Providing adequate nutritional support to critically

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1 J Vet Intern Med 2007;21:18 24 Percutaneous Endoscopic Gastrojejunostomy Tube Placement in Healthy Dogs and Cats Albert E. Jergens, Jo Ann Morrison, Kristina G. Miles, and William B. Silverman Background: Pancreatitis, hepatobiliary disease, and proximal gastrointestinal tract disorders are clinical situations where delivery of nutrients via jejunostomy tube is preferable to a feeding gastrostomy. A thorough description of the percutaneous endoscopic gastrojejunostomy (PEG-J) technique and practical guidelines for its use in small animals have not been reported. Hypothesis: That a simple technique of PEG-J tube placement in humans would be useful and safe in healthy dogs and cats. Animals: Twelve healthy dogs and 5 healthy cats were included in the study. Materials and Methods: Commercially prepared PEG-J tubes were modified for use in animals and positioned in the small intestine by endoscopic guidance. Eight dogs and 5 cats were bolus fed enteral diets for 14 days. Complications associated with the use of the PEG-J tube and responses to bolus feedings were assessed. Results: Jejunostomy tubes were placed distal to the caudal duodenal flexure in all dogs and cats. Complications associated with PEG-J tubes occurred in 5/12 dogs and 4/5 cats and included J-tube removal, local pain/inflammation, retrograde tube migration, and diarrhea. Bolus feeding (daily maintenance energy requirement [MER] divided q8h) through the jejunostomy catheter was well tolerated, maintained normal body weight, and was not associated with adverse gastrointestinal signs. Conclusions and Clinical Importance: Placement of a PEG-J tube is an effective, noninvasive technique for providing enteral nutritional support of healthy dogs and cats. Bolus-feeding techniques via PEG-J tubes maintain normal nutritional status in healthy dogs and cats. This procedure for jejunostomy feeding may be easily adapted for use in clinical practice outside of an intensive care facility. Key words: Bolus feeding; Complications; Endoscopy; Percutaneous endoscopic gastrojejunostomy (PEG-J); Enteral nutrition. Providing adequate nutritional support to critically ill patients is essential for recovery from illness. 1 5 Studies in humans and animal models have revealed that nutritionally depleted individuals have poorer recovery from surgical procedures, decreased immune function, longer hospitalization stays, and greater risk for complication or death than well-nourished patients. 6,7 Intense nutritional support enhances wound healing, augments immune function, and reduces morbidity and mortality in sick dogs and cats. 8 When possible, nutrition should be delivered enterally because this is easier, less expensive, and more physiologic than parenteral feeding. 4 A variety of methods exist for provision of enteral nutrition in animals, including nasoesophageal, esophagostomy, gastrostomy, and jejunostomy (enterostomy) feeding tubes. 2,4,9 11 Jejunostomy feeding tubes should be considered in anorectic patients that cannot tolerate gastric feeding and that have a functionally intact small intestinal tract. Specific clinical indications for jejunostomy feeding include uncontrollable gastric vomiting, gastroparesis, hepatobiliary disease, pancreatitis, and animals with increased risk for aspiration of gastric contents. 1,5,12 There are few published studies describing placement of jejunostomy feeding tubes in the dog and cat. Surgically placed jejunostomy tubes are the most From the Department of Veterinary Clinical Sciences (Jergens, Morrison, Miles), College of Veterinary Medicine, Iowa State University, Ames, IA; and the Department of Internal Medicine (Silverman), College of Medicine, University of Iowa, Iowa City, IA. Reprint requests: Albert E. Jergens, DVM, PhD, DACVIM, Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, IA 50010; ajergens@ iastate.edu. Submitted February 25, 2006; Revised June 18, 2006; Accepted August 1, Copyright E 2007 by the American College of Veterinary Internal Medicine /07/ /$3.00/0 widely used and familiar method for long-term feeding of the small intestine directly. 9,13 Sick animals, unfortunately, are often poor surgical candidates, and this technique is invasive and will require laparotomy or laparoscopy. An alternative approach to the surgical (open) jejunostomy technique is the placement of a feeding catheter via percutaneous techniques. Variations of this procedure have been used extensively in humans and include both direct percutaneous jejunostomy and percutaneous gastrojejunostomy (PEG-J) tubes placed under fluoroscopic or endoscopic guidance PEG-J tubes are preferred because they are well tolerated, provide better animal comfort, and allow ready access to the stomach for aspiration of luminal contents or gastric feeding, as the animal s condition dictates. 17 The placement and use of PEG-J tubes in dogs and cats has been evaluated only to a limited extent. 