Esophageal feeding tube placement and the associated complications in 248 cats

Inadvertent placement of an esophagostomy tube into the mediastinum of a cat

An 8-year-old neutered male Siberian forest cat was presented for respiratory distress. Endoscopy, exploratory surgery of the neck, and sternotomy confirmed initial placement of the esophagostomy tube (e-tube) into the mediastinum. The patient recovered from surgery, developed laryngeal paralysis, and then arrested and died within 48 h after surgery. Key clinical message: To the authors' knowledge, there are no other case reports documenting inadvertent placement of an e-tube into the mediastinum of a cat. This case report highlights the complications that can be associated with incorrect placement of an e-tube.

Use of feeding tubes in 112 cats in an internal medicine referral service (2015-2020)

OBJECTIVES

The aims of this study were to describe diseases, complications and outcomes associated with the use of feeding tubes in a population of sick cats with appetite disturbance managed at an internal medicine referral service.

METHODS

Clinicopathological data from cats receiving nasoenteral (NE) or oesophagostomy (O) tubes were studied. Cats were categorised according to their underlying disease and divided into subgroups (NE or O tube). The following factors associated with survival were analysed: disease category, type of tube and return to appetite.

RESULTS

Included in the study were 112 cats, representing 118 cases. Of the 118 cases, 98 (83%) and 20 (17%) received NE or O tubes, respectively. The most common underlying conditions were digestive (13.5%), hepatobiliary (11%) and upper urinary tract (11%) disorders. Hepatobiliary (50%) and upper respiratory tract (30%) conditions were predominant in the O tube group. Digestive (15%) and upper urinary tract (12%) diseases were more common in the NE tube group. Complications following tube placement occurred in 22/118 cases (18.6%). The global survival rate was 73% and did not differ between NE (71.4%) and O tube (80%) groups (P = 1.00) or disease categories (P = 0.61). Return of appetite before feeding tube removal occurred in 56 cases (47%), within a median of 3 days (range 1-30) and was not associated with mirtazapine administration (P = 1.00). Appetite returned earlier for cats with NE tubes (3 days, range 1-17) than for those with O tubes (33 days, range 5-60; P <0.05). Voluntary food intake was positively associated with survival (odds ratio 15.17). After discharge and feeding tube retrieval, return of appetite was observed in 67% of cases.

CONCLUSIONS AND RELEVANCE

Feeding tubes were predominantly placed for the management of appetite disturbance in cats with digestive, hepatobiliary and upper urinary tract diseases. While complications were frequent, they were mostly mild, easily managed and did not preclude feeding tube use. Return to appetite occurred in a large proportion of cats during or after assisted enteral feeding and was associated with survival.

2022 ISFM Consensus Guidelines on Management of the Inappetent Hospitalised Cat

PRACTICAL RELEVANCE

Inappetence may have many origins and, as a presenting sign or observation in the hospitalised patient, is common in feline practice. Nutritional assessment of every patient is encouraged, to identify the need for, and appropriate type of, intervention indicated. The impact of malnutrition may be significant on the feline patient, perpetuating illness, delaying recovery, slowing wound healing and negatively impacting gut health and immunity. Delayed intervention may result in the cat's deterioration; hence prompt control of contributing factors such as the underlying illness, pain, nausea, ileus and stress is vital to optimise voluntary food intake. Management is multimodal, comprising reduction of stress, medications and assisted nutrition in the form of tube feeding or parenteral nutrition. Use of antiemetic, analgesic, prokinetic and appetite stimulant medications may restore appetite, but placement of feeding tubes should not be delayed. Feeding tubes are generally well tolerated and allow provision of food, water and medication with minimal stress, although clinicians must be aware of complications such as stoma site infections and refeeding syndrome.

CLINICAL CHALLENGES

Cats are vulnerable to malnutrition owing to their unique metabolism and specific nutritional requirements. Moreover, their nature as a species means they are susceptible to stress in the hospital environment, which may result in reduced food intake; previous negative experiences may compound the problem. In particular, an inappropriate clinic environment and/or handling may cause or exacerbate inappetence in hospitalised patients, with negative impacts on recovery. Postponing interventions such as feeding tube placement to await improvement, owing to clinician or caregiver apprehension, may hinder recovery and worsen nutritional deficits.

