When you have a linear foreign body (LFB), the goal is to perform the surgery with the limited number of intestinal incisions as possible. Unless you have perforations, in which case resection and anastomoses will be required, you ‘should’ be able to perform LFB surgeries with just one enterotomy and one gastrotomy.
This blog outlines the Red Rubber Feeding Tube Technique to achieve this. I have not gone into details in this written outline regarding packing off your intestines, closing, ensuring you don’t have leakage, etc. Ensure you have good surgical technique throughout!
Also, it is very important to handle the tissue incredibly gently! I do pull on the LFB in this technique, however I always do this, and any tissue handling, incredibly gently! This is imperative to healthy tissue healing.
WHY use the Red Rubber Feeding Tube Technique?:
Every time you cut into the stomach or intestines, you have a potential location for tissue breakdown and dehiscence. You also have another location for inflammation and therefore adhesions in the future. Animals sometimes get repeated bowel obstructions (and sometimes are euthanized) just due to these adhesions, so minimizing this is incredibly important!
Also, less enterotomies means less surgical time. Less surgical time means less opportunity for prolonged hypertension, hypothermia, sedative drugs, etc.
Less enterotomies also means less stress and lying awake at night thinking, “did that break down?”
Also, it’s kinda fun!
How Linear Foreign Bodies (LFB) Form:
LFBs form by a string, with two anchors, being eaten by an animal. Usually, the large anchor gets stuck in the stomach, and the small anchor wiggles into the intestines, just pushing through. The string in between causes the intestines to all bunch up, and the string can act like a knife, cutting into the mesenteric border. The small anchor can often make it all the way into the colon, causing the intestines to plicate significantly along the string.
Red Rubber Feeding Tube Technique:
STEP 1: Explore the Abdomen
Start by palpating and exploring the abdomen, so you know exactly where your anchor are, and also examine the intestines carefully for any perforations!
STEP 2: Gastrotomy to Remove Large Anchor
Perform a gastrotomy. Once you get a handle on the large anchor, put VERY GENTLE pressure to pull the string of the LFB out. Cut as deep down as possible to cut as much of the string as possible, and let it flow into the intestines.
Explore the stomach afterwards to ensure no second FB is present in the stomach!
Close the gastrotomy.
You will notice that your plicated intestines will become less plicated as the pressure of the anchor from the stomach is released! Gently pull on the intestines to get the string of the LFB to move as aborally as possible down the intestines.
STEP 3: Enterotomy
Locating your enterotomy site is the most difficult part. You want to milk the LFB as aborally as possible. Pick your enterotomy site such that you can just still have some motion in the oral side of your LFB string. The goal is to be able to perform your enterotomy as aborally as possible (sometimes you can milk it all the way out the colon without needing to perform an enterotomy, but this is rare!), but still being able to pull the oral portion of the LFB out your enterotomy site!
Once you pick your site, perform an enterotomy, <1cm large, along the anti-mesenteric border. (If an RNA is required, double up this enterotomy with your RNA site). Pull the oral side of the string out your enterotomy site.
NOTE: Clamp the aboral side your enterotomy so you don't lose it when you cut your string!
STEP 4: Attach and Feed Red Rubber Feeding Tube
Tie the proximal aspect of the remaining string to the smooth rounded end of your red rubber feeding tube. Insert the feeding tube into the enterotomy site.
If you have a small animal you may need to cut the open end of the feeding tube smaller so it will fit through your intestines and through the ileocecal junction. 2. Pick the BIGGEST feeding tube size you can. At least 0.5cm diameter. If it is smaller it won’t be stiff and you won't be able to feed the tube through!
Milk the feeding tube through the intestines in an aboral direction (towards the colon). You will end up bunching the intestines over the feeding tube, holding the rounded end, and pulling the intestines over the feeding tube in order to get it to move forwards through the intestines (see video if you don’t understand this part). Milk the feeding tube all the way into the colon if possible!
STEP 5: Pull Feeding Tube Out Rectum
Once you get the tube down into the colon, feed it through and have an assistant rectal the patient, and grab the end of the feeding tube once they can feel it. Have your assistant pull the tube out of the rectum. The string and the caudal anchor will come with it!
Finish off by closing up your enterotomy site, and don’t forget to tack the omentum around your enterotomy site and flush the abdomen!
More Medical Information!
If you enjoyed this video, images, and information, check out our Instagram Stories with cases highlighted, as well as our Septic Shock for Dummies Webinar! Although this page is mainly non-clinical, there are some topics that bridge between clinical and non-clinical. In regards to Septic Shock, the mental aspect of these cases, and the communication with clients, needs to be addressed. This webinar covers all aspects, and gives you an algorithm and notes as well to help in your future cases!