11,17 Furthermore, the use of bolus feeding methods through PEG-J tubes and response to such feeding practices have not been previously reported. The purposes of this prospective study were to adapt a simple technique of PEG-J tube placement in humans for use in healthy dogs and cats, and to evaluate the utility and potential complications associated with short-term PEG-J tube use. Materials and Methods Animals Twelve young adult, mixed breed healthy dogs and 5 young adult, mixed breed healthy cats were used in this study. Each dog weighed,19 kg (median, 11.1 kg; range, kg) and each cat weighed,6 kg (median, 4.1 kg; range, kg). All animals were determined to be healthy by normal results of physical examination, complete blood count, serum biochemical analysis, urinalysis, and negative results on direct fecal smear and flotation. All animal procedures were approved by the Iowa State University Committee on Animal Care before study initiation.

2 PEG-J in Dogs and Cats 19 Fig 1. Endoscopic image of the closed snare being passed through the PEG tube. Equipment A video endoscope a used in routine diagnostic upper gastrointestinal (GI) endoscopy procedures was used for PEG-J tube placement. Standard biopsy forceps b were used to grasp a suture, which was needed for gastrostomy tube placement. All PEG-J tubes were supplied as commercially packaged gastro-jejunal feeding kits c consisting of a 24 French (24 F) gastrostomy tube with an interconnecting 12 French jejunal catheter, which passed through the gastrostomy opening. Catheter guide wires were supplied as inch (0.89-mm) curved-tip stylets d that were 270-cm long. Two lengths of jejunal feeding catheters were used, 65 cm and 95 cm. PEG-J Tube Technique General anesthesia was induced in all dogs and cats with thiopental sodium or propofol and maintained with isofluorane and oxygen. Animals were initially positioned in right lateral recumbency. PEG-J tubes were placed according to the method described by Leichus et al, 18 which required 4 sequential steps: (1) routine PEG tube placement; (2) deep guidewire passage into the small intestine; (3) endoscope retraction leaving the guide wire in place; and (4) jejunostomy feeding catheter placement over the guide wire. Pilot studies performed on 4 dogs refined and optimized the PEG-J technique that was used on the remainder of the research animals. Specifically, a PEG tube was placed as previously described. 19,20 The external portion of the PEG tube was trimmed to a length of 6 inches to maximize the amount of jejunostomy tube that could be passed into the small intestine. A standard loop snare was then passed through the PEG tube into the stomach and correctly positioned using endoscopic guidance (Fig 1). The snare was opened and the endoscope was advanced through the open snare toward the pylorus. The animal was then repositioned in left lateral recumbency, and the endoscope was advanced through the pylorus into the small intestine as far as possible (Fig 2). Before passage of the guide wire, copious amounts (15 20 ml) of water are flushed through the accessory channel of the endoscope. This process Fig 2. Schematic of the passage of the endoscope through the open snare and into the small intestine. served to lubricate the guide wire and facilitate rapid passage of the stylet distally into the small intestine (Fig 3). In pilot studies, correct placement of the guide wire was confirmed by fluoroscopy, but this step was later deleted as experience with PEG-J was gained. Once the guide wire had been placed, the endoscope was slowly retracted proximally as the guide wire continued to be passed distally through the accessory channel (Fig 4). As the endoscope was retracted back into the stomach, the tip of the endoscope was pulled past the open snare, which then was closed snugly on the guide wire. This step was confirmed with gentle traction on the snare. The endoscope was then removed from the animal as the proximal end of the guide wire extended out of the oral cavity. The operator next pulled the closed snare out through the gastrostomy tube and the grasped guide wire by then shaped like a U was observed exiting the orifice of the gastrostomy tube (Fig 5). The snare was released and an assistant gently pulled on the proximal end of the guide wire. When the operator felt the tug on the oral end of the U loop, the proximal end of the guide wire had been identified. The oral end of the guide wire was next pulled through the gastrostomy tube leaving the distal (aboral) end in the small intestine. The jejunostomy tube was flushed with water, which activated a lubricant on its inner diameter, and then threaded over the guide wire under endoscopic guidance until its proximal end was seated in the gastrostomy tube (Fig 6). The guide wire was then removed from the PEG-J tube. Abdominal radiographs were obtained after the procedure to confirm that the distal end of the jejunostomy tube was correctly positioned cm distal to the pylorus.

