University of Edinburgh
Development and Characterization of a Technique for Percutaneous Radiologic Gastrojejunostomy Tube Placement in the Dog Rebekah M. Mack, DVM; Benjamin Staiger, DVM, DACVS; Daniel K. Langlois, DVM, DACVIM; Stephen J. Mehler, DVM, DACVS; Nathaniel Lam, DVM, DACVS; Trevor Moore, DVM; Andrew Brown, DVM, DACVECC and Matthew W. Beal, DVM, DACVECCFrom Small Animal Clinical Sciences, Michigan State University, East Lansing, MI (Mack, Staiger, Langlois, Beal); Hope Veterinary Specialists, Malvern, PA (Mehler); VCA Family Animal Hospital, Pearl City, HI (Lam); College of Veterinary Medicine, Purdue University, West Lafayette, IN (Moore); and the College of Veterinary Medicine, University of Edinburgh, Edinburgh, Scotland (Brown).Please address correspondence and offprint requests to: Dr. Matthew W. Beal, 736 Wilson Rd., Michigan State University, East Lansing, MI 48824.This investigation was funded by the Michigan State University’s MSU College of Veterinary Medicine Companion Animal Fund.Dr. Matthew Beal was an advisory board member for Infiniti Medical LLC (Menlo Park, CA) at the time of this investigation. The authors declare no other conflicts of interest.Presented in part as an abstract at the American College of Veterinary Internal Medicine Forum in Montréal, Quebec, Canada, 2009. Running Title: Percutaneous Radiologic Gastrojejunostomy in DogsAbbreviationsEJesophagojejunostomyENenteral nutritionGJTgastrojejunal tubeHGWhydrophilic guide wirePRGJpercutaneous radiographic gastrojejunostomy tubeSDstandard deviationAbstractObjective: To develop and describe a technique for percutaneous radiologic gastrojejunostomy tube placement in the dog.Design: Prospective technique development study Setting: University teaching hospitalAnimals: Six healthy adult male beaglesInterventions: Following anesthetic induction, fluoroscopic and ultrasound guidance were used to identify an appropriate gastropexy site on the left lateral abdomen. Gastropexy was performed using gastrointestinal suture anchors. An over-the-wire catheter technique using fluoroscopic guidance was used to achieve jejunal access. An 18F/8F, 58 cm, dual-lumen gastrojejunal feeding tube was placed via serial over-the-wire dilation of the body wall using an 18F peel-away introducer kit. Tube location was determined radiographically immediately following placement and on days 2, 4, after emesis on day 4, and at time of gastrojejunal feeding tube removal (day 16 – 18). Measurements and Main Results: Percutaneous radiologic gastrojejunostomy (PRGJ) tube placement was successful in all dogs. Median time to pyloric passage with the guide wire was 23.5 minutes (range, 9 – 93 minutes). Median total procedure time was 53 minutes (range, 49 – 113 minutes). Significant tube migration was not observed at any point during the study. One dog developed linear foreign body obstruction secondary to the tube on day 5 that was relieved by release of the jejunal component. Other complications were minor and included mild to moderate peristomal inflammation in all dogs and removal of the feeding tube on day 3 by 1 dog. Feedings were well tolerated in all dogs.Conclusions: PRGJ tube placement in the dog is a safe and minimally invasive technique that allows for jejunal feeding without surgery or endoscopy. The high success rates, acceptable procedural times, and minimal complications are appealing for use in critically ill patients. Although additional evaluations are needed, PRGJ tube placement may be considered for dogs that require post-pyloric feeding with or without gastric decompression. Keywords: enteral nutrition, fluoroscopy, gastrojejunostomy, post-pyloric feeding IntroductionRecent studies in people and veterinary patients have reported associations between nutritional status and outcome.PEVuZE5vdGU+PENpdGUgSGlkZGVuPSIxIj48QXV0aG9yPkJydW5ldHRvPC9BdXRob3I+PFllYXI+
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ADDIN EN.CITE.DATA 1,3,5,6 Historically, parenteral nutrition was used in human and veterinary hospital settings, but improved methods for enteral support have allowed safe and controlled means of nutritional provision with fewer complications and lower costs.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcnVuZXR0bzwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+
