Complications and Outcomes of One-Step Low-Profile Gastrostomy Devices for Long-Term Enteral Feeding in Dogs and Cats
Sixteen dogs and cats with a variety of primary diseases were retrospectively evaluated following endoscopic placement of a one-step low-profile gastrostomy device. Overall, the devices were well tolerated, with most complications being minor in nature. Complications included bloody or purulent peristomal discharge, peristomal swelling, peristomal inflammation, discomfort associated with the device, leaking through the device, chewing at the device, premature removal of the device, peritonitis, and aspiration pneumonia. Dogs survived for up to 2241 days, and cats survived for up to 593 days after initial device placement. The median survival time after device insertion for dogs was 89 days, and for cats it was 87 days.
Introduction
Insertion of percutaneous endoscopic gastrostomy tubes has been shown to be a relatively safe and effective method for providing intermediate to long-term assisted enteral nutrition in both dogs and cats.1,2 Despite the benefits of standard-length gastrostomy tubes (i.e., those with a length of tubing that extends from the body wall after placement) in animals, these devices have several disadvantages, such as the bulkiness of the external portion of the tube (which is aesthetically displeasing to owners) and the increased potential for inadvertent or purposeful removal of the device by the animal.3,4 Such problems have been largely overcome in humans by the development of a replacement low-profile gastrostomy device that fits flush with the skin and is placed once the gastrocutaneous stoma from the initial gastrostomy tube matures.5–7 Tube occlusions also occur less frequently with low-profile gastrostomy devices, likely because of their shorter shaft length.8 The low-profile gastrostomy devices are also less prone to deterioration and incite less localized inflammation at the stoma site, because they are composed of silicone or polyurethane.3 These benefits generally result in fewer complications associated with the low-profile gastrostomy device and in less need for frequent replacement. The use of low-profile gastrostomy devices to replace standard gastrostomy tubes once a gastrocutaneous stoma has been established has also been previously described in small animals.9
The insertion of a one-step low-profile gastrostomy device as an initial and more permanent gastrostomy tube could eliminate the need to replace the primary gastrostomy tube and reduce the frequency of early complications from standard devices. In addition, the placement of a onestep low-profile gastrostomy device could result in substantial cost savings to the owner, because the procedure requires only a single anesthetic procedure and a single tube insertion. While placement of a one-step low-profile gastrostomy device as an initial enteral feeding device is considered to be safe and efficacious in humans, there is a paucity of information documenting the implementation of this device and associated complications in animals.6–8 Elliott et al. reported on 56 dogs that had gastrostomy tubes, most of which were placed endoscopically.3 Ten of the dogs received a one-step low-profile gastrostomy device; however, the study did not evaluate the long-term use, complications, or client impressions of the device.3 McCrackin Stevenson et al. evaluated the placement of a one-step low-profile gastrostomy device in 13 healthy kittens; however, long-term complications were not investigated, all the kittens were healthy, and owner impressions were not obtained.4 The purposes of this study were to evaluate the use of one-step low-profile gastrostomy devices in dogs and cats with a variety of spontaneous medical disorders, to determine short-term and long-term complications, to assess outcomes, and to obtain owner impressions of the utility of the device when used to provide nutritional support.
Materials and Methods
Case Material
Computerized medical records from the Veterinary Medical Teaching Hospital, University of California – Davis (VMTH UCD), were searched for dogs and cats that met four criteria: 1) a one-step low-profile gastrostomy device was inserted between November 1995 and July 2003 at VMTH UCD; 2) the device was placed using a routine placement technique via endoscopy (described below), similar to that previously described for standard-length gastrostomy tubes, and was maintained in place for at least 10 days; 3) no other gastrostomy feeding device was placed prior to the one-step low-profile gastrostomy device; 4) the animals were discharged from the hospital with the one-step low-profile gastrostomy device in place to allow the opportunity to obtain data on owner-observed complications and impressions.10 The study period ran from the time of initial device placement in November 1995 to November 2003.