3 20 Jergens et al Fig 3. Endoscopic images revealing correct positioning of the guide wire distally in the small intestine (A) and extending proximally into the gastric lumen under the incisura angularis (B). Jejunal Feeding The nutritional requirements of each animal were derived by calculation of their resting energy requirement (RER): RER (kcal/ d) 5 (30 3 body weight [BW kg ]) Next, the maintenance energy requirement (MER) was calculated by multiplying the RER by a factor of 1.3 to arrive at the total daily caloric requirements. Feeding via jejunostomy catheter was performed 6 hours after PEG-J placement with the following schedule: Day 1 1/3 MER divided into 3 separate feedings; Day 2 2/3 MER divided into 3 feedings; and Day 3 full MER divided into 3 feedings. Animals were fed exclusively by jejunostomy catheter for 14 consecutive days. One of 2 balanced veterinary enteral formulations e,f was fed to all animals. Bolus feedings were generally administered over a 10 to 15 minute period. The jejunostomy catheter was flushed before and after enteral feeding with 10 ml of tepid water to prevent Fig 4. Schematic of the retrograde extraction of the endoscope beyond the open snare. Note that the guide wire is positioned deeply within the lumen of the small bowel. Fig 5. Schematic revealing the intermediary maneuver in which the closed snare pulls the guide wire through the PEG tube.

4 PEG-J in Dogs and Cats 21 Fig 6. a dog. Endoscopic images revealing passage of the jejunostomy catheter through the pylorus (A) and positioned within the jejunum (B) of clogging. BW and body condition scores (BCS) 21 were recorded for each animal every 7 days. PEG-J Tube Monitoring and Complications A number of variables associated with PEG-J tube use were assessed on a daily or weekly basis. Complications were characterized as minor (depression, fever, localized infection, tube clogging, postprandial vomiting) or major (retrograde tube migration) in each animal. Complications associated with PEG-J tubes were uncommon but included jejunostomy tube removal (n 5 2), localized PEG infection (n 5 1), and retrograde tube migration (pilot study, n 5 2). Mild, transient (,24 hours) diarrhea of undetermined cause was observed in 2 dogs. Results PEG-J Tubes in Dogs Pilot studies revealed that the PEG-J procedure could be successfully adapted for use in medium-sized dogs. However, in 2/4 dogs, we observed retrograde migration of this shorter (65 cm) feeding tube back into the stomach within 7 days of placement (Fig 7). Subsequently, a second jejunostomy catheter (95 cm in length) was placed and retained in these 2 dogs for up to 30 days. PEG-J tube placement was performed without complication in the remaining 8 dogs, using the longer 95-cm jejunostomy tube, with an average procedural time of 45 minutes (median, 45 minutes; range minutes) per dog. Successful placement was defined by the jejunal catheter tip being located distal to the caudal duodenal flexure and extending into the jejunum. Correct positioning of the catheter tip was confirmed by fluoroscopy or contrast radiography (Fig 8). Bolus feedings (q8h) were generally initiated within 6 hours of PEG-J placement and were well tolerated in all dogs. Significant alterations in BW and BCS scores were not observed during the study period. Four dogs lost weight (median weight loss, 0.48 kg; range kg), 3 dogs gained weight, and 1 dog s weight was maintained during the 14-day feeding trial. Fig 7. Ventrodorsal abdominal radiograph (with contrast) revealing placement of a 65-cm PEG-J tube in a dog. Note that the distal catheter tip (arrow) is incorrectly positioned proximal to the caudal duodenal flexure. This tube subsequently retrograded back into the stomach.

