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Shah A, Busch RA, Koepsel EK, Eisa M, Woods M, Palchaudhuri S. Who Places Feeding Tubes and in What Scenario? Curr Gastroenterol Rep 2023:10.1007/s11894-023-00880-x. [PMID: 37452152 DOI: 10.1007/s11894-023-00880-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE OF REVIEW Enteral feeding is commonly used to provide patients with nutrition. Access via feeding tubes can be attained by multiple medical specialties through a variety of methods. RECENT FINDINGS There are limited data available on direct comparisons amongst gastroenterologist, interventional radiologists and surgeons, although there appears to be similar rates of complications. Fluroscopically and surgically placed feeding tubes may have a higher technical success rate than endoscopically placed tubes. The preferred specialty for feeding tube placement varies per institution, often due to logistical matters over technique or concern for complications. Ideally, a multidisciplinary team should exist to determine which approach is best in a patient-specific manner.
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Affiliation(s)
- Apeksha Shah
- Division of Gastroenterology and Hepatology, Cooper University Healthcare, Camden, NJ, USA.
- Division of Gastroenterology, Cooper Medial School of Rowan University (CMSRU), Cooper University Hospital, Camden, NJ, USA.
| | - Rebecca A Busch
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Erica Knavel Koepsel
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Mohamed Eisa
- Allegheny Center for Digestive Health, Allegheny Health Network, Pittsburgh, PA, USA
| | - Michael Woods
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sonali Palchaudhuri
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
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Siu J, Fuller K, Nadler A, Pugash R, Cohen L, Deutsch K, Enepekides D, Karam I, Husain Z, Chan K, Singh S, Poon I, Higgins K, Xu B, Eskander A. Metastasis to gastrostomy sites from upper aerodigestive tract malignancies: a systematic review and meta-analysis. Gastrointest Endosc 2020; 91:1005-1014.e17. [PMID: 31926149 DOI: 10.1016/j.gie.2019.12.045] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/26/2019] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Jennifer Siu
- Department of Otolaryngology-Head and Neck Cancer Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kaitlin Fuller
- Gerstein Science Information Centre, University of Toronto Libraries, Toronto, Ontario, Canada
| | - Ashlie Nadler
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Robyn Pugash
- Vascular/Interventional Radiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lawrence Cohen
- Division of Gastroenterology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Konrado Deutsch
- Department of Otolaryngology-Head and Neck Cancer Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Danny Enepekides
- Department of Otolaryngology-Head and Neck Cancer Surgery, University of Toronto, Toronto, Ontario, Canada; Head & Neck Surgical Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Irene Karam
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin Chan
- Division of Medical Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Canadian Centre for Applied Research in Cancer Control, Toronto, Canada
| | - Simron Singh
- Division of Medical Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ian Poon
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin Higgins
- Department of Otolaryngology-Head and Neck Cancer Surgery, University of Toronto, Toronto, Ontario, Canada; Head & Neck Surgical Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Bin Xu
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Cancer Surgery, University of Toronto, Toronto, Ontario, Canada; Head & Neck Surgical Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Otolaryngology-Head & Neck Surgery, Surgical Oncology, Michael Garron Hospital, Toronto, Ontario, Canada; Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Science, Toronto, Ontario, Canada
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Siddique MZ, Mehmood S, Ismail M, Yasmeen A, Asad-Ur-Rehman, Abu Bakar M, Khattak S, Syed AA, Yusuf MA. Pre-operative percutaneous endoscopic gastrostomy tube placement does not increase post-operative complications or mortality in oesophageal cancer. J Gastrointest Oncol 2019; 10:492-498. [PMID: 31183199 DOI: 10.21037/jgo.2019.03.