Percutaneous Endoscopic Gastrostomy: Strategies for Prevention and Management of Complications (original) (raw)
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Surgical Endoscopy, 2007
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.
Gastrointestinal Endoscopy, 2001
Background: Patients with head and neck cancer (HNC) benefit from nutritional support by means of PEG tubes, but endoscopy may be impossible when there is partial or complete trismus and/or stenosis or occlusion of the upper aerodigestive tract. Methods: PEG tubes were placed in 277 patients with HNC. Oral insertion of an endoscope into the esophagus was impossible in 27 patients. Transnasal endoscopy was performed (n = 4). In the cases of high-grade tumor obstruction, the endoscope was introduced into the esophagus through a straight laryngoscope (n = 9). When upper aerodigestive tract occlusion was present, endoscopy with PEG placement was successfully performed during surgery by means of the opened pharynx after tumor resection (n = 12). Results: In 25 of the 27 cases PEG tubes could be placed by using the above alternative techniques. There were no immediate complications, and no complications occurred within 30 days of PEG placement. Conclusions: Transnasal, straight laryngoscopic, or intraoperative open endoscopy can improve the success rate for PEG tube placement in patients with HNC.
Australian Journal of Otolaryngology, 2021
Background: Percutaneous endoscopic gastrostomy (PEG) placement facilitates nutritional support for head and neck cancer patients with impaired oral intake. The effectiveness of an otolaryngology driven PEG placement and the associated morbidity in an Australian head and neck cancer centre is presented. Methods: A retrospective case series was performed on 96 consecutive head and neck cancer patients who underwent PEG insertion by an otolaryngologists-head and neck (ORL-HN) surgeon within the St. Vincent's head and neck cancer service from 2016 to 2021. Primary outcomes measured included correct placement, and successful function of PEG for enteral nutrition, time to insertion, and concurrent procedures undertaken. Secondary outcomes included morbidity and procedure related mortality within 90 days of the procedure. Results: Successful and correct placement of PEG tube occurred in 100% (n=96). All PEG tubes functioned correctly permitting use. The mean time to insertion was 2.2±2.6 days. The proportion of PEG tubes inserted with a concurrent procedure was 39%. Major complications occurred in 3 (3%) patients: one solid organ injury, one intra-abdominal abscess and one buried bumper syndrome. There was a total of 6 (6%) minor complications reported; two with transient paralytic ileus, three with peristomal leakage, and one with a rectus sheath haematoma. There were no procedure related mortalities. Conclusions: The effectiveness of an otolaryngology driven PEG placement in an Australian head and neck cancer centre has been described, integrated as part of patient care. Success of insertion and morbidity rates were comparable with previously reported studies of similar populations. Patient and logistical benefits delivered include ability to perform procedures concurrent to PEG insertion and enhanced continuity of care.
Feasibility and Safety of Overtubes for PEG-Tube Placement in Patients with Head and Neck Cancer
Gastroenterology Research and Practice, 2015
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.
Clinical Otolaryngology, 2009
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.
British Journal of Oral and Maxillofacial Surgery, 2013
Patients with head and neck cancer who have resection, radiotherapy, chemoradiotherapy, or a combination of these require nutritional support to be implemented before treatment, and this may involve insertion of a prophylactic gastrostomy feeding tube. The aim of this study was to compare the use and complication rates of percutaneous endoscopic gastrostomy (PEG) and radiologically inserted gastrostomy (RIG) in these patients at a tertiary referral centre. We retrospectively reviewed gastrostomy data forms completed by nutritional support nursing staff over a recent 34-month period, which included information on method of insertion, 30-day postoperative serious and minor complications, and mortality. A total of 110 patients had prophylactic insertion of a gastrostomy (21 PEG, 89 RIG) over the study period. In the first 12 months 13 (31%) PEG feeding tubes were placed but in the last 12 months none were inserted using an endoscopic approach. Serious complications occurred with 2 (10%) PEG and 12 (13%) RIG; the most common cause was accidental removal of the tube (n = 13, 12%). Minor complications of peristomal infection, leakage, or blockage of the tube occurred in 6 (5%) gastrostomies. No patients died during the study period. In recent years, and in the absence of recommended guidelines, there has been an increase in the elective insertion of RIG in patients with head and neck cancer. Serious complications for both methods of insertion in this study are comparable with similar reports. However, with RIG there is a high rate of tubes becoming dislodged with the potential for serious consequences. The most appropriate method to insert a gastrostomy tube in patients with head and neck cancer remains unclear. Crown
2014
We present the results of a retrospective study of head and neck oncology patients who had a PEG inserted at three hospitals in the UK over 2 years. 100 patients were included in the study. The mean time for a PEG in-situ was 306.98 days (range 2-1214). 29 patients used the PEG for feeding for 15 days or less after surgery. The mean length of time a PEG was not used was 69.7 days (20-171). The most common complications were skin infection (12%), pain and discomfort (10%) and leakage (6%). One patient had leakage leading to death from abdominal complications (1%) and one other patient had a Mallory Weiss tear (1%). One patient had a severe skin infection and died later from bowel obstruction due to colon cancer. Overall 28% of patients had PEG complications. Complications of PEG tube insertion can be serious and life threatening in some cases. Almost one third of head and neck oncology patients in our study could have had their nutrition needs met by a naso-gastric tube. PEG insertion remains useful in supporting nutritional needs for head and neck oncology patients but should only be performed when a need is certain and its usage is likely to exceed three weeks duration.
Developing a protocol for gastrostomy tube insertion in patients diagnosed with head and neck cancer
Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 2014
Selecting patients with head and neck cancer requiring a pretreatment gastrostomy feeding tube is not straightforward. The nutritional status and functional deficits associated with the cancer, its treatment, and the long-term side effects predicate the need for gastrostomy tube placement. However, gastrostomy tubes are not without morbidity and are an added burden to the patient. The aim of this retrospective case series review was to evaluate the clinical characteristics of newly diagnosed patients with head and neck cancer treated with curative intent having gastrostomy placement, with the intent of developing a protocol to help with the timely selection of patients for pretreatment gastrostomy insertion. A gastrostomy tube was placed in 32%. A regression model identified 5 independent predictors (P < .001) to predict gastrostomy tube placement: overall clinical stage, tumor site, clinical T stage, patient age, and clinical N stage. A protocol to help the multidisciplinary team to decide whether a pretreatment gastrostomy tube should be placed is suggested.
Percutaneous radiological gastrostomy in patients with head and neck cancer
European Journal of Surgical Oncology (EJSO), 2001
To evaluate the results of percutaneous radiological gastrostomy in patients with head and neck cancer. Patients and methods: This was a retrospective study design. One hundred and eighteen patients with head and neck cancer were referred 130 times for gastrostomy tube placement between 1 April 1993 and 17 August 1998. Mean age was 60 years. All data were analysed by using the following parameters: success rate, complications and mortality. Complications were divided into major, minor (complication that needed only conservative treatment) and tube-related. Results: The success rate of percutaneous radiological gastrostomy was 97%. Major complications occurred in 6% of patients after gastrostomy tube placement. Minor complications occurred in 15% of patients. There was one tuberelated complication. Procedure-related mortality occurred in one patient. The results of this study show no difference from those known from the literature for the percutaneous method and confirm that radiological gastrostomy has significantly lower rates of major complications than other methods of gastrostomy placement. Conclusion: Percutaneous radiological gastrostomy tube placement is, in our opinion, an effective and reliable method for placing a feeding tube in patients with head and neck cancer.