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Nutritional parameters associated with hospital admissions in patients being treated for head and neck cancer. Support Care Cancer 2019; 28:341-349. [PMID: 31044309 DOI: 10.1007/s00520-019-04826-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE This study analysed nutritional parameters (baseline body mass index (BMI), weight changes and enteral nutrition (EN) use, and their association with hospital admissions during radiotherapy in patients with head and neck cancer (HNC)). METHODS A retrospective review of patients diagnosed with HNC and treated with radiotherapy between October 2012 and April 2014 was conducted. Data on each subject's diagnosis, age, sex, chemotherapy, previous surgery, EN use, weight changes, and BMI were examined for their association with hospital admissions during treatment. RESULTS Eighty-three patients were included, mean age (±standard deviation) = 61 (± 11 years). Thirty-four percent had self-reported weight loss at diagnosis, and mean BMI was 26.2 ± 5.3 kg/m2. Mean weight change during treatment was - 5.1 ± 6.2%. Ten patients used EN, with mean weight stabilisation during EN use (0.3 ± 5.1%). Higher presenting BMI, younger age, and definitive radiotherapy ± chemotherapy predicted greater weight loss (p < 0.05). Critical weight loss ≥ 5% was associated with a higher number of hospital admissions for nutrition reasons (n = 10) (p = 0.011) compared with those without critical weight loss (n = 2). EN use was associated with a higher number of nutrition-related admissions; however, it did not predict length of stay among those admitted. CONCLUSION Critical weight loss during radiotherapy was associated with unplanned nutrition-related hospital admissions. Higher BMI was associated with greater weight loss during radiotherapy, whilst EN use assisted in weight preservation. Further research around patient selection for nutritional interventions aimed at preventing critical weight loss and unplanned hospital admissions is needed.
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Paleri V, Patterson J, Rousseau N, Moloney E, Craig D, Tzelis D, Wilkinson N, Franks J, Hynes AM, Heaven B, Hamilton D, Guerrero-Urbano T, Donnelly R, Barclay S, Rapley T, Stocken D. Gastrostomy versus nasogastric tube feeding for chemoradiation patients with head and neck cancer: the TUBE pilot RCT. Health Technol Assess 2019; 22:1-144. [PMID: 29650060 DOI: 10.3310/hta22160] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Approximately 9000 new cases of head and neck squamous cell cancers (HNSCCs) are treated by the NHS each year. Chemoradiation therapy (CRT) is a commonly used treatment for advanced HNSCC. Approximately 90% of patients undergoing CRT require nutritional support via gastrostomy or nasogastric tube feeding. Long-term dysphagia following CRT is a primary concern for patients. The effect of enteral feeding routes on swallowing function is not well understood, and the two feeding methods have, to date (at the time of writing), not been compared. The aim of this pilot randomised controlled trial (RCT) was to compare these two options. METHODS This was a mixed-methods multicentre study to establish the feasibility of a RCT comparing oral feeding plus pre-treatment gastrostomy with oral feeding plus as-required nasogastric tube feeding in patients with HNSCC. Patients were recruited from four tertiary centres treating cancer and randomised to the two arms of the study (using a 1 : 1 ratio). The eligibility criteria were patients with advanced-staged HNSCC who were suitable for primary CRT with curative intent and who presented with no swallowing problems. MAIN OUTCOME MEASURES The primary outcome was the willingness to be randomised. A qualitative process evaluation was conducted alongside an economic modelling exercise. The criteria for progression to a Phase III trial were based on a hypothesised recruitment rate of at least 50%, collection of outcome measures in at least 80% of those recruited and an economic value-of-information analysis for cost-effectiveness. RESULTS Of the 75 patients approached about the trial, only 17 consented to be randomised [0.23, 95% confidence interval (CI) 0.13 to 0.32]. Among those who were randomised, the compliance rate was high (0.94, 95% CI 0.83 to 1.05). Retention rates were high at completion of treatment (0.94, 95% CI 0.83 to 1.05), at the 3-month follow-up (0.88, 95% CI 0.73 to 1.04) and at the 6-month follow-up (0.88, 95% CI 0.73 to 1.04). No serious adverse events were recorded in relation to the trial. The qualitative substudy identified several factors that had an impact on recruitment, many of which are amenable to change. These included organisational factors, changing cancer treatments and patient and clinician preferences. A key reason for the differential recruitment between sites was the degree to which the multidisciplinary team gave a consistent demonstration of equipoise at all patient interactions at which supplementary feeding was discussed. An exploratory economic model generated from published evidence and expert opinion suggests that, over the 6-month model time horizon, pre-treatment gastrostomy tube feeding is not a cost-effective option, although this should be interpreted with caution and we recommend that this should not form the basis for policy. The economic value-of-information analysis indicates that additional research to eliminate uncertainty around model parameters is highly likely to be cost-effective. STUDY LIMITATIONS The recruitment issues identified for this cohort may not be applicable to other populations undergoing CRT. There remains substantial uncertainty in the economic evaluation. CONCLUSIONS The trial did not meet one of the three criteria for progression, as the recruitment rate was lower than hypothesised. Once patients were recruited to the trial, compliance and retention in the trial were both high. The implementation of organisational and operational measures can increase the numbers recruited. The economic analysis suggests that further research in this area is likely to be cost-effective. FUTURE WORK The implementation of organisational and operational measures can increase recruitment. The appropriate research question and design of a future study needs to be identified. More work is needed to understand the experiences of nasogastric tube feeding in patients undergoing CRT. TRIAL REGISTRATION Current Controlled Trials ISRCTN48569216. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Vinidh Paleri
- Head and Neck Unit, The Royal Marsden Hospital, London, UK.,Division of Clinical Studies, Institute of Cancer Research, London, UK.,Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Patterson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Eoin Moloney
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Craig
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Dimitrios Tzelis
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nina Wilkinson
- Biostatistics Research group, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jeremy Franks
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Marie Hynes
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Ben Heaven
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - David Hamilton
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Rachael Donnelly
- Department of Radiation Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Stewart Barclay
- Department of Restorative Dentistry, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Tim Rapley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah Stocken
- Biostatistics Research group, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.,Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Yanni A, Dequanter D, Lechien JR, Loeb I, Rodriguez A, Javadian R, Van Gossum M. Malnutrition in head and neck cancer patients: Impacts and indications of a prophylactic percutaneous endoscopic gastrostomy. Eur Ann Otorhinolaryngol Head Neck Dis 2019; 136:S27-S33. [PMID: 30846293 DOI: 10.1016/j.anorl.2019.01.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 11/12/2018] [Accepted: 01/11/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Head and neck cancer (HNC) patients often experience malnutrition before and during treatment. Prophylactic gastrostomy has emerged as an efficient tool for ensuring adequate nutrition. However, there is no suitable algorithm able to identify patients at high risk of malnutrition. The aim of this study was to describe the nutritional management, to assess the impact of prophylactic gastrostomy, and to identify predictors of malnutrition. METHODS This retrospective study included 152 patients treated with surgery, radiotherapy, or chemotherapy for HNC. The patients were classified according to their gastrostomy status (prophylactic or non-prophylactic). Nutritional, tumoral and treatment characteristics were reported. Clinical and nutritional outcomes were measured 6 weeks after the beginning of treatment. In order to describe the nutritional management and the impact of prophylactic gastrostomy on patients, univariate analysis was generated using chi-square test and Mann-Whitney test or Student's t-test. Logistic regression was performed to identify factors associated with malnutrition. RESULTS Forty-one patients received prophylactic gastrostomy whereas 111 patients had no nutritional support. Prophylactic gastrostomy placement was associated with a lower initial body mass index, with severe malnutrition, and with initial oral intake disorder. Patients who did not experienced prophylactic gastrostomy had much worse outcomes such as hospital readmissions (P=0.042), relative weight loss at 6 weeks (P<0.0001), dysphagia, severe malnutrition, and poor state of health (P=0.001). Our complication rates (4.9%) were lower than the usual range (5.9-9.3%) and no life-threatening complication was reported. Positive N status, oral intake disorder, concomitant radiochemotherapy, nasopharyngeal, and hypopharyngeal tumor site were significant predictive factors for malnutrition. CONCLUSIONS Prophylactic percutaneous endoscopic gastrostomy showed advantages in terms of hospital readmissions, relative weight loss at 6 weeks, dysphagia, severe malnutrition, and poor state of health. Tumoral, nutritional and treatment characteristics seem to be predictors for malnutrition. Hence, physicians should integrate these factors in their nutrition algorithm approach.
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Affiliation(s)
- A Yanni
- Department of Stomatology and maxillofacial surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
| | - D Dequanter
- Department of Stomatology and maxillofacial surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium; Department of Otorhinolaryngology and Head and Neck Surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
| | - J R Lechien
- Department of Otorhinolaryngology and Head and Neck Surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium; Laboratory of Anatomy and Cell Biology, Department of Anatomy and Experimental Oncology, Faculty of Medicine, Mons School of Medicine, University of Mons (UMons), UMONS Research Institute for Health Sciences and Technology, Avenue du Champ-de-Mars, 6, 7000 Mons, Belgium.
| | - I Loeb
- Department of Stomatology and maxillofacial surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
| | - A Rodriguez
- Department of Otorhinolaryngology and Head and Neck Surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
| | - R Javadian
- Department of Stomatology and maxillofacial surgery, School of Medicine, Université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
| | - M Van Gossum
- Department of gastroenterology, School of Medicine, université Libre de Bruxelles, CHU Saint-Pierre, Brussels, Belgium
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Rowell NP. Tumor implantation following percutaneous endoscopic gastrostomy insertion for head and neck and oesophageal cancer: Review of the literature. Head Neck 2019; 41:2007-2015. [PMID: 30684284 DOI: 10.1002/hed.25652] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 12/18/2018] [Accepted: 12/28/2018] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Nicholas P Rowell
- Clinical Oncology, Kent Oncology Centre, Maidstone Hospital, Maidstone, Kent, United Kingdom
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55
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Retrospective comparison of outcomes and associated complications between large bore radiologically inserted gastrostomy tube types. Abdom Radiol (NY) 2019; 44:318-326. [PMID: 30073401 DOI: 10.1007/s00261-018-1717-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Multiple approaches to radiologically inserted gastrostomy (RIG) exist. The goal of this study was to compare 30-day outcomes and associated complications between large bore balloon-retained (BR), loop-retained (LR), and pull-type (PT) RIG devices. METHODS Data on 1477 patients who underwent RIG between January 1, 2005 and December 31, 2016 were collected retrospectively using a dedicated interventional radiology database and electronic medical record. Statistical analysis was performed to compare complication rates between BR, LR, and PT devices. RESULTS Ninety-eight percent (1477/1507) of the procedures were successfully performed. A total of 752 BR, 323 LR, and 402 PT gastrostomy tubes were placed. The overall complication rate for BR catheters was 5.7% (25 major [3.3%] and 18 minor [2.4%]). The overall complication rate for PT catheters was 3.7% (8 major [2.0%] and 7 minor [1.7%]). The overall complication rate for LR catheters was 1.6% (4 major [1.4%] and 1 minor [0.8%]). Compared to BR catheters, LR catheters had significantly fewer total complications (P = 0.01) but not minor complications (P = 0.052). There were no significant differences in the number of complications between LR and PT catheters or between BR and PT catheters. CONCLUSIONS Use of BR, LR, and PT devices for RIG is safe with a low incidence of complications. Compared to BR catheters, primary insertion of a LR gastrostomy was associated with significantly fewer overall complications within the first 30 days. Therefore, for initial tube placement, large bore LR catheters may be preferred over BR devices.