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ADDIN EN.CITE.DATA 1-4,6, ADDIN EN.CITE <EndNote><Cite><Author>Barr</Author><Year>2004</Year><RecNum>7</RecNum><DisplayText><style face="superscript">7</style></DisplayText><record><rec-number>7</rec-number><foreign-keys><key app="EN" db-id="dv55zwr5c5a20xewwp0ppfrv9wtpavrx0pav" timestamp="1404148435">7</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Barr, J.</author><author>Hecht, M.</author><author>Flavin, K. E.</author><author>Khorana, A.</author><author>Gould, M. K.</author></authors></contributors><auth-address>Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA. barrj@stanford.edu</auth-address><titles><title>Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol</title><secondary-title>Chest</secondary-title><alt-title>Chest</alt-title></titles><periodical><full-title>Chest</full-title><abbr-1>Chest</abbr-1></periodical><alt-periodical><full-title>Chest</full-title><abbr-1>Chest</abbr-1></alt-periodical><pages>1446-57</pages><volume>125</volume><number>4</number><keywords><keyword>Adult</keyword><keyword>*Critical Illness</keyword><keyword>*Enteral Nutrition</keyword><keyword>Evidence-Based Medicine</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Intensive Care Units</keyword><keyword>Length of Stay</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Prospective Studies</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2004</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>0012-3692 (Print)
0012-3692 (Linking)</isbn><accession-num>15078758</accession-num><urls><related-urls><url> Furthermore, mounting evidence supports direct benefits for gastrointestinal health in veterinary patients, including reduced villous atrophy, increased enterocyte survival, improved mucosal barrier integrity, and decreased bacterial translocation.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcnVuZXR0bzwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+
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ADDIN EN.CITE.DATA 1,6,8,9 Enteral nutrition is frequently delivered via nasoesophageal, nasogastric, esophageal, and gastrostomy tubes in critically ill dogs. While these feeding devices are simple to place, patients with vomiting or regurgitation may not consistently tolerate feedings delivered through them.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1wYmVsbDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+
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ADDIN EN.CITE.DATA 13-16 Numerous post-pyloric techniques, including: surgically placed jejunostomy and gastrojejunostomy tubes (GJT), laparoscopically placed jejunostomy tubes, endoscopically placed nasojejunostomy tubes, esophagojejunostomy (EJ) tubes, GJT, and fluoroscopically placed nasojejunal tubes have been described in veterinary medicine in recent years.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1wYmVsbDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+
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ADDIN EN.CITE.DATA 11,12, ADDIN EN.CITE <EndNote><Cite><Author>Jergens</Author><Year>2007</Year><RecNum>17</RecNum><DisplayText><style face="superscript">17</style></DisplayText><record><rec-number>17</rec-number><foreign-keys><key app="EN" db-id="dv55zwr5c5a20xewwp0ppfrv9wtpavrx0pav" timestamp="1404156874">17</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jergens, A. E.</author><author>Morrison, J. A.</author><author>Miles, K. G.</author><author>Silverman, W. B.</author></authors></contributors><auth-address>Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames 50010, USA. ajergens@iastate.edu</auth-address><titles><title>Percutaneous endoscopic gastrojejunostomy tube placement in healthy dogs and cats</title><secondary-title>J Vet Intern Med</secondary-title><alt-title>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</alt-title></titles><periodical><full-title>J Vet Intern Med</full-title><abbr-1>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</abbr-1></periodical><alt-periodical><full-title>J Vet Intern Med</full-title><abbr-1>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</abbr-1></alt-periodical><pages>18-24</pages><volume>21</volume><number>1</number><keywords><keyword>Animals</keyword><keyword>*Cats</keyword><keyword>*Dogs</keyword><keyword>Enteral Nutrition/instrumentation/methods/veterinary</keyword><keyword>Gastric Bypass/instrumentation/methods/*veterinary</keyword><keyword>*Health</keyword></keywords><dates><year>2007</year><pub-dates><date>Jan-Feb</date></pub-dates></dates><isbn>0891-6640 (Print)
0891-6640 (Linking)</isbn><accession-num>17338145</accession-num><urls><related-urls><url> Surgically placed jejunostomy tubes are associated with complications such as peristomal inflammation and infection, tube dislodgement, tube occlusion, and septic peritonitis.23 Complications have been reported in 17.5 to 40% of dogs.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Dcm93ZSBEVDwvQXV0aG9yPjxZZWFyPjE5OTc8L1llYXI+