EVIDENCE BASE

The 2022 ISFM Consensus Guidelines on Management of the Inappetent Hospitalised Cat have been created by a panel of experts brought together by the International Society of Feline Medicine (ISFM). Information is based on the available literature, expert opinion and the panel members' experience.

Repurposing medical devices as "button" esophagostomy tubes for extended nutritional support

Background

Esophagostomy tubes (E‐tubes) are widely utilized for extended nutritional support in dogs and cats. Problems associated with their use include the unwieldy excess (10‐20 cm) of external tubing, constant need for neck wraps and necessity for skin sutures, suture tract infection, and tube loss if sutures fail.

Objectives

To evaluate 2 different, low profile (LP) “button” products intended for use in people as enteral (jejunostomy [J] and gastrojejunostomy [G‐J]) feeding tubes for suitability as LP E‐tubes in dogs and cats.

Animals

A young giant breed dog that required extended (>6 months) nutritional and fluid support during recovery from severe neurological illness with protracted adipsia, anorexia, and dysphagia.

Methods

Prospective evaluation of 2 commercially available LP feeding devices after placement of a standard E‐tube. An LP J‐tube and an LP G‐J tube were assessed in consecutive 4‐week trials, for tube retention, patient comfort, stoma health, and functionality.

Results

Both products performed extremely and equally well as LP E‐tubes in this clinical patient, enhancing patient freedom and comfort by eliminating external tubing, skin sutures, and bandaging. The dual port G‐J tube allows medication delivery (eg, sucralfate) to the entire esophagus, but for safety alone (ie, to avoid aspiration), the single port J‐tube appears the best device for client‐owned patients.

Conclusions and Clinical Importance

The LP enteral feeding tubes from the human medical field can be successfully used as LP E‐tubes in dogs and cats, offering superior patient comfort, with no obvious detriment to the patient and main drawback of higher cost.

Investigation of a retroesophagoscopic approach to nasopharyngoscopy as an alternative to the conventional retroflexed endoscopic approach for selected indications in feline cadavers and client-owned cats

OBJECTIVE

To describe a retroesophagoscopic approach (ROSA) to nasopharyngoscopy and compare it with the conventional retroflexed endoscopic approach (REA).

ANIMALS

36 feline cadavers and 2 client-owned cats with nasopharyngeal disorders.

PROCEDURES

36 veterinarians participated in the experimental portion of the study involving feline cadavers. Each veterinarian performed the ROSA and REA to nasopharyngoscopy on a feline cadaver once, attempting to identify and biopsy 2 landmarks (soft palate and choanae) with each approach while time was recorded. Numeric scales were used to measure perceived ease of use and image quality for both techniques. Data were compared between approaches by an independent statistician. The ROSA approach was also used as part of the diagnostic workup for the 2 client-owned cats.

RESULTS

35 of the 36 (97%) veterinarians were able to identify and biopsy both landmarks using the ROSA, whereas 21 (58%) veterinarians were able to visualize both landmarks using the REA and 19 (53%) successfully biopsied the landmarks. Image quality for the soft palate was scored higher with the ROSA (median score, 7.5/10) than with the REA (4.5/10). The ROSA was fast and easy to perform. This approach was also successfully performed in the 2 client-owned cats with nasopharyngeal disorders, with no complications reported.

CONCLUSIONS AND CLINICAL RELEVANCE

The ROSA was found to be a fast, effective, and easy alternative endoscopic technique for assessment of the nasopharynx in cats. This approach may allow use of various instruments that could be relevant for interventional procedures. However, the ROSA was also invasive and should be considered for diagnostic and therapeutic purposes for selected indications only when REA is unsuccessful.