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56
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A Systematic Review and Meta-Analysis on Outcomes and Complications of Percutaneous Endoscopic Versus Radiologic Gastrostomy for Enteral Feeding. J Clin Gastroenterol 2018; 52:753-764. [PMID: 29924079 DOI: 10.1097/mcg.0000000000001082] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal technique for long-term enteral feeding has not yet been established. Both percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) are widely used. Aim was to extensively review outcomes of PEG and PRG. MATERIALS AND METHODS A systematic review using Medline, Embase, and Cochrane was performed, using standardized tools for assessing bias. Main outcomes were infectious and tube-related complications, procedure related and 30-day mortality. Pooled risk differences (RDs) with corresponding 95% confidence intervals (95% CIs) were calculated using random effects. Arcsine transformations were applied. RESULTS In total, 344 studies were identified, of which 16 were included, reporting on 934 PEGs and 1093 PRGs. No differences were found for infectious complications [RD, 0.03 (-0.05 to 0.11)], procedure-related mortality [RD, 0.01 (-0.04 to 0.06)], or 30-day mortality [RD, 0.06 (-0.01 to 0.13)]. Tube-related complications were higher in PRG [RD, 0.16 (0.06-0.26)]. Subgroup analysis was performed for head and neck cancer (HNC) and motor neuron disease. In HNC, this revealed significantly lower tube-related complications and procedure-related mortality after PEG. In motor neuron disease, no differences were seen. The level of evidence appears sufficient considering the low degree of heterogeneity. CONCLUSIONS No differences were found with regard to mortality or infectious complications. PEG showed lower risk of tube-related complications. Subgroup analysis revealed PEG to be favorable in HNC based on lower rates of procedure-related mortality and tube-related complications. Local experience and availability should be taken into account in the decision process.
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Jackson JE, Anderson NJ, Rolfo M, Wada M, Schneider M, Poulsen M, Fahandej M, Huynh A, Lee ST, Joon DL, Khoo V. 18F-FDG Metabolic Tumor Volume: Association with Short- and Long-Term Feeding Tube Use in Head and Neck IMRT. Dysphagia 2018; 34:341-349. [PMID: 30267142 DOI: 10.1007/s00455-018-9946-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 09/17/2018] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to investigate whether the metabolic tumor volume (MTV) of head and neck primary tumors may be a significant prognostic factor for feeding tube (FT) use and FT dependence. Seventy-nine patients with evaluable primary tumors, pre-therapy FDG-PET scans, treated with definitive intensity-modulated radiotherapy (IMRT) (± concurrent chemotherapy) for head and neck mucosal cancers were included. MTV was quantified and recorded for the primary lesion using a minimum standardized uptake value (SUV) threshold of 2.0. Patients were recommended prophylactic FT and followed up by a dietician for at least eight weeks of post-radiotherapy. Associations between MTV, dose to swallowing organs at risk, FT use, and FT dependence were analyzed. MTV was positively correlated with gross tumor volume (GTV) (r = 0.7357; p < 0.0001). MTVs larger than 17 cc were associated with higher rates of FT use (87.8% vs. 69.5%, p = 0.0067) and FT dependence at six weeks (76.7% vs. 41.7%, p = 0.0024) and six months (25.0% vs. 8.7%, p = 0.0088). Increasing MTV was associated with increasing mean dose to the oral cavity (p = < 0.0001), tongue base (p = 0.0009), and superior (SPCM) (p = 0.0001) and middle pharyngeal constrictor muscles (MPCM) (p = 0.0005). Increasing MTV was associated with increasing maximum dose to oral cavity (p = 0.0028), tongue base (p = 0.0056), SPCM (p = 0.0037), and MPCM (p = 0.0085). Pre-treatment MTV is a reproducible parameter that can be generated at or prior to a pre-treatment Multidisciplinary Tumor Board and may expedite decisions regarding placement of prophylactic FTs. Prospective evaluation in larger series is required to determine whether MTV is a more useful prognostic variable for FT use than clinical T-classification.
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Affiliation(s)
- James E Jackson
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, VIC, Australia.
- Radiation Oncology Centres, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, QLD, 4215, Australia.
- School of Medicine, Griffith University, Gold Coast, Australia.
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.
| | - Nigel J Anderson
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, VIC, Australia
- Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Maureen Rolfo
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, VIC, Australia
| | - Morikatsu Wada
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, VIC, Australia
| | - Michal Schneider
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
| | - Michael Poulsen
- Radiation Oncology Centres, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, QLD, 4215, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
| | - Maziar Fahandej
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, VIC, Australia
| | - Anna Huynh
- Radiation Oncology Centres, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, QLD, 4215, Australia
| | - Sze Ting Lee
- Centre for PET, Austin Health, Heidelberg, VIC, Australia
| | - Daryl Lim Joon
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, VIC, Australia
| | - Vincent Khoo
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness & Research Centre, Austin Health, Heidelberg, VIC, Australia
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
- Department of Clinical Oncology, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Chelsea, London, UK
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
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Heah H, Goepfert RP, Hutcheson KA, Garden AS, Gunn GB, Fuller CD, Lewin JS, Kupferman ME, Holsinger FC, Hessel AC, Gross ND. Decreased gastrostomy tube incidence and weight loss after transoral robotic surgery for low- to intermediate-risk oropharyngeal squamous cell carcinoma. Head Neck 2018; 40:2507-2513. [DOI: 10.1002/hed.25382] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/29/2018] [Accepted: 05/28/2018] [Indexed: 11/06/2022] Open
Affiliation(s)
- Harold Heah
- Department of Head and Neck Surgery; University of Texas MD Anderson Cancer Center; Houston Texas
- Department of Otolaryngology; Singapore General Hospital; Singapore
| | - Ryan P. Goepfert
- Department of Head and Neck Surgery; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Katherine A. Hutcheson
- Department of Head and Neck Surgery; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Adam S. Garden
- Department of Radiation Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
| | - G. Brandon Gunn
- Department of Radiation Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Clifton D. Fuller
- Department of Radiation Oncology; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Jan S. Lewin
- Department of Otolaryngology; Singapore General Hospital; Singapore
| | - Michael E. Kupferman
- Department of Head and Neck Surgery; University of Texas MD Anderson Cancer Center; Houston Texas
| | - F. Christopher Holsinger
- Department of Otolaryngology - Head and Neck Surgery; Stanford University Medical Center; Stanford California
| | - Amy C. Hessel
- Department of Head and Neck Surgery; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Neil D. Gross
- Department of Head and Neck Surgery; University of Texas MD Anderson Cancer Center; Houston Texas
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A novel percutaneous magnetically guided gastrostomy technique without endoscopy or imaging guidance: a feasibility study in a porcine model. Surg Endosc 2018; 32:4688-4697. [PMID: 30022288 DOI: 10.1007/s00464-018-6335-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/06/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND In order to simplify a percutaneous gastrostomy procedure and avoid the need of endoscopy or imaging methods, a novel percutaneous magnetically guided gastrostomy (PMG) technique was conceived. The aim of the present study is to evaluate the feasibility of a novel PMG technique with no endoscopy or any imaging guidance in a porcine model. METHODS Fourteen crossbred domestic pigs were used for prototype development (cadaveric experiments) and proof-of concept, survival study. The magnetic device was conceived using commercially available rare-earth neodymium-based magnets. The experimental design consisted of developing an internal magnetic gastric tube prototype to be orally inserted and coupled to an external magnet placed on the skin, which facilitated stomach and abdominal wall apposition for blind percutaneous gastrostomy tube placement. Then, a gastrostomy tube was percutaneously and blindly placed. RESULTS Twelve procedures were undertaken in animal cadavers and two in live models. The technique chosen consisted of using a magnetic gastric tube prototype using six 1 × 1-cm-ring magnets attached to its end. This device enabled successful magnetic coupling with a large (5 cm in diameter) magnet disc placed on the skin. For gastric tube placement, a direct trocar insertion allowed easier and safer placement of a gastric tube as compared to a needle-guide-wire dilation (Seldinger-based) technique. Gastropexy was added to avoid early gastric tube displacement. This novel PMG technique was feasible in a live model experiment. CONCLUSIONS A novel magnetically guided percutaneous gastrostomy tube insertion technique without the use of endoscopy or image-guidance was successful in a porcine model. A non-inferiority experimental controlled study comparing this technique to percutaneous endoscopic gastrostomy is needed to confirm its efficacy and safety.
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Zener R, Istl AC, Wanis KN, Hocking D, Kachura J, Alshehri S, Mujoomdar A, Latosinsky S, Wiseman D. Thirty-day complication rate of percutaneous gastrojejunostomy and gastrostomy tube insertion using a single-puncture, dual-anchor technique. Clin Imaging 2018; 50:104-108. [DOI: 10.1016/j.clinimag.2018.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 12/07/2017] [Accepted: 01/02/2018] [Indexed: 02/07/2023]
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Anderson NJ, Jackson JE, Smith JG, Wada M, Schneider M, Poulsen M, Rolfo M, Fahandej M, Gan H, Joon DL, Khoo V. Pretreatment risk stratification of feeding tube use in patients treated with intensity-modulated radiotherapy for head and neck cancer. Head Neck 2018; 40:2181-2192. [PMID: 29756389 DOI: 10.1002/hed.25316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 01/07/2018] [Accepted: 04/03/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The purpose of this study was to establish a risk stratification model for feeding tube use in patients who undergo intensity-modulated radiotherapy (IMRT) for head and neck cancers. METHODS One hundred thirty-nine patients treated with definitive IMRT (+/- concurrent chemotherapy) for head and neck mucosal cancers were included in this study. Patients were recommended a prophylactic feeding tube and followed up by a dietician for at least 8 weeks postradiotherapy (post-RT). Potential prognostic factors were analyzed for risk and duration of feeding tube use for at least 25% of dietary requirements. RESULTS Many variables had significant effects on risk and/or duration of feeding tube use in univariate analyses. Subsequent multivariable analysis showed that T classification ≥3 and level 2 lymphadenopathy were the best independent significant predictors of higher risk and duration of feeding tube use, respectively, in oral cavity, pharyngeal, and supraglottic primaries. CONCLUSION In patients treated with definitive IMRT, T classification ≥3 and level 2 lymphadenopathy can potentially stratify patients into 4 risk groups for developing severe dysphagia requiring feeding tube use.
