Percutaneous endoscopic gastrostomy (PEG) - a long-term follow-up study in head and neck cancer patients

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

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

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prophylactic versus reactive percutaneous endoscopic gastrostomy in oropharyngeal squamous cell carcinoma patients undergoing radical radiotherapy

BACKGROUND

Radiotherapy (RT) for oropharyngeal squamous cell cancer (OPSCC) is associated with malnutrition due to treatment-related mucositis and dysphagia. While percutaneous endoscopic gastrostomy (PEG) feeding can improve nutrition, it has acute and late complications, including dependence on PEG feeding. We retrospectively evaluated patient outcomes by whether gastrostomy placement was prophylactic (P-G) or reactive to RT complications (R-G).

METHODS

Retrospective analysis of OPSCC patients undergoing curative-intent RT at Waikato Hospital between 2010 and 2015.

RESULTS

Of 103 OPSCC patients treated with RT (+/- chemotherapy) 21 had P-G, 15 had R-G and 67 had none (No-G). P-G patients were significantly more likely to be female, older, have higher tumour stage and receive bilateral RT (all p < 0.05). P-G and No-G patients had similar rates and duration of hospital admission for complications during treatment, but both were significantly less than in R-G patients (admission rates 52.3%, 49.3% and 86.7%, and mean length of stay 3.5, 3.3 and 11.9 days, respectively; p < 0.001). R-G patients also had greater RT treatment delays than P-G or No-G patients (mean 1.1, 0.7 and 0.4 days, respectively, p < 0.05). No significant differences were noted between groups in PEG dependence or weight change during, or 1, 3 or 6 months after, RT. Weight loss was not significantly different with P-G than R-G despite more frequent use of bilateral RT fields in the former group.

CONCLUSIONS

P-G placement affords shorter and less frequent hospital admissions than R-G during RT for OPSCC, with no increased complications or gastrostomy-dependence rates.

Post cricoid tumours; a limiting factor for percutaneous endoscopic gastrostomy insertion in cancer patients: Results from a tertiary care hospital

BACKGROUND AND STUDY AIMS

The aim of this study was to review all episodes of PEG insertion in patients with head and neck cancer (HNC) at a cancer specialist centre.

PATIENTS AND METHODS

Using a structured data extraction form, we abstracted patients' demographic data and clinical information including the primary site of tumour, TNM staging, whether PEG tube was inserted successfully, any complications resulting from PEG tube insertion and duration the tube was in place.

RESULTS

We identified a total of 339 HNC patients who had received at least one attempted PEG tube insertion. The mean age of patients was 49.5 ± 14.5 years and 66% (n: 233/339) were males. 151/ 339 (44.5%) patients had a tumour in the pharynx and nasopharynx, 103/ 339 (30.4%) in oral cavity, 81/ 339 (23.9%) in post-cricoid region and 4 (1.1%) of the patients had a laryngeal carcinoma. Histopathologically, most tumours (75.8%) were squamous cell carcinoma presenting at a T4 (52.6%), N0 (38.3%) and M0 (91.7%) stage. PEG tube was successfully inserted in 303/339 (89.4%) patients. There were 36 PEG failures; 24 (66.6%) in postcricoid and laryngeal tumours, 8 (22.3%) in pharynx/nasopharynx and 4 (11.1%) in oral cavity tumours. Of the 81 patients with post-cricoid tumour, PEG tube was successfully inserted in 57/ 81 (70.3%) of the patients. Age, gender or T stage of the tumour was not found to be statistically significant predictors of PEG failure. The only significant factor was presence of post-cricoid or laryngeal tumours that increased the risk of PEG failure 12 times (95% confidence interval: 3.4 to 42.3).

CONCLUSION

PEG tube should be used as a first line feeding option in patients with all type of head and neck cancers, however, the attending clinicians should have this foresight of higher failure rates in patients with post-cricoid tumour.

Weight Loss as a Nutritional Indicator in Head and Neck Cancer Patients Undergoing Chemoradiotherapy: Contributing Factors and Its Impact on Disease Outcome

This is a retrospective study carried out at a tertiary care cancer center to assess weight loss in patients of head and neck cancers (HNCs) during treatment with chemoradiotherapy (CRT) and study various factors affecting it. Treatment and follow-up records of 77 patients of HNCs were studied and assessed for demographic, disease-specific variables, treatment parameters, weight loss during CRT, as well as survival at 2 years after treatment completion. A statistical analysis was conducted to assess the association of study variables with weight loss. It was also assessed if a correlation existed between weight loss during treatment and patient survival at 2 years. Of the study patients, 62.3% (48) suffered 5% or more weight loss during CRT while 23.4% (18) suffered a weight loss of 10% or more. No particular factor was identified having a statistically significant association with weight loss. Nutritional impairment is an important factor affecting the morbidity and possibly the mortality of patients of HNCs undergoing CRT. More robust studies are required to identify which factors affect weight loss during treatment and whether weight loss can be used as a parameter to prognosticate patients.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prospective experience of percutaneous endoscopic gastrostomy tubes placed by otorhinolaryngologist-head and neck surgeons: safe and efficacious

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.

