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PEG Tube Placement in Piglets

Justin L. Prater, BS, LATG, SRA Jenifer A. Sweet, BS, LAT, SRS Randy Pielemeier, BS, LATG, SRS Lindsay Tawoda, BS, LATG, SRT Bjorn A. Thorsrud, PhD

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PEG Tube Placement in Piglets

Justin L. Prater, BS, LATG, SRA; Jenifer A. Sweet, BS, LAT, SRS; Randy Pielemeier, BS, LATG, SRS; Lindsay Tawoda, BS, LATG, SRT; Bjorn A. Thorsrud, PhD
MPI Research, 54943 North Main Street, Mattawan, Michigan

INTRODUCTION
The placement of percutaneous endoscopic gastrostomy (PEG) tubes into the stomach is a technique first introduced in the 1980s as a method to administer nutrition to children who were unable to swallow. PEG tubes currently are highly valued in clinical patient populations in which standard feeding techniques are limited or impossible due to stroke, tumors or other surgical procedures that may impede proper patient nutrition. The use of PEG tubes in juvenile swine as a method of test material administration has not been researched, as oral gavage is a successful technique for test material administration in most commonly used animal species.1 The primary endpoint of the study was to determine cytokine levels of IL-1, IL-6, IL-8, and TNF, which would have been be adversely affected by repeated dosing via oral gavage.2 To reduce possible stress in these young animals, a PEG tube was surgically placed, as the use of PEG tubes in dogs and other large animals is a common procedure completed in veterinary practice as described in the literature.3

METHODS
PEG Tube Placement/Necropsy This study used a total of eight Yorkshire-crossbred piglets (Source: Baily Terra Nova) obtained on lactation day 1619 and weighing between 1.72.6kg. An IACUC and veterinary approved protocol was used to conduct surgery. All animals were anesthetized according to Table 1. Animals were intubated and ventilated as needed. Animals were implanted with a 20 French Bard PEG tube kit as follows: A flexible scope was threaded through the esophagus into the stomach for internal visualization of the procedure. A small incision was made in the skin and a catheter was inserted percutaneously into the stomach. A looped wire was threaded through the catheter, grasped with endoscopic graspers and exteriorized through the oral cavity. The looped wire was wound around the PEG tube and pulled out of the abdomen, exteriorizing the PEG tube. Medical tape and an external bumper was placed to further secure the device, and a clamp was placed on the distal end of the PEG tube. Triple antibiotic ointment was placed at the exteriorization site, the site was bandaged, and the animals were jacketed for the remainder of the study. Necropsy occurred four days following the start of dosing. The stomach and area around implant site were grossly examined. Table 1. Scheduled Medications and Dosages Drug Interval, Dose, and Route Day of Surgery 0.1 mg/kg IM 0.05 mg/kg IM 58 mg/kg IM To effect, inhalation intubated 0.02mg/kg IM 3 mg/kg IM SID 2 mg/kg maximum infused into incisions 25 mg/kg IV 5 mg/kg IM 1015 mL/kg/hr IV As needed for irrigation

RESULTS
Post-op Complications During recovery, it was noted that a few of the animals presented with slightly elevated body temperatures (~39C). By the following morning all of the animals were noted that they recovered well from the surgical procedure. Following initial dosing through the PEG tube, it was noted that one of the animals PEG tubes appeared to be leaking from a faulty stopper on the end of the PEG tube. This was remedied by tying in an injection cap with silk suture for all of the animals. After this, no more leaks were noted in any of the animals. Keeping the bandaged area dry proved challenging due to the liquid diet in bowls that the animals were receiving. All animals required one bandage change during the study, but this was able to be successfully done without the use of anesthesia or sedation. Canine jackets worked well for keeping the PEG tube safe from dislodgement from the sometimes fractious animals, and the jackets fit the animals comfortably. Necropsy Findings Animals were necropsied following completion of the study, with the area of the stomach being examined grossly for signs of leakage of stomach contents into areas outside of the PEG tube, evidence of infection, or dislodgment or blockage caused by the PEG tube. Gross necropsy showed no signs of infection, leakage or any other issues due to the PEG tube, and the implant appeared normal as seen with the images to the right.

OBJECTIVES
The primary objective of the surgical portions of this study was to determine the feasibility of the use and maintenance of a PEG tube to repeatedly administer substances directly into the stomach of preweaning juvenile swine without using standard oral gavage techniques, and by using the Gauderer-Ponsky technique for PEG tube placement.4 A second objective was to determine a successful bandaging routine that would prevent dislodgement of the PEG tube with minimal stress to the animal.

MATERIALS
Flexible Endoscope (22 mm x 140 cm) 20F Bard PEG tube kit, Reference Number 000329 Triple antibiotic ointment Lubricating jelly Endoscopic tower Medium canine jackets Bandaging supplies (Hypafix, Tefla pads, and medical tape)

Acepromazine maleate Atropine sulfate Telazol Isoflurane Buprenorphine Ketoprofen Bupivacaine Cefazolin Excede LRS 0.9% NaCl

CONCLUSION
The objective of this procedure was to determine if a PEG tube could be placed successfully in swine in a minimally invasive manner, which then would allow for multiple large volume dosages of a test article into the stomach of the animal without using standard oral gavage techniques. All animals in this study were able to be dosed multiple times through the PEG tube, and with proper maintenance all animals were able to be maintained on study until time of necropsy. With the exception of elevated body temperatures during recovery, the procedure was successful. The elevated body temperatures were believed to have been caused by the warm temperatures the room was being maintained at, from the acepromazine as administered as a pre-anesthetic, or most likely due to the jackets being placed on the animals. Necropsy showed no obvious signs of the PEG tube not working as intended. Placement of PEG tubes in swine was deemed a successful procedure and would be useful in future studies examining stress markers, in cases of an emergency, or when the use of a gastrointestinal device prevents proper diet intake, as with the implantation of a satiogenic device.

Post-op Care Following surgery, if bandaging was noted to be wet or not adhered to the skin, it was replaced. During bandage replacement, the exteriorization site was cleaned with 0.02% chlorhexidine solution and triple antibiotic ointment was applied around the exteriorization site to prevent possible infection. Animals did not display signs of discomfort during these procedures and tolerated bandage changes when necessary very well. Dosing Dosing was conducted under surgeon supervision to ensure tube patency and an appropriate seal at the exteriorization site. Animals were dosed BID. Two technicians were needed to dose. Animals were dosed through the PEG tube with approximately 80 mL of PBS or test material using a 60 cc syringe. The PEG tube was closed with an injection cap, the jacket was zipped back up, and animals were returned to their home cage. This procedure took approximately 10 minutes per animal, mornings/afternoons, for the study duration (3 days). Animals appeared comfortable during dose and did not struggle during handling or dosing.

REFERENCES
1 Svendsen, O (2006). The minipig in toxicology. Experimental and Toxicologic Pathology, 57(5), 335-339. 2 Brown, AP, Dinger, N, Levine, BS (2000). Stress produced by gavage administration in the rat. Journal of the American Association for Laboratory Animal Science, 39(1), 17-21. 3 Waddell, LS, Michel, KE (1998). Critical care nutrition: routes of feeding. Clinical Techniques in Small Animal Practice, 13(4), 197-203. 4 Deitel M, Bendago M, Spratt EH, Burul CJ, To TB (1988). Percutaneous endoscopic gastrostomy by the pull and introducer methods. Can J Surg 31 (2): 1024.