Q16. What are the complications from gastrostomy tube placement and is there a preferred method of placement?

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Evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer
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Findlay, M, Bauer, J, Brown, T, Head and Neck Guideline Steering Committee. COSA:Head and neck cancer nutrition guidelines/Nutrition implementation - Pre-treatment/What are the complications from gastrostomy tube placement and is there a preferred method of placement . In: Evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer. Sydney: Clinical Oncological Society of Australia. [Version URL: https://wiki.cancer.org.au/australiawiki/index.php?oldid=132311, cited 2023 May 28]. Available from: https://wiki.cancer.org.au/australia/COSA:Head_and_neck_cancer_nutrition_guidelines.


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17 April 2016 10:35:02




Q16. What are the complications from gastrostomy tube placement and is there a preferred method of placement?

Summary

Comparison of the studies in the literature in this area is limited due to the significant variation in definitions of major and minor complications.

There are six level III-2 neutral quality studies comparing different types of gastrostomy placement [1][2][3][4][5][6]. There appears to be higher procedure related mortality in the percutaneous radiological gastrostomy (PRG) group [2][1]. Complications are lower in percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy compared to laparoscopic placement overall [3]. Minor complications are higher in PEGs placed via the pull technique compared to PEGs inserted by the push technique [4]. Complication rates are higher in PRG compared to PEG [5]; minor complications appear to be greater in surgical tubes compared to PEG or PRG [1]; and complication rates are similar for PEG, radiologically inserted gastrostomy (RIG) and surgical tubes [2]. Complication rates and accidental removal was higher using the introducer PEG compared to the pull PEG[7] and mortality was higher although this did not reach statistical significance. No difference was seen for wound infections or perforations.

There are four level III-2 studies, two negative quality [8][9] and two neutral quality [10][11]. Amann reported a complication rate of 9.9% and that lower body mass index (BMI) is associated with more complications. Baschnagel et al. reported a major complication rate of 10%. Gibson reported that PEG placement may be more difficult in patients with head and neck cancer compared to neurology patients, but there are fewer complications. Sobani et al. found stromal leak (6.25%) and surgical site infection (12.5%) to be the only reported complications. There are four level III-3 studies, one positive quality [12] and three neutral quality [13][14][15]. One paper reported on outcomes with PRG with 0% major and 14% minor complications [13]. Two studies report on outcomes with a pull PEG with one documenting 8% major and 13% minor complications [14], and the other reporting 4.3% late complications with only one major infection (wall abscess) requiring chemotherapy discontinuation [15]. One study reporting on outcomes of patients receiving prophylactic PRG or PEG identified 0% major and 27% minor complications, with the most common being insertion site infection (44%) [12].

There was one level IV positive quality study [16], 26 level IV neutral quality studies [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42], and eight level IV negative quality studies [43][44][45][46][47][48][49][50]. Major complications range from 0% to 8%. Minor complications range from 0% to 40%. Procedure related mortality was reported with 10 papers reporting no mortality and five papers reporting rates from 0.7% to 5%. One study [19] reported increased risk of complications in gastrostomy placed during or after treatment compared to before treatment. One study has shown that for surgical treatment, PEG should be placed after surgical resection to reduce complications post PEG [33]. Patients who have an oral/throat infection are more likely to develop a stoma site infection post PEG [23].

There have been rare case reports in the literature of patients developing metastases at the gastrostomy site. Three theories have been proposed on the mechanism of this which includes either lymphatic spread, direct implantation with the pull technique using an endoscope or by swallowing of tumour cells. Cases have also been reported with radiological placement. A large series of 208 patients with active disease found an incidence rate of abdominal wall metastasis of 0.92% [24].

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Recommendation Grade
Procedure and associated choice of feeding tube should consider gastrostomy complications vary according to the tube type, insertion method and skill/expertise of those undertaking the procedure, as well as variations in the definitions of major and minor complications. Overall, there is a low procedure mortality rate (mean approx 1%). 		C
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References