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background The percutaneous endoscopic gastrostomy (PEG) tube in patients with oesophageal cancer is controversial, owing to a perceived risk of tumour seeding at the PEG site, theoretical difficulty in formation of gastric conduit during oesophagectomy and a fear of increased post-operative complications, including anastomotic leak. We aimed to assess the impact of PEG tubes on nutritional status and post-operative complications in patients with oesophageal cancer who underwent PEG tube insertion prior to neo-adjuvant treatment. Methods We performed a retrospective review of 800 patients with oesophageal or gastro oesophageal junction (GOJ) cancer, who underwent PEG insertion from June, 2010 to May, 2015. Out of these, 168 patients who fulfilled the inclusion criteria were analysed further. All of them were followed up for 3 years after treatment to assess overall survival. Thus, the follow up of the last patient included in the study was completed on May, 31, 2018. Results The average body mass index (BMI) of patients was maintained following PEG tube, during neo-adjuvant treatment (22.34±4.84 before PEG vs. 21.85±3.90 after PEG, P value: 0.1). Out of 168 patients, 33 (19.7%) developed a complication following PEG tube, with PEG site infection as the most common in 24 (14.2%). PEG-related mortality at 1 month was 0%. Ninety out of 168 patients (59%) underwent surgery after neo-adjuvant treatment. Three patients had tumour seeding at the PEG site and thus surgery could not be performed. Gastric conduit formation was possible in all 99 patients. Postoperative complications were seen in 17/99 (17%) patients, including surgical site infections in 7 (7.07%), anastomotic leak in 6 (6.06%) and anastomotic stricture in 4 (4.04%). Overall survival at 3 years was 87%. Conclusions Pre-operative PEG tube in oesophageal cancer is safe and does not compromise the future anastomosis. Also, it helps in maintaining the nutritional status during neo-adjuvant treatment.
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Affiliation(s)
- M Zeeshan Siddique
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital & Research Center (SKMCH & RC), Lahore, Pakistan
| | - Shafqat Mehmood
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital & Research Center (SKMCH & RC), Lahore, Pakistan
| | - Muhammad Ismail
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital & Research Center (SKMCH & RC), Lahore, Pakistan
| | - Ammara Yasmeen
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital & Research Center (SKMCH & RC), Lahore, Pakistan
| | - Asad-Ur-Rehman
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital & Research Center (SKMCH & RC), Lahore, Pakistan
| | - Muhammad Abu Bakar
- Department of Cancer Registry & Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital & Research Center (SKMCH & RC), Lahore, Pakistan
| | - Shahid Khattak
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital & Research Center (SKMCH & RC), Lahore, Pakistan
| | - Aamir Ali Syed
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital & Research Center (SKMCH & RC), Lahore, Pakistan
| | - M Aasim Yusuf
- Department of Internal Medicine, Shaukat Khanum Memorial Cancer Hospital & Research Center (SKMCH & RC), Lahore, Pakistan
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Vincenzi F, De Caro G, Gaiani F, Fornaroli F, Minelli R, Leandro G, Di Mario F, De' Angelis GL. Risk of tumor implantation in percutaneous endoscopic gastrostomy in the upper aerodigestive tumors. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:117-121. [PMID: 30561429 PMCID: PMC6502208 DOI: 10.23750/abm.v89i8-s.7894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Indexed: 01/25/2023]
Abstract
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)
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Affiliation(s)
- Francesca Vincenzi
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
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Molina Villalba C, Vázquez Rodríguez JA, Gallardo Sánchez F. Percutaneous endoscopic gastrostomy. Indications, care and complications. Med Clin (Barc) 2018; 152:229-236. [PMID: 30424936 DOI: 10.1016/j.medcli.2018.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 02/08/2023]
Abstract
Percutaneous endoscopic gastrostomy (PEG) is an effective and safe method for nutritional support in patients with malnutrition and impossibility of oral intake with an estimated survival higher than the months that require enteral nutrition beyond four weeks. The main indications include neoplasms of the upper air-digestive tract and neurological diseases, with dementia currently considered a controversial indication. Anatomical alterations and infectious diseases are the most frequent contraindications. There are different endoscopic techniques; the most widely used being the "pull" method, with a low mortality. Complications are more frequent in patients with multiple pathologies and the elderly. Wound infection, extraction of the tube, tube blockage and bronchoaspiratory pneumonia are the most prevalent complications. Adequate prior preparation of the patient and exhaustive maintenance of the tube can reduce the appearance of these.