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ADDIN EN.CITE.DATA 17,19 Although laparoscopically placed post-pyloric (jejunal) feeding tubes are less invasive, as reported, they extend procedural time approximately by twice that of other techniques. ADDIN EN.CITE <EndNote><Cite><Author>Hewitt</Author><Year>2004</Year><RecNum>20</RecNum><DisplayText><style face="superscript">20</style></DisplayText><record><rec-number>20</rec-number><foreign-keys><key app="EN" db-id="dv55zwr5c5a20xewwp0ppfrv9wtpavrx0pav" timestamp="1404157122">20</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hewitt, S. A.</author><author>Brisson, B. A.</author><author>Sinclair, M. D.</author><author>Foster, R. A.</author><author>Swayne, S. L.</author></authors></contributors><auth-address>Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON N1G 2W1, Canada.</auth-address><titles><title>Evaluation of laparoscopic-assisted placement of jejunostomy feeding tubes in dogs</title><secondary-title>J Am Vet Med Assoc</secondary-title><alt-title>Journal of the American Veterinary Medical Association</alt-title></titles><periodical><full-title>J Am Vet Med Assoc</full-title><abbr-1>Journal of the American Veterinary Medical Association</abbr-1></periodical><alt-periodical><full-title>J Am Vet Med Assoc</full-title><abbr-1>Journal of the American Veterinary Medical Association</abbr-1></alt-periodical><pages>65-71</pages><volume>225</volume><number>1</number><keywords><keyword>Animals</keyword><keyword>Dogs/*surgery</keyword><keyword>Enteral Nutrition/instrumentation/methods/*veterinary</keyword><keyword>Female</keyword><keyword>Jejunostomy/methods/*veterinary</keyword><keyword>Jejunum/*surgery</keyword><keyword>Laparoscopy/methods/*veterinary</keyword><keyword>Male</keyword><keyword>Postoperative Complications/epidemiology/veterinary</keyword><keyword>Prospective Studies</keyword><keyword>Random Allocation</keyword></keywords><dates><year>2004</year><pub-dates><date>Jul 1</date></pub-dates></dates><isbn>0003-1488 (Print)
0003-1488 (Linking)</isbn><accession-num>15239475</accession-num><urls><related-urls><url> A minimally invasive, endoscopic assisted “PEG-J” (percutaneous, endoscopically placed jejunostomy-through-gastrostomy tube) placement has also been described in healthy dogs. ADDIN EN.CITE <EndNote><Cite><Author>Jergens</Author><Year>2007</Year><RecNum>17</RecNum><DisplayText><style face="superscript">17</style></DisplayText><record><rec-number>17</rec-number><foreign-keys><key app="EN" db-id="dv55zwr5c5a20xewwp0ppfrv9wtpavrx0pav" timestamp="1404156874">17</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jergens, A. E.</author><author>Morrison, J. A.</author><author>Miles, K. G.</author><author>Silverman, W. B.</author></authors></contributors><auth-address>Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames 50010, USA. ajergens@iastate.edu</auth-address><titles><title>Percutaneous endoscopic gastrojejunostomy tube placement in healthy dogs and cats</title><secondary-title>J Vet Intern Med</secondary-title><alt-title>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</alt-title></titles><periodical><full-title>J Vet Intern Med</full-title><abbr-1>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</abbr-1></periodical><alt-periodical><full-title>J Vet Intern Med</full-title><abbr-1>Journal of veterinary internal medicine / American College of Veterinary Internal Medicine</abbr-1></alt-periodical><pages>18-24</pages><volume>21</volume><number>1</number><keywords><keyword>Animals</keyword><keyword>*Cats</keyword><keyword>*Dogs</keyword><keyword>Enteral Nutrition/instrumentation/methods/veterinary</keyword><keyword>Gastric Bypass/instrumentation/methods/*veterinary</keyword><keyword>*Health</keyword></keywords><dates><year>2007</year><pub-dates><date>Jan-Feb</date></pub-dates></dates><isbn>0891-6640 (Print)
0891-6640 (Linking)</isbn><accession-num>17338145</accession-num><urls><related-urls><url> However, fluoroscopic placement verification is still required and complications were observed in 40% of dogs including tube removal, retrograde tube migration, and peristomal inflammation.17 Additionally, a recent case series of endoscopically assisted EJ tube placement in clinical patients was published.22 Placement was successful in all patients, but similar complications of tube obstruction (40%), vomiting (80%), and peristomal inflammation (20%) were noted. Procedural length was not described. Fluoroscopic nasojejunal tube placement has been retrospectively described in dogs.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZWFsPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 11 Although successful placement occurred in greater than 90% of dogs, orad tube migration occurred in 25% of cases. Given the limitations of current post-pyloric feeding methods, development of alternate techniques is needed. Ideally, new methodologies would allow minimally invasive and consistently reliable tube placement. The purpose of this study was to characterize PRGJ placement in clinically healthy dogs. Procedural time, methodology, and complications were assessed. Furthermore, the effects of emesis on tube migration and placement were also evaluated.Materials and Methods Animals: Six young adult male intact beagles were used for study completion. The dogs were housed in freely accessible runs and fed a balanced commercial diet. The median age was 11 months (range, 10 – 12 