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.

Percutaneous endoscopic gastrostomy and jejunostomy: Indications and techniques

Nutritional support is essential in patients who have a limited capability to maintain their body weight. Therefore, oral feeding is the main approach for such patients. When physiological nutrition is not possible, positioning of a nasogastric, nasojejunal tube, or other percutaneous devices may be feasible alternatives. Creating a percutaneous endoscopic gastrostomy (PEG) is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk. Many diseases require nutritional support by PEG, with neurological, oncological, and catabolic diseases being the most common. PEG can be performed endoscopically by various techniques, radiologically or surgically, with different outcomes and related adverse events (AEs). Moreover, some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent. These conditions highlight many ethical problems that become difficult to manage as treatment progresses. The aim of this manuscript is to review all current endoscopic techniques for percutaneous access, their indications, postprocedural follow-up, and AEs.

Assessment of the effect of colored beverage on gastric returns after gastric tube replacement to enhance placement verification

BACKGROUND

Verification of appropriate placement of newly replaced gastrostomy tubes is essential prior to use to avoid potentially serious adverse events.

PROBLEM

A lack of standardized guidance regarding effective and practical means to verify placement exists. Aspiration or drainage of gastric-like contents is one mean suggested to help determine placement, yet when returns are minimal, this becomes challenging.

MATERIALS, METHOD, INTERVENTION

Oral ingestion or the instillation of a colored beverage prior to tube replacement was used in a midwestern healthcare clinical setting to enhance returns in both volume and color via the newly replaced gastrostomy tube. A retrospective review of this practice was conducted, which included 176 gastric tube replacements over 4 years.

RESULTS

A significant increase in volume of returns via the newly replaced tube was noted (P < .001) and a strong correlation of color to the ingested or consumed beverage was found with 95% of returns reflecting color tinting of the beverage or in many cases, strong color change to that of the beverage color.

CONCLUSION

Presented is a simple, cost-effective method that has shown to be clinically useful in assessing placement of newly replaced gastrostomy tubes that may be useful in other practices and settings.

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.

Endoscopic management of enteral tubes in adult patients - Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.

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.

Alexis St. Martin Gastropexy: A Novel Technique for Gastropexy During Percutaneous Endoscopic Gastrostomy Tube Placement

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a preferred method of long-term enteral nutritional support. Despite its ease of placement, it has a 4% major complication rate, requiring surgical intervention or hospitalization. Early PEG tube dislodgment can cause peritonitis, requiring emergent laparotomy at significant morbidity and cost. T-fasteners have been used as an adjunct gastropexy, but nearly one third migrate into the abdominal wall within the first 2 weeks. We describe a low-cost, minimally invasive technique using widely available surgical instruments to appose the gastric and abdominal walls.

METHODS

All PEG procedures were performed in our 60-bed surgical intensive care unit. Institutional IRB approval was obtained along with procedure specific consent for all patients. The adjunctive gastropexy procedure was performed on four patients at high risk for early PEG tube dislodgment. Following routine PEG tube placement, both ends of four 2-0 polyglactin ties were brought through the gastric and abdominal walls through separate stab incisions adjacent to the PEG tube exit site in the 3, 6, 9, and 12 o'clock positions. These were tied in the subcutaneous tissue, securing the gastric wall to the abdominal wall.

RESULTS

No PEG tube complications occurred. All patients were discharged to long-term care facilities with PEG tubes intact or electively removed.

CONCLUSIONS

We describe the results of a pilot study for a cost-effective, easily implementable, adjunct technique, named after the namesake of our institution, to decrease the incidence and severity of complications associated with PEG tube dislodgment. It was used in 4 patients at high risk for PEG tube dislodgment with satisfactory early results in all 4. Further recruitment of larger numbers of patients using this technique is ongoing to determine if this technique is truly effective at reducing PEG tube complications.

Risk of tumor implantation in percutaneous endoscopic gastrostomy in the upper aerodigestive tumors

Percutaneous endoscopic gastrostomy (PEG) has become a mainstay in providing enteral access for patients with obstructive head, neck and esophageal tumors. Tumor cell implantation is a rare complication in patients with aerodigestive cancers, who have undergone PEG tube placement. The objective of this review is to determine the incidence and contributing risk factors leading to the implantation of metastases into the abdominal wall following PEG placement. A comprehensive review of the literature in PUBMED (2008-2018) was performed. The literature search revealed reports of more than 50 cases of abdominal wall metastases after PEG placement. As most of these studies were case reports, the exact rate of metastasis remains unknown. Generally pharyngoesophageal location of primary cancer (100%), squamous cell histology (98%), poorly differentiated tumor cells (92%), advanced pathological stage (97%), and large primary cancer size were identified as strong risk factors for the development of stomal metastasis. Abdominal wall metastases following PEG placement are a rare but serious complication in patients with head and neck malignancy. (www.actabiomedica.it)