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Bechtold ML, Mir FA, Boumitri C, Palmer LB, Evans DC, Kiraly LN, Nguyen DL. Long-Term Nutrition. Nutr Clin Pract 2016; 31:737-747. [DOI: 10.1177/0884533616670103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
| | - Fazia A. Mir
- Department of Medicine, University of Missouri, Columbia, Missouri, USA
| | | | - Lena B. Palmer
- Department of Medicine, Loyola University, Chicago, Illinois, USA
| | - David C. Evans
- Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Laszlo N. Kiraly
- Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA
| | - Douglas L. Nguyen
- Department of Medicine, University of California, Irvine, California, USA
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Attoun A, Glastonbury C, Yee J. Metastatic Head and Neck Carcinoma in a Percutaneous Endoscopic Gastrostomy Site. Otolaryngol Head Neck Surg 2016; 131:321-3. [PMID: 15365554 DOI: 10.1016/j.otohns.2003.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Adam Attoun
- Department of Radiology, VA Medical Center, University of California, San Francisco, California, USA
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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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Abstract
Placement of percutaneous endoscopic gastrostomy or jejunostomy is a safe procedure with low periprocedural mortality, but overall mortality rates are high because of underlying disease conditions. These procedures are also associated with postprocedure complications. The clinically significant adverse events related to the procedures include infection (at tube site and peritonitis), bleeding, and aspiration. More rare associated events include buried bumpers, injury to adjacent viscera with subsequent fistula formation, and tumor seeding. There is a lack of guidelines about these procedures other than those concerning the use of antibiotics and the management of antithrombotics and anticoagulation before the procedure.
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Affiliation(s)
- Ajaypal Singh
- Division of Gastroenterology, Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medical Center, 5700 Sought Maryland Ave, Chicago, IL 60637-1470, USA
| | - Andres Gelrud
- Division of Gastroenterology, Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medical Center, 5700 Sought Maryland Ave, Chicago, IL 60637-1470, USA.
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Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World J Gastroenterol 2014; 20:7739-7751. [PMID: 24976711 PMCID: PMC4069302 DOI: 10.3748/wjg.v20.i24.7739] [Citation(s) in RCA: 300] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 02/26/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the “pull” technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.
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Prospective evaluation of peristomal cutaneous changes among patients with long-term percutaneous endoscopic gastrostomy. Adv Skin Wound Care 2014; 27:260-7. [PMID: 24836616 DOI: 10.1097/01.asw.0000449854.63913.25] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Percutaneous endoscopic gastrostomy (PEG) is the most commonly used procedure in patients requiring long-term tube feeding. Lack of universal terminology and variations in the description of long-term PEG cutaneous lesions make it difficult for clinicians to interpret, communicate, and formulate a plan of treatment. The authors designed a prospective study to assess the long-term PEG cutaneous lesions and the healthcare utilization. PATIENTS AND METHODS After the PEG procedure, patients followed up for more than 12 months were included. Results of physical examination of the PEG cutaneous lesions were recorded. Laboratory tests, including the standard urine strip test, which detected the presence of bilirubin, microbiologic culture, as well as computed tomography, were applied in patients with PEG long-term cutaneous complications. Unscheduled hospital visits also were recorded. RESULTS The mean follow-up duration after PEG was 28 ± 15 months. Among patients with long-term PEG, 33.6% of the patients had normal skin, 31.0% had skin erythema, 21.2% had wound discharge, 24.8% had granulation tissue, 15.0% had postinflammatory hyperpigmentation, 15.9% had scarring, 5.3% had side torsion, 29.2% had stoma retraction, and 5.3% had bulging lesions. Urine strip test can differentiate gastric content leakage from purulent exudate/serous fluid. All patients with bulging lesions required hospitalization. CONCLUSION Long-term PEG cutaneous problems are common. Appropriate physical examinations and laboratory tests can provide evidence to identify the causes, treat the patients with the PEG cutaneous problems, and decrease the risk for potential unscheduled hospital visits.