Locoregional Flap Reconstruction Following Oromaxillofacial Oncologic Surgery in Dogs and Cats: A Review and Decisional Algorithm

Primary treatment of most oromaxillofacial tumors in dogs and cats is resective surgery. Management of malignant tumors may be very challenging as wide/radical free-margin surgical removal must be achieved while preserving vital functions. Removal of orofacial tumors may result in large defects exposing the oral cavity or creating a communication with the nasal, pharyngeal, or orbital cavities. Such defects require orofacial reconstruction in order to restore respiratory and manducatory functions. The veterinary surgeon must be familiar with reconstructive techniques in order to prevent the inability of closing the defect, which could lead to an insufficient resection. Small oral defects exposing the nasal cavity are best closed with local random mucosal flaps. Closure of large oral defects may be better achieved with a facial or major palatine-based axial-pattern flap. Small to moderate facial defects can be closed with local advancement or transposition skin flaps. Reconstruction of large facial defects often requires the use of locoregional axial pattern flaps such as the caudal auricular, the superficial temporal, or the facial (angularis oris) myocutaneous axial pattern flaps. Recent publications have shown that the facial (angularis oris) flap is a very versatile and reliable flap in orofacial reconstructive surgery. A surgical decision algorithm based on the size, nature, and location of the defect is proposed.

Transoral approach for mandibular and sublingual sialoadenectomy in a cat

Sialocele is an uncommon condition in cats. The treatment of choice for sublingual sialocele is excision of the ipsilateral mandibular and sublingual salivary gland/duct complex. Lateral and ventral cervical approaches have been described for mandibular-sublingual sialoadenectomy; however, the transoral approach, described here, has never been reported in cats. Ranula in the present case was likely caused by an inadvertent trauma of the sublingual duct during resection of a sublingual lesion performed by the referring veterinarian. The definitive surgery consisted of mass removal and sialoadenectomy through a unique oral approach. The surgery was effective without complications encountered after 6 months of follow-up. Key clinical message: This article reports a novel, transoral approach, for mandibular and sublingual sialoadenectomy in the cat. This approach decreases the surgical time and prevents recurrence of the mucocele.

The effect of assisted enteral feeding on treatment outcome in dogs with inflammatory protein-losing enteropathy

BACKGROUND

The effect of assisted enteral feeding on treatment outcome in dogs with protein-losing enteropathy (PLE) is unknown.

OBJECTIVES

To determine if dogs with inflammatory PLE that had an enteral feeding tube placed had better outcome vs dogs with inflammatory PLE without a feeding tube.

ANIMALS

Fifty-seven dogs with inflammatory PLE.

METHODS

A retrospective study at a UK referral hospital identified dogs with inflammatory PLE using a standard diagnostic criterion. Positive outcome was defined as survival greater than 6 months or death unrelated to PLE and negative outcome as death related to PLE within 6 months of diagnosis. Several variables were assessed to identify factors for positive outcome using logistic regression.

RESULTS

Thirty-five (61%) and 22 (39%) dogs had a positive and negative outcome at 6 months, respectively. Of the 21 dogs that had a feeding tube placed within 5 days of gastrointestinal biopsy, 16 (76%) had a positive outcome and 5 (24%) had a negative outcome. Dogs treated with dietary treatment alone (P = .002) and dogs with an enteral feeding tube (P = .006) were significantly associated with a positive outcome. When stratified by treatment, assisted enteral feeding was significantly associated with a positive outcome in dogs treated with concurrent immunosuppressive treatment (P = .006), but there was insufficient data to evaluate dogs treated with dietary treatment alone.

CONCLUSIONS AND CLINICAL IMPORTANCE

Assisted enteral feeding in dogs with inflammatory PLE could be associated with improved treatment outcome, especially in those receiving immunosuppressive treatment, and should be considered in the treatment plan of these dogs.