Pharyngocutaneous fistula as an alternative access route for inserting a percutaneous endoscopic gastrostomy tube in head and neck cancer patients

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.

Effect of prophylactic percutaneous endoscopic gastrostomy tube on swallowing in advanced head and neck cancer: A randomized controlled study

BACKGROUND

Dysphagia is common in head and neck cancer. A percutaneous endoscopic gastrostomy (PEG) tube is used to facilitate nutrition; however, some retrospective studies have indicated that the PEG tube causes dysphagia.

METHODS

A randomized study of patients with head and neck cancer was conducted with up to 10 years of follow-up. Patients were randomized to either the prophylactic PEG tube group (study group) or the common clinical nutritional support group (control group). At each follow-up, a dietician assessed the oral intake, noted the patients' weight, and if the patients used a PEG tube. Dysphagia was also assessed by the quality of life questionnaire, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 Head and Neck 35-questions (EORTC-QLQ-H&N35).

RESULTS

One hundred thirty-four patients were included in this study. There was no significant difference in swallowing function between the groups after 12 months, 24 months, and 8 years based on the EORTC-QLQ-H&N35, the oral intake scale, tube dependence, esophageal intervention, weight, body mass index (BMI), and overall survival.

CONCLUSION

A prophylactic PEG tube can be used without an increased risk of long-term dysphagia in patients with head and neck cancer. © 2017 Wiley Periodicals, Inc. Head Neck 39: 908-915, 2017.

Enteral and Parenteral Nutrition in Terminally Ill Cancer Patients: A Review of the Literature

Many terminally ill patients who are able to eat appear to be eating less than they should, losing weight, and becoming malnourished, and many others develop difficulties with eating. These symptoms and signs are usually a marker of advanced cancer, rather than the cause of decreasing functional status, and providing supplemental nutrition rarely changes the course of the disease. This article reviews evidence on issues relevant to enteral and parenteral nutrition in patients with advanced cancer, including benefits, risks, and discomforts; how these types of nutrition are used and perceived, and how decisions are made; and how decision-making might be improved.

Feasibility and Safety of Overtubes for PEG-Tube Placement in Patients with Head and Neck Cancer

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.

Palliative percutaneous endoscopic gastrostomy placement for gastrointestinal cancer: Roles, goals, and complications

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.

Head and neck cancer patients' perceptions of quality of life and how it is affected by the disease and enteral tube feeding during treatment

AIM

To explore individual quality of life in patients with head and neck cancer from diagnosis up to 3 months after termination of radiotherapy.

RESEARCH QUESTIONS

1) Which areas in life are important to quality of life, and which are influenced by the disease and by having oral or enteral nutrition; and 2) Which areas in life are influenced by having a nasogastric feeding tube (NGT) or a percutaneous endoscopic gastrostomy (PEG) tube?

MATERIAL AND METHODS

Data were collected in 36 patients. Semi-structured interviews were conducted using an extended version of the Schedule for the Evaluation of Individual Quality of Life (SEIQoL) and analysed with content analysis.

RESULTS

Negative and positive experiences of quality of life in general were about relation to family, own health, and leisure activities. Negative impacts on physical, psychological, existential and social problems, but also positive experiences are described by the patients related to the disease. More than half expressed eating-related problems. Enteral nutrition entailed negative and positive experiences, and no greater variations were described by the patients with NGT or PEG tube. Overall, there were interindividual variations.

CONCLUSIONS

The patients' perception of general or disease-related quality of life was not affected by whether they had enteral nutrition or not. From the patients' perspective neither of the two feeding tubes (NGT or PEG) was clearly in favour. We suggest that more studies are needed on how the choice of enteral feeding tube can be evidence-based, and incorporating the patients' perspective.

Clinical Factors of Enteral Tube Feeding in Acute Ischemic Stroke Patients

OBJECTIVE

The aim of this study was to identify possible clinical factors associated with enteral tube feeding use and duration in acute ischemic stroke patients.

