Safety of pull-type and introducer percutaneous endoscopic gastrostomy tubes in oncology patients: a retrospective analysis

Abstract

BackgroundPercutaneous endoscopic gastrostomy (PEG) allows long-term tube feeding. Safety of pull-type and introducer PEG placement in oncology patients with head/neck or oesophageal malignancies is unknown.MethodsRetrospective analysis of 299 patients undergoing PEG tube placement between January 2006 and December 2008 revealed 57 oncology patients. All patients with head/neck or oesophageal malignancy were treated with chemo- and radiotherapy. In case of high-grade stenosis introducer Freka® Pexact PEG tube was placed (n = 24) and in all other patients (n = 33) conventional pull-type PEG tube. Short-term complications and mortality rates were compared.ResultsPatients' characteristics and clinical status were comparable in both groups. Short-term complications were encountered in 11/24 (48%) introducer PEG patients as compared to only 4/33 (12%) pull-type PEG patients (P < 0.05). Accidental removal of the introducer PEG tube occurred in 4/24 (17%) with need for surgical intervention in 1 vs. 0/33 (0%, P < 0.05). Wound infection occurred in 3/24 (12%) leading to septic shock and admission to intensive care unit (ICU) in 1 vs. 3/33 (9%, NS). Finally, 3/24 gastrointestinal perforations (12%) resulted from a difficult placement procedure vs. 1/33 (3%), leading to urgent surgical intervention and admission to ICU. Two introducer PEG patients died at ICU, resulting in an overall mortality rate of 8% vs. 0% (P = 0.091).ConclusionThe introducer Freka® Pexact PEG procedure for long-term tube feeding may lead to significantly higher complication and mortality rates in patients with head/neck or oesophageal malignancies treated with chemo- and radiotherapy. It is suggested to use the conventional pull-type PEG tube placement in this group of patients, if possible.

Percutaneous Endoscopic Gastrostomy in Direct Puncture Technique: When, Why and How?

“…Conventional PEG tubes are well secured with a button that is intragastrically located. In contrast, the DP PEG system is fixed with a balloon cuff similar to a Foley catheter and previous authors have reported rates of dislocation of up to 47.8% in long-term follow-up [15,25,26] . We demonstrated that tube dislocation occurs in about 25% of cases.…”

Usefulness of percutaneous endoscopic gastrostomy for supportive therapy of advanced aerodigestive cancer

“…Selection bias may be one reason. Van Dyck et al [20] reported that better follow-up of PEG tube daily care might be necessary. In almost all studies, the complication and mortality rates were low.…”

“…Therefore, recent data on the introducer method using T-fasteners show low complication rates of less than 11% and no mortality [38,[41][42][43][44][45] . However, Dyck's study shows that severe short-term complications may occur in patients with esophageal or head and neck tumors after place- ment of the introducer PEG tube with T-fasteners, leading to urgent surgical intervention and even death in a substantial number of patients [20] . Why the complication and mortality rates were high in Dyck's study is unclear.…”

“…The major complications of the standard pull/push method, which requires an esophageal lumen sufficient to pass a standard endoscope [30] , include peristomal wound infections, presumably resulting from contamination of the gastrostomy catheter as it passes through the oral cavity [14,31] , and tumor implantation at the PEG site [28,32] which are specific for pull/push method in the aerodigestive cancer patients. In the literature on patients with cancer, the overall complication and mortality rates of the pull/push method in patients with head and neck cancer are 10.9%-42.0% and 0%-5%, respectively [15,17,18,[20][21][22][33][34][35][36] . An overall complication rate of 0%-11% and mortality rate of 0% have been reported with the introducer method [15,16,37,38] compared with the pull/push method in patients with aerodigestive cancer.…”

“…Many studies have examined the usefulness of PEG for aerodigestive cancer. A PEG tube was inserted in patients with oral intake difficulties for the purpose of nutrition support in all stages and locations, including patients who had undergone chemotherapy and chemoradiation therapy with curative intent [17][18][19][20][21][22] . Chemotherapy or chemoradiation therapy is frequently associated with mucositis, dysphagia, loss of taste and anorexia.…”