tube. Usually a 20–30 Fr tube can be placed. Either a Foley catheter or a mushroom‐tipped tube are used in dogs and cats (Figure 4.6). The balloon of a Foley catheter has a tendency to rupture quickly because of the acidic environment. Mushroom‐tipped tubes are commonly use if long‐term utilization is anticipated. A low‐profile gastrostomy tube with a mushroom‐tipped can also be used.
Gastrostomy feeding tubes can be placed surgically during a laparotomy or percutaneously with endoscopy (Armstrong et al. 1990a, Armstrong and Hardie 1990b, Bright et al. 1991, Marks 1998). General anesthesia is required for the placement of a gastrostomy tube. The tubes are placed in the left side of the abdominal cavity into the body of the stomach.
4.3.3 Technique
4.3.3.1 Endoscopic Placement
Endoscopic placement of gastrostomy is recommended for patients not undergoing laparotomy. Endoscopic placement is contraindicated for patients with esophageal stricture.
The patient is placed in right lateral recumbency. A flexible endoscope is advanced in the stomach. After sufficient insufflation of the stomach an 18 gauge over‐the‐needle catheter is placed percutaneously in the lumen of the stomach. A suture is then threaded in the catheter. A snare or a grasping forceps can grab the suture in the lumen of the stomach. The suture is then pulled out through the esophagus and the mouth of the patient. The suture has to be long enough to exit in the oral cavity and still be present through the abdominal wall. Another over‐needle catheter is threaded over the suture and the gastrostomy tube securely attached to the suture. The proximal end of the gastrostomy tube is wedged in the flared end of the over‐needle catheter. A mushroom‐tipped catheter is used. The suture is then pulled from the abdominal wall to bring the gastrostomy tube in the lumen of the stomach. A small skin incision is made to facilitate the passage of the catheter through the abdominal wall. A Chinese finger‐trap suture with 2‐0 nylon is then used to secure the gastrostomy tube to the skin (Song et al. 2008). The endoscope can be reintroduced to confirm appropriate placement of the gastrostomy tube.
4.3.3.2 Surgical Placement
4.3.3.2.1 Laparoscopically Assisted
A single‐access port is inserted in the left side of the abdominal cavity caudal to the last rib. The port is placed lateral to the rectus abdominal muscle. After insufflation of the abdominal cavity a 5 mm rigid endoscope and 5 mm grasping forceps are used to visualize and grab the wall of the body of the stomach toward the fundus between the lesser and greater curvature. The stomach is brought against the abdominal wall and the single‐access port is removed. Small Gelpy retractors are used to keep the incision through the abdominal wall opened. A stay suture is placed in the wall of the stomach. A 3‐0 monofilament absorbable suture is then used to place a purse‐string suture in the wall of the stomach. A #11 blade is used to puncture the center of the purse‐string suture. The gastrostomy tube is then introduced in the lumen of the stomach. The purse‐string suture is tightened around the tube. If a Foley catheter has been used, the balloon is inflated with 5 ml of saline. Four pexy sutures are placed between the wall of the stomach and the transverse abdominalis muscle. A 3‐0 monofilament absorbable suture is used for the pexy. Another purse‐string suture is placed in the transverse abdominalis muscle around the tube to prevent its displacement. The subcutaneous tissue and skin are closed in a routine fashion around the tube. A Chinese finger‐trap suture with 2‐0 nylon is placed on the skin to secure the tube (Song et al. 2008).
4.3.3.2.2 Laparotomy
Gastrostomy tubes are frequently placed during a laparotomy. A purse‐string suture with 3‐0 monofilament absorbable suture is placed in the wall of the body of the stomach close to the junction with the fundus between the lesser and the greater curvature (Figure 4.7a–f).
A #11 blade is then used to penetrate the abdominal wall from the skin surface. The blade is introduced caudal to the last rib lateral to the rectus abdominalis muscle. A large size forceps grabs the blade in the abdominal cavity. The blade is withdrawn from the abdominal wall with the forceps. The forceps then grabs the feeding tube and pulls it inside the abdominal cavity. A puncture is made in the center of the purse‐string in the wall of the stomach. The gastrostomy tube is then introduced in the lumen of the stomach and the purse‐string is tightened. If a Foley catheter has been used, the balloon is inflated with 5 ml of saline. Four pexy sutures are placed between the wall of the stomach and the transverse abdominalis muscle around the gastrostomy tube. A 3‐0 monofilament absorbable suture is used for the pexy sutures. A Chinese finger‐trap suture with 2‐0 nylon is placed on the skin to secure the tube.
The laparotomy is closed in a routine fashion.
4.3.4 Tips
The utilization of the #11 blade and the forceps to go through the abdominal wall minimizes the size of the incision made in the abdominal wall for the placement of the gastrostomy tube. It minimizes the risk of peristomal inflammation.
4.3.5 Utilization
Gastrostomy tubes are not used in the first 24 hours after placement to allow a seal to form between the stomach wall and the abdominal wall. Feedings are then conducted four times a day with a blenderized diet. The total daily caloric requirements are calculated and divided in four feedings. The amount of food is delivered over 5–10 minutes. The tube should be flushed with water after each feeding to prevent obstruction of the tube.
4.3.6 Complications
Gastroesophageal reflux and vomiting can occur if the gruel is delivered too fast or cold. Increasing the frequency of the feeding and reducing the volume of each feeding might also help reduce the risk of vomiting. Peristomal inflammation can happen if leakage occurs around the tube.
Gastrostomy tubes can be dislodged accidentally or pulled by the dog. Premature removal of the tube may result in leakage and peritonitis. If the tube has been pulled accidentally it is usually possible to replace it immediately with heavy sedation. A new Foley catheter can be introduced into the stoma. A radiograph with water‐soluble iodine is used to confirm placement of the new tube in the stomach. Obstruction of the tube can occur. It is important to regularly flush the tube with saline. If the tube cannot be cleared the tube will need to be replaced.
4.4 Jejunostomy Tube
4.4.1 Indications
Jejunostomy tubes are indicated when feeding in the stomach is not possible. It is used to bypass a diseased upper gastrointestinal tract, resulting in chronic vomiting. It is also indicated in surgery to bypass an enterotomy or enterectomy. Jejunostomy tubes are often placed during the surgical treatment of peritonitis to be able to provide nutrients to a hyper‐metabolic patient without increasing of gastroesophageal reflux and aspiration pneumonia (Marks 1998; Daye et al. 1999; Heuter 2004; Hewitt et al. 2004).