Development of alternating, ipsilateral Horner syndrome and Pourfour du Petit syndrome associated with oesophagostomy tube placement in a cat

Case summary

A 12-year-old spayed female domestic shorthair cat was presented to a referral hospital for chronic intermittent hyporexia and weight loss. An abdominal ultrasound was performed, which revealed a mid-jejunal mass and mesenteric lymphadenomegaly. Surgical resection and placement of an oesophagostomy tube (O-tube) was performed. Upon recovery the cat exhibited signs of Horner syndrome, which resolved over the span of 2 weeks. Subsequently, the cat developed signs of unilateral Pourfour du Petit syndrome in the left eye at day 20 and unilateral Horner syndrome at day 25 ipsilateral to the O-tube insertion site. The O-tube was removed 32 days postoperatively, and Horner syndrome resolved 24 h later. Follow-up examination 15 months later did not show any recurrence of ocular signs.

Relevance and novel information

To our knowledge, this represents the first report of alternating ipsilateral Horner and Pourfour du Petit syndrome in a single patient that underwent placement of an O-tube. Neurological complications after O-tube placement are uncommon, with only a single previously published report of a cat developing Horner syndrome after O-tube placement. Veterinarians should consider potential ocular and neurological complications after O-tube placement and monitor for such signs postoperatively.

Oesophagostomy tube complications in azotaemic dogs: 139 cases (2015 to 2019)

OBJECTIVES

To retrospectively assess the rate of oesophagostomy tube-related complications in azotaemic dogs, the influence of the oesophagostomy tube (o-tube) duration and the therapeutic approach (medical versus haemodialysis) on the complication rate.

MATERIALS AND METHODS

Medical records were retrospectively reviewed in order to identify azotaemic dogswhich underwent o-tube placement. o-Tube duration (short-term versus long-term), time of o-tube change, therapeutic approach (medical versus haemodialysis), prevalence of minor (malposition, suture related, inflammation, muco-purulent discharge, abscess) and major (haemorrhage, malposition, obstruction, dislodgement, vomiting of the tube, food coming from the stoma) o-tube-related complications were extracted. Univariate and multivariate logistic regression analysis were performed to identify the risk factors for o-tube-related complications.

RESULTS

Tube-related complications were reported in 74 of 139 dogs (53%). Minor complications were reported in 66 of 74 (89%) and major complications in eight of 74 (11%). In azotaemic dogs, o-tube indwelling time (odds ratio (OR) 1.03; 95% confidence interval (CI) 1.01 to 1.05), and the use of haemodialysis (OR 40.12; 95% CI 9.18 to 175.20) were risk factors for o-tube-related complications.

CLINICAL SIGNIFICANCE

The majority of o-tube-related complications were minor, and easily manageable, with no need of hospitalisation, tube-removal or euthanasia. In azotaemic dogs, the use of haemodialysis was strongly associated with a higher risk of o-tube-related complications, possibly as a consequence of the presence of the neck bandage.

Short-term evaluation of immune levels and nutritional values of EN versus PN in gastric cancer: a systematic review and a meta-analysis

BACKGROUND

Postsurgical patients' oral feeding begins with clear fluids 1-3 days after surgery. This might not be sufficiently nutritious to boost the host immune system and provide sufficient energy in gastric neoplastic patients to achieve the goal of enhanced recovery after surgery (ERAS). Our objective was to analyze the significance of early postoperative feeding tubes in boosting patients' immunity and decreasing incidence of overall complications and hospital stay in gastric cancer patients' post-gastrectomy.

METHODS

From January 2005 to May 24, 2019, PubMed and Cochrane databases were searched for studies involving enteral nutrition (EN) feeding tubes in comparison to parenteral nutrition (PN) in gastric cancer patients undergoing gastrectomy for gastric malignancies. Relative risk (RR), mean difference (MD), or standard mean difference (SMD) with 95% confidence interval (CI) were used to estimate the effect sizes, and heterogeneity was assessed by using Q and χ² statistic with their corresponding P values. All the analyses were performed with Review Manager 5.3 and SPSS version 22.