months) and the median weight was 9.5 kg (range, 7 – 12 kg). All dogs were considered to be healthy based on normal physical examination, CBC, and serum biochemistry panel. This study was approved by the Institutional Animal Care and Use Committee at Michigan State University.Experimental Protocol: All 6 dogs underwent PRGJ tube placement. On day 1, GJT placement was performed under general anesthesia using the technique described below. Dog dependent, intermittent feeding with gradual escalation was utilized to reach resting energy requirements. Radiographic assessment of tube placement was performed on days 1, 2, 4, and at GJT removal (day 16 – 18). Four days following PRGJ placement, emesis was induced using conjunctival apomorphine.a The location of the distal tip of the jejunal component of the tube was assessed radiographically immediately before and after emesis. Clinically relevant tube migration was considered aborad movement of the distal tip of the jejunal component into the duodenum or stomach. The GJT remained in place for an additional 12 – 14 days after emesis induction. On day 16 – 18 the GJT was removed and the stoma was allowed to heal by second intention.Anesthetic Protocol: Dogs were premedicated with acepromazineb (0.05 mg/kg) IM 20 minutes prior to anesthetic induction. A 20-Ga over the needle catheter was placed into a cephalic vein. Anesthesia was induced using repeated 1 mg/kg IV propofolc boluses administered slowly to effect. Anesthesia was maintained via endotracheal intubation with isoflurane in 100% oxygen. Dogs were monitored with continuous pulse oximetry and ECG, and serial Doppler blood pressure measurement throughout the anesthetic period. Analgesia was provided with buprenorphined (0.01 mg/kg). The initial dose was given IV after successful PRGJ placement and before extubation. The same dose was administered IV every 6-8 hours, as needed for pain, for 48 hours after PRGJ placement. Technique: Following anesthetic induction, dogs were positioned in right lateral recumbency. An orogastric tube was placed to allow for gastric insufflation, and maintained throughout the procedure. Fluoroscopy was used to identify a location caudal to the left 13th rib where the gastric wall was apposed to the abdominal wall. This area would pose minimal risk to the patient and also serve as an appropriate anatomical location for an ostomy. Brief ultrasound examination ensured that the spleen was not interposed between the stomach and the body wall. This site was widely clipped and aseptically prepared and draped. Air was insufflated through the orogastric tube until the stomach extended beyond the 13th rib. The location was verified again with fluoroscopy, and 3 gastrointestinal suture anchorse were deployed through the body wall and stomach in a triangular pattern, creating a gastropexy (Figure 1). An 18-Ga, 5 – 6 cm introducer/puncture needlef was advanced through the center of the triangle created by the gastrointestinal suture anchors. A 0.035 in, 150 cm, standard stiffness, hydrophilic guide wire (HGW)g with a straight flexible tip was passed through the puncture needle and into the stomach. The 18-Ga needle was removed. A lubricated 65 cm, 5-Fr Berenstein catheterh was then passed over the HGW and used to direct the wire across the pylorus and into the small intestine. If pyloric visualization was difficult because of positioning, the patient was rotated upward into a more sternal position to allow the pylorus to fill with air. The Berenstein catheter and HGW (always leading with the wire) were advanced through the duodenum and into the jejunum, just beyond the duodenojejunal flexure. This is a location where the bowel turns dorsally following the ascending duodenum. Three to 5 mL of iodinated contrasti were infused through the Berenstein catheter to confirm the location of the catheter tip. The Berenstein catheter was then removed, leaving the HGW in place. Serial over-the-wire dilations of the body wall were accomplished using a coaxial dilator system and an 18-Fr peel-away introducer kit.j An 18-Fr/8-Fr, 58 cm, dual-lumen gastrojejunal feeding tube (GJT)k was advanced over the HGW and into the jejunum, past the duodenojejunal flexure (Figure 2). Again, 3 – 5 mL of iodinated contrast medium were used to ensure appropriate placement. The GJT was secured against the body wall using the integrated balloon (Silicone Internal Retention Balloon)l and external bolster (SECUR-LOK External Retention Ring?).m The balloon was insufflated with 10 – 12 mL sterile 0.9% NaCl (Figure 3). The GJT was left in place for 16 – 18 days to ensure complete stoma formation.Post-Procedural Monitoring: Dogs were monitored every 8 hours following PRGJ placement for 5 days, then every 12 hours for the remainder of the study period (through day 16 – 18). Major complications were defined as perforation of the duodenum or jejunum during placement, septic