DESIGN

The medical records of 410 acute ischemic stroke patients were reviewed. Brain lesions were classified into nine regions of interest according to the cerebral vascular system. Brain lesion volume, lesion side, National Institutes of Health Stroke Scale (NIHSS) score, type of feeding during admission, and demographic characteristics were compared between enteral tube feeding and non-enteral tube feeding groups.

RESULTS

Of the 410 patients, 61 used enteral feeding tubes. The mean age, NIHSS score, and brain lesion volume were significantly higher in the tube group than the nontube group (P < 0.001). Of the nine regions of interest, the right and left middle cerebral artery areas were strongly correlated with enteral tube feeding (P < 0.001). The NIHSS scores were significantly related to the duration of tube feeding (P < 0.05). The NIHSS consciousness subscores were significantly higher in the tube feeding group than in the non-tube feeding group (P < 0.05).

CONCLUSIONS

Older age, lesions in the middle cerebral artery territory, and larger lesions were identified as significant risk factors of enteral tube feeding. Especially, the NIHSS consciousness subscore needs to be evaluated precisely because it was the factor most closely related to the implementation and duration of enteral tube feeding.

Dysphagia in Head and Neck Cancer Patients: Pretreatment Evaluation, Predictive Factors, and Assessment during Radio-Chemotherapy, Recommendations

Progress in head and neck cancer (HNC) therapies has improved tumor response, loco-regional control, and survival. However, treatment intensification also increases early and late toxicities. Dysphagia is an underestimated symptom in HNC patients. Impairment of swallowing process could cause malnutrition, dehydration, aspiration, and pneumonia. A comprehensive literature review finalized in May 2012 included searches of electronic databases (Medline, Embase, and CAB abstracts) and scientific societies meetings materials (American Society of Clinical Oncology, Associazione Italiana Radioterapia Oncologica, Associazione Italiana di Oncologia Cervico-Cefalica, American Head and Neck Society, and European Society for Medical Oncology). Hand-searches of HNC journals and reference lists were carried out. Approximately one-third of dysphagia patients developed pneumonia requiring treatment. Aspiration pneumonia associated mortality ranged from 20% to 65%. Unidentified dysphagia caused significant morbidity, increased mortality, and decreased the quality of life. In this review we underline definition, causes, predictive factors of dysphagia and report on pretreatment and on-treatment evaluation, suggesting some key points to avoid underestimation. A multi-parameter assessment of swallowing problems may allow an earlier diagnosis. An appropriate evaluation might lead to a better treatment of both symptoms and cancer.

Weight loss in patients with head and neck cancer during and after conventional and accelerated radiotherapy

Background

Weight loss is common among patients with squamous cell carcinoma of the head and neck (SCCHN) and is mainly due to tumor and treatment related factors. The aim of the present study was to evaluate weight loss in patients with SCCHN undergoing two different radiotherapy (RT) schedules.

Material and methods

Nutritional data were analyzed from the ARTSCAN study, a controlled randomized prospective Swedish multicenter study conducted with the aim of comparing conventional fractionation (2.0 Gy per day, total 68 Gy during 7 weeks) and accelerated fractionation (1.1 + 2.0 Gy per day, total 68 Gy during 4.5 weeks). Seven hundred and fifty patients were randomized and 712 patients were followed from the start of RT in the present nutritional study.

Results

The patients had a weight loss of 11.3% (± 8.6%) during the acute phase (start of RT up to five months after the termination of RT). No difference in weight loss was seen between the two RT fractionation schedules (p = 0.839). Three factors were significantly predictive for weight loss during the acute phase, i.e. tumor site, overweight/obesity or lack of tube feeding at the start of RT. Moreover, the nadir point of weight loss occurred at five months after the termination of RT.

Conclusion

The results of the present study showed no difference in weight loss between the two RT fractionation schedules and also highlight that weight loss in SCCHN is a multifactorial problem. Moreover, the nadir of weight loss occurred at five months after the termination of treatment which calls for more intense nutritional interventions during the period after treatment.

Percutaneous endoscopic gastrostomy in cancer patients: predictors of 30-day complications, 30-day mortality, and overall mortality

BACKGROUND

Cancer patients benefit from percutaneous endoscopic gastrostomy (PEG) in many ways including nutritional support and venting in cases of malignant obstruction. Lack of high-quality studies with adequate follow-up has led to limited information regarding risk stratification and predictors of morbidity and mortality.