Information gathered from medical records of animals that met the inclusion criteria included signalment, body weight before and after one-step low-profile gastrostomy device placement, initial body condition score, underlying medical disease, results of a complete blood count (CBC) and serum biochemical profile prior to insertion of the gastrostomy device, size of the one-step low-profile gastrostomy device initially inserted, nutritional management, complications related to the one-step low-profile gastrostomy device, and outcomes.11,12 Resting energy requirement for all animals was calculated using the following equation: Resting energy requirement = 70* (body weight in kilograms)0.75.13 The animal’s survival time was taken as the number of days from initial device insertion until death or until November 30, 2003, if the animal was known to be alive.
Device Insertion Technique
Each animal was placed in right lateral recumbency while under general anesthesia, the left lateral abdomen was clipped and aseptically prepared, and an endoscope was used to assist with insertion of the device. The endoscope was introduced into the stomach, and the abdominal wall was transilluminated following insufflation of the stomach. An assistant applied finger pressure at a point approximately 3 inches caudal to the last rib and 3 to 4 inches ventral to the epaxial muscles. The assistant carefully trocharized the stomach with a 16-gauge needle, then threaded multifilament suture material through the needle into the gastric lumen. The endoscopist grasped the suture material with biopsy forceps and carefully withdrew the endoscope and biopsy forceps from the stomach still attached to the suture material. The suture material was tied to the wire loop attached to a plastic catheter sleeve at the distal end of the device [Figure 1]. The assistant then gently pulled the one-step low-profile gastrostomy device back into the animal’s stomach by exerting traction on the suture material from outside the abdominal wall. The one-step low-profile gastrostomy device was pulled into the stomach until the mushroom tip rested gently against the gastric mucosa. The folded, encased flanges of the device were pulled through the abdominal wall. Viewing through the endoscope was done to ensure that the mushroom tip was lying flush against the gastric mucosa away from the pyloric canal. The assistant freed the low-profile device [Figure 2] from the long catheter sleeve by gently grasping the loose end of the tear strip (black suture material in figure) located at the distal end. Silicone spacers (1- to 5-mm disks) were placed between the skin and flanges of the device to ensure an optimal shaft length and fit [Figure 3]. The assistant was careful to ensure that the flanges did not exert excessive pressure against the peristomal skin. The tube was not covered by a bandage or dressing, and water was introduced approximately 12 to 18 hours following placement of the tube.
Follow-up Methodology
Owners of animals that were discharged from VMTH UCD with the one-step low-profile gastrostomy device were contacted by telephone, and their responses to 22 questions were recorded. Eighteen of the questions had five possible answers available in the form of a grading scale that varied from question to question (e.g., from very positive to very negative, with differing numerical values), and the owner was asked to choose the most appropriate answer. Two of the questions required yes or no answers. One of the questions asked the length of the animal’s survival after device placement. The final question asked the owner for any additional comments.
Statistical Analysis
All data were analyzed using a computerized spreadsheet.a Results are expressed as the mean, median, and range when the data were not normally distributed, or mean ± standard deviation when the data were normally distributed. An exact log-rank test was used to compare the survival for dogs that received hemodialysis with the survival for those that did not. A P value <0.05 was considered significant.
Results
Study Subjects
Nine dogs and seven cats met the inclusion criteria for this study. The median and mean ages at the time of one-step low-profile gastrostomy device placement for all animals were 4.7 and 6.4 years, respectively. The median and mean ages for dogs were 4.2 and 4.6 years, respectively (range 0.5 to 13.7 years), and 8.1 and 8.8 years, respectively (range 2.3 to 14.3 years), for cats. Dog breeds represented were the shih tzu (n=2), Siberian husky (n=1), Jack Russell terrier (n=1), German shepherd dog (n=1), soft-coated wheaten terrier (n=1), Chinese shar pei (n=1), Dalmatian (n=1), and a toy poodle-cross (n=1). The cats included domestic short-hairs (n=4) and domestic longhairs (n=3). Six of the dogs were male (three castrated), and three were female (two spayed). Four of the cats were castrated males, and three were spayed females.
