Prophylactic percutaneous endoscopic gastrostomy in patients with head and neck cancer: Influence on nutritional status, utilisation rate and complications

Prediction of the need of enteral nutrition during radiation therapy for head and neck cancers

INTRODUCTION

Patients with a head and neck (HN) cancer undergoing radiotherapy risk critical weight loss and oral intake reduction leading to enteral nutrition. We developed a predictive model for the need for enteral nutrition during radiotherapy in this setting. Its performances were reported on a real-world multicentric cohort.

MATERIAL AND METHODS

Two models were trained on a prospective monocentric cohort of 230 patients. The first model predicted an outcome combining severe or early fast weight loss, or severe oral intake impairment (grade 3 anorexia or dysphagia or the prescription of enteral nutrition). The second outcome only combined oral intake impairment criteria. We trained a gradient boosted tree with a nested cross validation for Bayesian optimization on a prospective cohort and predictive performances were reported on the external multicentric real-world cohort of 410 patients from 3 centres. Predictions were explainable for each patient using Shapley values.

RESULTS

For the first and second outcome, the model yielded a ROC curve AUC of 81 % and 80%, an accuracy of 77 % and 77 %, a positive predictive value of 77 % and 72 %, a specificity of 78 % and 79 % and a sensitivity of 75 % and 73 %. The negative predictive value was 80 % and 80 %. For each patient, the underlying Shapley values of each clinical predictor to the prediction could be displayed. Overall, the most contributing predictor was concomitant chemotherapy.

CONCLUSION

Our predictive model yielded good performance on a real life multicentric validation cohort to predict the need for enteral nutrition during radiotherapy for HN cancers.

Role of Percutaneous Endoscopic Gastrostomy for the Nutrition of Head and Neck Cancer Patients before and up to 6 Months after Cancer Treatment

This retrospective monocentric cohort study analyzed patients with head and neck cancer according their nutritional status and association of percutaneous endoscopic gastrostomy (PEG) from admission to six months after treatment at a tertiary hospital in Germany from 2017 to 2019. A total of 289 patients (76.5% men; median age 62 years; 63.3% stage IV) were included. Univariate analyses and ANOVAs with repeated measures were performed to analyze differences over time. The percentage of patients requiring PEG was 14.9% (43 of 289 patients) before start of treatment (Z0), 14% (40 of 286 patients alive) after one week (Z1), 22.7% (58 of 255 patients) after six weeks (Z2) and 23% (53 of 230 patients) after six months (Z3) from the end of treatment. PEG placement was associated with alcohol or nicotine consumption, in oropharyngeal and hypopharyngeal carcinoma, squamous cell carcinoma, cancer stage III/IV, chemotherapy and impairment of food intake (all p < 0.05). Weight loss between Z1 and Z3 with PEG did not differ from patients without PEG at Z0 (p = 0.074), although patients with PEG at Z0 had a lower mean weight at the beginning. PEG was important for a quarter of the patients alive at Z3 and helped to prevent weight loss.

Predict nutrition-related adverse outcomes in head and neck cancer patients undergoing radiotherapy: A systematic review

BACKGROUND

Acute nutrition-related adverse outcomes are common in head and neck cancer patients undergoing radiotherapy. Predictive models can assist in identifying high-risk patients to enable targeted intervention. We aimed to systematically evaluate predictive models for predicting severe acute nutritional symptoms, insufficient intake, tube feeding, sarcopenia, and weight loss.

METHODS

We searched PubMed, Web of Science, EBSCO, Embase, WanFang, CNKI, and SinoMed. We selected studies developing predictive models for the aforementioned outcomes. Data were extracted using a predefined checklist. Risk of bias and applicability assessment were assessed using the Prediction model Risk of Bias Assessment Tool. A narrative synthesis was conducted to summarize the model characteristics, risk of bias, and performance.

