Prolonged anorexia is associated with poor outcomes in critically ill patients. Providing nutrition via the enteral route is preferred over parenteral nutrition whenever possible due to lower cost, a lower rate of complications and the provision of nutrients to the enterocytes themselves. Placement of oesophageal feeding tubes is quick, easy, relatively inexpensive and does not require the use of specialised equipment. It has largely replaced the placement of surgically and endoscopically placed gastrotomy (PEG) tubes in our hospital. Gastrotomy tubes are still used in some patients with oesophageal dysfunction or strictures or where very long term use of a feeding tube is envisaged since these may later be exchanged for a low-profile device. Oesophageal feeding tubes may also not perform satisfactorily in patients with persistent vomiting because the tube may be expelled although larger-bore tubes may stay in position if vomiting is not severe. There is a risk of aspiration if oesophageal feeding tubes are used in comatose or recumbent animals.
To place an oesophageal feeding tube the patient should be anaesthetised and placed in lateral recumbency. The skin of the lateral neck is aseptically prepared. A pair of curved, long-handled forceps are entered from the mouth into the oesophagus and the tip of the forceps pushed very firmly towards the ceiling. A 'tent' should be created where the tip of the forceps are positioned at the level of the middle of the neck. It is usually helpful to have an assistant hold the forceps.
A feeding tube is selected; usually a 14-Fr, 23-cm tube for cats and small dogs and a 14–20-Fr, 40-cm tube for larger dogs. Additional side holes can be added to the tube before placement if required. The tube can be marked at the level of the 7th intercostal space so that it lies in the distal oesophagus once placed.
A scalpel blade is then used to make a very small incision over the tip of the forceps. Pressure on the forceps is maintained so that the tip of the forceps protrudes through the side of the neck. The forceps are then opened a few millimeters and the tip of the feeding tube (the end that will eventually be in the oesophagus) inserted between the jaws of the forceps.
The forceps are then closed and pulled back out through the mouth. This results in a feeding tube that enters the neck but emerges from the mouth.
The tip of the feeding tube must then be redirected from the oral cavity down the oesophagus. A laryngoscope can be helpful to visualise the caudal oropharynx. An endotracheal tube or larger stomach tube can be advanced down the oesophagus to position the feeding tube. Once the oesophageal feeding tube is correctly positioned the open end of the tube usually swings around so that it is positioned close to the ear, travelling distally. Gently pulling the tube a short distance back and forth should result in it sliding easily confirming that the tube is correctly positioned. Positioning the tube in the oesophagus is more straightforward in cats than in dogs where it always seems to take a bit of jiggling.
Once positioned satisfactorily the tube is attached using either a Chinese-finger trap suture or a tape butterfly. The positioning of the tube can be checked radiographically. The tip of the tube should be positioned in the distal oesophagus not the stomach. The site where the tube exits the neck should be covered with a light dressing. It should initially be inspected and gently cleaned daily.
Feeding can commence once the patient is fully recovered from anaesthesia. If the patient has been anorexic for some time it is normal to commence feeding with only part of the daily food requirement gradually increasing this over 3–4 days until the patients daily energy requirement is being supplied. Before and after each feeding the tube should be flushed with a small amount of luke-warm water. The food should be prepared so that it is of the appropriate liquid consistency by mixing it in a blender with as much water as is necessary. Feeding is usually divided into five small meals given at four hourly intervals with one eight-hour interval overnight. The food is warmed to body temperature before it is given over about 15 minutes.
When the tube is no longer required it can be removed very simply without the need for sedation or anaesthesia. The stoma is left to heal by second intention, this happens very fast. Stricture development at the site of insertion appears to be very rare.