The animals selected for placement of the gastrostomy device had the following underlying diseases: renal (eight dogs, four cats), cardiac (one cat), esophageal (one dog, one cat), neoplastic (two cats), and gastrointestinal (one cat). Two cats had more than one disease reported at time of initial evaluation. One cat had concurrent hypertrophic cardiomyopathy and chronic renal failure, while the other had neoplasia and chronic renal failure. Of the 12 animals with renal disease, 11 had chronic renal failure (seven dogs, four cats), and one dog had acute renal failure secondary to ethylene glycol ingestion. Five dogs were receiving hemodialysis treatment when the one-step low-profile gastrostomy device was placed. The dog with esophageal disease had megaesophagus, while the cat with esophageal disease had dysmotility. One of the cats with neoplastic disease had a sublingual squamous cell carcinoma, and one had a ceruminous gland adenocarcinoma that caused discomfort upon opening of the mouth. The cat with gastrointestinal disease had lymphoplasmacytic gastritis and eosinophilic and lymphoplasmacytic enteritis.
The median and mean weights of dogs at the time of device placement were 15.4 and 14.1 kg, respectively (range 3.1 to 28.6 kg), and the median and mean weights of cats were 3.5 and 3.8 kg, respectively (range 2.5 to 5.9 kg). The median and mean body condition scores were 2.5 and 2.3, respectively, for dogs (range 1 to 3; n=6), and 3.5 and 3.3, respectively, for cats (range 2.5 to 4; n=6). Fifteen (eight dogs, seven cats) of the 16 animals had lost weight prior to insertion of the gastrostomy device. The remaining dog was gaining weight but refused to eat any of the diets selected to assist with management of her renal disease. Median and mean amounts of weight lost for the three dogs and five cats known to have lost weight after insertion of the gastrostomy device were 0.3 and 0.4 kg, respectively (range 0.1 to 1.2 kg). The average percentage of body weight lost was 6.7% (range 1.9% to 12.5%). Because the animals were weighed at varying times before and after initial device placement, it was not possible to elucidate whether the rate of weight loss had been attenuated in these animals. Three dogs and one cat gained weight after insertion of the gastrostomy device. Median and mean amounts of weight gained were 1.6 and 4.1 kg, respectively (range 0.4 to 12.6 kg). The average percentage of weight gained was 40.5% (range 2.2% to 82.1%). Body weight was not monitored after device placement in three dogs and one cat.
Laboratory Results
The results of laboratory tests performed at VMTH UCD during the week prior to the insertion of the one-step low-profile gastrostomy device were available for nine dogs and six cats. Most animals had received intravenous fluids or other treatments prior to laboratory testing. One cat received a blood transfusion prior to laboratory testing, while one dog received a blood transfusion after laboratory testing but before device placement; two dogs received hemodialysis after laboratory testing but before device placement. Dogs had a mean (± standard deviation) serum albumin concentration of 2.5±0.6 mg/dL (reference range 2.9 to 4.2 mg/dL). Cats had a mean (± standard deviation) serum albumin concentration of 2.7±0.4 mg/dL (reference range 1.9 to 3.9 mg/dL). Mean (± standard deviation) serum blood urea nitrogen concentration in dogs was 111±42 mg/dL (reference range 8 to 31 mg/dL), and in cats it was 89±67 mg/dL (reference range 18 to 33 mg/dL). Mean (± standard deviation) serum creatinine concentration in dogs was 6.6±2.9 mg/dL (reference range 0.5 to 1.6 mg/dL), and in cats it was 5.4±4.4 mg/dL (feline reference range 1.1 to 2.2 mg/dL).