peritonitis, subcutaneous abscess, gastrointestinal bleeding, frequent vomiting (> 3 times daily), small intestinal obstruction, or death. Minor complications were considered tube dislodgement, external leakage of gastric contents, peristomal inflammation or infection, tube migration, and intermittent (≤ 3 times daily) vomiting. The tube location, appearance of the peristomal site, abdominal discomfort, evidence of vomiting, and basic vital signs were recorded. The stoma site was evaluated every 6 hours for inflammation and infection using the local qualifiers erythema (present or absent), induration (present or absent), and discharge. Discharge, if present, was classified as serous, serosanguinous, mucoid, or purulent in nature based on gross inspection. Infection was considered to be present if both erythema and induration were present and also accompanied mucoid or purulent discharge, and discomfort at the stoma site. The presence of lethargy, fever, abdominal pain, or frequent vomiting prompted abdominal radiographic and / or ultrasonographic evaluation. Statistical AnalysisTube migration (distance of tube tip from the duodenojejunal flexure as compared to original placement) was evaluated in each dog with a paired t-test with Bonferroni correction for multiple comparisons (all time points) using commercially available software.n For all analyses, P < 0.05 was considered significant. Descriptive statistics were used to describe the mean, median, and standard deviation (SD) for all time points considered when evaluating tube migration. ResultsSuccessful placement was achieved in 100% of cases (6/6). The median time to traverse the pylorus was 23.5 minutes (range, 9 – 93 min). Median total procedural time was 53 minutes (range, 49 – 113 minutes; Table 1). On day 1, there was a mean distance of 343.5 ± SD 50.9 mm from the end of the jejunal tube to the duodenojejunal flexure. Day 2 and day 4 mean distances were 325.8 ± SD 54.3 mm, and 332.6 ± SD 33.3 mm, respectively. Post-emesis distance on day 4 was a mean of 293 ± SD 53.9 mm. On day 16 – 18 at GJT removal, the mean distance was 314.8 ± SD 39.8 mm. Migration occurred in every dog directionally towards and away from the duodenojejunal flexure (Table 2), but these differences were not significant. Furthermore, clinically relevant tube migration, as defined by movement of the tip of the jejunal component of the tube into either the duodenum or stomach, was not observed in any dog. The single major complication was a severe enteroplication (linear foreign body) over the jejunal segment of the GJT on day 5 in 1 dog. This dog developed intractable vomiting, abdominal distention, and abdominal pain consistent with gastrointestinal obstruction. Radiographs revealed small intestinal plication, which was confirmed with ultrasound examination.?The?plication?was relieved by releasing the jejunal component of the PRGJ, which then passed in the feces.?Releasing the jejunal component was accomplished by deflating the gastric retention balloon and withdrawing the gastric component of the GJT over a hydrophilic guide wire. Once the length of the gastric component of the GJT was withdrawn, the jejunal tubing was exposed and was cut, thus freeing the remaining tubing to pass.? In order to maintain the ostomy, a?10-Fr Foley cathetero was placed over the wire and secured using a purse string and finger trap suture pattern in the skin.?This dog was included in monitoring analysis for days 1 through 4, but excluded from the extended monitoring analysis. The dog recovered without additional intervention and completed the study period.?Minor complications included occasional vomiting ≤ 3 times daily (2/6 dogs), removal of the PRGJ on day 3 (1/6 dogs), and peristomal inflammation (6/6 dogs) and infection (1/6 dogs). The dog who removed the PRGJ on day 3 was excluded from all post- procedural analysis. In order to maintain the ostomy, a 10-Fr Foley cathetero was placed over the wire and secured using a purse string and finger trap suture pattern in the skin. The dog recovered uneventfully. Vomiting and ptylism in 2 dogs occurred immediately upon anesthetic recovery; no further episodes occurred. All dogs experienced mild ostomy complications. This included mild inflammation (1/6), moderate inflammation (5/6), and infection (1/6). The dog with peristomal infection recovered uneventfully after treatment with cephalexinp (22 mg/kg PO q 12 h for 10 days) and local peristomal cleaning.DiscussionThis study is the first to characterize a technique for minimally invasive PRGJ tube placement in dogs. The success rate and overall procedural time compare favorably to other reported post-pyloric feeding methods.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1wYmVsbDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+