RESULTS

A total of 2941 studies were retrieved and 19 were included. Study outcome measure were different symptoms (n = 11), weight loss (n = 5), tube feeding (n = 3), and symptom or tube feeding (n = 1). Predictive factors mainly encompassed sociodemographic data, disease-related data, and treatment-related data. Seventeen studies reported area under the curve or C-index values ranging from 0.610 to 0.96, indicating moderate to good predictive performance. However, candidate predictors were incomplete, outcome measures were diverse, and the risk of bias was high. Most of them used traditional model development methods, and only two used machine learning.

CONCLUSIONS

Most current models showed moderate to good predictive performance. However, predictors are incomplete, outcome are inconsistent, and the risk of bias is high. Clinicians could carefully select the models with better model performance from the available models according to their actual conditions. Future research should include comprehensive and modifiable indicators and prioritize well-designed and reported studies for model development.

The Arabic EAT-10 and FEES in dysphagia screening among cancer patients: a comparative prospective study

Head and neck cancer treatments, such as radiotherapy, chemotherapy, and surgery, have diverse effects on patients, leading to dysphagia as a significant post-treatment issue. This study aims to evaluate the effectiveness of the Arabic version of the EAT-10 screening instrument (A-EAT-10) using Fiber-Optic Endoscopic Evaluation of Swallowing (FEES) as an imperfect gold standard. Additionally, we seek to establish a correlation between A-EAT-10 and PEG tube insertion in head and neck cancer (HNC) patients. Our sample comprised 130 head and neck cancer patients with varying cancer types at King Hussein Cancer Center (KHCC). We followed these patients throughout their distinct treatment plans up to one month after their final treatment session. During follow-up visits, we administered the A-Eat-10 instrument to monitor dysphagia. FEES were conducted at the initial and concluding visits to compare results with A-EAT-10 scores. The results in our tests, assuming independence or dependence, demonstrated excellent agreement. A-EAT-10 exhibited outstanding predictive capabilities with an AUC ranging from 93 to 97%. A-EAT-10 tended to slightly overestimate dysphagia at later treatment stages by approximately 20% compared to FEES, with an RR of 1.2 (95% CI 0.91, 1.56, p-value = 0.21), indicating statistical insignificance. In conclusion, A-EAT-10 is an excellent option for dysphagia evaluation, offering non-invasive, straightforward, and cost-effective advantages compared to FEES. Its utility extends to predicting the need for PEG tube insertion at initial patient visits, making it a valuable tool for informed treatment decisions. Notably, A-EAT-10 demonstrates a diminishing correlation with FEES over time.

Utility of prophylactic percutaneous endoscopic gastrostomy tube in head and neck cancer patients undergoing concurrent chemoradiation: A prospective observational cohort

PURPOSE

The necessity of prophylactic percutaneous endoscopic gastrostomy (PPEG) before concurrent chemoradiation (CCRT) in head and neck cancer (HNC) patients remains uncertain. We evaluated the utilization rate of PPEG tube. Weight changes and tube dependence were also assessed.

MATERIALS AND METHODS

This prospective cohort study evaluated the utilization rate of PPEG tube in patients with newly diagnosed HNC undergoing CCRT. Baseline characteristics, nutrition status, and weight loss data were collected and compared between use and non-use groups.

RESULTS

110 patients (94.8%) used PPEG tube (70 fully-used and 40 partially-used groups). Non-users had a tendency to lose weight more than partially and fully-used groups; 9.13%, 3.42%, and 1.95%, respectively (p = 0.085). Fully-used group had significantly longer time of tube dependence than partially-used group, 7.0 months versus 4.9 months (p = 0.012). The type of PPEG tube use (full use or partial use) and presence of dysphagia were significantly related to tube dependence. The time ratio of tube dependence for partially-used patients versus fully-used patients was 0.82 (95% CI: 0.68-0.99) (p = 0.039). The time ratio for patients with symptoms of dysphagia was 1.29 (95% CI: 1.02-1.63) (p = 0.032). At the end of CCRT, 96.6% of patients agreed that PPEG tube was necessary.

CONCLUSION

We recommend PPEG for patients undergoing CCRT. Partial use of PPEG with continuous oral intake as tolerated is strongly encouraged to maintain weight, and to reduce risk of tube dependence. Future study to evaluate effective swallowing exercise is warranted.

