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 25-28 September, 2018 | Singapore
2) Gastrostomy Tubes: PEG Tubes (Percutaneous endoscopically placed gastrostomy):
Gastrostomy tubes are indicated in patients with chronic diseas- es requiring long-term/life-time nutritional support such as those suffering from chronic or irreversible diseases affecting the oro- pharynx or oesophagus. PEG tubes should not be placed when only short term usage is anticipated (<7 days), in cats considered poor anaesthetic candidates or when complications such as wound healing or severe coagulopathy are present. Gastrostomy tubes can be placed 1) blind percutaneously (e.g. ELD applicator), 2) surgically during laparotomy or 3) endoscop- ically.
Percutaneous endoscopically placed gastrostomy (PEG) tubes
are often the preferred method of gastrostomy placement be- cause visibility is ideal and the procedure is fast, effective and safe in most circumstances.
The most common complications associated with PEG tubes include insertion site infection, peristomal pain, peristomal leak- age, chewing/dislodgement of the tube by patient, and tube occlusion. Other less common complications include injury to adjacent organs (e.g. spleen, colon, small intestine), bleeding (intraperitoneal, abdominal wall, organs), ‘buried bumper’ syn- drome, and gastric outflow obstruction.
Equipment:
A standard gastroscope is utilised to facilitate placement of the feeding tube. The commercial kits contain - besides the feed- ing tube with conical end - the following material, large over- the-needle catheter (16G), double looped strong suture material (long enough from mouth to side of abdomen, 70-100cm), scal- pel, material to fix feeding tube on outside (clips or suture) and adaptor for feeding syringe.
There are two types of PEG tubes available, commercial kits (adapted from human medicine) which contain all material for quick placement, and “home-made” kits which are cheaper but more cumbersome to build/place and therefore more time con- suming. With both ‘kits’, the placement takes place the same way – a “guide wire” of suture material is pushed via a needle through the abdominal and gastric wall into the gastric lumen, grabbed endoscopically and pulled via oesophagus through the mouth. The PEG is then attached and pulled via the “guide wire” into place. Commercial PEG tubes are either silicone or polyure- thane and can withstand gastric acidity for the animal’s lifetime. In cats 16 Fr to 20 Fr size is used.3 The inner flange is different between different brands but all are suitable for cats.3
A step-by-step guide of PEG tube placement in cats can be ac- cessed for more in-depth instruction.3
Once the PEG is in place, the site is lightly wrapped with occlu- sive dressing, a body or stretch netting is commonly sufficient in cats and no buster collar needed. Daily cleaning of the stoma with an antibiotic or iodine cream is important. Feeding can be begin 24hours post-placement after performing a contrast radio- graph to confirm the absence of peritoneal leakage. Initially, the cat can be given 5-6 divided meals with an increase in volume, decrease in frequency, over the course of a week.. While prob- lems with PEG feeding is rare2-4, they can arise and should be dealt with according to guidelines.2
PEG tubes can stay in place for many months, even lifelong. A PEG tube must stay in place in place for at least 3-4 weeks to ensure adequate adhesion formation.3 Removal should always occur endoscopically as the inside flange of commercial kits is too large to pass naturally when the tube is cut from the outside.
These tubes lie flush against the body wall giving a more cos- metic appearance. It also seems to allow for the cat to resume normal activity without heavy bandages or risk of tube dislodge- ment via entrapment on objects. In the author’s experience, they seem to have a low complication rate and offer high owner sat- isfaction compared to more traditional tubes.
They can be placed either as a ‘two step approach’ following the initial placement of a PEG tube, or a ‘one step approach’. The latter approach eliminates the initial placement of a traditional PEG tube.
‘Two-Step’ Low Profile Placement:
These tubes can be placed percutaneously after a secure gas- tropexy and stoma have been achieved using a traditional PEG tube. Stoma tract maturation typically occurs in 4-6 weeks. Low profile buttons have two types of internal fixation flange: 1) bal- loon 2) non-balloon.
In the author’s experience, balloon buttons seem to have a high failure rate due to spontaneous deflation and/or bursting result- ing in dislodgement. For this reason, the author recommends the use of a non-balloon buttons due to its resilience to long- term exposure to gastric acid and their superior retention disc compared to balloon material. Due to availability (or lack thereof) of appropriately sized infant-sized low profile tubes in cats, the author will often chose to place a slightly larger traditional 20F PEG and replace with a smaller 18F x 1.5cm low profile non-bal- loon (AMT Mini-One Button Low Profile). This size seems to be suitable for most breeds/size and BCS. The tube uses a stiff sty- let with string/toggle system to aid in flange deployment. Re- moval also relies on a stiff stylet to straighten the mushroom tip resulting in little resistance during traction.
‘One-Step’ Low Profile Placement Methods:
A One-Step method for placing low profile buttons can be used as an alternative to the above method. This can be achieved via ‘pull technique’ (see One-Step Low Profile, non-balloon button) which is placed in a similar fashion to a normal PEG tube (author’s choice in cats 16G x 1.7cm with retention discs).
Summary
Enteral feeding devices should be employed early when it is recognised that the patient is not meeting its nutritional and energy needs or requires long-term pharmacological management in a non-compliant patient.. Proper tube placement, handling, and client communication are essential for tube longevity and patient safety. Enteral feeding is the preferred method of nutritional support in patients with functional gastrointestinal tracts. Remember, ‘If the gut works, use it!’
Further Reading/References:
1. Saker KE, Remillard RL. Critical care nutrition and enteral-assisted feeding. In: Hand MS, Thathcer CD, Remillard RL, Rodebush P and Novotny BJ (eds). Small Animal Clinical Nutrition 5th ed. Mark Morris Institure, Topeka KS, 2010, pp. 439-476.
2. Ireland LM, Hohenhaus AE, Broussard JD, Weissman BL. A comparison of owner management and complications in 67 cats with esophagostomy and percutaneous endoscopic gastrostomy feeding tubes. J Am Anim Hosp Assoc2003 (39), 241-246.
3. Neiger, R., Robertson E., Stengal C. (2013) Gastrointestinal endoscopy in the cat: Diagnostics and therapeutics. J Fel Med Surg 15, 993-1005.
4. Armstrong PJ, Hardie EM. Percutaneous endoscopic gastrostomy. A retro- spective study of 54 clinical cases in dogs and cats. J Vet Intern Med 1990 (4),202-206.
      Low Profile Button Tubes:
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43RD WORLD SMALL ANIMAL VETERINARY ASSOCIATION CONGRESS AND 9TH FASAVA CONGRESS






































































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