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Percutaneous endoscopic gastrostomy site metastasis from head and neck squamous cell carcinoma: case series and literature review. J Otolaryngol Head Neck Surg 2013; 42:20. [PMID: 23672761 PMCID: PMC3651229 DOI: 10.1186/1916-0216-42-20] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 01/06/2013] [Indexed: 02/01/2023] Open
Abstract
Objectives To present our experience with head and neck squamous cell carcinoma (HNSCC) seeding of percutaneous endoscopic gastrostomy (PEG) sites and to review all reported cases to identify risk factors and develop strategies for complication avoidance. Materials and methods The records of 4 patients with PEG site metastasis from HNSCC were identified from the authors’ institution. Thirty-eight further cases were reviewed following a PubMed search and evaluation of references in pertinent articles. Results Review of 42 cases revealed the average time from PEG to diagnosis of metastatic disease to be 8 months. Average time to death from detection of PEG disease was 5.9 months. One-year survival following PEG metastasis was 35.5% with an overall mortality of 87.1%. Conclusion PEG site metastatic disease portends a poor prognosis. Early detection and aggressive therapy may provide a chance of cure. Changes in PEG technique or in timing of adjunctive therapies are possible avenues in further research to prevent this complication.
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Sheykholeslami K, Thomas J, Chhabra N, Trang T, Rezaee R. Metastasis of untreated head and neck cancer to percutaneous gastrostomy tube exit sites. Am J Otolaryngol 2012; 33:774-8. [PMID: 22917953 DOI: 10.1016/j.amjoto.2012.07.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 07/16/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) has become a mainstay in providing enteral access for patients with obstructive head and neck tumors. PEG tube placement is considered safe and complications are infrequent. METHODS A comprehensive review of the literature in MEDLINE (1962-2011) was performed. We report herein 3 new cases. RESULTS The literature search revealed 43 previous cases. The interval between PEG placement and diagnosis of metastasis ranged from 1 to 24 months. CONCLUSIONS Metastatic cancer should be considered in patients with head and neck cancer that have persistent, unexplained skin changes at PEG site, anemia, or guaiac positive stools without a clear etiology. The direct implantation of tumor cells through instrumentation is the most likely explanation, although hematogenous and/or lymphatic seeding is also a possibility. Our review of the literature and clinical experience indicate that the "pull" technique of PEG placement may directly implant tumor cells at the gastrostomy site.
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Tessier W, Piessen G, Briez N, Boschetto A, Sergent G, Mariette C. Percutaneous radiological gastrostomy in esophageal cancer patients: a feasible and safe access for nutritional support during multimodal therapy. Surg Endosc 2012; 27:633-41. [DOI: 10.1007/s00464-012-2506-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 07/05/2012] [Indexed: 01/16/2023]
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Chang WK, Huang WC, Yu CY, Hsieh TY. Long-term percutaneous endoscopic gastrostomy: characteristic computed tomographic findings. ACTA ACUST UNITED AC 2012; 36:684-8. [PMID: 21203756 DOI: 10.1007/s00261-010-9678-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Patients with a long-term PEG may suffer from complications and received physical and endoscopic examinations. However, these examinations do not provide information between skin and stomach. We present the findings of computed tomography (CT) for patients with long-term percutaneous endoscopic gastrostomy (PEG). After 1 year PEG (183 patients), 57 patients had received CT examinations. Skin indentation, soft-tissue thickening, peritoneal gap, internal bumper migration, and clinical abnormalities detected by CT examination were recorded. Thickness of subcutaneous fat, muscle, and abdominal wall along the tract were measured. The same parameters at 3 cm away from the tract were obtained for comparison. CT demonstrated that 28 (49.1%) patients present soft-tissue thickening, 19 (33.3%) patients present skin indentation, and 24 (42.1%) patients present a peritoneal gap. One patient with internal bumper migration, 3 patients had buried bumper syndrome, 2 patients had gastric herniation, and 1 patient had esophageal cancer metastasizes to the PEG site. Thickness of subcutaneous fat, muscle, and abdominal wall decreased significant. CT can provide detailed anatomy and orientation along the PEG tube. Familiarity of the CT appearance can minimize potential complications before PEG tube replacement.
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Affiliation(s)
- Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Chengong Rd., Sec. 2, Neihu, Taipei 114, Taiwan, ROC.
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Head and neck cancer metastasis to the percutaneous endoscopic gastrostomy (PEG) tube site: a report of two cases. JOURNAL OF RADIOTHERAPY IN PRACTICE 2010. [DOI: 10.1017/s1460396910000075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AbstractObjective: Percutaneous endoscopic gastrostomy (PEG) tube insertion is used as an alternative to surgical gastrostomy in patients with head and neck cancers for nutritional support.Methods: We report two cases of head and neck cancer with metastasis to the surgical PEG tube site. The clinical and treatment-related details are discussed.Conclusions: Metastasis to PEG tube site is a rare occurrence.
