, pull the catheter into the esophagus and out through the mouth. Then turn the tip back into the esophagus and push it in as far as possible. With your finger on the catheter in the mouth, pull gently on the same time at the other end of the catheter coming out of the incision. Once the catheter inside the esophagus unfolds down along the esophagus, the external part of the catheter will flip to point towards the head. Pull the catheter until the marked part of the tube is visible above the skin. Place the catheter plug in the end of the catheter.

Just above the marked area of the tube, swipe the catheter with clean gauze, and then wrap a piece of tape leaving wings on either side. Suture each wing to the skin using a simple interrupted stitch. Apply a dab of triple antibiotic ointment at the incision site.

Apply a light bandage placing the catheter along the dorsal neck area with the tip of the catheter pointing caudally. Use cast padding as the first layer followed by vet wrap. Secure the catheter to the neck bandage using tape.

Feeding Through the Esophagostomy Tube

The large bore of these catheters allows the feeding of a gruel recovery diet. If you need to dilute with water, dilute the food to the consistency of a soft pudding. Make sure the mixture has no lumps that can clog in the tube.

Calculate the amount of food needed using the standard enteral feeding calculation:

RER (resting energy requirement) = 30 x (body weight in kg) + 70

For patients <2kg or >45kg use this calculation

RER = 70 x body weight in kg

RER ÷ kcal/ml = ml of formula/day

Feeding Schedule

Warm the food to body temperature and administer through a catheter tip syringe over 10-15 minutes. Medications can be mixed into the food and given through the tube. Medications in tablet form should be ground up before adding to the food. Medications in capsule form are opened and the powder is mixed with the food.

On day 1, divide the formula into feedings every 3-4 hours. Follow each meal with 10mls of warm water. Then, increase the volume of food administered and decrease the number of feedings until 3 meals are administered per day.

Change the bandage every 1-2 days and clean around the incision site with an antiseptic. Complications are generally uncommon but can include premature removal, vomiting, and infection at the exit site.

Transition to Oral Feeding

Watch for signs of interest in food. Always allow the patient to try to lap up the blended diet before tube feeding. When the patient is eating voluntarily, then start subtracting food from the tube feeding and giving it orally and continue to increase the amount. Once the patient has eaten voluntarily for several days, the tube can be removed.

Removing the Tube

Remove the wrap. Snip the skin sutures and withdraw the tube slowly. Wipe around the incision site with an antiseptic. Place a light wrap around the neck for 24 hours. The incision will heal by second intention.

Conclusion

Placing an esophagostomy tube in a dental patient allows for quicker and more comfortable healing by bypassing the oral cavity. Feeding through the tube and tube care can be easily taught to clients allowing the patient to recover at home. Rechecks at the clinic should be performed weekly where the bandage can be changed and the tube checked.