Dogs had a mean (± standard deviation) hematocrit of 29%±9% (reference range 40% to 55%). Cats had a mean (± standard deviation) hematocrit of 27%±10% (reference range 30% to 50%). White cell counts in the dogs ranged from 5600 to 43,700 cells/μL (median 12,000 cells/μL; mean 19,211 cells/μL; reference range 6000 to 13,000 cells/μL). In the cats, white cell counts ranged from 8690 to 35,270 cells/μL (median 11,950 cells/μL; mean 15,227 cells/μL; reference range 4500 to 14,000 cells/μL). Neutrophil counts in the dogs ranged from 4989 to 35,910 cells/μL (median 9360 cells/μL; mean 16,051 cells/μL; reference range 3000 to 10,500 cells/μL). In the cats, neutrophil counts ranged from 5979 to 33,683 cells/μL (median 8811 cells/μL; mean 12,823 cells/μL; reference range 2000 to 9000 cells/μL).
Gastrostomy Device Placement
The number of animals with initial one-step low-profile gastrostomy device placements varied each year during the study period. Five devices were inserted (in four dogs, one cat) in 1998; four were placed (in two dogs, two cats) in 1997 and 1999 (in three dogs, one cat); two were inserted in cats in 2003; and one was placed in a cat in 2002. The onestep low-profile gastrostomy devices used were all produced by the same manufacturer.b The sizes used were 18 Fr (one dog, five cats) and 24 Fr (eight dogs, two cats). The shaft lengths of the devices varied, ranging from 1.2 cm (four cats), 1.7 cm (one dog, one cat), 2.4 cm (two dogs, one cat), 2.7 cm (one cat), to 3.4 cm (six dogs).
Nutritional Support
All diets fed to the animals in this study were initially blended with water to achieve a consistency that allowed administration via syringe. Eleven of the animals in this study (eight dogs, three cats) were initially fed one of five commercially available, canned renal diets through the one-step low-profile gastrostomy device.c One dog was also periodically fed a cottage cheese and rice mixture, and two cats were periodically fed a canned liquid renal dietd in addition to their canned renal diets. Other diets given through the device included a commercially available, canned critical care diete (two cats); a novel-protein, single-carbohydrate diet (one cat); a commercially available, maintenance canned diet (one cat); and a commercially available, maintenance dry diet (one dog). No tubes occluded while the animals were hospitalized. The exact caloric amount fed through the device was recorded for six dogs and five cats. The average percentage of calculated resting energy requirement fed was 140%. The average percentage of calculated resting energy requirement fed to the dogs was 177% (range 139% to 272%). The average percentage of calculated resting energy requirement fed to the cats was 97% (range 50% to 129%).
Complications
Complications associated with the placement of the one-step low-profile gastrostomy device are summarized in Table 1. Complications at the gastrocutaneous stoma site occurred in a total of 10 animals (six dogs, four cats). One cat developed mild peristomal inflammation 231 days after initial placement, from the device becoming too tight against the skin from weight gain. This case was managed by removal of one of the silicone spacers without the need for chemical restraint. No animals developed severe swelling or inflammation or formed an abscess at the stoma site. Two dogs and two cats experienced discomfort associated with the onestep low-profile gastrostomy device. Discomfort occurred in three animals within 24 hours of device placement and in one dog 1863 days after insertion from peristomal inflammation. Six animals (three dogs, three cats; 37.5%) had no complications from the gastrostomy device. No associations were detected between preoperative laboratory test results and any of the complications. Nine animals (six dogs, three cats) were vomiting prior to insertion of the gastrostomy device. Eleven animals (seven dogs, four cats) vomited after the device was placed, including five dogs and two cats that had been vomiting previously. It was not possible to determine if vomiting was influenced by the device placement in these cases. Of the three animals (two dogs, one cat) that had regurgitation prior to gastrostomy device placement, one dog and one cat continued to regurgitate after insertion of the device, although the frequency was reduced.
