Percutaneous endoscopic gastrostomy as a standard procedure in head and neck surgery

Percutaneous endoscopic gastrostomy site metastasis from head and neck squamous cell carcinoma: case series and literature review

Objectives

To present our experience with head and neck squamous cell carcinoma (HNSCC) seeding of percutaneous endoscopic gastrostomy (PEG) sites and to review all reported cases to identify risk factors and develop strategies for complication avoidance.

Materials and methods

The records of 4 patients with PEG site metastasis from HNSCC were identified from the authors’ institution. Thirty-eight further cases were reviewed following a PubMed search and evaluation of references in pertinent articles.

Results

Review of 42 cases revealed the average time from PEG to diagnosis of metastatic disease to be 8 months. Average time to death from detection of PEG disease was 5.9 months. One-year survival following PEG metastasis was 35.5% with an overall mortality of 87.1%.

Conclusion

PEG site metastatic disease portends a poor prognosis. Early detection and aggressive therapy may provide a chance of cure. Changes in PEG technique or in timing of adjunctive therapies are possible avenues in further research to prevent this complication.

Percutaneous Endoscopic Gastrostomy for Long-Term Feeding of Patients With Oropharyngeal Tumors

Secondary malnutrition in patients with oropharyngeal tumors can be the cause of substantial morbidity. The present, prospective study examined 30 patients receiving treatment for an oropharyngeal tumor. Percutaneous endoscopic gastrostomy (PEG) was performed 1 wk prior to the start of therapy in 15 patients, and 15 patients were temporarily fed by nasogastric tube after surgery. Anthropometric and laboratory parameters were measured in both patient groups at five defined times. Based on these parameters, the nutritional status of the PEG patients was found to be substantially better. The present study was able to show that the prophylactic placement of a PEG tube greatly improves the nutritional status of the patients before and after surgery and minimizes the catabolism of the body's fat depots.

Comparison of the use of endoscopic and radiologic gastrostomy in a single head and neck cancer unit

BACKGROUND

Head and neck cancer patients frequently require gastrostomy feeding. Different insertion techniques have been described. The aim of the present study was to compare clinical results of percutaneous endoscopic and radiological gastrostomies in patients treated in a regional head and neck cancer unit.

METHODS

The records of patients who received either percutaneous endoscopic gastrostomy (PEG) or percutaneous radiological gastrostomy (PRG) between August 1997 and February 2001 were reviewed retrospectively. Documented complications (leak, infection, nausea and vomiting, ileus, bleeding, peritonitis) were recorded, compared and evaluated.

RESULTS

There were 74 patients (56 PEG, 18 PRG), most with stage III and IV head and neck malignancy. There was a significantly lower incidence of complications in PEG than PRG (11% vs 44%, P = 0.004). There was a delay of feeding due to tube placement in 4% of PEG and 22% of PRG (P < 0.025). Major complications occurred in 3.6% and 5.6% of PEG and PRG, respectively. Generally the complication rate for either form of gastrostomy was comparable with other studies. No procedure-related deaths occurred.

CONCLUSION

Selection bias, technique and tube type appeared to influence the complication rate in the present review. Percutaneous endoscopic gastrostomy will remain the authors' preferred method while PRG will be reserved for those cases for whom endoscopic placement is deemed to be impractical.

Insertion of percutaneous endoscopic gastrostomy tubes by a maxillofacial surgical team in patients with oropharyngeal cancer

This study assessed the clinical outcome after insertion of a percutaneous endoscopic gastrostomy tube (PEGT) by a maxillofacial team in a series of 54 patients. The indication for PEG feeding was any patient with oropharyngeal cancer who was unlikely to return to oral feeding within 14 days. Fifty-two patients (96%) had tubes successfully inserted at the time of examination under anaesthesia (n = 19) or definitive operation (n = 33). Feeding was established at a median of 2 days (range 1-6). Median duration of tube feeding was 18 weeks (range 4-70). There were no deaths or major complications and 10 minor complications. No tube was lost or required premature removal. We conclude that insertion of a PEG tube is a procedure that can be done safely by maxillofacial surgeons.

