Minimizing Small Animal Esophageal Feeding Tube Complications

Esophageal feeding tubes (e-tubes) are assisted-feeding devices that enable targeted delivery of nutrients, calories, medications, and fluids. Challenges associated with e-tubes faced by the veterinary team include ensuring proper placement, preventing dislodgement, providing stoma care, troubleshooting clogged tubes, and achieving an ideal diet slurry for ease of administration. Although complications can occur, the authors recommend the following protocols to help minimize issues and improve assisted-feeding outcomes.

Esophageal Feeding Tube Placement

E-tubes can be easily placed in patients of varying sizes through a relatively straightforward surgical procedure that typically results in minimal postoperative pain and brief hospitalization. Supplies suggested for e-tube placement are listed in BOX 1 and helpful tips for tube placement in medium to large dogs in BOX 2.

With proper stoma hygiene and regular care, e-tubes can remain in place indefinitely when medically indicated. In addition, removal is typically uncomplicated; after the sutures are cut, the tube can be removed. The stoma heals very quickly, usually within 1 to 2 days. Although e-tube placement requires that the patient be under general anesthesia, the procedure takes relatively little time, which helps minimize risks associated with general anesthesia. However, standard anesthetic precautions and monitoring remain essential. At the time of initial tube placement, do not empirically prescribe perioperative antibiotics.

Step 1. Placing the E-Tube

1. Position the anesthetized and intubated patient in right lateral recumbency.
2. Clip a wide area and aseptically prepare the skin.
3. Insert the tube and tunneling device (VIDEO 1).
   1. Connect the proximal end of the tube to the tunneling device. Ensure that the mouth gag remains in place during oral cavity passage (to prevent overextension of the mandibular joint).
   2. Pass the distal tube end and tunneling device orally until the tube meets resistance at the lower esophageal sphincter.
   3. Use a laryngoscope to confirm proper esophageal placement.

Step 2. Tunneling

1. Elevate the esophagostomy tunneler tip until it tents the skin approximately two-thirds of the distance from the ear to the shoulder (FIGURE 1).
   

   FIGURE 1. The esophagostomy tunneler placed orally and tenting the skin.

2. Position the tunneler dorsal to the jugular vein to help clear the pharynx and upper esophageal sphincter.
3. Dissect over the tunneler tip with a #11 scalpel blade until it emerges through the skin.
4. Pull the tunneler completely through with the attached tube until the tube angle shifts toward the ear (FIGURE 2). Ensure the e-tube does not wrap around the endotracheal tube while pulling.
   

   FIGURE 2. The esophageal feeding tube pulled through the stoma.

Step 3. Confirming E-Tube Position

1. Verify e-tube position in the esophagus and not in the airway through either of the following options.
   1. Radiographic confirmation that the distal tube tip is within the esophagus at the 7th to 9th intercostal space (FIGURE 3).
      

      FIGURE 3. Radiographic confirmation of appropriate placement of the esophageal feeding tube in the esophagus extending to the 7th–9th intercostal spaces.

   2. Endoscopic visualization of the distal tube tip where the heartbeat is visible (just below the heart base) (FIGURE 4).
      

      FIGURE 4. Confirmation of appropriate esophageal feeding tube placement via endoscopic visualization. The distal end of the tube is placed at the level of the heartbeat.

Step 4. Securing the E-Tube

1. Mark the tube at skin level with a permanent marker.
2. Position suture wings 1 to 2 centimeters from the mark.
3. Anchor the wings to the tube with 0 Prolene suture (Ethicon, ethicon.com).
4. Suture the wings to the skin.
5. Apply tissue glue to the seam of the tube.
6. Create a stacked finger trap pattern with glue above the suture wing to prevent the tube from sliding (FIGURE 5).
   

   FIGURE 5. The esophageal feeding tube is secured to the anchoring device and the device is secured to the skin as described in the text. The stacked finger trap above the anchoring device prevents the tube from slipping through the anchoring device.

Step 5. Completing the Process

1. Trim the e-tube to the appropriate length to accommodate the anchoring device.
2. Attach a neck band or appropriately sized Kitty Kollar (kittykollar.com) to prevent inadvertent dislodgement.
3. Place the administration cap on the e-tube.
4. Secure the final positioning with a collar or neck band (FIGURE 6).
   