Benefits of prophylactic percutaneous gastrostomy in patients with nasopharyngeal cancer receiving concurrent chemoradiotherapy: A multicenter analysis

PURPOSE

Prophylactic percutaneous endoscopic gastrostomy (PPEG) is widely used for patients with head and neck cancer undergoing concurrent chemoradiation (CCRT). Nevertheless, the necessity of its use in patients with nasopharyngeal cancer (NPC) is uncertain. This study aimed to evaluate the benefits of PPEG on prevention of weight loss and treatment tolerance in patients with NPC receiving CCRT.

MATERIALS AND METHODS

A retrospective multicenter chart review of 904 patients, 378 in the PPEG group and 526 in the non-PPEG group, was conducted. Baseline characteristics, weight loss, and treatment tolerance were analyzed and compared between the two groups.

RESULTS

There was no significant difference in the mean baseline body mass index (BMI) between the groups. At the end of CCRT, no difference in weight loss was found between the 2 groups (non-PPEG group, 6.6%; PPEG group, 5.9%). Nonetheless, the subgroup analysis demonstrated that a baseline BMI < 18.5 kg/m² (underweight) and non-intensity-modulated radiation therapy (IMRT) technique were independent factors associated with prevention of weight loss by PPEG. More patients in the PPEG group were able to complete planned cycles of chemotherapy (73.3% vs. 49.0%, P < .0001).

CONCLUSION

Although the benefits of PPEG on prevention of weight loss were not observed for the entire cohort, we found a potentially protective effect of PPEG in some subgroups of patients. Additionally, PPEG significantly enhanced chemotherapy tolerance. Therefore, PPEG tube insertion should be strongly considered for patients with NPC receiving CCRT, particularly for underweight patients and those undergoing a non-IMRT technique.

Percutaneous endoscopic gastrostomy prior to esophagectomy for esophageal cancer - a systematic review and meta-analysis

BACKGROUND

For resectable esophageal cancer (EC), it remains controversial whether to place percutaneous endoscopic gastrostomy (PEG) before the curative surgery to provide nutritional support during the neoadjuvant therapy.

OBJECTIVE

To compare surgical outcomes for patients who received preoperative PEG and those without PEG placement (No-PEG) insertion prior to surgery in a potentially operable EC.

METHODS

A comprehensive literature search was conducted to identify randomized and non-randomized studies comparing PEG and No-PEG groups.

RESULTS

Four retrospective studies with a total number of 1,027 patients were identified and included in this meta-analysis. The differences in anastomotic leakage, anastomotic stricture, morbidity, pulmonary complications, wound infection, and hospital stay were not statistically significant between the two groups. Operation time was significantly shorter in the PEG group. There was no PEG-related gastric conduit failure and no leak from the PEG site in the PEG group.

CONCLUSION

We conclude preoperative PEG for resectable EC is a safe procedure with no adverse effect on the gastric tube construction and anastomosis, it can be selectively inserted for EC patients with marked weight loss and malnutrition or those at risk of developing malnutrition during neoadjuvant therapy.

Digestion-Specific Acupuncture Effect on Feeding Intolerance in Critically Ill Post-Operative Oral and Hypopharyngeal Cancer Patients: A Single-Blind Randomized Control Trial

Malnourishment is prevalent in patients suffering from head and neck cancer. The postoperative period is crucial in terms of nutritional support, especially after composite resection and reconstruction surgery. These patients present with a number of risk factors that aggravate feeding intolerance, including postoperative status, prolonged immobility, decreased head elevation, mechanical ventilation, and applied sedative agents. Routine management protocols for feeding intolerance include prokinetic drug use and post-pyloric tube insertion, which could be both limited and accompanied by detrimental adverse events. This single-blind clinical trial aimed to investigate the effects of acupuncture in postoperative feeding intolerance in critically ill oral and hypopharyngeal cancer patients. Twenty-eight patients were randomized into two groups: Intervention group and Control group. Interventions were administered daily over three consecutive postoperative days. The primary outcome revealed that the intervention group reached 70% and 80% of target energy expenditure (EE) significantly earlier than the control group (4.00 ± 1.22 versus 6.69 ± 3.50 days, p = 0.012), accompanied by higher total calorie intake within the first postoperative week (10263.62 ± 1086.11 kcals versus 8384.69 ± 2120.05 kcals, p = 0.004). Furthermore, the intervention group also needed less of the prokinetic drug (Metoclopramide, 20.77 ± 48.73 mg versus 68.46 ± 66.56 mg, p = 0.010). In conclusion, digestion-specific acupuncture facilitated reduced postoperative feeding intolerance in oral and hypopharyngeal cancer patients.

