A Comparison of Owner Management and Complications in 67 Cats With Esophagostomy and Percutaneous Endoscopic Gastrostomy Feeding Tubes

Introduction

The prompt attention to nutritional management of inappetant veterinary and human patients has been shown to decrease morbidity and mortality.^1–5 Enteral feeding is preferable whenever possible, as compared to parenteral routes. Intestinal morphological structure is sustained, and function is preserved by providing nutritional support to the gastrointestinal tract through the abatement of villus atrophy, preservation of the mucosal barrier, and maintenance of immunological function.^1–5 Patients receiving enteral nutrition are able to obtain treatment at home rather than remain in the hospital. This is a preferable situation for many pets and their owners.

Placement of enteral feeding tubes may utilize nasal, pharyngeal, esophageal, gastric, or jejunal routes. The advantages, limitations, placement techniques, and associated complications of these various tube types have been previously described.^25–12 It has been recommended that the enteral supplementation route chosen should be based on the anticipated amount of time that nutritional support will be indicated, the primary disease process involved, the functional capacity of the gastrointestinal tract, attending clinician experience, as well as the patient and owner tolerance of the feeding device.⁵ Gastrostomy, pharyngostomy, and esophagostomy tubes have been successfully used as enteral feeding routes for outpatients when nutritional supplementation is required for an extended period of time (i.e., >1 week).^2561013–18

Gastrostomy tubes have traditionally been considered the most well-tolerated enteral feeding device.⁵⁶¹³¹⁹ The introduction of the percutaneous endoscopic gastrostomy (PEG) tube to veterinary medicine in 1986 provided a less invasive alternative to surgically placed gastric feeding tubes and replaced much of the use of pharyngostomy tubes.¹⁶¹³ The PEG tubes were considered preferable to pharyngostomy tubes for reducing complications such as laryngeal obstruction, epiglottic entrapment, inhibition of voluntary food intake, interference with deglutition, and vomition.^23561319 The placement of PEG tubes requires expensive endoscopy equipment and specialized training. Blind PEG tube placement techniques have been described.^520–23 Limitations of this technique include difficult placement in obese patients, the inability to ensure adequate positioning and apposition of the mushroom tip to the gastric wall, and contraindication in patients that possess esophageal disorders.^5202223 The use of PEG tubes poses the risk of peritonitis and sepsis associated with incomplete adhesion formation between the gastric and peritoneal walls. These life-threatening complications are a concern with premature tube removal prior to 2 weeks after placement.^6132024

The development of the esophagostomy (E) tube has provided an alternative to the use of pharyngostomy and gastrostomy tubes.¹⁰²⁵ Several studies have been published over the past few years indicating that E tubes have few major complications, are well tolerated by patients, and are simple to place.^5101624–26 Esophagostomy tubes are placed at the midcervical region, thereby avoiding the pharyngostomy tube complications of airway obstruction and interference with oral intake.⁵⁹²⁴²⁵ Although minor complications involving E tubes may commonly occur, life-threatening complications are rare.^1016242627 Previously reported complications with a minor or moderate degree of severity include tube obstruction, patient tube removal, vomiting, peristomal cellulitis, and infection.^16242627

To the authors’ knowledge, E and PEG tube methods of enteral feeding have not been directly compared with regard to owner management and rate of complications. The purposes of this study were to evaluate and compare owner management complications and ease of use for E and PEG feeding tubes in cats requiring enteral nutrition as an adjunct therapy in the management of a primary disease process.

Materials and Methods

A retrospective study was conducted to evaluate and compare the use and complications of E and PEG tubes in feline patients. The medical records of feline patients having either of these tubes placed between July 1997 and July 2001 at the Animal Medical Center were evaluated. The following criteria were required for entry into the study: the feeding tube must have been placed at the authors’ facility; the patient was discharged from the hospital with the feeding tube in place; and the feeding tube was used to provide enteral nutrition at home for at least 1 week.