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Affiliation(s)
- Nigel J Anderson
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia.,Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - James E Jackson
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia.,School of Medicine, Griffith University, Gold Coast, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | | | - Morikatsu Wada
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Michal Schneider
- Department of Medical Imaging and Radiation Sciences, Monash University, Victoria, Australia
| | - Michael Poulsen
- Radiation Oncology Centres, Gold Coast University Hospital, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Maureen Rolfo
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Maziar Fahandej
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia.,Department of Palliative Care, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Hui Gan
- Olivia Newton-John Cancer Research Institute, Austin Health, Heidelberg, Victoria, Australia
| | - Daryl Lim Joon
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Vincent Khoo
- Department of Radiation Oncology, Olivia Newton John Cancer Wellness and Research Centre, Austin Health, Heidelberg, Victoria, Australia.,Department of Medical Imaging and Radiation Sciences, Monash University, Victoria, Australia.,Department of Clinical Oncology, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Chelsea, London, UK.,Department of Medicine, University of Melbourne, Victoria, Australia
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Currie BM, Getrajdman GI, Covey AM, Alago W, Erinjeri JP, Maybody M, Boas FE. Push versus pull gastrostomy in cancer patients: A single center retrospective analysis of complications and technical success rates. Diagn Interv Imaging 2018; 99:547-553. [PMID: 29716845 DOI: 10.1016/j.diii.2018.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/12/2018] [Accepted: 04/12/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE To compare the technical success and complication rates of push versus pull gastrostomy tubes in cancer patients, and to examine their dependence on operator experience. MATERIALS AND METHODS A retrospective review was performed of 304 cancer patients (170 men, 134 women; mean age 60.3±12.6 [SD], range: 19-102 years) referred for primary gastrostomy tube placement, 88 (29%) of whom had a previously unsuccessful attempt at percutaneous endoscopic gastrostomy (PEG) placement. Analyzed variables included method of insertion (push versus pull), indication for gastrostomy, technical success, operator experience, and procedure-related complications within 30 days of placement. RESULTS Gastrostomy tubes were placed for feeding in 189 patients and palliative decompression in 115 patients. Technical success was 91%: 78% after endoscopy had previously been unsuccessful and 97% when excluding failures associated with prior endoscopy. In the first 30 days, there were 29 minor complications (17.2%) associated with push gastrostomies, and only 8 minor complications (7.5%) with pull gastrostomies (P<0.05). There was no significant difference in major complications (push gastrostomy 5.3%, pull gastrostomy 5.6%). For decompressive gastrostomy tubes, the pull technique resulted in lower rates of both minor and major complications. There was no difference in complications or technical success rates for more versus less experienced operators. CONCLUSION Pull gastrostomy tube placement had a lower rate of complications than push gastrostomy tube placement, especially when the indication was decompression. The technical success rate was high, even after a failed attempt at endoscopic placement. Both the rates of success and complications were independent of operator experience.
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Affiliation(s)
- B M Currie
- Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275, York avenue, New York, NY 10065, United States; Department of Radiology, Hospital of the University of Pennsylvania, 3400, Spruce Street, Philadelphia, PA 19104, United States
| | - G I Getrajdman
- Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275, York avenue, New York, NY 10065, United States
| | - A M Covey
- Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275, York avenue, New York, NY 10065, United States
| | - W Alago
- Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275, York avenue, New York, NY 10065, United States
| | - J P Erinjeri
- Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275, York avenue, New York, NY 10065, United States
| | - M Maybody
- Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275, York avenue, New York, NY 10065, United States
| | - F E Boas
- Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275, York avenue, New York, NY 10065, United States.
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63
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Wirth R. [Percutaneous endoscopic gastrostomy in geriatrics : Indications, technique and complications]. Z Gerontol Geriatr 2018; 51:237-245. [PMID: 29349584 DOI: 10.1007/s00391-017-1363-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/06/2017] [Accepted: 12/12/2017] [Indexed: 11/26/2022]
Abstract
The technique of percutaneous endoscopic gastrostomy (PEG) was introduced in 1979 as a semi-invasive approach for children with the need for a gastric fistula in order to avoid an operative intervention. The suture pull-through method was rapidly established and is now omnipresent. Because scientific evidence is broadly missing, there is some uncertainty about the indications in geriatric medicine. Guidelines do not recommend the insertion of a PEG in patients with severe dementia and malnutrition. Tube feeding is mainly recommended as a temporary method for patients who cannot take oral nutrition for more than 3 days or for whom the energy intake for more than 10 days presumably covers less than 50% of their needs, assuming that the overall prognosis is reasonable. Insertion of a PEG is only recommended if artificial nutrition is expected to be necessary for more than 3-4 weeks or if a nasogastric tube is not tolerated.
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Affiliation(s)
- Rainer Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne - Universitätsklinikum der Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland.
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Wopken K, Bijl HP, Langendijk JA. Prognostic factors for tube feeding dependence after curative (chemo-) radiation in head and neck cancer: A systematic review of literature. Radiother Oncol 2018; 126:56-67. [DOI: 10.1016/j.radonc.2017.08.022] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 08/07/2017] [Accepted: 08/21/2017] [Indexed: 12/31/2022]
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Hvas CL, Farrer K, Blackett B, Lloyd H, Paine P, Lal S. Reduced 30-day gastrostomy placement mortality following the introduction of a multidisciplinary nutrition support team: a cohort study. J Hum Nutr Diet 2017; 31:413-421. [DOI: 10.1111/jhn.12520] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- C. L. Hvas
- Department of Hepatology and Gastroenterology; Aarhus University Hospital; Aarhus C Denmark
- Intestinal Failure Unit; Salford Royal NHS Foundation Trust; Mancheter UK
| | - K. Farrer
- Intestinal Failure Unit; Salford Royal NHS Foundation Trust; Mancheter UK
| | - B. Blackett
- Nutrition Support Team; Salford Royal NHS Foundation Trust; Manchester UK
| | - H. Lloyd
- Nutrition Support Team; Salford Royal NHS Foundation Trust; Manchester UK
| | - P. Paine
- Department of Gastroenterology; Salford Royal NHS Foundation Trust; Manchester UK
- The University of Manchester; Manchester UK
| | - S. Lal
- Intestinal Failure Unit; Salford Royal NHS Foundation Trust; Mancheter UK
- The University of Manchester; Manchester UK
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66
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Al-Abboodi Y, Ridha A, Fasullo M, Naguib TH. Risks of PEG tube placement in patients with cirrhosis-associated ascites. Clin Exp Gastroenterol 2017; 10:211-214. [PMID: 28979154 PMCID: PMC5589105 DOI: 10.2147/ceg.s142644] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
This study examined the safety of placing percutaneous endoscopic gastrostomy (PEG) tube in people with liver cirrhosis. The target population was further subdivided into people with ascites (case group) and people without ascites (control). We compare the morbidity and the mortality difference of PEG placement in cirrhotic patients with ascites vs cirrhotic patients without ascites. We then examined multiple factors including sex, race, chronic illness including hypertension, congestive heart failure, and others and their influence on the inpatient mortality of all cirrhotic patients who had PEG placement. A total of 38,175 inpatient PEG tube placements were identified. Only 583 patients out of 38,175 had a history of cirrhosis. One hundred seven had ascites and the rest did not. Mean age of the patients was 61.14 years. Patient demography included (65.2%) male and the rest were female, 359 were white (64.4%), 90 black (14.8%), 84 Hispanic (13.7%), 23 Asians (3.3%), 7 Native Americans (0.4%), and 20 others (3.5%). Complications from PEG procedure in cirrhosis with ascites vs non-ascites included bleeding of 4 (0.8%) vs 2 (1.9%) (P=0.35), surgical site infection 2 (0.4%) vs 1 (0.9%) (P=0.51), and urinary tract infection 105 (22.1%) vs 34 (23.8%) (P=0.34), respectively. There was no colonic injury in either group. The total inpatient mortality was 75 out of the 583. Fifty-six (11.8%) were in the ascites group and 19 (17.8%) in the non-ascites group (P=0.097). Factors including ascites, postsurgical bleeding, and surgical site infection did not have influence on the inpatient mortality and there were no statistical differences between the two groups.
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Affiliation(s)
- Yasir Al-Abboodi
- Internal Medicine Department, Saint Davis Round Rock Medical Centre, Round Rock, TX, USA
| | - Ali Ridha
- Internal Medicine Department, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Matthew Fasullo
- Internal Medicine Department, Umass Memorial Medical Center, Worcester, MA, USA
| | - Tarek H Naguib
- Internal Medicine Department, Texas Tech University Health and Sciences Center, Amarillo, TX, USA
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Ruohoalho J, Aro K, Mäkitie AA, Atula T, Haapaniemi A, Keski-Säntti H, Kylänpää L, Takala A, Bäck LJ. Prospective experience of percutaneous endoscopic gastrostomy tubes placed by otorhinolaryngologist-head and neck surgeons: safe and efficacious. Eur Arch Otorhinolaryngol 2017; 274:3971-3976. [PMID: 28865046 DOI: 10.1007/s00405-017-4732-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 08/24/2017] [Indexed: 10/18/2022]
Abstract
Percutaneous endoscopic gastrostomy (PEG) is often the treatment of choice in head and neck cancer (HNC) patients needing long-term nutritional support. Prospective studies on PEG tube placement in an otorhinolaryngologist service are lacking. At our hospital, otolaryngologist-head and neck (ORL-HN) surgeons-have performed PEG insertions for HNC patients since 2008. We prospectively analyzed 127 consecutive HNC patients who received their PEG tubes at the Department of Otorhinolaryngology-head and neck surgery, and evaluated the outcome of PEG tube insertions performed by ORL-HN surgeons. To compare time delays before and after, PEG placement service was transferred from gastrointestinal surgeons to ORL-HN surgeons, and we retrospectively analyzed a separate group of 110 HNC patients who had earlier received PEG tubes at the Department of Gastrointestinal Surgery. ORL-HN surgeons' success rate in PEG insertion was 97.6%, leading to a final prospective study group of 124 patients. Major complications occurred in four (3.2%): two buried bumper syndromes, one subcutaneous hemorrhage leading to an abscess in the abdominal wall, and one metastasis at the PEG site. The most common minor complication was peristomal granulomatous tissue affecting 23 (18.5%) patients. After the change in practice, median time delay before PEG insertion decreased from 13 to 10 days (P < 0.005). The proportion of early PEG placements within 0-3 days increased from 3.6 to 14.6% (P < 0.005). PEG tube insertion seems to be a safe procedure in the hands of an ORL-HN surgeon. Independence from gastrointestinal surgeons' services reduced the time delay and improved the availability of urgent PEG insertions.