5 22 Jergens et al Fig 8. Ventrodorsal abdominal radiograph (with contrast) revealing placement of a 95-cm PEG-J tube in a dog. The distal catheter tip is optimally positioned well beyond the distal duodenal flexure. PEG-J Tubes in Cats As compared with the procedure in dogs, PEG-J placement in cats was easier and quicker to perform. Successful placement of a 65-cm jejunostomy feeding tube was performed in all 5 cats with a mean procedural time of 23 minutes (median, 25 minutes; range, minutes [Fig 9]). Bolus feedings were well tolerated and effective in maintaining BW and BCS scores of each cat during the 14-day feeding trial. Complications were minor and included soft stools (n 5 2), transient fever (n 5 1), and pain at the gastrostomy tube exit site (n 5 4). Radiographic studies of the febrile cat confirmed correct placement and functional integrity of the PEG-J tube. The rectal temperature in this cat returned to normal within 24 hours of empiric antimicrobial therapy. Discussion Indications for jejunostomy tube feeding include proximal gastrointestinal tract disease, acute or chronic pancreatitis, and hepatobiliary disorders. 1,5,12 The most common method of percutaneous endoscopic jejunostomy in humans involves the placement of a jejunal feeding tube through a previously placed PEG using endoscopic guidance Iterations of this transpyloric technique may involve (1) use of a weighted jejunostomy tube passed through the PEG tube and advanced into the small intestine by means of a suture (secured to the tip of the catheter), which is grasped with biopsy forceps; (2) passage of a guide wire through the PEG Fig 9. Ventrodorsal abdominal radiograph confirming correct positioning of a 65-cm PEG-J catheter (guide wire intact) in a cat. tube, which is grasped with forceps and advanced into the small intestine, where the jejunostomy tube is then threaded over the guide wire; and (3) placement of a PEG-J tube as described in the present study. 18,22,23,g While there are several techniques for placement of PEG-J tubes, the potential advantage of one method over another has not been verified by clinical trials. An advantage of the technique reported here is that it allows the endoscopist to place the jejunostomy tube farther into the small intestine in a shorter period of time. There are few studies evaluating the use of PEG-J techniques in dogs and cats. McCrackin et al 11 was first to develop and describe a technique for conversion of PEG to PEG-J in dogs. In this earlier report, jejunostomy tube placement was revealed to be a safe and feasible technique in dogs $18 kg. Retention of the enterostomy tube in these dogs ranged from 2 to 22 days with few complications observed. Eleven dogs were fed an enteral diet through the jejunostomy tube at least twice daily; however, tolerance to and complications of PEG-J tube feedings were not reported. In a separate study, Jennings et al 23 reported successful treatment of pancreatitis of cats by means of an endoscopically placed gastrojejunostomy tube. A weighted tip jejunostomy catheter was passed through the PEG tube to the level of the pyloric opening and then blindly fed into the small bowel. The authors used constant rate infusion of a liquid diet for 7 days to maintain nutritional status in this cat with good results. More recently, different

6 PEG-J in Dogs and Cats 23 methods of jejunal feeding tube placement in the dog and cat have been described. 17 The goal of the present investigation was to develop a relatively simple technique for PEG-J placement that had real-world application to clinical practice. In this regard, the technique had to be simple to learn, employ commercially available feeding catheters, have a low risk for serious complications, and permit bolus jejunal feedings by operators outside of a critical care facility. These study results indicate that this improved PEG-J technique can be used for the administration of nutritional support in healthy dogs and cats for up to 14 days. Furthermore, interpretation of these data reveals that bolus feedings every 8 hours through a PEG-J catheter are well tolerated, that they maintain adequate nutritional status in healthy animals, and that