Medical records were reviewed to determine the following information: type of tube placed; breed; age; sex; primary diagnosis; amount of weight change while tube was in place; length of time tube was in place; duration of time from tube placement until voluntary food consumption; complications experienced by the owner during the treatment period; and ease of owner tube management. Percutaneous endoscopic gastrostomy^a and E tubes^b were placed using modified versions of previously described techniques and various types of commercially available tubes.^{56101920252628} Standardization of feeding tube placement techniques was not possible because of the retrospective nature of this study.

Minor complications were defined as those that posed no health risk to the patient. These included peristomal inflammation, scratching at the tube and bandage, tube nozzle dislodgement, and tube obstruction.^{1–356101319} Moderate complications were defined as those that posed a nonlife-threatening health risk to the patient. These included vomiting, vomition of the tube, tube migration, stomal site infection, and tube removal by the patient (at least 14 days after placement for PEG tubes). Major complications were defined as those that posed a life-threatening health risk to the patient. Examples would include aspiration pneumonia, airway obstruction, PEG tube removal <14 days after placement, and peritonitis.

An attempt was made to contact all owners regarding the tube management and complications encountered at home. Owners were asked to subjectively rate their initial reluctance to the tube placement (i.e., extreme, moderate, mild, or no reluctance), ease of the initial feeding experience (i.e., no difficulty; mild, moderate, or extreme difficulty), and eventual comfort with the tube management (i.e., very comfortable, moderately comfortable, uncomfortable, or unable to use the tube). Owners were asked to report any complications experienced and their willingness to use another feeding tube.

The Mann-Whitney U test was utilized to compare data between the two groups for age, weight change while the tube was in place, length of time the tube was in place, number of days the tube was in place prior to voluntary food consumption, and the rate and severity of complications experienced.

Results

Sixty-seven cats met the criteria for entry into the study. Twenty-one cats (17 domestic shorthair [DSH], one domestic longhair [DLH], three purebred) with a mean age of 10 years (median, 11 years) had PEG tubes placed. Forty-six cats (37 DSH, one DLH, eight purebred) with a mean and median age of 10 years had E tubes placed. Of the cats with PEG tubes, nine were castrated males, 11 were spayed females, and one was an intact female. Of the cats with E tubes, 23 were castrated males, one was an intact male, and 22 were spayed females.

The following primary disease processes were indications for E tube placement: hepatic lipidosis (n=14); cholangiohepatitis (n=3); lymphoma (n=10); severe stomatitis (n=3); inflammatory bowel disease (IBD) (n=2); upper respiratory infection (n=2); and disseminated mastocytosis, hyperthyroidism, multiple myeloma, chronic malnutrition, oral squamous cell carcinoma, undiagnosed hepatopathy, bronchopneumonia, diabetes mellitus/insulin overdose, ceruminous gland adenocarcinoma, pancreatitis, pancreatic carcinoma, chronic renal failure/congestive heart failure (one cat each). The following primary disease processes were indications for PEG tube placement: hepatic lipidosis (n=5); IBD (n=2); chronic renal failure (n=2); oral squamous cell carcinoma (n=3); cutaneous mast cell neoplasia (n=2); and nasal lymphosarcoma, esophageal stricture, esophageal foreign body, esophagitis secondary to turpentine ingestion, amelioblastoma, mandibular osteoma, retrobulbar salivary carcinoma (one cat each).

Overall summary data on the use of PEG and E tubes in these 67 cases, results of the owner management survey, and severity of any reported complications are presented in Tables 1, 2, and 3, respectively. A statistical difference could not be detected between PEG tubes and E tubes in any variables assessed, except for the length of time a feeding tube was in place.

Two cats with PEG tubes managed to remove the feeding tubes prematurely. One cat removed the tube 42 days after placement, and the other removed it on day 67. Gastric and peritoneal wall adhesions were well established; therefore, complications of leakage into the peritoneal cavity and peritonitis were not observed. The feeding tubes were not replaced, because both cats were consuming adequate quantities of food at the time of tube removal. Five cats with E tubes removed their feeding tubes prematurely (on days 13, 23, 26, 28, 36). Esophagostomy tubes were replaced in two cats. The remaining three cats were consuming adequate quantities of food and did not require replacement of the feeding tubes. None of the cats experienced any problems secondary to patient tube removal.