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Affiliation(s)
- Johanna Ruohoalho
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029, Helsinki, Finland.
| | - Katri Aro
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029, Helsinki, Finland
| | - Antti A Mäkitie
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029, Helsinki, Finland.,Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Timo Atula
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029, Helsinki, Finland
| | - Aaro Haapaniemi
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029, Helsinki, Finland
| | - Harri Keski-Säntti
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029, Helsinki, Finland
| | - Leena Kylänpää
- Department of Gastrointestinal and General Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 340, 00029, Helsinki, Finland
| | - Annika Takala
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029, Helsinki, Finland
| | - Leif J Bäck
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 263, 00029, Helsinki, Finland
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Nesemeier R, Dunlap N, McClave SA, Tennant P. Evidence-Based Support for Nutrition Therapy in Head and Neck Cancer. CURRENT SURGERY REPORTS 2017; 5:18. [PMID: 32288971 PMCID: PMC7102400 DOI: 10.1007/s40137-017-0179-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Patients diagnosed with head and neck (H&N) cancer often present in a malnourished state for varied reasons; nutritional optimization is therefore critical to the success of treatment for these complex patients. This article aims to review the current nutrition literature pertaining to H&N cancer patients and to present evidence-based strategies for nutritional support specific to this population. RECENT FINDINGS Aggressive nutritional intervention is frequently required in the H&N cancer patient population. Rehabilitating nutrition during operative and nonoperative treatment improves compliance with treatment, quality of life, and clinical outcomes. When and whether to establishing alternative enteral access are points of controversy, although recent evidence suggests prophylactic enteral feeding tube placement should not be universally applied. Perioperative nutritional optimization including preoperative carbohydrate loading and provision of arginine-supplemented immunonutrition has been shown to benefit at-risk H&N cancer patients. SUMMARY With multidisciplinary collaboration, H&N cancer patients can receive individualized nutritional support to withstand difficult cancer treatment regimens and return to acceptable states of nutritional health.
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Affiliation(s)
- Ryan Nesemeier
- Department of Otolaryngology-Head and Neck Surgery, University of Louisville, 529 S Jackson St., 3rd Floor, Louisville, KY 40202 USA
| | - Neal Dunlap
- Department of Radiation Oncology, University of Louisville, Louisville, KY USA
| | - Stephen A. McClave
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, University of Louisville, Louisville, KY USA
| | - Paul Tennant
- Department of Otolaryngology-Head and Neck Surgery, University of Louisville, 529 S Jackson St., 3rd Floor, Louisville, KY 40202 USA
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Di Palma LDV, Mello GFDSE, Granados CL, Glória RD, Dalbem CS, Cruz RLD, Ayres ACM, Lisboa RSC, Pelosi AD, Ferreira MA, Mansur GR, Silva SGD, Ribeiro TCD, Dias FL. Pharyngocutaneous fistula as an alternative access route for inserting a percutaneous endoscopic gastrostomy tube in head and neck cancer patients. Endosc Int Open 2017; 5:E630-E634. [PMID: 28691045 PMCID: PMC5500110 DOI: 10.1055/s-0043-106581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 03/02/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Performing a percutaneous endoscopic gastrostomy (PEG) in head and neck cancer (HNC) patients can be challenging because of the presence of trismus, pharyngeal obstruction by tumor, and pharyngoesophageal strictures or fistula. Pharyngocutaneous fistula (PCF) is a major postoperative concern in patients submitted to total laryngectomy (TL). In the medical literature to date, the cervical fistula has been used as an access to PEG in only four reports. The aim of this study was to evaluate the safety of cervical fistula for insertion of a PEG tube. PATIENTS AND METHODS Retrospective study at a single tertiary referral center, regarding the technical feasibility, safety and outcomes of a PEG tube introduced by a cervical fistula in HNC patients with obstructive lesions of the oropharynx. RESULTS The procedure was technically successful in all 21 patients. A PEG tube was used for a minimum of 1 month and a maximum of 120 months. Twelve patients died while using the PEG tube, 8 had it taken out because it was no longer needed, and only 1 had the tube still in use. Adverse events occurred in 8 patients: granuloma (19 %), dermatitis (9.5 %), accidental late removal of the tube (9.5 %), periprocedural gastric wall hematoma (9.5 %), peristomal wound infection (4.7 %), buried bumper syndrome (4.7 %), and traumatic gastric ulcer (4.7 %). CONCLUSION A postoperative cervical fistula can successfully work as a reliable and safe access for a PEG tube procedure in HNC patients, avoiding unnecessary surgery and reducing costs.
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Affiliation(s)
| | - Gustavo Francisco de Souza e Mello
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil,Corresponding author Gustavo Francisco de Souza e Mello, MD, PhD Department of Digestive EndoscopyCancer Hospital IBrazilian National Cancer InstitutePraça Cruz Vermelha 23Rio de Janeiro – RJ, CEP 20230-130
| | - Cindy Lis Granados
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Ricardo Dardengo Glória
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Caroline Sauter Dalbem
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Rolantre Lopes da Cruz
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Ana Carolina Maron Ayres
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Renata Sofia Camara Lisboa
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Alexandre Dias Pelosi
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Maria Aparecida Ferreira
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Gilberto Reynaldo Mansur
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Simone Guaraldi da Silva
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | | | - Fernando Luiz Dias
- Department of Digestive Endoscopy, Cancer Hospital I, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
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PEG Insertion in Patients With Dementia Does Not Improve Nutritional Status and Has Worse Outcomes as Compared With PEG Insertion for Other Indications. J Clin Gastroenterol 2017; 51:417-420. [PMID: 27505401 DOI: 10.1097/mcg.0000000000000624] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) tubes are commonly utilized as a method of enteral feeding in patients unable to obtain adequate oral nutrition. Although some studies have shown improved mortality in select populations, the safety and effectiveness of PEG insertion in patients with dementia compared with those with other neurological diseases or head and neck malignancy remains less well defined. OBJECTIVE To evaluate the nutritional effectiveness, rate of rehospitalization, and risk of mortality among patients with dementia compared with patients with other neurological diseases or head and neck cancers who undergo PEG placement. MATERIALS AND METHODS We conducted a retrospective analysis from a prospective database of patients who underwent PEG placement at an academic tertiary center between 2008 and 2013. The following data were collected: indication for PEG, patient demographics, biochemical markers of nutritional status rehospitalization, and survival rates. RESULTS During the study period, 392 patients underwent PEG tube placement. Indications for PEG were dementia (N=165, group A), cerebrovascular accident (N=124, group B), and other indications such as oropharyngeal cancers and motor neuron disease (N=103, group C). The mean follow-up time after PEG was 18 months (range, 3 to 36 mo). No differences in baseline demographics were noted. PEG insertion in the dementia (group A) neither reduced the rehospitalization rate 6 months' postprocedure compared with groups B and C (2.45 vs. 1.86 and 1.65, respectively; P=0.05), nor reduced the mortality rate within the first year post-PEG placement (75% vs. 58% and 38% for groups A, B, and C, respectively, P=0.001), as well, it did not improve survival at 1 month after the procedure (15% vs. 3.26% and 7.76%, for groups A, B, C, respectively, P<0.01). The presence of dementia was also associated with shorter mean time to death (7.2 vs. 8.85 and 8 mo for groups A, B, C, respectively, P<0.05). The rate of improvement of the nutritional biomarker albumin was lower in the dementia group [3.1. to 2.9 vs. 3.2 to 3.3 and 3 to 3.3 g/dL for groups A, B, and C, respectively (P<0.02)]. Multivariate regression analysis showed that the presence of dementia was an independent predictor for mortality rate within the first year and 1-month mortality rate in patients undergoing PEG insertion with odds ratio 3.22 (95% confidence interval, 1.52-4.32) and odds ratio 2.52 (95% confidence interval, 1.22-3.67). CONCLUSIONS PEG insertion in patients with dementia neither improve both short-term and long-term mortality nor rehospitalization rate as compared with patients who underwent PEG placement for alternate indications such as other neurological diseases or head and neck malignancy and even was associated with shorter time to death. Furthermore, PEG insertion in patients with dementia did not improve albumin. Therefore, careful selection of patients with dementia is warranted before PEG placement weighing the risks and benefits on a personalized basis.
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71
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Increasing Serum Albumin Level Shortly After Gastrostomy Tube Insertion Predicts Longer Survival in Elderly Patients With Dementia. J Clin Gastroenterol 2017; 51:339-344. [PMID: 27479141 DOI: 10.1097/mcg.0000000000000616] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOAL To identify factors influencing survival after percutaneous endoscopic gastrostomy (PEG) tube insertion in elderly patients with severe dementia. BACKGROUND Use of PEG in patients with dementia raises medical and ethical questions. STUDY The cohort included 189 patients aged ≥64 years with severe dementia who underwent PEG tube insertion in 2002 to 2011 at a tertiary hospital and were followed through 2014. Data were collected on background diseases, laboratory tests conducted 14 (±10) days before and 90 (±10) days after PEG, and date of death. Multivariate Cox regression analysis was performed and cumulative survival curves plotted. RESULTS Mean baseline serum albumin level was significantly lower in patients who died ≤30 days after PEG (n=32, 16.9%) than patients who survived longer (2.9±0.5 vs. 3.3±0.5 g/dL, P<0.001), and significantly higher in patients who survived 1 year after PEG (n=96, 50.8%) than patients who died earlier (3.4±0.5 vs. 3.1±0.5 g/dL, P=0.002). No significant differences were found for the other laboratory parameters. After adjustment for background diseases, serum albumin level above the median (3.3 g/dL) was the only predictor of survival (hazard ratio 0.51; 95% confidence interval, 0.37-0.72; P<0.001). Patients with stable/increased serum albumin levels at 90 days after PEG (n=80, 42.3%) survived longer than patients with decreased levels. The only predictor of survival after adjustment for age and background diseases was a stable/increased albumin level at 90 days (hazard ratio 0.59; 95% confidence interval, 0.42-0.85; P=0.004). CONCLUSIONS Survival after PEG tube insertion is associated with a higher serum albumin level at baseline and a stable/increased serum albumin level during follow-up.