Two dogs either pulled out their gastrostomy device or had it pulled out by another pet after they were discharged (one on a single occasion, the other on five separate occasions). In both dogs, the low-profile gastrostomy device was reinserted into the existing gastrocutaneous stoma under general anesthesia. The original gastrostomy device was replaced in two dogs. One dog had his device replaced on day 6 after developing peritonitis (when the stomach detached from the feeding device and food inadvertently went into the peritoneal space). This animal underwent peritoneal lavage and gastropexy, and he subsequently recovered. The other dog had his device first replaced on day 606, when a longer shaft length was required due to weight gain. One dog developed recurrent aspiration pneumonia secondary to his megaesophagus; this resolved with antibiotic administration.
Outcomes
The follow-up period for animals in the study was at least 3 months and as long as 8 years. The median and mean survival times after device insertion for dogs were 89 and 352 days, respectively (range 12 to 2241 days), and 87 and 173 days, respectively (range 12 to 593 days), for the cats. The median and mean survival times for all animals combined were 88 and 288 days, respectively. The five dogs receiving hemodialysis had median and mean survival times of 53 and 76 days, respectively (range 12 to 198 days), whereas the dogs that did not receive hemodialysis had median and mean survival times of 253 and 697 days, respectively (range 42 to 2241 days). These differences were not significantly different (P=0.13), owing to the small numbers of dogs compared. Necropsy findings were reviewed for five dogs and one cat. In all of these animals, the one-step low-profile gastrostomy device was still in place within a well-healed gastropexy site, and the device did not contribute to the death or demise of the animal.
Thirteen of the 16 animals in this study were known to be dead at the end of the study period. In no cases did the device placement directly contribute to the deaths. Two cats were lost to follow-up at days 4 and 231 after insertion of the gastrostomy device. One dog was alive at the end of the study period (2241 days after initial insertion) and was still being fed through a low-profile gastrostomy device. All 15 animals (nine dogs, six cats) with information available on their status 1 week after device insertion were still alive. Of 15 animals (nine dogs, six cats) with information available regarding their status 1 month after device placement, 12 (seven dogs, five cats; 80%) were alive. Of 14 animals (nine dogs, five cats) with information available on their status at 1 year after initial device insertion, three (two dogs, one cat; 21.4%) were still alive.
Owner Survey
Ten owners (of six dogs, four cats) were contacted by telephone. Their responses are summarized in Table 2. All owners responded that they had never used the antireflux valve for stomach decompression or bloat. Five dog owners and three cat owners responded that their pets had vomited at least once at home after the one-step low-profile gastrostomy device had been placed, although only half of the owners believed that the vomiting was due to feeding too quickly or overfeeding. The animals owned by people that were receptive to placing a one-step low-profile gastrostomy device in another pet tended to have longer survival times (median survival 97.5 days; range 61 to 2241 days) than the animals owned by people unwilling to consider insertion of another gastrostomy device (median survival 39.5 days; range 12 to 400 days).
Discussion
The benefit of improved nutritional status on survival of humans and experimental animals with various diseases has been well established.14–17 Enteral nutrition is the preferred route of nutritional support, as this method provides better physiological maintenance of intestinal structure and function, decreases mucosal permeability to bacteria and endotoxins, and preserves secretory immunoglobulin A concentrations in biliary tract secretions.18,19 Enteral feeding is indicated in patients that cannot ingest adequate amounts of calories but have sufficient gastrointestinal function to allow the digestion and absorption of feeding solutions delivered into the gastrointestinal tract.10,14 The benefits of percutaneous endoscopic gastrostomy devices have been well described; however, the reduced longevity of latex catheters and the disadvantages of tube lengths that extend beyond the stoma site have been well documented.1–3
The one-step low-profile gastrostomy device kit used in the study reported here contains a percutaneous stoma measuring device that is thrust through the skin and into the stomach under direct visualization of the endoscopist. This action allows the stoma tract length to be measured more accurately and ensures a comfortable fit of the device against the skin. The devices are available in six different lengths and in two French sizes (18 and 24 Fr). The use of silicone spacers supplied by the manufacturer has helped ensure that the devices can be adapted to animals with different stoma tract lengths. The placement of the silicone spacers may allow a more snug fit between the skin of the animal and the flanges of the device. When peristomal swelling or weight gain occurred after placement, the spacers were removed without the need for sedation or anesthesia.