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ADDIN EN.CITE.DATA 10-12,17,20,21 The use of fluoroscopic guidance alone to place the PRGJ tube is a unique benefit because other techniques require concurrent laparotomy, laparoscopy, or endoscopy in addition to fluoroscopy.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5KZXJnZW5zPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA 17-21 Recent reports in people have documented advantages of percutaneous radiologic placement of gastrojejunostomy tubes as performed in our canine study, including a very high success rate of appropriate GJT placement, easier placement of the jejunal component, and reduced procedural time.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MdTwvQXV0aG9yPjxZZWFyPjE5OTM8L1llYXI+PFJlY051
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ADDIN EN.CITE.DATA 27,28 Peristomal infection was diagnosed in only 1 dog in our report; however, mild to moderate peristomal inflammation was observed in all dogs. In general, peristomal inflammation is the most common complication associated with percutaneous feeding tubes and is considered a minor, often expected, complication in both dogs and people.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5KZXJnZW5zPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48
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ADDIN EN.CITE.DATA 17,26,29,30 The inflammation observed in dogs in this report may be attributable to the technique itself, as a self-limiting local inflammatory response has been well described in people.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BaG1hZDwvQXV0aG9yPjxZZWFyPjIwMDM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 11-13,18,21,23 Clinically significant migration, defined as the tip of the jejunal component of the tube entering the duodenum or stomach, was not observed in any dog in our report over the 16 – 18 day monitoring period. Nor was there evidence of any clinically significant effect with migration of the tip of the tube noted throughout the study. Two dogs vomited on single occasions (immediately following anesthesia) with no evidence of tube migration. Furthermore, the induction of emesis on day 4 did not affect tube position. These are important findings, as the targeted patient group for post-pyloric feeding commonly has gastrointestinal signs that increase the risk for tube migration or dislodgement. Although these initial findings are encouraging, they must be interpreted with caution since dogs with frequent vomiting or diseased intestinal tracts could be more susceptible to tube migration. A potentially serious complication in 1 dog was the development of an intestinal obstruction. Small bowel obstruction is a known possible complication of jejunal feeding tubes in people but has not been reported in dogs.13,14,PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MdTwvQXV0aG9yPjxZZWFyPjE5OTM8L1llYXI+PFJlY051
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ADDIN EN.CITE.DATA 30,31 The GJT used in our report is not pigtailed and is unlikely to remain in place for extended periods of time. Nonetheless, 1 dog did develop an obstruction on day 5. Radiographically and ultrasonographically, the obstruction was consistent with a linear foreign body. This was easily addressed by releasing the jejunal component, which passed uneventfully, making surgical intervention unnecessary. Thus, unexpected vomiting or abdominal pain in patients with GJT should prompt clinicians to pursue diagnostic imaging to rule out an obstructive complication. This study has limitations. The small number of dogs used in this study were healthy. It is unknown whether procedural characteristics and success would differ in a population of sick animals. Dogs with active regurgitation, multiple episodes of vomiting, or functional ileus might pose unique challenges in terms of tube placement and tube migration, and specific studies should be done to determine clinical outcomes with GJT placement. Toy breed dogs might pose a particular challenge for successful placement because the placement technique requires an approximately 5 cm circumferential area for placement of the gastrointestinal suture anchors. This is a technique in which experience and operator skill are important. Lack of experience might lead to longer procedural times in sick animals. Given the advanced equipment required, this procedure will most commonly be performed at referral centers, by experienced operators. Equipment requirements may limit the application of this technique, though the field of interventional radiology is expanding. The specific tube type used in this study was a dual-lumen 18-Fr GJT. This tube is available in multiple outer diameters (16-Fr, 18-Fr, 22-Fr) and multiple lengths. Advantages in using this type of device include simultaneous feeding and decompression, clearly marked ports, and over-the-wire compatibility. The GJT used in this particular study does not allow for separation of the