Twelve owners of the 21 cats that received PEG tubes were surveyed. Twenty-four owners of the 46 cats that received E tubes were surveyed [Table 2]. All owners surveyed reported that they would be willing to use another feeding tube in the future, if medically indicated.

Discussion

Esophagostomy tubes have been used with increased frequency during the past 5 years at the authors’ facility (unpublished data). The authors believe the increased popularity of the E tube is because of the ease of placement and low cost compared to PEG tubes. Both types of enteral feeding devices allow a physiological method by which to provide nutritional support to patients that have some degree of gastrointestinal function but are unwilling or unable to take in sufficient quantities of food orally. The data of this report does not suggest that one type of tube has significant advantages over the other with regard to maintaining body weight, inhibition of voluntary food intake, owner management complications, or ease of owner management. Complications associated with placement were not addressed in this study because of the lack of standardization of placement techniques. In addition, it is difficult to assess both placement and management complications in the same population of cats. Cats that experienced significant problems at placement may not have been discharged with a feeding tube.

Comparisons between the two populations of cats were similar with respect to breed, age, and sex. The breed was predominantly DSH, and all but two cats were neutered. The mean age for both groups of cats was 10 years. The authors believe this reflects the typical hospital feline population at the authors’ facility. The mean age of the cats in this study is believed to be representative of the typical age of patients with these disease processes, and it is not believed to be related to the authors’ practice of enteral nutritional support.²⁹³⁰

Cats in both groups began to consume food voluntarily approximately 1 to 2 weeks after feeding tube placement. In spite of the differences in duration of tube feedings, both tubes proved efficacious for maintaining body weights. The PEG tubes evaluated in this study remained in place for a significantly longer period of time when compared to E tubes (P=0.0034), ranging from a minimum of 7 days to a maximum of 318 days (mean, 92 days; median, 43 days). The E tubes were in place from a minimum of 5 days to a maximum of 98 days (mean, 29 days; median, 26 days). The placement duration for each tube type was comparable to previously reported studies.^6182426

It was not the purpose of this paper to evaluate the maximum length of time each type of feeding tube could remain in place. Conclusions regarding the maximum amount of time that a feeding tube type may remain in place may not be made based on this data. The type of tube placed for each patient was not randomized. Bias by the clinician may have resulted in the selection of E tubes for cats with a shorter anticipated need for enteral nutritional support. Cats chosen to receive PEG tubes may have had a longer anticipated need for enteral nutritional support. Previous publications have advocated PEG tubes for medium- and long-term nutritional support of weeks to months.^23561928

The most common indications for placement of both feeding tube types were neoplasia and hepatic disease. The authors’ data indicates that E tubes were used more often than PEG tubes for treatment of hepatic lipidosis. Seventy-four percent of cats with hepatic lipidosis in this study had E tubes placed, and 26% had received PEG tubes. The authors believe these percentages reflect a hospital bias toward use of the E tube for treatment of this disease because of the simplicity of placement and anticipated duration of treatment. These medical conditions have previously been reported to be common indications for feeding tube placement for feline patients in other studies.^615192426

No difference was found between PEG tubes and E tubes when complication severity and frequency were statistically compared. The most common complications found with PEG tubes were vomiting and stomal site infection. These problems were frequently reported findings in other studies.²⁶¹⁵¹⁷ The most common complications reported with E tubes were vomiting, scratching at the tube and bandage, patient removal of the tube, mechanical difficulties (i.e., tube obstruction, tube nozzle dislodgement), and tube vomition. The types of complications were found to be similar to other previous publications.^516242627 Complication rates for PEG tubes and E tubes were found to be higher as compared to those implied in other studies.⁶¹⁶²⁴ This may be the result of the authors’ surveying of owners regarding tube feeding difficulties experienced at home in addition to the medical record review.