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Tyng CJ, Santos EFV, Guerra LFA, Bitencourt AGV, Barbosa PNVP, Chojniak R. Computed tomography-guided percutaneous gastrostomy: initial experience at a cancer center. Radiol Bras 2017; 50:109-114. [PMID: 28428654 PMCID: PMC5397002 DOI: 10.1590/0100-3984.2015.0219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Gastrostomy is indicated for patients with conditions that do not allow adequate oral nutrition. To reduce the morbidity and costs associated with the procedure, there is a trend toward the use of percutaneous gastrostomy, guided by endoscopy, fluoroscopy, or, most recently, computed tomography. The purpose of this paper was to review the computed tomography-guided gastrostomy procedure, as well as the indications for its use and the potential complications.
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Affiliation(s)
- Chiang Jeng Tyng
- PhD, Attending Physician, Imaging Department, A.C.Camargo Cancer Center, São Paulo, SP, Brazil
| | - Erich Frank Vater Santos
- MD, Radiologist, Resident in Interventional Radiology, Imaging Department, A.C.Camargo Cancer Center, São Paulo, SP, Brazil
| | - Luiz Felipe Alves Guerra
- MD, Resident in Radiology and Diagnostic Imaging, Hospital Universitário Cassiano Antonio de Morais - Universidade Federal do Espírito Santo (HUCAM-UFES), Vitória, ES, Brazil
| | | | | | - Rubens Chojniak
- PhD, Head of the Imaging Department, A.C.Camargo Cancer Center, São Paulo, SP, Brazil
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Sim JS, Kim SY, Lee YJ, Seo JH, Kim DJ, Choe JW, Lee D, Jung SW, Lee SW. Indication and Clinical Outcomes of Percutaneous Endoscopic Gastrostomy: A Single-center Retrospective Analysis. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2017. [DOI: 10.7704/kjhugr.2017.17.3.138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Ju Sung Sim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Seoung Young Kim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ye Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ji Hye Seo
- Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Dong Ju Kim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jung Wan Choe
- Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Dongwon Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Sung Woo Jung
- Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Sang Woo Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
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Busch JD, Herrmann J, Adam G, Habermann CR. Radiologically inserted gastrostomy: differences of maintenance of balloon- vs. loop-retained devices. Scand J Gastroenterol 2016; 51:1423-1428. [PMID: 27687634 DOI: 10.1080/00365521.2016.1216590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare outcome and associated complications of ballon- vs. loop-retained devices for radiologically inserted gastrostomy (RIG). METHODS From 2007 to 2011 233 patients (age 63.7 ± 10.6 years) were referred for a RIG because of pharyngeal stricture Intervention was performed with four different devices: balloon-retained - Freka® GastroTube, Fresenius Kabi (n = 121); MIC® Gastrostomy Feeding Tube, Kimberly-Clark (n = 34); Russell® Gastrostomy Tray, Cook Medical Inc. (n = 17); and loop-retained - Tilma® Gastrostomy Set, Cook Medical Inc. (n = 50). Follow-up was performed with regard to RIG-related complications, cause of removal and fatalities. Revision-free survival times after RIG were evaluated using Kaplan-Meier analysis and group differences by log-rank tests. For analysis of demographic and methodical variables multivariate Cox regression models were used. RESULTS With a primary technical success rate of 95.3% (222/233) a total of 92 instances of revisions were necessary in 66 patients (66/233, 28.3%) during follow-up (mean 182.8 ± 86.6 days). The most common complication was tube dislodgement (14.3%). There were no significant differences between the distinct devices (p = 0.098), but analyzing the data in subgroups of balloon-compared to loop-retained gastrostomy tubes we observed a significantly higher probability of minor complications for the latter (p = 0.023). CONCLUSION As it is significantly less prone to minor complications we recommend the use of balloon-retained gastrostomy tubes to improve the practicability and maintenance of RIG.
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Affiliation(s)
- J D Busch
- a Department of Diagnostic and Interventional Radiology and Nuclear Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany.,b Department of Diagnostic and Interventional Radiology and Nuclear Medicine , Section of Pediatric Radiology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - J Herrmann
- a Department of Diagnostic and Interventional Radiology and Nuclear Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany.,b Department of Diagnostic and Interventional Radiology and Nuclear Medicine , Section of Pediatric Radiology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - G Adam
- a Department of Diagnostic and Interventional Radiology and Nuclear Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - C R Habermann
- c Catholic Marienkrankenhaus GmbH , Institute of Diagnostic and Interventional Radiology , Hamburg , Germany
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Xu Y, Guo Q, Lin J, Chen B, Wen J, Lu T, Xu Y, Zhang M, Pan J, Lin S. Benefit of percutaneous endoscopic gastrostomy in patients undergoing definitive chemoradiotherapy for locally advanced nasopharyngeal carcinoma. Onco Targets Ther 2016; 9:6835-6841. [PMID: 27853378 PMCID: PMC5104288 DOI: 10.2147/ott.s117676] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIM To evaluate the impact of percutaneous endoscopic gastrostomy (PEG) tube on nutritional status, treatment-related toxicity, and treatment tolerance in patients with locally advanced nasopharyngeal carcinoma (NPC) who underwent chemoradiotherapy. PATIENTS AND METHODS We enrolled 133 consecutive non-metastatic NPC (III/IV stage) patients, who were treated with prophylactic PEG feeding before the initiation of concurrent chemoradiotherapy (CCRT) between June 1, 2010 and June 30, 2014. Meanwhile, another 133 non-PEG patients, who were matched for age, gender, and tumor, node, metastases stage, were selected as historical control cohort. Weight and nutritional status changes from pre-radiotherapy to the end of radiotherapy were evaluated, and treatment tolerance and related acute toxicities were analyzed as well. RESULTS We found that significantly more patients (91.73%) in the PEG group could finish two cycles of CCRT, when compared with those in the non-PEG group (57.89%) (P<0.001). We also indicated that more patients (50.38%) in the non-PEG group experienced weight loss of ≥5%, while the phenomenon was only found in 36.09% patients in the PEG group (P=0.019). In addition, the percentage of patients who lost ≥10% of their weight was similar in these two groups. Changes in albumin and prealbumin levels during radiotherapy in the non-PEG group were higher than those obtained for the PEG group with significant differences (P-values of 0.023 and <0.001, respectively). Furthermore, patients in the PEG group had significantly lower incidence of grade III acute mucositis than those in the non-PEG group (22.56% vs 36.84%, P=0.011). Tube-related complications occurred only in 14 (10.53%) patients in the PEG group, including incision infection of various degrees. CONCLUSION PEG and intensive nutrition support may help to minimize body weight loss, maintain nutritional status, and offer better treatment tolerance for patients with locally advanced NPC who underwent CCRT.
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Affiliation(s)
- Yun Xu
- Department of Radiation Oncology, Fujian Provincial Cancer Hospital; Fujian Provincial Key Laboratory of Translational Cancer Medicine, Fuzhou, Fujian, People's Republic of China
| | - Qiaojuan Guo
- Department of Radiation Oncology, Fujian Provincial Cancer Hospital; Fujian Provincial Key Laboratory of Translational Cancer Medicine, Fuzhou, Fujian, People's Republic of China
| | - Jin Lin
- Department of Radiation Oncology, Fujian Provincial Cancer Hospital; Fujian Provincial Key Laboratory of Translational Cancer Medicine, Fuzhou, Fujian, People's Republic of China
| | - Bijuan Chen
- Department of Radiation Oncology, Fujian Provincial Cancer Hospital; Fujian Provincial Key Laboratory of Translational Cancer Medicine, Fuzhou, Fujian, People's Republic of China
| | - Jiangmei Wen
- Department of Radiation Oncology, Fujian Provincial Cancer Hospital; Fujian Provincial Key Laboratory of Translational Cancer Medicine, Fuzhou, Fujian, People's Republic of China
| | - Tianzhu Lu
- Department of Radiation Oncology, Fujian Provincial Cancer Hospital; Fujian Provincial Key Laboratory of Translational Cancer Medicine, Fuzhou, Fujian, People's Republic of China
| | - Yuanji Xu
- Department of Radiation Oncology, Fujian Provincial Cancer Hospital; Fujian Provincial Key Laboratory of Translational Cancer Medicine, Fuzhou, Fujian, People's Republic of China
| | - Mingwei Zhang
- Department of Radiation Oncology, Fujian Provincial Cancer Hospital; Fujian Provincial Key Laboratory of Translational Cancer Medicine, Fuzhou, Fujian, People's Republic of China
| | - Jianji Pan
- Department of Radiation Oncology, Fujian Provincial Cancer Hospital; Fujian Provincial Key Laboratory of Translational Cancer Medicine, Fuzhou, Fujian, People's Republic of China
| | - Shaojun Lin
- Department of Radiation Oncology, Fujian Provincial Cancer Hospital; Fujian Provincial Key Laboratory of Translational Cancer Medicine, Fuzhou, Fujian, People's Republic of China
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Lim JH, Choi SH, Lee C, Seo JY, Kang HY, Yang JI, Chung SJ, Kim JS. Thirty-day mortality after percutaneous gastrostomy by endoscopic versus radiologic placement: a systematic review and meta-analysis. Intest Res 2016; 14:333-342. [PMID: 27799884 PMCID: PMC5083262 DOI: 10.5217/ir.2016.14.4.333] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/10/2016] [Accepted: 02/22/2016] [Indexed: 02/07/2023] Open
Abstract
Background/Aims A percutaneous gastrostomy can be placed either endoscopically (percutaneous endoscopic gastrostomy, PEG) or radiologically (radiologically-inserted gastrostomy, RIG). However, there is no consistent evidence of the safety and efficacy of PEG compared to RIG. Recently, 30-day mortality has become considered as the most important surrogate index for evaluating the safety and efficacy of percutaneous gastrostomy. The aim of this meta-analysis was to compare the 30-day mortality rates between PEG and RIG. Methods Major electronic databases (MEDLINE, Embase, Scopus, and Cochrane library) were queried for comparative studies on the two insertion techniques of gastrostomy among adults with swallowing disturbance. The primary outcome was the 30-day mortality rate after gastrostomy insertion. Forest and funnel plots were generated for outcomes using STATA version 14.0. Results Fifteen studies (n=2,183) met the inclusion criteria. PEG was associated with a lower risk of 30-day mortality after tube placement compared with RIG (odds ratio, 0.60; 95% confidence interval [CI], 0.38–0.94; P=0.026). The pooled prevalence of 30-day mortality of PEG was 5.5% (95% CI, 4.0%–6.9%) and that of RIG was 10.5% (95% CI, 6.8%–14.3%). No publication bias was noted. Conclusions The present meta-analysis demonstrated that PEG is associated with a lower probability of 30-day mortality compared to RIG, suggesting that PEG should be considered as the first choice for long-term enteral tube feeding. Further prospective randomized studies are needed to evaluate and compare the safety of these two different methods of gastrostomy.