gastric component from the jejunal component. Therefore the entire tube must be removed if any portion is removed. Clinically there would be an advantage to having a device where the gastric portion could be maintained for feeding and support long term. Additionally, there is a limited choice in lengths in the 18-Fr size, which is the most appropriate for most dogs. Although not used during this study, the dual lumen tube allows for gastric decompression and feeding. This could be particularly useful for patients that have high residual volumes or require long-term enteral nutrition, but not necessarily continued jejunal feeding. This methodology also allows a single operator to perform the procedure from start to finish, which is not possible with many previously reported methods.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5KUzwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+PFJlY051
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ADDIN EN.CITE.DATA 12,17,20,21Although limitations exist, PRGJ tube placement is a feasible procedure in the dog, and these initial observations suggest that this procedure is associated with a high success rate, relatively short procedural times, and few complications. These tubes possess the added benefit of having 2 lumens, which allows gastric suctioning, jejunal feeding, and the ability to transition to long-term feeding into the stomach. This is an advantage that has not been reported with other post-pyloric feeding methods. Further investigation in the clinical setting is needed, but PRGJ tube placement as reported herein may be considered for dogs that require post-pyloric feeding. FootnotesaApokyn, US WorldMeds LLC, St. Matthews, KYbPromAce Injectable, Boehringer Ingelheim, Ingelheim, GermanycPropovan, Piramal Healthcare, Bethlehem, PAdBuprenex, Reckitt Benckiser Healthcare, Richmond, VAeSAF-T-PEXY T-Fasteners, Kimberly-Clark Healthcare, Irving, TXf5 – 6 cm introducer/puncture needle, Cook Medical, Bloomington, INgHydrophilic Wire 260 mm, floppy; Merit Medical, South Jordan, UTh5F Berenstein catheter, Infiniti Medical LLC, Menlo Park, CAiOmnipaque 300, Bracco Diagnostics, Monroe Township, NJjG/TJ introducer kits 18F, Kimberly-Clark Healthcare, Irving, TXkDual-lumen 18F gastrojejunal feeding tube, Kimberly-Clark Healthcare, Irving, TXlSilicone internal retention balloon, Kimberly-Clark Healthcare, Irving, TXmSECUR-LOK External Retention Ring, Kimberly-Clark Healthcare, Irving, TXnData Analysis, Excel 2007, Redmond, WAoFoley silicone coated latex catheter, BARD Medical, Summit, NYpKeflex, Flynn Pharma LTD, Stevenage, United KingdomReferences ADDIN EN.REFLIST 1. Brunetto MA, Gomes MO, Andre MR, et al. Effects of nutritional support on hospital outcome in dogs and cats. J Vet Emerg Crit Care 2010;20(2):224–231.2. Gramlich L, Kichian K, Pinilla J, et al. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition 2004;20(10):843–848.3. Liu DT, Brown DC, Silverstein DC. Early nutritional support is associated with decreased length of hospitalization in dogs with septic peritonitis: A retrospective study of 45 cases (2000 – 2009). J Vet Emerg Crit Care 2012;22(4):453–459.4. Peter JV, Moran JL, Phillips-Hughes J. A meta-analysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Crit Care Med 2005;33(1):213–220;260–261.5. Heyland DK, Dhaliwal R, Drover JW, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Parenter Enteral Nutr 2003;27(5):355–373.6. Mohr AJ, Leisewitz AL, Jacobson LS, et al. Effect of early enteral nutrition on intestinal permeability, intestinal protein loss, and outcome in dogs with severe parvoviral enteritis. J Vet Intern Med 2003;17(6):791–798.7. Barr J, Hecht M, Flavin KE, et al. Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol. Chest 2004;125(4):1446–1457.8. Chan DL. The inappetent hospitalised cat: clinical approach to maximising nutritional support. J Feline Med Surg 2009;11(11):925–933.9. Qin HL, Su ZD, Hu LG, et al. Effect of early intrajejunal nutrition on pancreatic pathological features and gut barrier function in dogs with acute pancreatitis. Clin Nutr 2002;21(6):469–473.10. Campbell JA, Jutkowitz LA, Santoro KA, et al. Continuous versus intermittent delivery of nutrition via nasoenteric feeding tubes in hospitalized canine and feline patients: 91 patients (2002 – 2007) J Vet Emerg Crit Care 2010;20(2):232–236.11. Beal MW, Brown AJ. Clinical experience utilizing a novel fluoroscopic technique for wire-guided nasojejunal tube placement in the dog: 26 cases (2006 – 2010). J Vet Emerg Crit Care 2011;21(2):151–157.12. Wohl, JS. Nasojejunal feeding tube placement using fluoroscopic guidance: technique and clinical experience in dogs. J Vet Emerg Crit Care 2006;16(S1):S27–33.13. Lu DS, Mueller PR, Lee MJ, et al. Gastrostomy conversion to transgastric jejunostomy: technical problems, causes of failure, and proposed solutions in 63 patients. Radiology 