Although not statistically supported by the data, tube obstruction could have been a more common problem with E tubes because of their smaller diameter (14 French) as compared to PEG tubes (20 French). The smaller diameter may have been the reason many owners perceived difficulty passing food through the E tubes. Owners described methods of alleviating this problem by using smaller syringes (best results were reported with 6-cc and 12-cc syringes) or changing food types and consistency. Most tube obstructions were treated by the owner applying gentle pressure and suction while flushing warm water or a carbonated liquid through the tube. Subsequent obstructions were prevented or reduced in frequency by flushing warm water through the tube before and after enteral feeding and medication treatments.

Due to anatomical location, E tubes may be more susceptible than PEG tubes to scratching-induced tube migration or premature removal. Owners in this study subjectively reported an increase in the incidence of cats scratching at the E tube and bandage and a greater resistance to restraint for feedings as their cat’s strength improved. Stomal site inflammation, infection, and scratching at the tube bandage resolved in many cases with improved tube ostomy site care. Ostomy sites should be inspected daily, and owners should be instructed on proper stomal wound care and bandage changing. Patients that continue to scratch at the tube site should wear an Elizabethan collar to prevent premature tube removal.

In this study, five cats with E tubes vomited the aboral end of the tube, resulting in displacement of the tube into the oral cavity. Three of these cats subsequently bit off but did not swallow the ends of the tubes. Vomiting may have been a result of the primary disease process, tube displacement, or related to the rate, volume, or temperature of the feedings. Two cats required replacement of the E tubes, one cat had a PEG tube placed, and two cats did not require a replacement feeding tube because they were eating sufficient quantities of food. Decreasing the food volume, increasing the frequency of feeding, using antiemetics, and feeding food at room temperature successfully abated signs for most cats.

Three cats experienced approximately 5-cm migrations of their E tubes aborally through the lower esophageal sphincter, resulting in vomiting. Two of the cats required repositioning and resuturing of the tube to skin, and the remaining cat was managed by repositioning the tube and applying a more secure cervical bandage. Tube placement was confirmed radiographically. Enteral feeding resumed without vomiting in all three cats. The displacement of the tubes was thought to be from patient scratching and disruption of the anchoring sutures.

The survey of owners revealed similar conclusions for both feeding tube types regarding outpatient feeding tube management. Clients in both groups described having experienced no reluctance or mild reluctance to the recommendation of a feeding tube. Most owners reported no difficulty or mild difficulty with the initial tube feedings for both PEG and E tubes. All owners became very to moderately comfortable managing their cat’s feeding treatments with a PEG tube. Almost all owners became very to moderately comfortable with the E tube feedings. One elderly woman described increased difficulty with restraint of her cat and hired a technician to administer feeding treatments at her home. Most owners felt their pets benefited significantly from the feeding tubes. Overall, clients responded favorably to their experiences with both types of tubes. These findings were similar to those of another study regarding use of the gastrostomy tube by owners at home.¹⁷

Due to the retrospective nature of the study design and diversity of diseases, the type of tube chosen for each patient was not randomized, and the placement techniques were not standardized. The groups were not large enough to analyze individual disease processes and their outcomes with respect to the different feeding tubes. Consequently, this data cannot be used to compare complications of tube placement, responses of particular disease processes to tube feedings, or to recommend a type of feeding tube for treatment of specific medical conditions.

Conclusion

The PEG tube continues to be a successful method of providing long-term enteral nutrition for cats. The E tube requires less skill and time for placement, making it an excellent alternative to the PEG tube. The authors’ study suggests a similar efficacy for each feeding tube in maintaining patient body weight, ease of owner management, and complication severity and frequency. The authors suggest that the decision to select one tube over another should include the skill of the veterinarian in placing the feeding tube and the length of anesthesia thought tolerable by a critical patient. Owner education regarding tube feeding management, stomal site care, and common potential complications is crucial for the successful outpatient use of feeding tubes.