this technique of PEG-J provides an attractive alternative to in-house, continuous-infusion feeding practices. While this technique of PEG-J tube placement is straight forward, we agree with others 11 that attention to some details is necessary to ensure successful catheter placement. Pilot studies demonstrated that passing the endoscope through the open snare, while the dog was in right lateral recumbency (versus left lateral recumbency) was easiest for the endoscopist. Repositioning the animal in left lateral recumbency then facilitated aboral passage of the endoscope through the pylorus into the small intestine. Passage of the guide wire deeply into the jejunum was also deemed critical to prevent retrograde catheter migration into the stomach. In general, approximately 225 cm of the guide wire should be passed before endoscope extraction from the animal. This procedure assured that the guidewire extended well into the jejunum before threading on the jejunostomy catheter. Both of the catheters that migrated retrograde were observed to have their distal tips inadequately positioned proximal to the caudal duodenal flexure on abdominal radiographs. Last, we observed that applying mild tension to the guide wire exiting the PEG would reduce the intragastric portion of the stylet and minimize looping of the guide wire in the stomach. Large loops were problematic because they shortened the length of jejunostomy catheter that could be passed into the small intestine. Major complications that prevented jejunostomy tube function were observed in 2 dogs of the pilot study. The complication rate associated with use of jejunostomy tubes is low and complications are usually not fatal; 82% of dogs and cats with surgically placed jejunostomy tubes failed to develop complications. 24 Focal cellulitis at the skin exit site, tube dislodgement, and tube occlusion were observed in affected animals. 24 PEG-J tube complications reported by others include tube mutilation or removal by the animal, retrograde migration of nonweighted jejunostomy catheters, peritonitis secondary to peritoneal leakage, and knotting or kinking of migrated feeding tubes. 4,8,11,17 Jejunostomy catheter removal was performed by 2 dogs of the present study and underscores the need to place large Elizabethan collars on these animals. Four of 5 cats developed pain at the PEG-J tube skin exit site, which appeared unrelated to focal infection. Rather, local discomfort was attributable to the use of larger size (24 F) gastrostomy tubes included in the commercial feeding kit. Only 24 F size PEG tubes for use with the combination jejunostomy catheter are made by the manufacturer at this time. We currently recommend that short-term (24 48 hours) analgesia be provided in cats following PEG-J tube placement. It is generally recommended that jejunostomy tube feeding be administered by constant-rate infusion with a liquid diet. 4,17,23 This rationale is premised on the concern that vomiting, abdominal cramping, diarrhea or all 3 may occur with diets administered too quickly. There is surprisingly little veterinary literature to support this contention. Of interest, the incidence of vomiting and diarrhea observed in separate studies that used continuous infusion jejunal feeding methods was relatively low. 7,23,24 Only McCrackin et al 11 previously reported using bolus feedings through PEG-J tubes in dogs, apparently without complication. However, the specifics of the feeding protocol and the length of time that the dogs were jejunally fed were not detailed in this earlier report. The present study provided evidence that bolus feedings through a jejunostomy catheter were easy to perform, well tolerated, and did not result in significant adverse gastrointestinal complications. Mild diarrhea was the most prevalent sign but was not deemed clinically significant. In conclusion, our results reveal that placement of a PEG-J tube is an effective, noninvasive technique for providing enteral nutritional support in dogs and cats. The PEG-J tube was implanted using an identical technique with slight modifications between species. The success of PEG-J tube placement is most dependent on correct distal catheter tip