AIMS

Elucidate predictors of complications and mortality with long-term follow-up in cancer patients undergoing PEG.

METHOD

Retrospective review of all patients undergoing PEG placement at MD Anderson Cancer Center from January 1, 2004 to December 31, 2006. Statistical analysis included descriptive statistics, Kaplan-Meier survival estimates, and Cox proportional hazards regression analyses.

RESULTS

A total of 218 subjects underwent PEG. Those with American Society of Anesthesiology (ASA) scores of 4, 4E, or 5E were at significant risk of a major complication in the first 30 days. Multivariate analysis revealed ASA scores ≥4, elevated WBC count, and advanced tumor stage to be independent predictors of mortality in the first 30 days and INR >1.5 and diversion/venting as an indication for PEG placement to be independent predictors of overall mortality.

CONCLUSIONS

Patients with high baseline illness severity are more likely to have complications and are at increased risk of mortality after PEG. Our study results suggest that particular attention be directed to ASA score, INR, WBC counts, transfusion requirements, presence of advanced malignancies, and the indication for PEG placement when determining risk of complications or death. Patients undergoing venting PEG are expected to have short post-PEG survival but improvement in quality of life likely justifies the risks associated with PEG placement.

Nasogastric and percutaneous endoscopic gastrostomy tube use in advanced head and neck cancer patients: a comparative study

To compare the efficacy of percutaneous endoscopic gastrostomy (PEG) and nasogastric (NGT) tube administration of enteral nutrition in head and neck cancer patients undergoing curative treatment, the authors conducted a prospective study to compare nutritional outcomes, complications, and patient satisfaction. PEG patients sustained significantly less reduction in nutritional parameters, measured at 6 weeks post insertion, as compared with NGT patients. There was also a statistically significant difference between the two groups in patient's quality of life scores and complications. Comparison could not be done at 6 months because all patients were converted to PEG feeding due to the earlier findings. The authors conclude that PEG is more efficacious than NGT as a channel for nutrition in advanced head and neck cancer patients over a short duration.

Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010.For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established.

OBJECTIVES

To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications.

SEARCH METHODS

Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012.

SELECTION CRITERIA

Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information.

MAIN RESULTS

One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012.Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study.Weight loss was greater for the NG group at six weeks post-treatment than for the PEG group (P = 0.001). At six months post-treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post-treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively.We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review.

AUTHORS' CONCLUSIONS

There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required.

Percutaneous endoscopic gastrostomy in oropharyngeal cancer patients treated with intensity-modulated radiotherapy with concurrent chemotherapy

BACKGROUND

The clinical benefit of routine placement of prophylactic percutaneous endoscopic gastrostomy (pPEG) tubes was assessed in patients with oropharyngeal cancer (OPC) who are undergoing intensity-modulated radiotherapy (IMRT) with concurrent chemotherapy.

METHODS

From 1998 through 2009, 400 consecutive patients with OPC who underwent chemoradiation were included. Of these, 325 had a pPEG and 75 did not (nPEG). Weight and albumin change from baseline to mid-IMRT, end of IMRT, 1 month post-IMRT, and 3 months post-IMRT were evaluated. The treating physicians prospectively recorded acute and late toxicities.

RESULTS

Significantly lower absolute weight loss at end of IMRT (6.80 kg vs 8.38 kg, P = .007), 1 month post-IMRT (9.06 kg vs 11.33 kg, P = .006), and 3 months post-IMRT (11.10 kg vs 13.09 kg, P = .044) was noted in the pPEG versus nPEG groups. This benefit in reduction of percent weight loss was consistently significant only among patients with BMI < 25. Significant differences were noted in hospital admission rate (15.1% vs 26.7%, P = .026) and volume of nonchemotherapy hydration (8.9 liters vs 17.2 liters, P = .004). There were no differences in percent albumin change, acute dysphagia, acute mucositis, acute xerostomia, chronic dysphagia, radiation treatment duration, and overall survival. Multivariate analysis noted age >55 years (P < .001), female sex (P < .001), and T3/4 category disease (P < .001) were significantly associated with prolonged PEG use.

CONCLUSIONS

Although pPEG reduced absolute and percent weight loss and need for hospitalizations in our cohort of patients with OPC undergoing chemoradiation, no differences were noted in radiation treatment duration, toxicity, and overall survival. Prolonged PEG use correlated with age >55 years, female sex, and T3/T4 tumors.