1993;187(3):679–683.14. Barkmeier JM, Trerotola SO, Wiebke EA, et al. Percutaneous radiologic, surgical endoscopic, and percutaneous endoscopic gastrostomy/gastrojejunostomy: comparative study and cost analysis. J Vasc Interv Radiol 1998;21(4):324–328.15. Jabbar A, McClave SA. Pre-pyloric versus post-pyloric feeding. Clin Nutr 2005;24(5):719–726.16. Marik PE, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit Care 2003;7(3):R46–51.17. Jergens AE, Morrison JA, Miles KG, et al. Percutaneous endoscopic gastrojejunostomy tube placement in healthy dogs and cats. J Vet Intern Med 2007;21(1):18–24.18. Crowe DT, Devey JJ. Clinical experience with jejunostomy feeding tubes in 47 small animal patients. J Vet Emerg Crit Care 1997;7(1):7–19.19. Cavanaugh RP, Kovak JR, Fischetti AJ, et al. Evaluation of surgically placed gastrojejunostomy feeding tubes in critically ill dogs. J Am Vet Med Assoc 2008;232(3):380–388.20. Hewitt SA, Brisson BA, Sinclair MD, et al. Evaluation of laparoscopic-assisted placement of jejunostomy feeding tubes in dogs. J Am Vet Med Assoc 2004;225(1):65–71.21. Campbell SA, Daley CA. Endoscopically assisted nasojejunal feeding tube placement: technique and results in five dogs. J Am Anim Hosp Assoc 2011;47(4):e50–55.22. Cummings F, Daley CA. Esophagojejunostomy feeding tube placement in 5 dogs with pancreatitis and anorexia. Vet Med International 2014;(2014):article ID197294.23. Swann HM SD, Michel K. Complications associated with use of jejunostomy tubes in dogs and cats: 40 cases (1989 – 1994). J Am Anim Hosp Assoc 1997;210(12):1764–1767.24. Kim CY, Patel MB, Miller MJ, Jr., et al. Gastrostomy-to-gastrojejunostomy tube conversion: impact of the method of original gastrostomy tube placement. J Vasc Interv Radiol 2010;21(7):1031–1037.25. Maetani I, Tada T, Ukita T, et al. PEG with introducer or pull method: a prospective randomized comparison. Gastrointest Endosc 2003;57(7):837–841.26. Ahmad I, Mouncher A, Abdoolah A, et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy--a prospective, randomised, double-blind trial. Aliment Pharmacol Ther 2003;18(2):209–215.27. Shastri YM, Hoepffner N, Tessmer A, et al. New introducer PEG gastropexy does not require prophylactic antibiotics: multicenter prospective randomized double-blind placebo-controlled study. Gastrointest Endosc 2008;67(4):620–628.28. Lim CH, Park JM, Cho YK, et al. Successful control of peristomal infection by introducer-type percutaneous endoscopic gastrostomy: a retrospective historical control study. Dig Dis Sci 2011;56(7):2024–2029.29. Jafri NS, Mahid SS, Minor KS, et al. Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy. Aliment Pharmacol Ther 2007;25(6):647–656.30. Friedman JN, Ahmed S, Connolly B, et al. Complications associated with image-guided gastrostomy and gastrojejunostomy tubes in children. Pediatrics 2004;114(2):458–461.31. Hughes UM, Connolly BL, Chait PG, et al. Further report of small-bowel intussusceptions related to gastrojejunostomy tubes. Pediatr Radiol 2000;30(9):614–617.32. Hui GC, Gerstle JT, Weinstein M, et al. Small-bowel intussusception around a gastrojejunostomy tube resulting in ischemic necrosis of the intestine. Pediatr Radiol 2004;34(11):916–918.Table 1: Procedural characteristics and acute complications associated with percutaneous radiographic gastrojejunostomy tube placement in 6 dogs.Time across Pylorus (min)Time to Dilator (min)Total Time (min)ComplicationsDog 1 841113Hematochezia*, VomitingDog 2 224556NoneDog 3213755Vomiting*Dog 4 93120126Ptyalism*Dog 5 93057NoneDog 6253549Ptyalism*Median23.53953Complications with an * occurred perioperatively. min, minutes.Table 2: Migration over time of the distal tip of the percutaneous radiographic gastrojejunostomy tube in 5 dogs.Day 2Day 4 (pre-emesis)Day 4 (post- emesis)16 – 18 daysDog 132– 49– 8– 10Dog 2322145101Dog 422– 4525– 7551796161tube removedDog 65221042 (+) indicates movement of the distal tip towards the duodenojejunal flexure, while (–) indicates movement of the distal tip away from the duodenojejunal flexure. All measurements in mm. *5/6 dogs are represented in this table, 1 dog (Dog 3) was removed from maintenance phase due to self-removal or PRGJ on day 3.Figure 1. Dorsoventral positioned radiograph illustrating placement of gastrointestinal suture anchors (*) in a triangular pattern. The endoscope in the image was only utilized for intraluminal image acquisition.Figure 2. Lateral radiograph illustrating gastrointestinal suture anchors (*), silicone internal retention balloon (B), external bolster (E), and positioning of the tube in the descending duodenum (arrowheads), caudal duodenal flexure (CDF), ascending duodenum (arrows), and the tip of the tube in the jejunum (J).Figure 3. Gastrojejunal tube secured using SECUR-LOK External Retention Ring caudal to the 13th rib. Separate jejunal and gastric ports are visible. ................
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