positioning in the small intestine and prevention of iatrogenic removal (in dogs). Bolus feeding techniques via PEG-J tubes in healthy dogs and cats are well tolerated and maintain normal nutritional status. This technique for jejunostomy feeding may be easily adapted for use in routine practice outside of an intensive care facility. Footnotes a GIF-100 video scope, Olympus America Inc, Melville, NY b Radial jaw biopsy forceps, Boston Scientific Corp, Watertown, MA c Gastro-Jejunal feeding tube, Wilson-Cook Medical Inc, Winston- Salem, NC d Radifocus Glidewire, Boston Scientific Corp, Watertown, MA e Prescription diet a/d, Hills Pet Nutrition Inc, Topeka, KS f Iams Eukanuba Recovery Formula, The Iams Company, Dayton, OH g Jergens AE. Percutaneous endoscopic jejunostomy tubes: Clinical applications and technique. Proceedings of the 23rd ACVIM Forum, 2000 (abstract)

7 24 Jergens et al Acknowledgments We thank Amy Hodnefield, AHT, and Chimene Peterson, AHT, for their excellent technical assistance with developing this PEG-J technique. References 1. Armstrong PJ, Hand MS, Frederick GS. Enteral nutrition by tube. Vet Clin North Am Small Anim Pract 1990;20: Armstrong PJ, Lippert AC. Selected aspects of enteral and parenteral nutritional support. Semin Vet Med Surg (Small Anim) 1988;3: Giner M, Laviano A, Meguid MM, et al. In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition 1996;12: Marks SL. The principles and practical application of enteral nutrition. Vet Clin North Am Small Anim Pract 1998;28: Crowe DT. Nutritional support for the hospitalized patient: An introduction to tube feeding. Comp Cont Ed Pract Vet 1990;12: Dempsey DT, Mullen JL, Buzby GP. The link between nutritional status and clinical outcome: Can nutritional intervention modify it? Am J Clin Nutr 1988;47: Crowe DT, Devey JJ. Esophagostomy tubes for feeding and decompression: Clinical experience in 29 small animal patients. J Am Anim Hosp Assoc 1997;33: Orton EC. Enteral hyperalimentation administered via needle catheter-jejunostoma as an adjunct to cranial abdominal surgery in dogs and cats. J Am Vet Med Assoc 1986;188: Abood SK, Buffington CAT. Enteral feeding of dogs and cats: 51 cases ( ). J Am Anim Hosp Assoc 1992;201: Crowe DT, Devey JJ. Clinical experience with jejunostomy feeding tubes in 47 small animal patients. J Vet Emerg Crit Care 1996;7: McCrackin MA, DeNovo RC, Bright RM, et al. Endoscopic placement of a percutaneous gastroduodenostomy feeding tube in dogs. J Am Vet Med Assoc 1993;203: Crowe DT. Enteral nutrition for critically ill or injured patients. Part II. Compend Contin Educ Pract Vet 1986;8: Seim HB, Willard MD. Postoperative care of the surgical patient. In: Fossum TW, ed. Small Animal Surgery. St Louis, MO: Mosby; 2000: Bumpers HL, Luchette CA, Doerr RJ, et al. A simple technique for insertion of PEJ via PEG. Surg Endosc 1994; 8: Ponsky JL, Aszodi A. Percutaneous endoscopic jejunostomy. Am J Gastroenterol 1984;79: Ponsky JL, Gauderer MWL, Stellato TA, et al. Percutaneous approaches to enteral alimentation. Am J Surg 1985;149: Heuter K. Placement of jejunal feeding tubes for postgastric feeding. Clin Tech Small Anim Pract 2004;19: Leichus L, Patel R, Johlin F. Percutaneous endoscopic gastrostomy/jejunostomy (PEG/PEJ) tube placement: A novel approach. Gastrointest Endosc 1997;45: Bright RM, Burrows CF. Percutaneous endoscopic tube gastrostomy in dogs. Am J Vet Res 1988;49: Mathews KA, Binnington AG. Percutaneous incisionless placement of a gastrostomy tube utilizing a gastroscope: Preliminary observations. J Am Anim Hosp Assoc 1986;22: Burkholder WJ. Use of body condition scores in clinical assessment of the provision of optimal nutrition. J Am Vet Med Assoc 2000;217: DeLegge MH, Patrick P, Gibbs R. Percutaneous endoscopic gastrojejunostomy with a tapered tip, non-weighted jejunal feeding tube: Improved placement success. Am J Gastroenterol 1996;91: Jennings M, Center SA, Barr SC, et al. Successful treatment of feline pancreatitis using an endoscopically placed gastrojejunostomy tube. J Am Anim Hosp Assoc 2001;37: Swann HM, Sweet DC, Michel K. Complications associated with use of jejunostomy tubes in dogs and cats: 40 cases ( ). J Am Vet Med Assoc 1997;210: