A Model for Predicting Gastrostomy Tube Placement in Patients Undergoing Surgery for Upper Aerodigestive Tract Lesions

Abstract

IMPORTANCE Identifying high-risk patients in the preoperative period can allow physicians to optimize nutritional status early for better outcomes after head and neck cancer resections. OBJECTIVE To develop a model to predict preoperatively the need for gastrostomy tube (G-tube) placement in patients undergoing surgery of the upper aerodigestive tract. DESIGN, SETTING, AND PARTICIPANTS This retrospective medical record review included all adult patients diagnosed with head and neck cancers who underwent tumor resection from 2007 through 2012 at Wake Forest Baptist Health, a level 1 tertiary care center. Records were screened for patient demographics, tumor characteristics, surgical treatment type, and postoperative placement of G-tube. A total of 743 patients underwent resection of head and neck tumors. Of these, 203 were excluded for prior G-tube placement, prior head and neck resection, G-tube placement for chemoradiotherapy, and resection for solely nodal disease, leaving 540 patients for analysis. MAIN OUTCOMES AND MEASURES Placement of postoperative G-tube. RESULTS Of the 540 included patients, 23% required G-tube placement. The following variables were significant and independent predictors of G-tube placement: preoperative irradiation (odds ratio [OR], 4.1; 95% CI, 2.4–6.9; P < .001), supracricoid laryngectomy (OR, 26.0; 95% CI, 4.9–142.9; P < .001), tracheostomy tube placement (OR, 2.6; 95% CI, 1.5–4.4; P < .001), clinical node stage N0 vs N2 (OR, 2.4; 95% CI, 1.4–4.2; P = .01), clinical node stage N1 vs N2 (OR, 1.6; 95% CI, 0.8–3.3; P = .01), preoperative weight loss (OR, 2.0; 95% CI, 1.2–3.2; P = .004), dysphagia (OR, 2.0; 95% CI, 1.2–3.2; P = .005), reconstruction type (OR, 1.9; 95% CI, 1.1–2.9; P = .02), and tumor stage (OR, 1.8; 95% CI, 1.1–2.9; P = .03). A predictive model was developed based on these variables. In the validation analysis, we found that the average predicted score for patients who received G-tubes was statistically different than the score for the patients who did not receive G-tubes (P = .01). CONCLUSIONS AND RELEVANCE We present a validated and comprehensive model for preoperatively predicting the need for G-tube placement in patients undergoing surgery of the upper aerodigestive tract. Early enteral access in high-risk patients may prevent complications in postoperative healing and improve overall outcomes, including quality of life.

The association between gastrostomy tube placement, poor post-operative outcomes, and hospital re-admissions in head and neck cancer patients

“…In order to better identify those with the greatest need for gastrostomy tube placement, a recent predictive model based on variables available to the surgeon in the pre-operative period was developed to identify patients at high risk of G-tube placement in the post-operative period. The goal of this model was to identify high risk patients early, prior to resection, in order to avoid poor outcomes potentially related to poor nutritional status [3]. The model gives each patient a predictive probability score for placement of a G-tube in the post-operative period by entering the presence or absence of several pre-operative variables into the predictive equation.…”

Optimising nutrition support in patients with head and neck cancer

“…The established MST for identifying patients at risk of malnutrition (Ferguson et al, 1999a) was for the first time found to be associated with predicting proPEG in the low risk group of patients. As the MST identifies patients with baseline weight loss this supports other studies which have identified baseline weight loss to be predictive of proPEG (Beaver et al, 2001;Gardine et al, 1988;Mangar et al, 2006;Mays et al, 2014;Orphanidou et al, 2011). Finally a positive p16 status was also found to be predictive of proPEG in the low risk group of patients.…”

“…The study by Lango et al (2016) was completed in patients receiving (chemo) radiotherapy but had a small sample in comparison (n=84). Pre-treatment weight loss was the only other patient factor supported by a number of level III and IV studies (Beaver et al, 2001;Gardine et al, 1988;Mangar, Slevin, Mais, & Sykes, 2006;Mays, Moustafa, Worley, Waltonen & D'Agostino, 2014;Orphanidou et al, 2011).…”

“…Guidelines for gastrostomy selection in the surgical population have also been developed in the UK (Jack, Dawson, Reilly, & Shoaib, 2012), and more recently a predictive model has been developed and validated in the USA (Mays et al, 2014). Despite the accuracy of this predictive model, it is quite complex and will be challenging to transfer into a clinical setting.…”

“…Consideration needs be given to the surgical population, as there is increasing evidence that patients undergoing certain surgical procedures may also warrant proPEG (Jack et al, 2012;Mays et al, 2014). Revalidation of the protocol in a patient cohort with a larger proportion of patients receiving helical-IMRT is currently underway, and will address previous limitations by accounting for duration of gastrostomy use.…”