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Zuercher BF, Grosjean P, Monnier P. Percutaneous endoscopic gastrostomy in head and neck cancer patients: indications, techniques, complications and results. Eur Arch Otorhinolaryngol 2010; 268:623-9. [PMID: 21046412 DOI: 10.1007/s00405-010-1412-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 10/13/2010] [Indexed: 12/13/2022]
Abstract
The aim of this study was to review our experience in percutaneous endoscopic gastrostomy (PEG) performed in patients with cancer of the upper aerodigestive tract. Descriptive retrospective study of 142 patients (115 males, 27 females), mean age 62.4 years (25-84 years), with head and neck or esophageal cancer, who underwent PEG tube insertion between January 2006 and December 2008. The studied parameters were indications, success rate, rate and type of complications, and their management. Percutaneous endoscopic gastrostomy was inserted before chemoradiation therapy in 80% and during or after cancer treatment in 20% of the patients. PEG placement was possible in 137 patients (96%). Major complications were observed in 9 (7%) and minor complications in 22 (17%) of the 137 patients. Seven of the 9 patients with a major complication needed revision surgery. The mortality directly related to the procedure was 0.7%. Percutaneous endoscopic gastrostomy tube insertion has a high success rate. In patients with upper aerodigestive tract cancer, PEG should be the first choice for enteral nutrition when sufficient oral intake is not possible. Although apparently easy, the procedure may occasionally lead to severe complications. Therefore, a strict technique and knowledge of clinical signs of possible complications are mandatory.
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Affiliation(s)
- Barbara F Zuercher
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital (CHUV), 1011, Lausanne, Switzerland.
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Klune JR, Zuckerbraun B, Tsung A. Isolated skeletal muscle metastasis following successful treatment of laryngeal cancer: case report. INTERNATIONAL SEMINARS IN SURGICAL ONCOLOGY 2010; 7:1. [PMID: 20187979 PMCID: PMC2838919 DOI: 10.1186/1477-7800-7-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Accepted: 02/28/2010] [Indexed: 12/01/2022]
Abstract
Skeletal muscle metastases from tumors are a rare occurrence and can present difficult management decisions. We report here on a patient that had been previously treated for squamous cell laryngeal cancer with surgical resection and adjuvant systemic chemotherapy that presented with a metastasis to the rectus abdominis muscle without evidence of recurrent disease at the primary site. After a metastatic workup with PET/CT scan suggested this to be an isolated lesion, surgical excision with negative margins was performed based upon limited treatment options secondary to the location of the tumor and his favorable prognosis suggested by his pathological staging at the time of the initial resection. Here we discuss the incidence of distant metastases from laryngeal cancer and appropriate screening methods. Additionally, skeletal muscle metastases and treatment considerations are discussed.
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Affiliation(s)
- John R Klune
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
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Seeding of the Percutaneous Endoscopic Gastrostomy Tract from Esophageal Squamous Cell Cancer Presenting as an Acutely Bleeding Malignant Gastric Ulcer: A Novel Clinicoendoscopic Presentation. South Med J 2008; 101:35-9. [PMID: 18176289 DOI: 10.1097/smj.0b013e31815d28d2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tsai JK, Schattner M. Percutaneous endoscopic gastrostomy site metastasis. Gastrointest Endosc Clin N Am 2007; 17:777-86. [PMID: 17967381 DOI: 10.1016/j.giec.2007.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Metastases to gastrostomy sites are a rare but significant complication of percutaneous endoscopic gastrotomy (PEG) placement in cancer patients. Both direct seeding and hematogenous spread have been suggested as possible mechanisms. This article outlines the incidence, presentation, pathogenesis, and management of PEG-site metastases.