Prophylactic gastrostomy in locally advanced head and neck cancer: results of a national survey among radiation oncologists

BACKGROUND

Nutritional complications in patients with locally advanced head and neck cancer (LA-HNC) treated by concurrent chemoradiotherapy (CCRT) often lead to placement of a prophylactic gastrostomy (PG) tube, while indication lacks harmonization. Our aim was to explore the current PG tube utilization among Belgian radiation oncology centers.

METHODS

A survey was distributed to all 24 Belgian Radiation oncology departments, with questions about the number of patient treated per year, whether the PG indication is discussed at the multidisciplinary board, placement technique, time of starting nutrition and removal, its impact on swallowing function and importance of clinical factors. For the latter Relative Importance and Discordance Indexes were calculated to describe the ranking and agreement.

RESULTS

All 24 centers submitted the questionnaire. Twenty three treat more than 20 head and neck (HNC) patients per year, while four (1 in 21-50; 3 in 51-100) are not discussing the gastrostomy tube indication at the multidisciplinary board. For the latter, endoscopic placement (68%) is the dominant technique, followed by the radiologic (16%) and laparoscopic (16%) methods. Seventy-five percent start the enteral nutrition when clinically indicated, 17% immediately and 8% from the start of radiotherapy. Majority of specialists (19/24) keep the gastrostomy tube until the patient assume an adequate oral feeding. Fifteen centres are considering PG decrease swallowing function. Regarding factors and their importance in the decision for the PG, foreseen irradiated volume reached highest importance, followed by 'anatomical site', 'patients' choice' and 'postoperative versus definitive' and 'local expertise', with decreasing importance respectively. Disagreement indexes showed moderate variation.

CONCLUSIONS

The use of a PG tube for LAHNC patients treated by CCRT shows disparity at national level. Prospective studies are needed to ensure proper indication of this supportive measure.

Laparoscopic vs open insertion of feeding gastrostomy tube in adults with head and neck cancers: A case-matched comparative study

BACKGROUND

Patients with head and neck cancers may require feeding tube gastrostomy (FTG) during their treatment. Surgical gastrostomy is indicated in patients who fail or unsuitable for endoscopic or radiologic FTG insertion.

OBJECTIVE

The aim of this study was to compare the outcomes of a novel laparoscopic technique to the insertion of feeding tube gastrostomy (FTG) in patients with head and neck cancer vs conventional open surgery.

METHODS

Patients were randomly matched on a 1:1 basis according to whether the procedure was therapeutic or prophylactic and whether a concomitant less major surgical procedure was required.

RESULTS

The groups (17 patients in each group) were comparable for age, sex distribution, ASA score, body mass index, serum albumin levels and the frequencies of previous upper abdominal surgery, hypoalbuminaemia and prior chemoradiotherapy and/or cancer surgery. There were no conversions to open surgery. No significant differences were detected between the groups with regard to the operating time (median, 40 vs 60 minutes, P = .053) and 30-day clinically significant morbidity (17.6% vs 23.5%, P = .180) or mortality (11.8% in each group). However, laparoscopy was associated with significantly shorter hospital stay (0 vs 2.8 days, P < .001) and greater proportion of day-case procedures (64.7% vs 0%, P < .001).

CONCLUSIONS

Laparoscopic insertion of FTG is safe, can be performed as a day-case procedure, and is associated with shorter hospital stay compared with open surgery; it should be preferred over open surgery where local expertise exists.