Prophylactic percutaneous endoscopic gastrostomy tube placement in treatment of head and neck cancer: a comprehensive review and call for evidence-based medicine

BACKGROUND

Patients with head and neck cancers (HNCs) are at increased risk of experiencing malnutrition, which is associated with poor outcomes. Advances in the treatment of HNCs have resulted in improved outcomes that are associated with severe toxic oral side effects, placing patients at an even greater risk of malnutrition. Prophylactic placement of percutaneous endoscopic gastrostomy (PEG) tubes before treatment may be beneficial in patients with HNC, especially those undergoing more intense treatment regimens. PEG tube placement, however, is not without risks.

METHODS

A comprehensive review of the literature was conducted.

RESULTS

Systematic evidence assessing both the benefits and harm associated with prophylactic PEG tube placement in patients undergoing treatment for HNC is weak, and benefits and harm have not been established.

CONCLUSIONS

More research is necessary to inform physician behavior on whether prophylactic PEG tube placement is warranted in the treatment of HNC.

Prophylactic feeding tubes for patients with locally advanced head-and-neck cancer undergoing combined chemotherapy and radiotherapy-systematic review and recommendations for clinical practice

GOALS

This work aimed to determine the benefits and risks of prophylactic feeding tubes for adult patients with squamous cell carcinoma of the head and neck who receive combined chemotherapy and radiotherapy with curative intent and to make recommendations on the use of prophylactic feeding tubes and the provision of adequate nutrition to this patient population.

METHODS

A national multidisciplinary panel conducted a systematic review of the evidence and formulated recommendations to guide clinical decision-making. The draft evidence summary and recommendations were distributed to clinicians across Canada for their input.

MAIN RESULTS

No randomized controlled trials have directly addressed this question. Evidence from studies in the target population was limited to seven descriptive studies: two with control groups (one prospective, one retrospective) and five without control groups. Results from ten controlled studies in patients treated with radiotherapy alone were also reviewed.

CONCLUSIONS

The available evidence was insufficient to draw definitive conclusions about the effectiveness of prophylactic feeding tubes in the target patient population or to support an evidence-based practice guideline. After review of the evidence, of guidelines from other groups, and of current clinical practice in Canada, the multidisciplinary panel made consensus-based recommendations regarding comprehensive interdisciplinary clinical care before, during, and after cancer treatment. The recommendations are based on the expert opinion of the panel members and on their understanding of best clinical practice.

Nutritional surveillance and weight loss in head and neck cancer patients

PURPOSE

This retrospective single-institution cohort study aims to evaluate if therapeutic approach, tumour site, tumour stage, BMI, gender, age and civil status predict body weight loss and to establish the association between weight loss on postoperative infections and mortality.

METHODS

Consecutive patients with head and neck cancer were seen for nutritional control at a nurse-led outpatient clinic and followed-up for 2 years after radiotherapy. Demographic, disease-specific and nutrition data were collected from case records. The primary outcome measure was maximum body weight loss during the whole study period.

RESULTS

The nadir of body weight loss was observed 6 months after radiotherapy. In total, 92 patients of 157 (59%) with no evidence of residual tumour after treatment received enteral nutrition. The mean maximum weight loss for patients receiving enteral nutrition and per oral feeding was 13% and 6%, respectively (p < 0.001). Using multivariate analysis, tumour stage (p < 0.001) was the only independent factor of maximum weight loss. Weight loss was not significantly related to risk for postoperative infection.

CONCLUSIONS

Weight loss is frequently noted among head and neck cancer patients during and after treatment. Weight loss was not found to be associated with postoperative infections and mortality. Nutritional surveillance is important in all patients, but special attention should be given to those on enteral nutrition and those with more advanced disease.

Use of gastrostomy in head and neck cancer: a systematic review to identify areas for future research

OBJECTIVES

To perform a systematic review of studies, which investigate the role of gastrostomy tube feeding in head and neck squamous cell cancer.

DESIGN

A systematic review of the English literature, identifying areas of clinical equipoise and recommendations for future studies.

MAIN OUTCOME MEASURES

Varying practices in G-tube use in HNSCC, the benefits and disadvantages of G-tubes, the effect of G-tube placement on multidimensional outcomes in patients with head and neck cancer, including quality of life and health economics and to draw themes that may lend themselves to future research.

RESULTS

The search identified 216 articles of which 59 were considered relevant. During treatment, a significant number of patients need enteral nutritional supplementation through nasogastric or G-tubes. Gastrostomy tubes have a good safety profile. Most clinicians agree that the use should be restricted to advanced tumours. Studies on prophylactic insertion of G-tubes do not show a consistent advantage to the nutritional status compared with NG tubes. At 1 year, G-tube retention rates vary between 10% and 30%. The presence of a feeding tube has a negative impact on quality of life. Placing G-tubes may have an adverse effect on swallowing after chemoradiation.