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Affiliation(s)
- Joo Hyun Lim
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Seung Ho Choi
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Changhyun Lee
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Ji Yeon Seo
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Hae Yeon Kang
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Jong In Yang
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Su Jin Chung
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
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77
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Peritonitis following percutaneous gastrostomy tube insertions in children. Pediatr Radiol 2016; 46:1444-50. [PMID: 27173980 DOI: 10.1007/s00247-016-3628-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 02/16/2016] [Accepted: 04/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Percutaneous retrograde gastrostomy has a high success rate, low morbidity, and can be performed under different levels of sedation or local anesthesia in children. Despite its favourable safety profile, major complications can occur. Few studies have examined peritonitis following percutaneous retrograde gastrostomy in children. OBJECTIVE To identify potential risk factors and variables influencing the development and early diagnosis of peritonitis following percutaneous retrograde gastrostomy. MATERIALS AND METHODS We conducted a retrospective case-control study of children who developed peritonitis within 7 days of percutaneous retrograde gastrostomy between 2003 and 2012. From the 1,504 patients who underwent percutaneous retrograde gastrostomy, patients who developed peritonitis (group 1) were matched by closest date of procedure to those without peritonitis (group 2). Peritonitis was defined according to recognized clinical criteria. Demographic, clinical, procedural, management and outcomes data were collected. RESULTS Thirty-eight of 1,504 children (2.5%; 95% confidence interval, 1.8-3.5) who underwent percutaneous retrograde gastrostomy developed peritonitis ≤7 days post procedure (group 1). Fever (89%), irritability (63%) and abdominal pain (55%) occurred on presentation of peritonitis. Group 1 patients were all treated with antibiotics; 41% underwent additional interventions: tube readjustments (8%), aspiration of pneumoperitoneum (23%), laparotomy (10%) and intensive care unit admission (10%). In group 1, enteral feeds started on average 3 days later and patients were discharged 5 days later than patients in group 2. There were two deaths not directly related to peritonitis. Neither age, gender, weight, underlying diagnoses nor operator was identified as a risk factor. CONCLUSION Peritonitis following percutaneous retrograde gastrostomy in children occurs in approximately 2.5% of cases. No risk factors for its development were identified. Medical management is usually sufficient for a good outcome. Patients with peritonitis are delayed starting feeds and have a hospital stay that is an average of 5 days longer than those without.
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78
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Retes FA, Kawaguti FS, de Lima MS, da Costa Martins B, Uemura RS, de Paulo GA, Pennacchi CM, Gusmon C, Ribeiro AV, Baba ER, Geiger SN, Sorbello MP, Kulcsar MA, Ribeiro U, Maluf-Filho F. Comparison of the pull and introducer percutaneous endoscopic gastrostomy techniques in patients with head and neck cancer. United European Gastroenterol J 2016; 5:365-373. [PMID: 28507748 DOI: 10.1177/2050640616662160] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/04/2016] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Felipe A Retes
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Fabio S Kawaguti
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Marcelo S de Lima
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Bruno da Costa Martins
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Ricardo S Uemura
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Gustavo A de Paulo
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Caterina Mp Pennacchi
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Carla Gusmon
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Adriana Vs Ribeiro
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Elisa R Baba
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Sebastian N Geiger
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Mauricio P Sorbello
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
| | - Marco A Kulcsar
- Department of Head and Neck Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Ulysses Ribeiro
- Gastrointestinal Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Fauze Maluf-Filho
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil
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Paleri V, Wood J, Patterson J, Stocken DD, Cole M, Vale L, Franks J, Guerrero-Urbano T, Donnelly R, Barclay S, Rapley T, Rousseau N. A feasibility study incorporating a pilot randomised controlled trial of oral feeding plus pre-treatment gastrostomy tube versus oral feeding plus as-needed nasogastric tube feeding in patients undergoing chemoradiation for head and neck cancer (TUBE trial): study protocol. Pilot Feasibility Stud 2016; 2:29. [PMID: 27965848 PMCID: PMC5154009 DOI: 10.1186/s40814-016-0069-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 05/17/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND There are 7000 new cases of head and neck squamous cell cancers (HNSCC) treated by the NHS each year. Stage III and IV HNSCC can be treated non-surgically by radio therapy (RT) or chemoradiation therapy (CRT). CRT can affect eating and drinking through a range of side effects with 90 % of patients undergoing this treatment requiring nutritional support via gastrostomy (G) or nasogastric (NG) tube feeding. Long-term dysphagia following CRT is a primary concern for patients. The effect of enteral feeding routes on swallowing function is not well understood, and the two feeding methods have, to date, not been compared to assess which leads to a better patient outcome. The purpose of this study is to explore the feasibility of conducting a randomised controlled trial (RCT) comparing these two options with particular emphasis on patient willingness to be randomised and clinician willingness to approach eligible patients. METHODS/DESIGN This is a mixed methods multicentre study to establish the feasibility of a randomised controlled trial comparing oral feeding plus pre-treatment gastrostomy versus oral feeding plus as required nasogastric tube feeding in patients with HNSCC. A total of 60 participants will be randomised to the two arms of the study (1:1 ratio). The primary outcome of feasibility is a composite of recruitment (willingness to randomise and be randomised) and retention. A qualitative process evaluation investigating patient, family and friends and staff experiences of trial participation will also be conducted alongside an economic modelling exercise to synthesise available evidence and provide estimates of cost-effectiveness and value of information. Participants will be assessed at baseline (pre-randomisation), during CRT weekly, 3 months and 6 months. DISCUSSION Clinicians are in equipoise over the enteral feeding options for patients being treated with CRT. Swallowing outcomes have been identified as a top priority for patients following treatment and this trial would inform a future larger scale RCT in this area to inform best practice. TRIAL REGISTRATION ISRCTN48569216.
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Affiliation(s)
- Vinidh Paleri
- Department of Otolaryngology–Head and Neck Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- University of Manchester, Manchester, UK
| | | | - Joanne Patterson
- City Hospitals Sunderland NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Deborah D. Stocken
- Clinical Trials and Biostatistics, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Mike Cole
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Health Economics, Newcastle University, Newcastle upon Tyne, UK
| | | | | | | | - Stewart Barclay
- Restorative Dentistry, Newcastle Dental Hospital, Newcastle upon Tyne, UK
| | - Tim Rapley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Bravo JGP, Ide E, Kondo A, de Moura DTH, de Moura ETH, Sakai P, Bernardo WM, de Moura EGH. Percutaneous endoscopic versus surgical gastrostomy in patients with benign and malignant diseases: a systematic review and meta-analysis. Clinics (Sao Paulo) 2016; 71:169-78. [PMID: 27074179 PMCID: PMC4797561 DOI: 10.6061/clinics/2016(03)09] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 11/30/2015] [Indexed: 12/13/2022] Open
Abstract
To compare the complications and mortality related to gastrostomy procedures performed using surgical and percutaneous endoscopic gastrostomy techniques, this review covered seven studies. Five of these were retrospective and two were randomized prospective studies. In total, 406 patients were involved, 232 of whom had undergone percutaneous endoscopic gastrostomy and 174 of whom had undergone surgical gastrostomy. The analysis was performed using Review Manager. Risk differences were computed using a fixed-effects model and forest and funnel plots. Data on risk differences and 95% confidence intervals were obtained using the Mantel-Haenszel test. There was no difference in major complications in retrospective (95% CI (-0.11 to 0.10)) or randomized (95% CI (-0.07 to 0.05)) studies. Regarding minor complications, no difference was found in retrospective studies (95% CI (-00.17 to 0.09)), whereas a difference was observed in randomized studies (95% CI (-0.25 to -0.02)). Separate analyses of retrospective and randomized studies revealed no differences between the methods in relation to mortality and major complications. Moreover, low levels of minor complications were observed among endoscopic procedures in randomized studies, with no difference observed compared with retrospective studies.
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81
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Antibacterial gauzes are effective in preventing infections after percutaneous endoscopic gastrostomy placement: a retrospective analysis. Eur J Gastroenterol Hepatol 2016; 28:297-304. [PMID: 26735159 DOI: 10.1097/meg.0000000000000561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The most common complication after percutaneous endoscopic gastrostomy (PEG) placement is peristomal wound infection (up to 40% without antibiotic prophylaxis). Single-dose parenteral prophylactic antibiotics as advised by current guidelines decrease the infection rate to 9-15%. We assume a prolonged effect of local antibiotic treatment with antibacterial gauzes. This study is the first to describe the effect of antibacterial gauzes in preventing infections in PEG without the use of antibiotics. METHODS A retrospective data analysis was carried out of all patients with PEG insertion between January 2009 and October 2014 in the Catharina Hospital Eindhoven. Data include placement and the period of the first 2 weeks after PEG placement, and long-term follow-up. All patients received a locally applied antibacterial gauze polyhexamethylene biguanide immediately following PEG insertion for 3 days. No other antibiotics were administered. The main outcomes were wound infection, peritonitis, and necrotizing fasciitis; secondary outcomes included other complications. RESULTS A total of 331 patients with only antibacterial gauzes were analyzed. The total number of infections 2 weeks after PEG insertion was 9.4%, including 8.2% minor and 1.2% major infections (peritonitis). No wound infection-related mortality or bacterial resistance was found. Costs are five times lower than antibiotics, and gauzes are more practical and patient friendly for use. CONCLUSION Retrospectively, antibacterial gauzes are at least comparable with literature data on parenteral antibiotics in preventing peristomal wound infection after PEG placement, with an infection rate of 9.4%. Rates of other complications found in this study were comparable with current literature data.
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McDonald MW, Liu Y, Moore MG, Johnstone PAS. Acute toxicity in comprehensive head and neck radiation for nasopharynx and paranasal sinus cancers: cohort comparison of 3D conformal proton therapy and intensity modulated radiation therapy. Radiat Oncol 2016; 11:32. [PMID: 26922239 PMCID: PMC4769827 DOI: 10.1186/s13014-016-0600-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 01/23/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To evaluate acute toxicity endpoints in a cohort of patients receiving head and neck radiation with proton therapy or intensity modulated radiation therapy (IMRT). METHODS Forty patients received comprehensive head and neck radiation including bilateral cervical nodal radiation, given with or without chemotherapy, for tumors of the nasopharynx, nasal cavity or paranasal sinuses, any T stage, N0-2. Fourteen received comprehensive treatment with proton therapy, and 26 were treated with IMRT, either comprehensively or matched to proton therapy delivered to the primary tumor site. Toxicity endpoints assessed included g-tube dependence at the completion of radiation and at 3 months after radiation, opioid pain medication requirement compared to pretreatment normalized as equivalent morphine dose (EMD) at completion of treatment, and at 1 and 3 months after radiation. RESULTS In a multivariable model including confounding variables of concurrent chemotherapy and involved nodal disease, comprehensive head and neck radiation therapy using proton therapy was associated with a lower opioid pain requirement at the completion of radiation and a lower rate of gastrostomy tube dependence by the completion of radiation therapy and at 3 months after radiation compared to IMRT. Proton therapy was associated with statistically significant lower mean doses to the oral cavity, esophagus, larynx, and parotid glands. In subgroup analysis of 32 patients receiving concurrent chemotherapy, there was a statistically significant correlation with a greater opioid pain medication requirement at the completion of radiation and both increasing mean dose to the oral cavity and to the esophagus. CONCLUSIONS Proton therapy was associated with significantly reduced radiation dose to assessed non-target normal tissues and a reduced rate of gastrostomy tube dependence and opioid pain medication requirements. This warrants further evaluation in larger studies, ideally with patient-reported toxicity outcomes and quality of life endpoints.