Radiological percutaneous gastrostomy

Long-term gastrostomy tubes have a widely accepted role in providing nutritional support. Traditionally, they have been placed by surgeons and by endoscopists. In the last decade, radiologists have come to play a major role in the placement of gastrostomy and gastrojejunostomy devices, and can usually do so as effectively and at lesser expense. A technique for placement is outlined, with a discussion of patient selection and complications. A review of the literature is provided.

Percutaneous endoscopic gastrostomy for patients with severe cerebral injury

Early enteral nutrition improves the outcome of severely injured patients. To provide enteral nutrition, various methods are available. In a restrospective study we analysed the outcome of 24 severely traumatized patients (mean ISS = 44), in whom a percutaneous endoscopic gastrostomy (PEG) was used for enteral nutrition. All patients had been admitted to the intensive care unit with major cerebral injury. The mean duration of intensive care treatment and the in hospital stay were 28 and 71 days, respectively. PEG was introduced 14 days after hospital admittance. Enteral nutrition through the PEG was administered for 45 days. Four patients died, 8 patients were discharged from the hospital while being fed via the PEG and 12 patients resumed normal feeding and the PEG was removed. Three severe complications occurred; 1 patient aspirated massively and died; in 2 patients intra-abdominal leakage of the enteral nutrition occurred. Both patients recovered from this complication. We conclude that because of the advantages of early enteral nutrition on the one hand and the drawbacks of nasogastric feeding tubes on the other, in injured patients with severe cerebral damage, PEG placement is justified, despite the risk of complications.

Stomal seeding of head and neck cancer by percutaneous endoscopic gastrostomy tube placement

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes have replaced nasogastric tubes and Stamm gastrostomy tubes as a preferred means of feeding for patients with head and neck cancers, as recommended by the results of large series. A patient with stomal seeding of squamous cell carcinoma of the upper aerodigestive tract by PEG placement was reported. A review of literature was performed.

METHODS

A Medline search of implantation of squamous cell carcinoma from the upper aerodigestive tract to PEG exit site since the introduction of PEG was performed.

RESULTS

Two reports of implantation of squamous cell carcinoma of the upper aerodigestive tract to PEG exit site were found. Both patients and our patient were staged T4.

CONCLUSIONS

Implantation of squamous cell carcinoma from the upper aerodigestive tract to the PEG exit site is a rare and late complication. Its prevalence is not known. For patients with a significant amount of squamous cell carcinoma in the upper aerodigestive tract, we recommend Stamm gastrostomy over PEG insertion by the pull technique. There is no report of such late complication by the push technique.

Acceptance and perception of percutaneous endoscopic gastrostomy by patients with upper aerodigestive tract cancer

Surgeons have identified a role for percutaneous endoscopic gastrostomy (PEG) in selected patients with upper aerodigestive tract cancer, but little is known about the patient's acceptance and perception of PEG. Nineteen patients with upper aerodigestive tract cancer had placement of a PEG and were asked about their perceptions via a series of descriptors and associated questions. The 13 patients who had PEG placement under local anaesthesia and intravenous midazolam were questioned 12-16 h later and reported that the procedure was comfortable and not as bad as expected. These patients together with a further 6 patients who had placement under general anaesthesia were questioned about their acceptance of the PEG tube after 10 days. Comfort, ease of use and maintenance, and coverage by clothing confirms that PEG is an acceptable delivery system for enteral nutrition in patients with upper aerodigestive tract cancer.

Closure of large orocutaneous fistulas in end-stage malignant disease

Expanding Silastic foam was used to close and dress a large orocutaneous salivary fistula secondary to a massive local recurrence of squamous cell carcinoma. The technique is simple, rapid, and effective. The patient found the dressing superior in every way to the traditional absorbent dressings previously supplied. We recommend this technique for the closure of large defects in the head and neck.

Implantation metastasis following percutaneous endoscopic gastrostomy

Since it was first described, the original percutaneous endoscopic gastrostomy (PEG) technique has proved to be a valuable adjunct in patients with head and neck tumours. This procedure is being increasingly utilized in the face of swallowing impairment related to head and neck carcinoma. Although generally well tolerated, it may be associated with complications. In this report, we document tumour implantation at the percutaneous endoscopic gastric site and review the report cases. It appears that implantation metastasis does alter prognosis.