CONCLUSIONS

There is a lack of consensus among clinicians about indications for placing G-tubes. There is sufficient equipoise in this area for further investigation of the effect of varying feeding practices on functional outcomes, quality of life and health economics.

The practice of gastrostomy tube placement across a Canadian regional health authority

OBJECTIVES

We sought to conduct an assessment of the practice of gastrostomy (G) tube placement across an entire city, which would reflect usual clinical care as compared with referral center practice.

METHODS

We reviewed and retrospectively extracted data from patient records for all percutaneous endoscopic G (PEG) and radiological percutaneous G (RPG) tube placements at six Winnipeg hospitals between 1 April 2005 and 31 March 2007.

RESULTS

A total of 418 patients had G tubes (376 PEG, 42 RPG) inserted during the study period. The most common indications were cerebrovascular accidents (25%), head and neck cancer (23%), and head trauma (10%). The position of the external bolster was not documented in 38% of patients. The median time to the first complication was 10 days, initiation of feeding was 48 hours, and tube removal was 40 days. Complications developed in 102 (24%) patients. Patients with RPG tubes had more infections and were less likely to receive prophylactic antibiotics (P<0.001). In multivariate analysis, complications were more likely to occur in patients with RPG tubes and after insertions by lowest procedure volume physicians. Overall mortality was 12% within 30 days of G-tube placement. Death of one patient was directly related to peritonitis after G-tube insertion.

CONCLUSIONS

In usual clinical practice, there is an underuse of prophylactic antibiotics and a delay in the institution of nutritional support after G-tube placement. A small but significant proportion of patients may develop major complications, with associated risk of mortality. The higher complication rate after procedures performed by lowest volume physicians needs further evaluation.

Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy

BACKGROUND

For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established.

OBJECTIVES

To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications.

SEARCH STRATEGY

Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was May 2009.

SELECTION CRITERIA

Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information.

MAIN RESULTS

One randomised controlled trial was eligible for inclusion in this review. However, a high degree of bias was identified in the study.Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual.Weight loss was greater for the NG group at six weeks post-treatment than for the PEG group (P = 0.001). At six months post-treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post-treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively.We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review.

AUTHORS' CONCLUSIONS

There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required.

Prospective study of percutaneous endoscopic gastrostomy tubes versus nasogastric tubes for enteral feeding in patients with head and neck cancer undergoing (chemo)radiation

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes have largely replaced nasogastric tubes (NGTs) for nutritional support of patients with head and neck cancer undergoing curative (chemo) radiotherapy without any good scientific basis.

METHODS

A prospective study was conducted to compare PEG tubes and NGTs in terms of nutritional outcomes, complications, patient satisfaction, and cost.

RESULTS

There were 32 PEG and 73 NGT patients. PEG patients sustained significantly less weight loss at 6 weeks post-treatment (median 0.8 kg gain vs 3.7 kg loss, p < .001), but had a high insertion site infection rate (41%), longer median duration of use (146 vs 57 days, p < .001), and more grade 3 dysphagia in disease-free survivors at 6 months (25% vs 8%, p = .07). Patient self-assessed general physical condition and overall quality of life scores were similar in both groups. Overall costs were significantly higher for PEG patients.

CONCLUSION

PEG tube use should be selective, not routine, in this patient population.

Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis

OBJECTIVES

To measure morbidity and mortality rates following insertion of gastrostomy tubes in head and neck cancer patients. To determine evidence for any relationship between gastrostomy insertion technique and complication rates.

DESIGN

A prospective cohort study and qualitative systematic review.

SETTING

Multi-cancer networks in the South West of England, Hampshire and the Isle of White.

PARTICIPANTS

One hundred and seventy-two patients with head and neck cancer undergoing gastrostomy tube insertion between 2004 and 2005. Percutaneous endoscopic gastrostomy (PEG) was performed in 121 patients. Fifty-one patients had radiologically inserted gastrostomy (RIG). Twenty-seven studies reporting outcomes following 2353 gastrostomy procedures for head and neck cancer.

MAIN OUTCOME MEASURES

Post-procedure mortality, major and minor complications.

