Percutaneous endoscopic gastrostomy using the direct method for aerodigestive cancer patients

Direct percutaneous endoscopic gastrostomy for nutritional support in patients with aerodigestive tract cancers

BACKGROUND

Conventional pull-through percutaneous endoscopic gastrostomy (PEG) risks infection and tumour implantation in head and neck cancers. Endoscopically inserted direct gastrostomy has lower rates of complications but is underutilised.

AIMS

To describe the endoscopic steps for direct gastrostomy insertion and review our single-centre experience to assess the technical feasibility and safety.

METHODS

Patients who underwent endoscopic direct gastrostomy insertion between December 2016 and June 2021 were included. A 24Fr introducer kit for gastrostomy feeding tube (Avanos Healthcare, Australia) was used. Patient and tumour characteristics, procedural data and 30-day outcomes were recorded.

RESULTS

Thirty patients underwent direct PEG insertion (mean age 64 years and 24 male). All were planned for or currently undergoing radiotherapy. Twenty-six (87%) of 30 cases were performed under conscious sedation over a median procedure time of 21 min (interquartile range 11 min). No tumour seeding was seen, and one case of PEG-site infection was observed.

CONCLUSIONS

Direct PEG is safe and effective and should be considered for patients with aerodigestive tract cancer in need of nutritional support.

Malnutrition, Cancer Stage and Gastrostomy Timing as Markers of Poor Outcomes in Gastrostomy-Fed Head and Neck Cancer Patients

For percutaneous endoscopic gastrostomy (PEG)-fed head and neck cancer (HNC) patients, risk markers of poor outcomes may identify those needing more intensive support. This retrospective study aimed to evaluate markers of poor outcomes using TNM-defined stages, initial anthropometry [body mass index (BMI), mid-upper arm circumference (MUAC), tricipital skinfold (TSF), mid-arm muscle circumference (MAMC)] and laboratory data (albumin, transferrin, cholesterol), with 138 patients, 42-94 years old, enrolled. The patients had cancer, most frequently in the larynx (n = 52), predominantly stage IV (n = 109). Stage IVc presented a four times greater death risk than stage I (OR 3.998). Most patients presented low parameters: low BMI (n = 76), MUAC (n = 114), TSF (n = 58), MAMC (n = 81), albumin (n = 47), transferrin (n = 93), and cholesterol (n = 53). In stages I, III, IVa, and IVb, MAMC and PEG-timing were major survival determinants. Each MAMC unit increase resulted in 16% death risk decrease. Additional 10 PEG-feeding days resulted in 1% mortality decrease. Comparing IVa/IVb vs. IVc, albumin and transferrin presented significant differences (p = 0.042; p = 0.008). All parameters decreased as severity of stages increased. HNC patients were malnourished before PEG, with advanced cancer stages, and poor outcomes. Initial MAMC, reflecting lean tissue, significantly increases survival time, highlighting the importance of preserving muscle mass. PEG duration correlated positively with increased survival, lowering death risk by 1% for every additional 10 PEG-feeding days, signaling the need for early gastrostomy.

Comparison of Clinical Outcomes Between Surgical Gastrostomy and Percutaneous Endoscopic Gastrostomy with Introducer Technique in Patients with Upper Aerodigestive Malignancies: A Single-Center Analysis

BACKGROUND

Conventional percutaneous endoscopic gastrostomy (PEG) in patients with upper aerodigestive malignancies inevitably carries a risk of stomal metastasis that could be avoided by the direct insertion of the gastrostomy tube through the abdomen. This study compared the efficacy and safety between surgical gastrostomy (SG) and Introducer PEG in patients with upper aerodigestive malignancies.

METHODS

We retrospectively reviewed patients with upper aerodigestive malignancies undergoing SG or Introducer PEG. Procedure data, postprocedural clinical outcomes and 30-day mortality were assessed.

RESULTS

In total, 99 patients were feasible to analysis: 53 were in the SG group, and 46 were in the Introducer PEG group. The SG group had a higher incidence of (in-hospital) major complications [28.3% VS 4.3%, p = 0.002], a longer procedure duration [52.02 ± 21.30 VS 21.46 ± 8.22 min, p < 0.001], higher pain scores at 24 h [median (interquartile range, IQR); 5(3-8) VS 1(0-5), p < 0.001] and longer length of hospitalization (LOH) [median (IQR); 5(4-6) days VS 3(2-4) days, p < 0.001)]. In-hospital (3.8% VS 0%, p = 0.493) and 30-day mortality (17.0% VS 13.0%, p = 0.586) were not different between the two groups. In univariate analysis, high BMI, anemia (hemoglobin <11 g/dL), normal nutritional status (serum albumin >3 g/dL) and procedural type were found to be predicting factors for complications. Procedural type (Introducer PEG) was an independent factor for major complications in multivariate analysis [OR = 0.12, 95% CI 0.02-0.61, p= 0.011].

CONCLUSIONS

In patients with upper aerodigestive malignancies, Introducer PEG was associated with lower rate of (in-hospital) major complications, faster operative time, lower pain scores and shorter LOH.

CLINICAL TRIALS REGISTRY NUMBER

TCTR20181220004.

Feasibility, safety and outcome of endoscopic gastrostomy in patients with esophageal cancer

Introduction

Background and aims: esophageal cancer (EC) is an important health problem worldwide with high morbidity and mortality. EC patients are likely to develop malnutrition. The aim of this study was to assess the feasibility and safety of endoscopic gastrostomy (PEG) feeding in EC cancer, and to identify risk factors associated with poor prognosis. Methods: a retrospective observational study was performed using records from EC patients referred for PEG. Age, gender, cancer histologic subtype, indication for gastrostomy, and mortality data were recorded. NRS 2002, body mass index (BMI), hemoglobin, serum albumin, transferrin and total cholesterol were collected at the day of PEG. An association between anthropometric, clinical and laboratorial data with patient survival was assessed. Results: data were obtained for forty-one EC patients (36 men and 5 women) aged 39-88 years (mean, 62 years). Gastrostomy was possible in all patients referred to PEG (27 patients selected for curative treatment and 14 patients for palliative nutrition). No major complications occurred. Mean survival after PEG was 18.1 months, and mortality rate at 3 months was 31.7 %. Most patients (34; 82.9 %) died under PEG feeding. Mean BMI was 21.3 kg/m2 and 14 patients (34.1 %) patients had low BMI. Serum albumin, transferrin and total cholesterol were low in 10 (24.4 %), 20 (48.8 %) and 18 (43.9 %) patients, respectively. Higher BMI (R = 0.30), serum albumin (R = 0.41) and transferrin (R = 0.47) tended to be positively correlated with survival (p < 0.005). Conclusions: PEG is a feasible and safe technique for enteral feeding in EC patients. Higher BMI, serum albumin and transferrin levels at admission predict a better outcome. Enteral feeding through PEG should be considered early in EC patients due to their higher risk of malnutrition, which is associated with shorter survival.

Metastasis to gastrostomy sites from upper aerodigestive tract malignancies: a systematic review and meta-analysis

BACKGROUND AND AIMS

Metastasis to the gastrostomy site in patients with upper aerodigestive tract (UADT) malignancies is a rare but devastating adverse event that has been poorly described. Our aim was to determine the overall incidence and clinicopathologic characteristics observed with development of gastrostomy site metastasis in patients with UADT cancers.

METHODS

This was a systematic review and meta-analysis of 6138 studies retrieved from Medline, EMBASE, CINAHL, and the Cochrane Register after being queried for studies including gastrostomy site metastasis in patients with UADT malignancies.

RESULTS

The final analysis included 121 studies. Pooled analysis showed an overall event rate gastrostomy site metastasis of .5% (95% confidence interval [CI], .4%-.7%). Subgroup analysis showed an event rate of .56% (95% CI, .40%-.79%) with the pull technique and .29% (95% CI, .15%-.55%) with the push technique. Clinicopathologic characteristics observed with gastrostomy site metastasis were late-stage disease (T3/T4) (57.8%), positive lymph node status (51.2%), and no evidence of systemic disease (M0) (62.8%) at initial presentation. The average time from gastrostomy placement to diagnosis of metastasis was 7.78 ± 4.9 months, average tumor size on detection was 4.65 cm (standard deviation, 2.02), and average length of survival was 7.26 months (standard deviation, 6.23).

CONCLUSIONS

Gastrostomy site metastasis is a rare but serious adverse event that occurs at an overall rate of .5%, particularly in patients with advanced-stage disease, and is observed with a very poor prognosis. These findings emphasize a need for clinical practice guidelines to include a regular assessment of the PEG site and highlight the importance of detection and management of gastrostomy site metastasis by the multidisciplinary care oncology team.

The efficacy of a novel percutaneous endoscopic gastrostomy simulator using three-dimensional printing technologies

BACKGROUND AND AIM

We developed a novel training simulator for percutaneous endoscopic gastrostomy (PEG) and determined its efficacy and realism in PEG insertion training.

METHODS

The gastrostomy simulator was made using three-dimensional printing and silicone molding technology. The simulator is of two types: pull type and introducer type. We enrolled 20 participants, comprising 10 beginners with no experience of PEG insertion and 10 PEG-experienced endoscopists. Each participant underwent two training sessions for the two simulator types. We recorded the simulation time, self-evaluation, and difficulty score based on a 5-score scale for PEG insertion among the participants. Subsequently, simulator performance was assessed via a questionnaire based on a 7-point Likert scale.

RESULTS

The mean time to completion of PEG simulation decreased from 11.9 (5.2) to 9.0 (4.0) min for the pull type and from 13.8 (7.0) to 12.0 (5.8) min for the introducer type in the beginner group. The mean self-evaluation scores of beginners increased from 2.2 (1.1) to 3.1 (0.7) (pull type) and from 2.2 (1.2) to 3.3 (0.8) (introducer type). The mean procedure difficulty scores of beginners decreased from 3.4 (1.1) to 2.7 (0.9) (pull type) and from 4.4 (0.5) to 3.0 (0.8) (introducer type). The improvement of skill score was 6.3 (1.2) for the beginner group. The general realism score of the simulator for handling was judged to be 6.0 (0.9) by the experienced group.

CONCLUSIONS

The three-dimensional-printed simulator for PEG insertion can be useful for training of beginner endoscopists and shows good efficacy and realism.

Tumor implantation following percutaneous endoscopic gastrostomy insertion for head and neck and oesophageal cancer: Review of the literature

BACKGROUND

Because of publication bias, there is uncertainty about the true incidence of tumor seeding or implantation in patients with head and neck or oesophageal cancer undergoing percutaneous endoscopic gastrostomy (PEG) insertion.

METHODS

In order to obtain a more reliable estimate of risk, a systematic review was undertaken. Randomized or non-randomized studies and case reports were identified by electronic searching. A risk of bias assessment was carried out for each study.

RESULTS

Ninety-eight cases from 74 published case reports and 1 unpublished case were identified. Synchronous distant metastases were present in 37%. Analysis of case series (6192 patients) considered to carry a moderate risk of bias suggests an incidence of seeding after PEG insertion of 0.32%. Studies carrying a lower risk of bias indicate a risk of seeding closer to 1 in 2000.

CONCLUSION

The true risk of seeding after PEG insertion is probably less than 1 in 1000.

Prolonged Versus Short-Duration Use of Nasogastric Tubes in Patients with Head and Neck Cancer During Radiotherapy Alone or Combined Chemoradiotherapy

To compare safety and effectiveness of prolonged (>28 days) versus short duration (≤28 days) use of nasogastric tube for enteral nutrition and weight loss prevention during curative radiotherapy with or without concurrent chemotherapy or cetuximab for head and neck cancer patients. We performed a retrospective study and database review of all patients at our center, treated with radiotherapy for head and neck cancer receiving enteral nutrition by nasogastric tube. Type of treatment, weight and body mass index changes, and related complications (gastroesophageal reflux, pneumonia, ulcer, feeding tube obstruction, or dislocation) were documented. Comparison between patients with prolonged (>28 days, group A) and short duration (≤28 days, group B) of EN through nasogastric tube was performed. Data expressed as mean ± SD or median (min; max) values as appropriate, and analyzed by ANOVA repeated measures and Kaplan-Meier estimates. We identified 114 patients who fulfilled the inclusion criteria. Among them, 10% were treated with radiotherapy alone, while 90% received concurrent chemotherapy or cetuximab. Ninety-four patients (82%, group A) had a nasogastric tube in place for a period >28 days and 20 (18%, group B) for ≤28 days during treatment. Patients were mainly men (86 patients, 75%), with a median age of 61 years (range 49-73) and advanced stage IV disease in most cases (87 patients, 76%) without differences between both groups (p = 0.53, 0.47, and 0.30, respectively). Treatment discontinuation did not occur within both groups. Fifty-six patients (49%) developed complications, without a significant difference between both groups (P = 0.23). Body weight and BMI changes did not differ during EN (-0.8 ± 4.5 and -0.3 ± 1.6), the oncological treatment (-5.3 ± 4.0 and -1.8 ± 1.4), or 6 months after the end of treatment (-0.6 ± 4.4 and -0.2 ± 1.5). Our findings suggest that prolonged enteral nutrition by nasogastric tube is safe and effective in preventing weight loss during curative radiotherapy or radio-chemotherapy for head and neck cancer.

Comparison of the pull and introducer percutaneous endoscopic gastrostomy techniques in patients with head and neck cancer

BACKGROUND AND STUDY AIMS

Percutaneous endoscopic gastrostomy (PEG) in head and neck cancer (HNC) patients is associated with higher complication and mortality rates when compared to a general patient population. The pull technique is still the preferred technique worldwide but it has some limitations. The aim of this study is to compare the pull and introducer PEG techniques in patients with HNC.

PATIENTS AND METHODS

This study is based on a retrospective analysis of a prospectively collected database of 309 patients with HNC who underwent PEG in the Cancer Institute of São Paulo.

RESULTS

The procedure was performed with the standard endoscope in 205 patients and the introducer technique was used in 137 patients. There was one procedure-related mortality. Age, sex and albumin level were similar in both groups. However in the introducer technique group, patients had a higher tumor stage, a lower Karnofsky status, and presented more frequently with tracheostomy and trismus. Overall, major, minor, immediate and late complications and 30-day mortality rates were similar but the introducer technique group presented more minor bleeding and tube dysfunctions.

CONCLUSION

The push and introducer PEG techniques seem to be both safe and effective but present different complication profiles. The choice of PEG technique in patients with HNC should be made individually.

Malnutrition and Clinical Outcome of 234 Head and Neck Cancer Patients who Underwent Percutaneous Endoscopic Gastrostomy

Head and neck cancer (HNC) patients who underwent percutaneous endoscopic gastrostomy (PEG) present malnutrition risk and speech impairments. Their assessment relies on objective anthropometric/laboratory data. Focusing on HNC PEG patients, our aims were to evaluate: 1) outcome; 2) nutritional status when the patients underwent PEG; and 3) association of nutritional status/outcome, creating a survival predictive model. We evaluated the outcome based on NRS 2002, dietary assessment, body mass index (BMI), mid-upper arm circumference (MUAC), triceps skinfold thickness (TSF), mid-arm muscle circumference (MAMC), albumin, transferrin, and cholesterol on the day of gastrostomy. Using BMI, TSF, MAMC, and laboratory data, a survival predictive model was created. Of the 234 patients (cancer stages III-IV), 149 died, 33 were still PEG-fed, and 36 resumed oral intake (NRS-2002≥3, caloric needs <50% in all). BMI was 12.7-43. 189, 197, and 168 patients displayed, respectively, low MUAC, TSF, and MAMC. 91, 155, and 119 patients displayed low albumin, transferrin, and cholesterol. Albumin, cholesterol, and transferrin were strongly associated with the outcome. A predictive model was created, discriminating between short-term survivors (<4 months) and long-term survivors. HNC patients were malnourished. Using anthropometric/laboratory parameters, a predictive model provides discrimination between patients surviving PEG for <4 months and long-term survivors. Teams taking care of PEG patients may provide special support to potential short-term survivors.

Development of a prediction model of adverse events after stent placement for esophageal cancer

BACKGROUND AND AIMS

Self-expandable metal stent (SEMS) positioning is the recommended method for palliation of dysphagia from esophageal cancer, although it is not adverse event-free. The present study was aimed at identifying predictors for adverse events and at proposing a statistical model to predict them.

METHODS

We performed a retrospective analysis of a prospectively collected database. All patients who underwent SEMS placement for stricture due to esophageal cancer between 2002 and 2011 in a tertiary-care center were identified. Multivariable regression analysis in the presence of competing risk events was used to identify factors associated with SEMS-related adverse events and to build a prediction model.

RESULTS

A total of 267 patients were included. According to the competing risk regression analysis, only 2 variables were significantly associated with the risk of SEMS-related adverse events: prior chemoradiotherapy (CRT), yielding a hazard ratio (HR) of 1.687 (95% confidence interval [CI], 1.076-2.644), and the SEMS length (HR 0.884; 95% CI, 0.798-0.980) for every 10-mm length increase. Based on the estimated probability curves, after 4 months from SEMS placement, the probability of an adverse event in patients who did receive prior CRT was 50.9% compared with 34.4% in those who did not receive prior therapy, which was reduced to 9.2% and 15.1%, respectively, if a 180 mm-length stent was used. The ability of the predictive model to differentiate between patients who did and did not experience the adverse event was moderate (c-index: 0.617).

CONCLUSION

The rate of SEMS-related adverse events was higher in patients with previous CRT and lower in patients receiving longer stents. Both factors were used to build an accurate predictive model.

Peritonitis related to percutaneous endoscopic gastrostomy using the direct method for cancer patients

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) using the direct method is generally indicated for cancer patients. However, there are little available data about peritonitis related to this method. The aim of this retrospective analysis was to assess peritonitis related to PEG using the direct method in patients with cancer.

METHODS

We assessed the prevalence of peritonitis and the relationship between peritonitis and patients' backgrounds, as well as the clinical course after peritonitis.

RESULTS

Between December 2008 and December 2011, peritonitis was found in 9 (2.1 %) of 421 patients. Of the 9 patients with peritonitis, 4 had received PEG prior to chemoradiotherapy. Emergency surgical drainage was required in 1 patient, and the remaining 8 recovered with conservative treatment. Peritonitis occurred within 8 days of PEG for 8 of the 9 patients and occurred within 2 days of suture removal for 4 of the 9 patients.

CONCLUSION

Peritonitis related to PEG using the direct method was less frequent for cancer patients. Peritonitis tended to occur within a few days after removal of securing suture and in patients with palliative stage.

Percutaneous endoscopic gastrostomy for decompression of malignant bowel obstruction

BACKGROUND

Previous reports on percutaneous endoscopic gastrostomy (PEG) for bowel decompression have included a relatively small number of patients and the details of post-procedural outcomes and complications are lacking. The aim of the present study was to evaluate the outcomes and safety of PEG for bowel decompression in a relatively large number of patients with malignant bowel obstruction.

PATIENTS AND METHODS

Over a 10-year period, 76 patients with malignant bowel obstruction were referred to the main referral cancer center in Shizuoka prefecture for PEG to obtain decompression. The method for gastrostomy was carried out by the pull-method, the modified introducer method and the percutaneous endoscopic gastrojejunostomy method. Patient demographics, procedural success, complications, elimination of nasal intubation, and survival were reviewed.

RESULTS

Successful placement was achieved in 93% of patients (71/76). Procedure-related complications occurred in 21% ofpatients (15/71), of which the majority involved stomal leakage (eight patients), and wound infection (six patients). There were no procedure-related deaths. Among the 55 patients who required nasal intubation before PEG, a trans-gastrostomy intestinal tube was inserted in 16 patients. The need for further nasal intubation was eliminated in 96% of the patients (53/55). The median survival time was 63 days (range, 8-444 days) after PEG placement.

CONCLUSIONS

PEG for bowel decompression in patients with malignant obstruction can be carried out with an acceptable risk of minor complications. In combination with a trans-gastrostomy intestinal tube insertion, the elimination of nasal intubation can be achieved in most patients.