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Affiliation(s)
- John K Tsai
- Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA
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21
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Cappell MS. Risk factors and risk reduction of malignant seeding of the percutaneous endoscopic gastrostomy track from pharyngoesophageal malignancy: a review of all 44 known reported cases. Am J Gastroenterol 2007; 102:1307-11. [PMID: 17488255 DOI: 10.1111/j.1572-0241.2007.01227.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM To comprehensively review all known reported cases of stomal metastases after percutaneous endoscopic gastrostomy (PEG) to systematically identify risk factors for this complication and to develop strategies for reducing this risk. METHODS Reported cases were identified by computerized literature searches. Criteria for risk factors for stomal metastases included: a substantially higher relative rate of this factor in patients with stomal metastases than expected from pharyngoesophageal malignancy in general, and biologic plausibility of this phenomenon. LITERATURE REVIEW Review of all 44 known stomal metastases revealed the following. The mean patient age was 59.0+/-10.0 (SD) yr, and 79% of patients were male. Pathologically proven stomal metastases were located in the abdominal wall (PEG exit site) in 63%, in the gastric wall (PEG entrance site) in 7%, and in both walls in 30%. Mean survival after diagnosis was only 4.3+/-3.8 months. Pathologic risk factors for stomal metastases included: (a) pharyngoesophageal location of primary cancer (in 100% of cases, 0% other locations); (b) squamous cell histology (in 98%, adenocarcinoma in 2%); (c) poorly or moderately differentiated histology (in 92%, well differentiated in 8%); (d) advanced pathologic stage (in 97%, early stage in 3%); and (e) large primary cancer size at diagnosis (mean diameter 4.2+/-2.3 cm). These risk factors appeared to be quantitatively large (e.g., 98% of cases had squamous histology vs 50% expected rate, odds ratio 40.1, OR CI 6.31-246.4, P<0.0001). Therapeutic risk factors for stomal metastases included: (a) endoscopic PEG placement (in 98%, surgical gastrostomy in 2%); (b) pull-string PEG technique (in 98%, push-guidewire in 2%, direct-introducer in 0%); (c) primary cancer untreated or known local recurrence after treatment before PEG (in 87%); and (d) time>or=3 months after PEG insertion (in 100%, <3 months in 0%; mean interval 7.8+/-5.2 months after PEG). Four of the currently reported risk factors are novel (pathologic factors d,e; therapeutic factors a,d). CONCLUSIONS Strong risk factors for stomal metastases include: pharyngoesophageal primary cancer, squamous cell histology, less well-differentiated cancer, large size, and advanced cancer stage. The risk may be reduced in patients with risk factors by radiotherapy, chemotherapy, or cancer surgery before PEG; by substituting the push-guidewire for the pull-string technique for PEG; and possibly by use of a sheath with the pull-string technique.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, Royal Oak, Michigan 48073, USA
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Coletti D, Genuit T, Ord R, Engroff S. Metastasis to the percutaneous endoscopic gastrostomy site in the patient with head and neck cancer: a case report and review of the literature. J Oral Maxillofac Surg 2006; 64:1149-57. [PMID: 16781352 DOI: 10.1016/j.joms.2006.03.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Domenick Coletti
- Department of Oral and Maxillofacial Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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McClave SA, Ritchie CS. The role of endoscopically placed feeding or decompression tubes. Gastroenterol Clin North Am 2006; 35:83-100. [PMID: 16530112 DOI: 10.1016/j.gtc.2005.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The minimally invasive nature of endoscopically placed gastrostomy tubes makes them a viable consideration in palliative care. Complications related to the procedure appear to correlate with age and underlying comorbidities.However, in many instances, the scientific basis for establishing benefit or harm from tube placement is methodologically inadequate. Decisions must be preceded by a discussion of the value and potential risk of artificial nutrition in a particular setting, respecting the wishes and beliefs of each patient and his or her family. The decision to use PEG placement for any reason should be consistent with legal and ethical principles, reflect patient autonomy over any other consideration (including beneficence), and arise from a clear determination of the goals of care (and whether the PEG placement will truly help meet those goals). Whenever possible, further studies with better design are needed to evaluate whether the use of PEG truly affects quality of life and patient outcome in palliative care. PEG tubes for decompression are placed successfully most of the time. Symptom relief occurs usually within 7 days of the procedure. Overall, the morbidity related to the PEG procedure for decompression is only slightly higher than when the same technique is used for nutritional purposes. The appropriate timing for PEG tube placement for nutritional support and for decompression throughout the course of disease progression may be difficult to determine and yet may be a factor in its overall efficiency. Only minor modifications of the basic technique used for PEG placement for nutritional purposes are required to adapt the technique to a variety of other applications in palliative care.