RESULTS

In the present series, mortality rates were 1.0% (1/121) for PEG and 3.9% (2/51) for RIG. Overall major complication rates following PEG and RIG were 3.3% (4/121) and 15.6% (9/51) respectively. In our systematic review and meta-analysis of 2379 head and neck cancer patients, we observed fatality rates of 2.2% (95% CI 0.014-0.034) following PEG and 1.8% (95% CI 0.010-0.032) following RIG. Furthermore, major complication rates following PEG were 7.4% (95% CI 5.9-9.3%) and 8.9% (95% CI 7.0-11.2%) after RIG.

CONCLUSIONS

Procedure related mortality rates following gastrostomy in head and neck cancer patients are higher than those in mixed patient populations. Major complication rates following RIG in head and neck cancer patients are greater than those following PEG. Major complications following PEG in patients with head and neck cancer appear no worse than in mixed pathology groups. We have identified that RIG is associated with increased morbidity and mortality in patients who are ineligible for PEG. The serious nature of the complications associated with gastrostomy particularly in patients with head and neck cancer requires careful consideration by the referring physician.

Randomized study of percutaneous endoscopic gastrostomy versus nasogastric tubes for enteral feeding in head and neck cancer patients treated with (chemo)radiation

Percutaneous endoscopic gastrostomy (PEG) tubes have largely replaced nasogastric tubes (NGT) for nutritional support of patients with head and neck cancer undergoing curative (chemo)radiotherapy without any good scientific basis. A randomized trial was conducted to compare PEG tubes and NGT in terms of nutritional outcomes, complications, patient satisfaction and cost. The study was closed early because of poor accrual, predominantly due to patients' reluctance to be randomized. There were 33 patients eligible for analysis. Nutritional support with both tubes was good. There were no significant differences in overall complication rates, chest infection rates or in patients' assessment of their overall quality of life. The cost of a PEG tube was 10 times that of an NGT. The duration of use of PEG tubes was significantly longer, a median 139 days compared with a median 66 days for NGT. We found no evidence to support the routine use of PEG tubes over NGT in this patient group.

Clinical experience of percutaneous endoscopic gastrostomy in Taiwanese patients--310 cases in 8 years

Although percutaneous endoscopic gastrostomy (PEG) has become a popular method for long-term tube feeding worldwide, there are only a few reports about its application in Taiwan. From May 1997 to May 2005, we performed 302 PEG insertions successfully in 310 attempts (97.4% success rate) using modified Ponsky's pull method with 24-Fr feeding tubes. All the patients received PEG for tube feeding except for two patients with cancerous peritonitis for decompression. The underlying diseases in these 308 patients who received PEG for tube feeding were 161 cerebrovascular accidents (52.3%), 62 head and neck cancers (20.1%), 21 cases of Parkinsonism (6.8%), and others. There were 11 major complications (3.6%) and 57 minor complications (18.9%). Ten patients (3.3%) died within 30 days after PEG insertion. However, no procedure-related mortality occurred. In conclusion, PEG is an effective method for tube feeding and drainage with a high success rate. PEG insertion was often indicated for patients with dysphagia caused by cerebrovascular accident, head and neck cancer, and Parkinsonism in Taiwan. It is a relatively safe procedure, with a 3.6% rate of major complications and 18.9% rate of minor complications.

Effect of oral nutritional supplementation on weight loss and percutaneous endoscopic gastrostomy tube rates in patients treated with radiotherapy for oropharyngeal carcinoma

GOALS

Malnutrition in the head and neck cancer population is a widely recognized factor contributing to negative outcomes. The goal of this study was to determine if providing complimentary oral nutritional supplementation for patients undergoing definitive radiation therapy for oropharyngeal carcinoma reduced weight loss and the need for percutaneous endoscopic gastrostomy (PEG) tube placement.

MATERIALS AND METHODS

The data from 79 patients undergoing radiotherapy for oropharyngeal cancer were extracted and analyzed retrospectively from an institutional Human Investigation Committee approved database for the study of advanced radiation therapy techniques for head and neck cancer. Forty patients were treated before the initiation of a nutritional supplementation program, and 39 patients received supplementation. Patients were stratified by type of treatment (radiation alone or chemoradiation) and whether or not they had a PEG tube.

RESULTS

All patient groups receiving supplementation manifested a significant decrease in weight loss compared to those who did not receive it. Nutritional supplementation was associated with a 40% relative reduction in weight loss in patients treated with radiotherapy alone (6.1 vs 10.1%, p = 0.008) and a 37% reduction in weight loss in patients treated with chemoradiotherapy (6.7 vs 10.7%, p = 0.007). When patients were stratified by the presence or absence of a PEG tube, both groups experienced a 39% relative reduction in weight loss (with PEG, 5.7 vs 9.3%, p = 0.028; without PEG, 6.9 vs 11.2%, p = 0.002). Supplementation was associated with a decreased need for PEG tube placement (31% decreased to 6%) in patients treated with radiotherapy alone.