   FIGURE 6. The esophageal feeding tube (e-tube) should be cut to the length that allows it to be secured under the e-tube protection device. A wrap or appropriately sized Kitty Kollar (kittykollar.com) can be placed around the patient’s neck and used to further protect the tube.

Esophageal Feeding Tube Maintenance

For preventing complications at the e-tube site, proper daily care is critical (BOX 3). The stoma must be protected from abscess formation (e.g., resulting from food accumulation or an improperly secured e-tube). Immediate cleaning of any contamination is recommended. A 5-minute application of dilute bleach provides antiseptic and anti-inflammatory benefits.¹ The dilute bleach solution is prepared by mixing ¼ teaspoon bleach with ½ cup tap or bottled water to make a 0.008% solution. Gauze or a cotton pad is dampened with the solution and applied to the stoma site for 5 minutes twice daily to minimize the risk for infection and control inflammation. Bleach degrades rapidly because of 5 factors: 1) dilution of hypochlorite concentration, 2) high solution temperature, 3) acidic solution pH, 4) concentration of impurities that catalyze decomposition, and 5) light exposure.² Therefore, the solution should be prepared immediately before application to ensure its effectiveness. In the authors’ experience, this protocol has resulted in markedly decreased infections at their institutions. For at-home care, clients can be advised to wear gloves and apply the solution to the pet in a well-ventilated area.

Esophageal Feeding Tube Complications

Accidentally Removed E-Tube

When the e-tube is inadvertently removed, time is critical because the stoma mucosa begins contracting immediately. First, attempt to insert the largest comfortable-fitting temporary tube, such as a red rubber catheter or an open-ended ureteral catheter (BOX 3). The temporary tube should pass through the stoma into the esophagus without excess force or resistance. If nothing passes easily, try inserting an appropriately sized guidewire (sized to fit the dilators) (FIGURE 7). Confirm proper placement with radiographic imaging to ensure that the guidewire follows the path of the esophagus and terminates in the stomach. Use serially sized dilators to slowly stretch the stoma. Lubricate the stoma and dilators with lidocaine gel for pain control; dilation is usually tolerated well by the patient with just topical analgesia.

FIGURE 7. Placement of a guidewire into the stoma before dilation and esophageal feeding tube (e-tube) replacement in a dog after inadvertent e-tube removal.

After the stoma is dilated to the feeding tube size, lubricate the e-tube and slide it over the guidewire. Remove the guidewire and check e-tube placement with a radiograph (7th to 9th intercostal space) and anchor it with suture. For Mila feeding tubes (milainternational.com), the 15-cm mark on the tube generally corresponds to the correct placement on the average cat or small dog. In the authors’ experience, the anchor technique described above for the Mila winged flange is usually well tolerated by the patient and often results in a healthier stoma than the purse string technique.

Stoma Site Infection

Treatment of a suspected infection begins with a systematic topical approach (BOX 3), using systemic antibiotics only when topical treatment proves insufficient. The cleaning procedure requires preparing a dilute betadine solution in 0.9% saline (approximately 0.5% final concentration of dilute betadine solution), creating a tea-colored mixture. Using either an open-ended tomcat catheter or an IV catheter connected to a 6-mL syringe, thoroughly flush the site until all purulent material is removed. During irrigation, gently massage any palpable pockets beneath the stoma to ensure complete removal of the material. For particularly severe local infections, after thorough cleansing consider applying medical-grade honey directly to the affected skin to provide anti-inflammatory, antioxidant, and antibacterial properties.³ Medical-grade honey products should be sourced from reputable medical suppliers to ensure proper storage conditions and product integrity.

Cover the treated area with a sterile 2 × 2 gauze pad and secure it beneath a collar or neck band. The dressing must be changed every 24 hours until the discharge resolves, typically within 2 to 3 days. After the discharge has resolved, return to the standard twice-daily dilute bleach protocol for ongoing maintenance. For abscesses that have become walled off from the stoma, first lance and flush the abscess before implementing the above protocol. Should the infection persist despite appropriate topical therapy, obtain a culture and sensitivity to guide selection of systemic antibiotics. Continue the topical protocol concurrently with the systemic antibiotic administration. If the infection cannot be controlled with these measures, the feeding tube should be removed.