Head and Neck Cancer Tumor Seeding at the Percutaneous Endoscopic Gastrostomy Site

The National Institutes of Health National Cancer Institute estimates that over 13,000 new cases of head and neck cancer (HNC) will be diagnosed in 2017. Patients with HNC often require enteral nutrition (EN) via gastrostomy tube to provide nutrition support and hydration because of tumor obstruction of the oropharynx and/or cumulative effects of chemoradiation therapy. The percutaneous endoscopic gastrostomy (PEG) tube has become the preferred technique for EN access because placement is considered a minimally invasive procedure. There are 3 methods of PEG placement: Gauderer-Ponsky "pull," Sachs-Vine "push," and Russell "push" method. The Gauderer-Ponsky "pull" method has become the preferred method of PEG placement. It has been previously reported that the rate of stomal metastasis can be 0.5%-1% of those undergone the Gauderer-Ponsky "pull" method that is consistent with HNC morphology. Other researchers believe the rate may be as high as 0.5%-3%. This article reviews the 3 methods of PEG placement, as well as all potential complications, including metastatic seeding at the PEG site. In addition, 1 additional case of tumor seeding at the PEG site will be reviewed. Consideration for avoidance of the Gauderer-Ponsky pull method of PEG placement or other methods of feeding tube placement where the gastrostomy tube has to pass through the oral cavity before exiting the abdominal wall in patients with squamous cell carcinoma of the head and neck should be considered.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

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

BACKGROUND AND STUDY AIMS

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Percutaneous endoscopic gastrostomy with Funada-style gastropexy greatly reduces the risk of peristomal infection

BACKGROUND AND AIMS

Peristomal wound infections are common complications of percutaneous endoscopic gastrostomy (PEG). The Funada-style gastropexy device has two parallel needles with a wire loop and suture thread, and was developed about 20 years ago in Japan. This kit has allowed us to perform dual gastropexy very easily; PEG with gastropexy has become a very popular technique in Japan. The present study aimed to compare the advantages and disadvantages of PEG with the gastropexy technique with the standard 'pull' method.

METHODS

We retrospectively reviewed 182 consecutive, non-randomized patients undergoing PEG in our hospital, and a comparative analysis was made between the gastropexy (87 patients) and non-gastropexy (95 patients) groups.

RESULTS

The rates of patients having erythema (11.6% vs. 47.9%; P < 0.001), exudates (2.3% vs. 14.9%; P < 0.01) and infection (0% vs. 6.4%; P = 0.01) in the peristomal area were lower in the gastropexy than in the non-gastropexy group. The rate of minor bleeding from the peristomal area was higher in the gastropexy than in the non-gastropexy group (12.8% vs. 2.1%; P < 0.01), but no patient required a blood transfusion. Mean procedure time was longer in the gastropexy group than in the non-gastropexy group (31 vs. 24 min; P < 0.001). The 30-day mortality rates were 4.7% and 5.3% respectively, and these deaths were not related to the gastrostomy procedure.

CONCLUSION

PEG with gastropexy markedly reduces peristomal inflammation. Although minor bleeding and a longer procedure time were disadvantages, there were no severe complications. The findings suggested that PEG with Funada-style gastropexy was a safe and feasible method for reducing early complications of PEG.

Gastroenteric tube feeding: Techniques, problems and solutions

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction, and patients who are critically ill. However, despite the benefits and widespread use of enteral tube feeding, some patients experience complications. This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding, together with associated complications and special aspects. We conducted an extensive literature search on PubMed, Embase and Medline using index terms relating to enteral access, enteral feeding/nutrition, tube feeding, percutaneous endoscopic gastrostomy/jejunostomy, endoscopic nasoenteric tube, nasogastric tube, and refeeding syndrome. The literature showed common routes of enteral access to include nasoenteral tube, gastrostomy and jejunostomy, while complications fall into four major categories: mechanical, e.g., tube blockage or removal; gastrointestinal, e.g., diarrhea; infectious e.g., aspiration pneumonia, tube site infection; and metabolic, e.g., refeeding syndrome, hyperglycemia. Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route, gastrointestinal complications are without doubt the most common. Complications associated with enteral tube feeding can be reduced by careful observance of guidelines, including those related to food composition, administration rate, portion size, food temperature and patient supervision.