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Affiliation(s)
- Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, 1365 Clifton Rd NE Suite A1300, Atlanta, GA, 30322, USA.
| | - Yuan Liu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health of Emory University, Atlanta, GA, USA.
| | - Michael G Moore
- Department of Otolaryngology/Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Peter A S Johnstone
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
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83
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Validation of an updated evidence-based protocol for proactive gastrostomy tube insertion in patients with head and neck cancer. Eur J Clin Nutr 2016; 70:574-81. [DOI: 10.1038/ejcn.2015.230] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 12/11/2015] [Accepted: 12/19/2015] [Indexed: 12/11/2022]
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Yuan Y, Zhao Y, Xie T, Hu Y. Percutaneous endoscopic gastrostomy versus percutaneous radiological gastrostomy for swallowing disturbances. Cochrane Database Syst Rev 2016; 2:CD009198. [PMID: 26837233 PMCID: PMC8260094 DOI: 10.1002/14651858.cd009198.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Gastrostomy has been established as the standard procedure for administering long-term enteral nutrition in individuals with swallowing disturbances. Percutaneous gastrostomy is a less-invasive approach than open surgical gastrostomy, and can be accomplished via endoscopy (percutaneous endoscopic gastrostomy or PEG) or sonographic or fluoroscopic guidance (percutaneous radiological gastrostomy or PRG). Both techniques have different limitations, advantages, and contraindications. In order to determine the optimal technique for long-term nutritional supplementation many studies have been conducted to compare the outcomes of these two techniques; however, it remains unclear as to which method is superior to the other with respect to both efficacy and safety. OBJECTIVES To compare the safety and efficacy of PEG and PRG in the treatment of individuals with swallowing disturbances. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, January 2016); MEDLINE (1946 to 22 January 2016); EMBASE (1980 to 22 January 2016); the reference lists of identified articles; databases of ongoing trials, including the Chinese Cochrane Centre Controlled Trials Register; and PubMed. We applied no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing PEG with PRG in individuals with swallowing disturbances, regardless of the underlying disease. DATA COLLECTION AND ANALYSIS Two authors independently evaluated the search results and assessed the quality of the studies. Data analyses could not be performed as no RCTs were identified for inclusion in this review. MAIN RESULTS We identified no RCTs comparing PEG and PRG for percutaneous gastrostomy in individuals with swallowing disturbances. The large body of evidence in this field comes from retrospective and non-randomised controlled studies and case series. Based on this evidence, both PEG and PRG can be safely performed in selected individuals, although both are associated with major and minor complications. A definitive RCT has yet to be conducted to identify the preferred percutaneous gastrostomy technique. AUTHORS' CONCLUSIONS Both PEG and PRG are effective for long-term enteral nutritional support in selected individuals, though current evidence is insufficient to recommend one technique over the other. Choice of technique should be based on indications and contraindications, operator experience and the facilities available. Large-scale RCTs are required to compare the two techniques and to determine the optimal approach for percutaneous gastrostomy.
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Affiliation(s)
- Yong Yuan
- West China Hospital, Sichuan UniversityDepartment of Thoracic SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Yongfan Zhao
- West China Hospital, Sichuan UniversityDepartment of Thoracic and Cardiovascular SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Tianpeng Xie
- West China Hospital, Sichuan UniversityDepartment of Thoracic and Cardiovascular SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Yang Hu
- West China Hospital, Sichuan UniversityDepartment of Thoracic and Cardiovascular SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
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Gastrostomy in head and neck cancer: current literature, controversies and research. Curr Opin Otolaryngol Head Neck Surg 2015; 23:162-70. [PMID: 25692626 DOI: 10.1097/moo.0000000000000135] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW This article explores the literature on the role of gastrostomy tube feeding use in the management of head and neck cancer, with special attention to its indications, timing of insertion, advantages, complications and quality of life issues. RECENT FINDINGS The current guidelines in place across different countries and two ongoing randomized controlled trials are discussed in detail, and placed in the context of current evidence. SUMMARY There remains a lack of consensus about when and which enteral feeding routes (gastrostomy or nasogastric tube) should be used and controversy about the long-term effects on swallowing function as well as quality of life for patients. Local guidelines should be used or generated to guide practice or patients enrolled into existing trials until higher level evidence is generated.
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Khanh NT, Iyer NG. Management of post-operative fistula in head and neck surgery: Sweeping it under the carpet? World J Otorhinolaryngol 2015; 5:93-104. [DOI: 10.5319/wjo.v5.i4.93] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 07/19/2015] [Accepted: 09/28/2015] [Indexed: 02/06/2023] Open
Abstract
The most dreaded complication in head and neck surgery is the development of fistula. Fistulas are common and devastating. The prevalence and the risk factors that contribute to fistula formation after head and neck procedures were discussed briefly. The main goal of this manuscript is to discuss current management of head and neck fistula. We believed that the best management strategy for head and neck fistulas is prevention. We recommend a holistic preventive approach during the perioperative period. The roles of different types of wound products and hyperbaric oxygen therapy were also discussed and highlighted. We also discussed the operative repair of fistulas, which relies on the tenet of providing well-vascularized tissue to an area of poor wound healing. Most often, the surgeon’s preference and range of operative skills dictate the timing and the type of repair. We highlighted the use of the pectoralis major, a well-known flap, as well as a novel technique in the surgical repair of complex, difficult-to-heal head and neck fistula.
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Usefulness of Prophylactic Percutaneous Gastrostomy Placement in Patients with Head and Neck Cancer Treated with Chemoradiotherapy. Dysphagia 2015; 31:84-9. [PMID: 26487063 DOI: 10.1007/s00455-015-9661-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 10/14/2015] [Indexed: 01/06/2023]
Abstract
Chemoradiotherapy (CRT) has evolved as the preferred organ preservation strategy in the treatment of locally advanced head and neck cancer (HNC). This approach increases malnutrition, and thus, establishing a direct enteral feeding route is essential. To evaluate the usefulness of prophylactic percutaneous endoscopic gastrostomy (PEG) in HNC patients receiving definitive CRT, we performed a prospective evaluation of HNC patients over a 6-month period. Patients and tumor characteristics, nutritional status 30 days after PEG insertion and technique complications were evaluated. We also assessed the long-term PEG usage. Forty-seven PEGs were placed and only 2 patients did not use it. The mean time of PEG use was 131 days (4-255) and mean duration of exclusive utilization was 71 days (4-180). On 30th day after procedure, 34/45 (76 %) patients had lost weight, but only 10/45 (22 %) patients had lost more than 10 % of their initial weight. The most frequent complications were minor peristomal infections, which were correlated with proton-pump inhibitor use before PEG placement (OR 3.91, 95 % CI 1.01-15.2, and p = 0.049). One year later, 19 % of patients in remission continue needing PEG. Enteric nutritional support is essential during and after CRT in HNC patients. Most patients lost weight even with PEG. One-fifth of patients in remission required long-term PEG utilization.
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Bernstein OA, Campbell J, Rajan DK, Kachura JR, Simons ME, Beecroft JR, Jaskolka JD, Ringash J, Ho CS, Tan KT. Randomized Trial Comparing Radiologic Pigtail Gastrostomy and Peroral Image-Guided Gastrostomy: Intra- and Postprocedural Pain, Radiation Exposure, Complications, and Quality of Life. J Vasc Interv Radiol 2015; 26:1680-6; quiz 1686. [PMID: 26316137 DOI: 10.1016/j.jvir.2015.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 06/12/2015] [Accepted: 07/15/2015] [Indexed: 01/16/2023] Open
Abstract
PURPOSE To prospectively compare radiologically created pigtail gastrostomy (PG), in which the tube is inserted directly through the abdominal wall, versus peroral image-guided gastrostomy (POG), in which the tube is inserted through the mouth. Pain profiles (primary outcome measure), fluoroscopy times, total room times, technical success, complications, and quality of life (QOL) were measured. MATERIALS AND METHODS Sixty patients were prospectively randomized to receive 14-F PG or 20-F POG tubes. All patients received prophylactically created gastrostomies before radiation therapy for head and neck squamous-cell carcinoma. Patients receiving palliative treatment were excluded, as were those with established pharyngeal obstruction. Pain was measured by numeric rating scale (NRS) scores for 6 weeks after the procedure and by intraprocedural fentanyl and midazolam doses and postprocedural 24-h morphine doses. Fluoroscopy times, total room times, technical success, complications up to 6 months, and gastrostomy-related QOL (using the Functional Assessment of Cancer Therapy-Enteral Feeding questionnaire) were determined. RESULTS Fifty-six patients underwent the randomized procedure. The POG group required significantly higher intraprocedural midazolam and fentanyl doses (mean, 1.2 mg and 67 μg, respectively, for PG vs 1.9 mg and 105 μg for POG; P < .001) and had significantly longer fluoroscopy times (mean, 1.3 min for PG vs 4.8 min for POG; P < .0001). NRS scores, morphine doses, total room times, technical success, complication rates, and QOL did not differ significantly between groups. The one major complication, a misplaced PG in the peritoneal cavity, followed a technical failure of POG creation. CONCLUSIONS Despite the differences in insertion technique and tube caliber, the measured outcomes of POG and PG are comparable.