The results of the current study illustrate the ease with which the one-step low-profile gastrostomy devices were inserted and the prolonged times that these devices could be kept in place before requiring replacement (up to 606 days in one dog). Although the one-step low-profile gastrostomy devices are relatively expensive initially (cost is approximately $200 excluding shipping), the cost may be offset by the prolonged periods of time they can be used and the relatively minor complications associated with their use. The overall duration of one-step low-profile gastrostomy devices in this study was decreased because of a relatively large number of animals that succumbed to kidney failure before the devices required replacement.
In a previous report, there was an increased 30-day mortality risk following percutaneous endoscopic gastrostomy tube placement in hospitalized humans with hypoalbumine-mia.21 In the study reported here, animals with poor prognoses because of their underlying clinical disease (e.g., hemodialysis-dependent renal disease) had shorter survival times. No obvious relationship was seen between survival time and serum albumin concentration, although there were a number of limitations in the current study that may have masked such an effect, such as low animal numbers (no cats in the study were hypoalbuminemic), the inclusion of animals with multiple diseases, the large proportion of animals with poor long-term prognoses, and a lack of standardization of treatments administered prior to and after device insertion.
Complications occurred frequently in animals with onestep low-profile gastrostomy devices, although they were usually easily managed and of minor consequence. Dogs in this study had a larger number of complications than cats [Table 1]. Interestingly, no cats dislodged their gastrostomy devices, in contrast to a previous study.4 It is possible that the cats in this study were too ill and less able to remove their tubes than those in the previous report. Six of nine dogs developed at least one complication related to placement of the gastrostomy device. The high number of minor complications seen in this study may be related to the extended time the tubes were left in place in some animals. This theory was supported by the fact that the dog with the most complications also had the longest survival time. The only major complication was in the dog that required peritoneal lavage and gastropexy after his stomach detached from the device.
Most animals that received a one-step low-profile gastrostomy device were at or below an ideal body condition score at the time of device placement, and they were losing weight prior to insertion of the device. Eight of 12 animals continued to lose weight after device insertion, which may have been a result of inadequate caloric intake or vomiting after being fed. Alternatively, caloric needs may have been higher than predicted in some animals in the study because of catabolic states associated with the primary diseases and amino acid loss with hemodialysis.22 In comparison to dogs, cats were fed lower caloric amounts relative to their calculated resting energy requirement. It was not possible to determine whether the cats were intentionally fed less aggressively than the dogs or whether this difference reflected more conservative feeding guidelines adopted at the VMTH UCD in recent years (i.e., feeding at the calculated resting energy requirement while in the hospital rather than using an illness energy factor as a multiplier). It is possible that the more conservative feeding guidelines used for the cats in the later years of the study may have altered the frequency of some of the complications associated with overfeeding. The benefits of the one-step low-profile gastrostomy device became readily apparent when it was noted that a relatively large number of animals (n=6) received medications and all of their calories through the device. Two cats and eight dogs had a 24-Fr one-step low-profile gastrostomy device inserted, which allowed a variety of diets, including a kibble-based slurry, to be fed with little difficulty.