CONCLUSIONS

Providing complimentary oral nutritional supplementation significantly decreases weight loss and the need for PEG tube placement in patients undergoing radiation therapy for oropharyngeal cancer.

Patients experience with long-term percutaneous endoscopic gastrostomy feeding following primary surgery for oral and oropharyngeal cancer

Percutaneous endoscopic gastrostomy feeding (PEG) has an important role in providing nutritional support in selected patients undergoing treatment for oral and oropharyngeal cancer. Although morbidity data have been published there is very little from the patient perspective. The aim of this project was to devise, pilot and survey a PEG specific questionnaire and relate outcomes to health-related quality of life. A cross-sectional survey was conducted in April 2005 of patients who were alive and disease free and treated by primary surgery for oral and oropharyngeal squamous cell carcinoma between 1992 and June 2004. The survey comprised the University of Washington Quality of Life questionnaire and a 24 item PEG questionnaire. Of 344 alive and disease free patients, 243 (71%) responded. Clinical characteristics of responders and non responders were similar. Mean age of responders was 65 (SD 12) and 59% were male. There were 193 (79%) patients who never had a PEG as part of their treatment, 30 (12%) who had their PEG removed (median 7 months), and 20 (8%) who still had a PEG (median 34 months). Patients with PEGs reported significant deficits in all UW-QOL domains compared to non-PEG or PEG-removed patients and also reported a much poorer quality of life. The major PEG related problems were not those of discomfort, leakage or blockage, but interference with family life, intimate relationships, social activities, and hobbies. More can be done to counsel and support patients with long-term PEG placement.

The introducer technique is the optimal method for placing percutaneous endoscopic gastrostomy tubes in head and neck cancer patients

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes are often placed in head and neck cancer patients to provide nutritional support, but studies have found the complication rates to be higher than other subsets of patients who undergo PEG placement. Complication rates as high as 50% have been reported, with the bulk of these complications being PEG site issues (i.e., cellulitis, abscess, fascitis, and tumor implantation). Because the pull technique has been the primary technique used, the theory is that the transoral tube passage is the source of the complications in these patients. Alternatively, the introducer technique uses a transabdominal approach to place the device, avoiding any tube contamination by upper aerodigestive organisms or tumor cells. At our institution, this technique has been used exclusively for head and neck cancer patients and this article reports our experience.

METHODS

One hundred forty-nine head and neck cancer patients who had a prophylactic PEG tube placed were reviewed from January 1, 1999 to December 31, 2003. The rates of placement success, morbidity, and complications were determined.

RESULTS

Successful placement was achieved in 148 (99%) patients without any PEG-related deaths. Overall, 17 complications (11%) occurred, with only one major complication (0.7%) identified. PEG site infections were uncommon with only five cases (3.4%) and all were mild cellulitis.

CONCLUSIONS

The introducer technique is the safest method for PEG tube placement in head and neck cancer patients. The overall rate of complications is low and PEG site infectious complications are rare. The introducer technique should be the method of choice for PEG tubes in head and neck cancer patients.

Complication rate lower after percutaneous endoscopic gastrostomy than after surgical gastrostomy: a prospective, randomized trial

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has increasingly replaced surgical gastrostomy (SG) as the primary procedure for the long-term nutrition of patients with swallowing disorders. This prospective randomized study compares PEG with SG in terms of effectiveness and safety.

METHODS

This study enrolled 70 patients with swallowing disorders, mainly attributable to neurologic impairment. All the patients, eligible for both techniques, were randomized to PEG (pull method) or SG. The groups were comparable in terms of age, body mass index, and underlying diseases. Complications were reported 7 and 30 days after the operative procedure.

RESULTS

The procedures were successfully completed for all the patients. The median operative time was 15 min for PEG and 35 min for SG (p < 0.001). The rate of complications was lower for PEG (42.9%) than for SG (74.3%; p < 0.01). The 30-day mortality rates were 5.7% for PEG and 14.3% for SG (nonsignificant difference).

CONCLUSION

The findings show PEG to be an efficient method for gastrostomy tube placement with a lower complication rate than SG. In addition, PEG is faster to perform and requires fewer medical resources. The authors consider PEG to be the primary procedure for gastrostomy tube placement.