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Affiliation(s)
- Ondina A Bernstein
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada.
| | - Jennifer Campbell
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Dheeraj K Rajan
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - John R Kachura
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Martin E Simons
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - J Robert Beecroft
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey D Jaskolka
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Jolie Ringash
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Chia S Ho
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Kong Teng Tan
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
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Brown TE, Crombie J, Spurgin AL, Tripcony L, Keller J, Hughes BGM, Dickie G, Kenny LM, Hodge RA. Improving guideline sensitivity and specificity for the identification of proactive gastrostomy placement in patients with head and neck cancer. Head Neck 2015; 38 Suppl 1:E1163-71. [DOI: 10.1002/hed.24184] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 03/02/2015] [Accepted: 07/03/2015] [Indexed: 01/28/2023] Open
Affiliation(s)
- Teresa E. Brown
- Department of Nutrition and Dietetics; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Jane Crombie
- Department of Speech Pathology; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Ann-Louise Spurgin
- Department of Speech Pathology; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Lee Tripcony
- Cancer Care Services, Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Jacqui Keller
- Cancer Care Services, Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Brett G. M. Hughes
- Cancer Care Services, Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
- School of Medicine, University of Queensland; Queensland Australia
| | - Graeme Dickie
- Cancer Care Services, Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Lizbeth Moira Kenny
- Cancer Care Services, Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Robert A. Hodge
- Department of ENT/Head and Neck Surgery; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
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Tamura A, Kato K, Suzuki M, Sone M, Tanaka R, Nakasato T, Ehara S. CT-Guided Percutaneous Radiologic Gastrostomy for Patients with Head and Neck Cancer: A Retrospective Evaluation in 177 Patients. Cardiovasc Intervent Radiol 2015; 39:271-8. [DOI: 10.1007/s00270-015-1170-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 06/24/2015] [Indexed: 11/30/2022]
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Holliday EB, Garden AS, Rosenthal DI, Fuller CD, Morrison WH, Gunn GB, Phan J, Beadle BM, Zhu XR, Zhang X, Hanna E, Glisson BS, Hutcheson KA, El-Naggar AK, Hong JH, Hung TM, Uzel EK, Lewis G, Frank SJ. Proton Therapy Reduces Treatment-Related Toxicities for Patients with Nasopharyngeal Cancer: A Case-Match Control Study of Intensity-Modulated Proton Therapy and Intensity-Modulated Photon Therapy. Int J Part Ther 2015. [DOI: 10.14338/ijpt-15-00011.1] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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92
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Swallowing outcomes and PEG dependence in head and neck cancer patients receiving definitive or adjuvant radiotherapy +/− chemotherapy with a proactive PEG: A prospective study with long term follow up. Oral Oncol 2015; 51:622-8. [DOI: 10.1016/j.oraloncology.2015.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 03/14/2015] [Accepted: 03/18/2015] [Indexed: 11/30/2022]
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93
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Impact of weight loss in patients with head and neck carcinoma undergoing radiotherapy: is it an underestimated phenomenon? A radiation oncologist’s perspective. Eur J Clin Nutr 2015; 69:757-60. [DOI: 10.1038/ejcn.2015.65] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 12/22/2014] [Accepted: 02/27/2015] [Indexed: 02/07/2023]
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94
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Feasibility and Safety of Overtubes for PEG-Tube Placement in Patients with Head and Neck Cancer. Gastroenterol Res Pract 2015; 2015:612610. [PMID: 25977688 PMCID: PMC4419231 DOI: 10.1155/2015/612610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/24/2015] [Indexed: 01/16/2023] Open
Abstract
Background. Percutaneous endoscopic gastrostomy (PEG) placement using the “pull” technique is commonly utilized for providing nutritional support in head and neck cancer (HNC) patients, but it may be complicated by peristomal metastasis in up to 3% of patients. Overtube-assisted PEG placement might reduce this risk. However, this technique has not been systemically studied for this purpose to date. Methods. Retrospective analysis of consecutive patients with HNC who underwent overtube-assisted PEG placement at Westmead Hospital, Australia, between June 2011 and December 2013. Data were extracted from patients' endoscopy reports and case notes. We present our technique for PEG insertion and discuss the feasibility and safety of this method. Results. In all 53 patients studied, the PEG tubes were successfully placed using 25 cm long flexible overtubes, in 89% prophylactically (before commencing curative chemoradiotherapy), and in 11% reactively (for treatment of tumor related dysphagia or weight loss). During a median follow-up period of 16 months, 3 (5.7%) patients developed peristomal infection and 3 others developed self-limiting peristomal pain. There were no cases of overtube-related adverse events or overt cutaneous metastases observed. Conclusions. Overtube-assisted PEG placement in patients with HNC is a feasible, simple, and safe technique and might be effective for preventing cutaneous metastasis.
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95
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Mobily M, Patel JA. Palliative percutaneous endoscopic gastrostomy placement for gastrointestinal cancer: Roles, goals, and complications. World J Gastrointest Endosc 2015; 7:364-369. [PMID: 25901215 PMCID: PMC4400625 DOI: 10.4253/wjge.v7.i4.364] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 12/11/2014] [Accepted: 01/12/2015] [Indexed: 02/05/2023] Open
Abstract
Percutaneous endoscopic gastrostomy tube placement is an invaluable tool in clinical practice that has an important role in the palliative care of patients with gastrointestinal cancer. While there is no extensive data regarding the use of this procedure in patients with gastrointestinal malignancy, inferences can be made from the available information derived from studies of similar or mixed populations. Percutaneous endoscopic gastrostomy tubes can be used to provide enteral nutrition for terminal malignancies of the upper gastrointestinal tract as well as for decompression of malignant obstructions. The rates of successful placement for cancer patients with either of these indications are high, similar to those in mixed populations. There is no conclusive evidence that the procedure will help patients reach nutritional goals for those needing alimental supplementation. However, it is effective at relieving symptoms caused by malignant obstruction. A high American Society of Anesthesiologist physical status score and an advanced tumor stage have been shown to be independent predictors of poor outcomes following placement in cancer patients. This suggests the potential for similar outcomes in the palliative care of patients with advanced stage gastrointestinal cancer who may be in relatively poor physiologic condition. However, this potential should not preclude its use in patients with terminal gastrointestinal cancer considering the high rate of successful tube placement, the possible benefits and the ultimate goal of comfort in palliative care.
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96
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Burney RE, Bryner BS. Safety and long-term outcomes of percutaneous endoscopic gastrostomy in patients with head and neck cancer. Surg Endosc 2015; 29:3685-9. [DOI: 10.1007/s00464-015-4126-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 02/13/2015] [Indexed: 11/30/2022]
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97
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Shaw SM, Flowers H, O'Sullivan B, Hope A, Liu LWC, Martino R. The effect of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement on swallowing and swallow-related outcomes in patients undergoing radiotherapy for head and neck cancer: a systematic review. Dysphagia 2015; 30:152-75. [PMID: 25737196 DOI: 10.1007/s00455-014-9592-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/11/2014] [Indexed: 11/29/2022]
Abstract
Patients undergoing radiotherapy for head and neck cancer (HNC) often experience malnutrition and dehydration during treatment. As a result, some centres place PEG tubes prophylactically (pPEG) to prevent these negative consequences. However, recent research has suggested that pPEG use may negatively affect swallowing physiology, function and/or quality of life, especially in the long term. The purpose of this study was to systematically review the literature on pPEG use in HNC patients undergoing radiotherapy and to determine its impact on swallowing-related outcomes. The following electronic databases were searched for all relevant primary research published through February 24, 2014: AMED, CINAHL, the Cochrane Library, Embase, Healthstar, Medline, and PsycINFO. Main search terms included HNC, radiotherapy, deglutition disorders, feeding tube(s), and prophylactic or elective. References for all accepted papers were hand searched to identify additional relevant research. Methodological quality was assessed using Cochrane's Risk of Bias. At all levels, two blinded raters provided judgments. Discrepancies were resolved by consensus. The search retrieved 181 unique citations. Twenty studies met our inclusion criteria. Quality assessment revealed that all studies were at risk for bias due to non-randomized sampling and unreported or inadequate blinding. Ten studies demonstrated selection bias with significant baseline differences between pPEG patients and controls. Results regarding the frequency and severity of dysphagia and swallowing-related outcomes were varied and inconclusive. The impact of pPEG use on swallowing and swallowing-related outcomes remains unclear. Well-controlled, randomized trials are needed to determine if pPEG places patients at greater risk for developing long-term dysphagia.
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Affiliation(s)
- Stephanie M Shaw
- Department of Speech-Language Pathology, Faculty of Medicine, University of Toronto, 160-500 University Ave., Toronto, ON, M5G 1V7, Canada,
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99
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Im JP, Cha JM, Kim JW, Kim SE, Ryu DY, Kim EY, Kim ER, Chang DK. Proton pump inhibitor use before percutaneous endoscopic gastrostomy is associated with adverse outcomes. Gut Liver 2014; 8:248-53. [PMID: 24827620 PMCID: PMC4026641 DOI: 10.5009/gnl.2014.8.3.248] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS Knowledge of the risk factors associated with adverse outcomes after percutaneous endoscopic gastrostomy (PEG) may be helpful for developing PEG recommendations. The purpose of this study was to identify the clinical risk factors associated with adverse clinical outcomes after PEG, especially regarding the use of proton pump inhibitors (PPIs). METHODS We retrospectively reviewed the data from PEG patients at seven university hospitals between June 2006 and January 2012. All patients were followed up through February 2012 after PEG, and the clinical risk factors for adverse clinical outcomes after PEG were analyzed. RESULTS Data from 1,021 PEG patients were analyzed. PPI users were more frequently included in the complication group than the noncomplication group (p=0.040). PEG-related complications (p=0.040) and mortality (p=0.003) were more frequent in the PPI group than in the control group. In the subgroup analysis of complicated PEG cases, infectious complications were more frequently found in the PPI group than in the control group (35.8% vs 27.8%). After adjustment for multiple possible confounding factors, PPI users (odds ratio, 1.531; 95% confidence interval, 1.017 to 2.305) and diabetic patients had increased mortality after PEG. CONCLUSIONS PPI use may be associated with adverse outcomes in patients with PEG; however, further prospective studies investigating this issue are warranted.
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Affiliation(s)
- Jong Pil Im
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Ji Won Kim
- Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Seong Eun Kim
- Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Dong Yup Ryu
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Eun Young Kim
- Department of Internal Medicine, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Kyung Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Oppong P, Pitts N, Chudleigh V, Latchford A, Roy A, Rocket M, Lewis S. Pain and Anxiety Experienced by Patients Following Placement of a Percutaneous Endoscopic Gastrostomy. JPEN J Parenter Enteral Nutr 2014; 39:823-7. [DOI: 10.1177/0148607114551798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 08/12/2014] [Indexed: 01/12/2023]
Affiliation(s)
- Philip Oppong
- Department of Gastroenterology, Derriford Hospital, Plymouth, UK
| | - Narrie Pitts
- Department of Gastroenterology, Derriford Hospital, Plymouth, UK
| | | | | | - Amy Roy
- Department of Oncology, Derriford Hospital, Plymouth, UK
| | - Mark Rocket
- Department of Anaesthesia, Derriford Hospital, Plymouth, UK
| | - Stephen Lewis
- Department of Gastroenterology, Derriford Hospital, Plymouth, UK
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