Overall, owners reported that the one-step low-profile gastrostomy device was easy to maintain and to use. Most owners required no assistance when feeding their pet, which was similar to the findings of previous studies when owners of animals with standard gastrostomy tubes were surveyed.2,19 Most owners contacted (n=6) felt that the onestep low-profile gastrostomy device increased their pet’s quality of life and life span, but only five owners said that they would place another gastrostomy tube in a pet in the future. This later response was considerably less favorable than in other studies where standard gastrostomy tubes were inserted.20 Interestingly, the owners that would not use a one-step low-profile gastrostomy device again in another pet were the same owners that were reluctant to have the device placed initially. These owners did not believe that the life span of their pet had been increased significantly by insertion of the device. While the cause for the relationship is not clear, when owner perceptions were less positive, the period from device insertion to death tended to be shorter. It was not discernible whether owners initially reluctant to have the procedure done also elected euthanasia earlier or if the owner perceptions were affected by the eventual outcome of the case. Regardless, it would be prudent to assess the prognosis for the underlying disease processes present in each case prior to discussing placement of a gastrostomy device. Careful selection of animals receiving a one-step low-profile gastrostomy device may increase the percentage of owners reporting a favorable outcome. Avoiding the insertion of gastrostomy tubes in acutely ill patients or in those with a poor short-term prognosis has reduced the incidence of major complications in humans, and these factors require further evaluation in animals.23 For animals that have a poor prognosis, it may be reasonable to consider using an alternative feeding device, such as an esophagostomy tube that is cheaper than the one-step low-profile gastrostomy device and less likely to be associated with severe complications if removed prematurely by the animal.2
Limitations of this study included the lack of animal standardization and protocols, as well as incomplete data sets typical of a retrospective evaluation and owner survey. A controlled prospective study with both one-step low-profile gastrostomy devices and standard-length gastrostomy tubes would allow direct comparison of the complications and outcomes. A larger study population and standardization of the management protocols before and after device insertion may allow definitive identification of predictive clinical or biochemical parameters useful as prognostic indicators. Additional studies are now required to permit continued refinement in differentiating the optimal feeding strategy for individual animals. This process will likely reinforce the benefit of nutritional support in reducing morbidity and mortality in hospitalized animals.
Conclusion
Based on the results of this study, a one-step low-profile gastrostomy device was easy to insert and was usually associated with only minor complications. Dogs in the study survived for up to 2241 days after initial device placement, and cats survived for up to 593 days. Many owners felt that the device had increased their pet’s quality of life and life span. Future studies are warranted to evaluate whether outcomes improve with better case selection and use of recently adopted lower-calorie feeding practices while animals are in the hospital.
Microsoft Office Excel 2003; Microsoft Corporation, Redmond, WA 98052
Applied Medical Technology One Step Button; Applied Medical Technology, Inc., Cleveland, OH 44128; now renamed as EndoVive Low Profile Percutaneous Endoscopic Gastrostomy kit; Boston Scientific, Natick, MA 01760
Hill’s Prescription Diet Canine k/d, Hill’s Prescription Diet Feline k/d, Hill’s Prescription Diet Canine u/d; Hill’s Pet Nutrition, Inc., Topeka, KS 66601; Purina Veterinary Diets NF Kidney Function brand Canine Formula; Nestlé Purina PetCare Company, St. Louis, MO 63164; Waltham Veterinary Diet Canine Low Phosphorus/Low Protein (recently renamed Royal Canin Veterinary Diet Renal LP); Royal Canin USA, Inc., St. Charles, MO 63301
Clinicare RF Specialized Feline Liquid Diet; Abbott Laboratories, Abbott Park, IL 60064
Hill’s Prescription Diet Canine/Feline a/d; Hill’s Pet Nutrition, Inc., Topeka, KS 66601
Citation: Journal of the American Animal Hospital Association 42, 3; 10.5326/0420197
Citation: Journal of the American Animal Hospital Association 42, 3; 10.5326/0420197
Citation: Journal of the American Animal Hospital Association 42, 3; 10.5326/0420197
One-step low-profile gastrostomy device with flanges as it comes contained within a catheter sleeve. Four separate silicone spacers are also present.
One-step low-profile gastrostomy device with flanges released after tearing the surrounding catheter sleeve open by pulling on the attached black suture material.
One-step low-profile gastrostomy device separated from catheter sleeve, showing a single 5-mm silicone spacer (arrow) inserted over the shaft, and three other separate silicone spacers of varying thickness.
Contributor Notes