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Affiliation(s)
- Stephen A McClave
- Division of Gastroenterology/Hepatology, University of Louisville School of Medicine, 550 South Jackson Street, KY 40202, USA.
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Silas AM, Pearce LF, Lestina LS, Grove MR, Tosteson A, Manganiello WD, Bettmann MA, Gordon SR. Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy: A comparison of indications, complications and outcomes in 370 patients. Eur J Radiol 2005; 56:84-90. [PMID: 16168268 DOI: 10.1016/j.ejrad.2005.02.007] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2004] [Revised: 02/11/2005] [Accepted: 02/16/2005] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Percutaneous access to the stomach can be achieved by endoscopic or fluoroscopic methods. Our objective was to compare indications, complications, efficacy and outcomes of these two techniques. METHODS Records of 370 patients with feeding tubes placed either endoscopically by gastroenterology, or fluoroscopically by radiology, at our university-based tertiary care center over a 54-month period were reviewed. RESULTS 177 gastrostomies were placed endoscopically and 193 fluoroscopically. Nutrition was the most common indication in each group (94 and 92%), but the most common underlying diagnosis was neurologic impairment in the endoscopic group (n=89, 50%) and malignancy in the fluoroscopic group (n=134, 69%) (p<0.001). Complications in the first 30 days were more common with fluoroscopic placement (23% versus 11%, p=0.002), with infection most frequent. Correlates of late complications were inpatient status (OR 0.26, 95%CI: 0.13-0.51) and a diagnosis of malignancy (OR 2.2, 95%CI: 1.03-4.84). Average follow-up time was 108 days in the fluoroscopic group and 174 days in the endoscopic group. CONCLUSIONS Both endoscopic and fluoroscopic gastrostomy tube placement are safe and effective. Outpatient status was associated with greater early and late complication rates; minor complications such as infection were greater in the fluoroscopic group, while malignancy was associated with late complications.
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Affiliation(s)
- Anne M Silas
- Department of Radiology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
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Eipe N, Dildeep A, Samuel T. Endobronchial metastasis: an anesthetic complication? Can J Anaesth 2005; 52:550-1. [PMID: 15872142 DOI: 10.1007/bf03016544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Wang KK, Wongkeesong M, Buttar NS. American Gastroenterological Association technical review on the role of the gastroenterologist in the management of esophageal carcinoma. Gastroenterology 2005; 128:1471-505. [PMID: 15887129 DOI: 10.1053/j.gastro.2005.03.077] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Kenneth K Wang
- Barrett's Esophagus Unit, St. Mary's Hospital, Mayo Clinic, Rochester, Minnesota, USA
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Brown DB. An Enterostomy Practice is Good for Your Patients and You: How to Target Referrals and Avoid Trouble. J Vasc Interv Radiol 2004. [DOI: 10.1016/s1051-0443(04)70207-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Malnutrition is a common and significant problem in patients with cancer. Enteral nutrition support is an important therapy and is preferred over parenteral nutrition in the setting of a functional gastrointestinal tract. Familiarity with the indications for enteral support, the choice of an enteral access device, and the selection of an enteral formula are critical for the care of patients with cancer and malnutrition. Enteral nutrition has proven efficacy in patients receiving radiation to the head and neck, those with persistent dysphagia, and critically ill patients with impaired gastric emptying. Placement of feeding tubes through the nose or percutaneously provides a mechanism to deliver nutrients when proximal obstructions or oropharyngeal dysphagia prevent adequate oral intake. Direct access to the jejunum can be safely obtained endoscopically and is very useful in patients who require enteral nutrition support following a gastrectomy or esophagectomy or have impaired gastric emptying. Standard polymeric formulas are appropriate for most patients. Specialized formulas designed to enhance immune function may decrease infectious complications but do not improve survival.
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Affiliation(s)
- Mark Schattner
- Gastroenterology and Nutrition Service, Department of Medicine, Memoiral Sloan-Kettering Cancer Center, New York, NY, USA.
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