Obstructed Tube

Factors that contribute to e-tube occlusion can be structural or procedural. Structural elements, such as narrow tube diameter and/or excessive tube length, create inherent risks. Procedural factors, particularly improper medication administration and insufficient flushing protocols, significantly increase obstruction likelihood. In addition, inadequately blended slurry can lead to diet residue accumulation within the tube lumen.

Because obstruction represents a significant yet avoidable complication, prevention is paramount for e-tube management. To avoid clogged e-tubes, implement a strict regimen of flushing with 10 to 15 mL of water before and after feeding or medication administration. When administering multiple medications, flush with at least 5 mL of water between each medication. Consult a pharmacist to determine which medications can be added directly to the slurry and which medications pose higher obstruction risks. Obstruction risk might be increased when using enteric-coated, time-released, or sustained-release tablet or capsule formulations. When fiber supplements are prescribed, thorough flushing will help prevent accumulation. To achieve optimal consistency and minimize obstruction risk, prepare slurries by using pitcher-style blenders rather than wand-style models.

When managing an obstruction, begin with warm water irrigation. The technique requires a methodical approach using a 60-mL syringe—never smaller as smaller syringes generate dangerous pressure levels that could compromise tube integrity. Apply gentle, rhythmic pressure and suction while flushing. If the initial warm water flush proves ineffective, progress to other declogging solutions (BOX 3).^4,5

Best Practices

Equipment

Equipment selection significantly affects slurry quality. A variable-speed pitcher blender consistently outperforms wand-style alternatives, offering superior particle size reduction and texture uniformity. Optimal blending duration typically ranges from 3 to 6 minutes, although lower-powered blenders may require extended processing time to achieve proper consistency.⁶

Slurry Consistency

The target consistency must account for multiple factors: dietary components (including dry, canned, liquid diet, water), tube length and diameter, and syringe capacity for meal administration. The International Dysphagia Diet Standardization Initiative (IDDSI) provides a valuable framework for assessing liquid viscosity (go.navc.com/44ZIgNB).⁷ Although the IDDSI strategy was not created primarily for feeding tube slurries, an IDDSI score of level 2 to 3 often indicates an effective thickness for e-tubes in veterinary patients. Silicone o-ring syringes are recommended because they do not degrade as readily as rubber syringes after washing (BOX 1).

Nutritional Density

Nutritional density requires careful consideration when formulating the slurry. Using water alone as a diluent often results in inadequate caloric density, potentially compromising patient nutrition. For patients that need higher calorie intake, incorporating liquid enteral diet products as the primary diluent can significantly improve nutritional delivery while maintaining appropriate consistency.

Storage

After the desired slurry has been created, store it in an airtight container and refrigerate it within 2 hours. Discard the remaining slurry if it is not used within 3 to 4 days.

Cleaning

Equipment that was used to prepare the slurry should be cleaned after each use according to the manufacturers’ guidelines. In the absence of specific instructions, adhere to FDA and CDC food safety protocols for equipment decontamination.⁸ Begin the cleaning process by completely disassembling the blender. Clean all components thoroughly with soapy, warm water. Similarly, wash all ancillary equipment such as spoons, measuring cups, syringes, and bowls. Rinse all items in warm water to remove any soap residue. Sanitize the items by soaking in 2 gallons of water with 2 tablespoons (30 mL) of chlorine bleach for 2 minutes.⁹ Remove objects from the chlorine soak and allow to air dry—do not dry with a towel.

Summary

Effective management of e-tubes requires careful attention to guidelines, which can help minimize complications associated with the tube and the patient. In addition, ensuring proper care throughout all phases of e-tube management—including thorough cleaning of equipment after each use—helps maintain the integrity of feeding support. With consistent monitoring and clear communication between the veterinary team and clients, e-tubes can provide a reliable and stress-free long-term solution for patients requiring enteral nutrition.