RESULTS

Nine randomized trials (n = 1437) and 5 retrospective studies (n = 421) comparing EN feeding tubes and PN were deemed eligible for the pooled analyses, with a categorized time frame of PODs ≥ 7 and PODs < 7. Ratio of CD4+/CD8+ in EN feeding tubes was the only outcome of PODs < 7, which showed significance (MD 0.22, 95% CI 0.18-0.25, P < 0.00001). Regarding other immune indicators, significant outcomes in favor of EN feeding tubes were measured on POD ≥ 7: CD3+ (SMD 1.71; 95% CI 0.70, 2.72; P = 0.0009), CD4+ (MD 5.84; 95% CI 4.19, 7.50; P < 0.00001), CD4+/CD8+ (MD 0.28; 95% CI 0.20; 0.36, P < 0.00001), NK cells (SMD 0.94; 95% CI 0.54, 1.30; P < 0.00001), nutrition values, albumin (SMD 0.63; 95% CI 0.34, 0.91; P < 0.001), prealbumin (SMD 1.00; 95% CI 0.52, 1.48; P < 0.00001), and overall complications (risk ratio 0.73 M-H; fixed; 95% CI 0.58, 0.92; P = 0.006).

CONCLUSION

EN feeding tube support is an essential intervention to elevate patients' immunity, depress levels of inflammation, and reduce the risk of complications after gastrectomy for gastric cancer. Enteral nutrition improves the innate immune system and nutrition levels but has no marked significance on certain clinical outcomes. Also, EN reduces the duration of hospital stay and cost, significantly.

Characterization of Fungal Colonization of Indwelling Esophagostomy Tubes

Fungal colonization of feeding tubes occurs rapidly in people, resulting in decreased structural integrity and complications such as luminal obstruction and tube failure. Esophagostomy tubes (E-tubes) are commonly used in dogs and cats for enteral support, but data are lacking regarding colonizing fungi and the impact of colonization on tube integrity. In this study, esophagostomy tubes were collected in lieu of disposal from dogs and cats undergoing feeding tube exchange. Fungi were isolated with culture and identified using morphological characteristics. Scanning electron microscopy was used to evaluate the surface characteristics of the tubes. Two silicone and one polyurethane E-tube were evaluated. Fungi associated with the normal microbiota, including Candida sp. and Penicillium sp., as well as environmental fungi were identified. This case series represents the first documentation of fungal colonization of silicone and polyurethane E-tubes in dogs and cats. Additionally, this is the first report to document degenerative changes in a silicone E-tube.

Esophageal feeding tube placement and the associated complications in 248 cats

Background

Esophageal feeding tubes are commonly used to provide enteral nutrition to cats, but their use is associated with adverse effects.

Objectives

To evaluate the complications associated with e‐tube placement in cats and to identify factors predisposing to these complications.

Animals

Cats that had an esophageal feeding tube placed (n = 248).

Methods

This was a retrospective case review in which clinical records were interrogated across 2 referral centers to identify records of cats that had esophageal tubes placed. Clinical data were collected for signalment, clinical indication, method of placement, time of removal, and any complications. Logistic regression was then employed to assess the odds of an increase in complications, including infection and death.

Results

For those cats that survived to discharge, tubes were in place for a median of 11 days, ranging from 1 to 93 days. Complications occurred in 35.8% of the cats, with the most common being tube dislodgement (14.5%), followed by stoma site infections (12.1%). Cats receiving glucocorticoids or oncolytic agents (OR = 3.91; 95% CI, 1.14‐13.44) and with discharge at the stoma site (OR = 159.8; CI, 18.9‐1351) were at an increased odds of developing a stoma site infection, whereas those with a lower weight (OR = 1.33; 95% CI, 1.02‐1.75) or (pancreatic [OR = 4.33; 95% CI, 1.02‐18.47], neoplastic [OR = 15.44; 95% CI, 3.67‐65.07], respiratory [OR = 19.66; 95% CI, 2.81‐137.48], urogenital [OR = 5.78; 95% CI, 1.15‐28.99], and infectious diseases [OR = 11.57; 95% CI, 2.27‐58.94]) had an increased odds of death. The duration of time in place and the cat being discharged with the tube in place were not associated with an increased risk of infection or death.

Conclusions and clinical importance

Owners should be made aware of the potential risks involved and their predisposing factors.