Longitudinal complications associated with PEG: Rate and severity of 30-day and 1-year complications experienced by patients after primary PEG insertion

BACKGROUND AND AIMS

Percutaneous Endoscopic Gastrostomy (PEG) feeding is utilised in patients with exceptionally poor oral intake but is associated with both short and long-term complications. This study reviews longitudinal PEG complications and compares key subgroups.

METHODS

Single-centre retrospective observational study of all patients receiving PEG insertion between January 2016 and December 2018.

RESULTS

306 patients met the inclusion criteria. The mean age at insertion was 67 years. The majority were cared for in their own home (80.4%) by themselves or family (74.9%). 127 PEG tubes were inserted for dysphagia and 165 prophylactically prior to treatment for head and neck cancer. In the first 30 days 16.7% experienced a complication. The most frequently reported was peristomal pain (9.2%). In the first year, 35.6% experienced at least one complication, 12.4% two complications and 6.6% three complications and 6.5% required inpatient treatment for their complication. The most common was pain (14.4%) followed by site weeping, site infection and external overgranulation. Patients with dysphagia took longer to develop complications, had fewer complications and took longer to require management by members of the secondary care team than those with head and neck cancer. Discounting peristomal pain, there was no difference in total complications between patients caring for themselves when compared to those receiving professional input.

CONCLUSION

One third of patients will experience a complication related to their PEG tube over 1 year, but the majority are managed in an outpatient setting. This study has implications for planning support services and consenting and counselling patients pre-PEG-insertion.

PEG site metastasis in oropharyngeal squamous cell carcinoma managed with cetuximab and radiotherapy: A case report

Percutaneous endoscopic gastrostomy (PEG) tube insertion is commonplace in head and neck cancer (HNC) patients. A rare but serious complication of PEG insertion in HNC is PEG site metastasis (PSM), which may precipitate rapid deterioration. We present the first case of PSM in a HNC patient managed without chemoradiotherapy and/or surgery, but rather with concurrent radiotherapy and cetuximab, followed by second-line pembrolizumab. Following histopathologic diagnosis of PSM, positron emission tomography confirmed primary site recurrence and multiple metastases in the axilla, abdomen and pelvis, managed palliatively with focal abdominal wall radiotherapy, pembrolizumab and carboplatin. The patient deteriorated and passed away 20 months after initial HNC diagnosis, 5 months after confirmation of PSM. Patients and clinicians should be aware of PSM in HNC. Though a proven prevention strategy is yet to be confirmed, prompt PSM diagnosis spares the patient unnecessary antibiotics for presumed infection and suggests the possibility of intra-abdominal metastases.

Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.

Nutritional Support in Head and Neck Radiotherapy Patients Considering HPV Status

Malnutrition is a common problem in patients with head and neck cancer (HNC), including oropharyngeal cancer (OPC). It is caused by insufficient food intake due to dysphagia, odynophagia, and a lack of appetite caused by the tumor. It is also secondary to the oncological treatment of the basic disease, such as radiotherapy (RT) and chemoradiotherapy (CRT), as a consequence of mucositis with the dry mouth, loss of taste, and dysphagia. The severe dysphagia leads to a definitive total impossibility of eating through the mouth in 20-30% of patients. These patients usually require enteral nutritional support. Feeding tubes are a commonly used nutritional intervention during radiotherapy, most frequently percutaneous gastrostomy tube. Recently, a novel HPV-related type of OPC has been described. Patients with HPV-associated OPC are different from the HPV- ones. Typical HPV- OPC is associated with smoking and alcohol abuse. Patients with HPV+ OPC are younger and healthy (without comorbidities) at diagnosis compared to HPV- ones. Patients with OPC are at high nutritional risk, and therefore, they require nutritional support in order to improve the treatment results and quality of life. Some authors noted the high incidence of critical weight loss (CWL) in patients with HPV-related OPC. Other authors have observed the increased acute toxicities during oncological treatment in HPV+ OPC patients compared to HPV- ones. The aim of this paper is to review and discuss the indications for nutritional support and the kinds of nutrition, including immunonutrition (IN), in HNC, particularly OPC patients, undergoing RT/CRT, considering HPV status.