  1. ↑ 1.0 1.1 1.2 Cosentini EP, Sautner T, Gnant M, Winkelbauer F, Teleky B, Jakesz R. Outcomes of surgical, percutaneous endoscopic, and percutaneous radiologic gastrostomies. Arch Surg 1998 Oct;133(10):1076-83 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9790204.
  2. ↑ 2.0 2.1 2.2 Rustom IK, Jebreel A, Tayyab M, England RJ, Stafford ND. Percutaneous endoscopic, radiological and surgical gastrostomy tubes: a comparison study in head and neck cancer patients. J Laryngol Otol 2006 Jun;120(6):463-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16772054.
  3. ↑ 3.0 3.1 Bankhead RR, Fisher CA, Rolandelli RH. Gastrostomy tube placement outcomes: comparison of surgical, endoscopic, and laparoscopic methods. Nutr Clin Pract 2005 Dec;20(6):607-12 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16306297.
  4. ↑ 4.0 4.1 Tucker AT, Gourin CG, Ghegan MD, Porubsky ES, Martindale RG, Terris DJ. 'Push' versus 'pull' percutaneous endoscopic gastrostomy tube placement in patients with advanced head and neck cancer. Laryngoscope 2003 Nov;113(11):1898-902 Available from: http://www.ncbi.nlm.nih.gov/pubmed/14603043.
  5. ↑ 5.0 5.1 Neeff M, Crowder VL, McIvor NP, Chaplin JM, Morton RP. Comparison of the use of endoscopic and radiologic gastrostomy in a single head and neck cancer unit. ANZ J Surg 2003 Aug;73(8):590-3 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12887525.
  6. ↑ Van Dyck E, Macken EJ, Roth B, Pelckmans PA, Moreels TG. Safety of pull-type and introducer percutaneous endoscopic gastrostomy tubes in oncology patients: a retrospective analysis. BMC Gastroenterol 2011 Mar 16;11:23 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21410958.
  7. ↑ van den Berg MG, Rasmussen-Conrad EL, Gwasara GM, Krabbe PF, Naber AH, Merkx MA. A prospective study on weight loss and energy intake in patients with head and neck cancer, during diagnosis, treatment and revalidation. Clin Nutr 2006 Oct;25(5):765-72 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16698130.
  8. ↑ .
  9. ↑ Gibson SE, Wenig BL, Watkins JL. Complications of percutaneous endoscopic gastrostomy in head and neck cancer patients. Ann Otol Rhinol Laryngol 1992 Jan;101(1):46-50 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1728885.
  10. ↑ Sobani ZU, Ghaffar S, Ahmed BN. Comparison of outcomes of enteral feeding via nasogastric versus gastrostomy tubes in post operative patients with a principle diagnosis of squamous cell carcinoma of the oral cavity. J Pak Med Assoc 2011 Oct;61(10):1042-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22356051.
  11. ↑ Baschnagel AM, Yadav S, Marina O, Parzuchowski A, Lanni TB Jr, Warner JN, et al. Toxicities and costs of placing prophylactic and reactive percutaneous gastrostomy tubes in patients with locally advanced head and neck cancers treated with chemoradiotherapy. Head Neck 2014 Aug;36(8):1155-61 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23852670.
  12. ↑ 12.0 12.1 Hughes BG, Jain VK, Brown T, Spurgin AL, Hartnett G, Keller J, et al. Decreased hospital stay and significant cost savings after routine use of prophylactic gastrostomy for high-risk patients with head and neck cancer receiving chemoradiotherapy at a tertiary cancer institution. Head Neck 2013 Mar;35(3):436-42 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22605643.
  13. ↑ 13.0 13.1 .
  14. ↑ 14.0 14.1 .
  15. ↑ 15.0 15.1 Assenat E, Thezenas S, Flori N, Pere-Charlier N, Garrel R, Serre A, et al. Prophylactic percutaneous endoscopic gastrostomy in patients with advanced head and neck tumors treated by combined chemoradiotherapy. J Pain Symptom Manage 2011 Oct;42(4):548-56 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21477980.
  16. ↑ Zuercher BF, Grosjean P, Monnier P. Percutaneous endoscopic gastrostomy in head and neck cancer patients: indications, techniques, complications and results. Eur Arch Otorhinolaryngol 2011 Apr;268(4):623-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21046412.
  17. ↑ Saunders JR Jr, Brown MS, Hirata RM, Jaques DA. Percutaneous endoscopic gastrostomy in patients with head and neck malignancies. Am J Surg 1991 Oct;162(4):381-3 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1951893.
  18. ↑ Beaver ME, Myers JN, Griffenberg L, Waugh K. Percutaneous fluoroscopic gastrostomy tube placement in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 1998 Oct;124(10):1141-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9776193.
  19. ↑ 19.0 19.1 .
  20. ↑ Avery C, Shenoy S, Shetty S, Siegmund C, Mazhar I, Taub N. The prospective experience of a maxillofacial surgeon with the percutaneous endoscopic gastrostomy technique. Int J Oral Maxillofac Surg 2008 Feb;37(2):140-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18023146.
  21. ↑ Lorentzen T, Nolsøe CP, Adamsen S. Percutaneous radiologic gastrostomy with a simplified gastropexy technique under ultrasonographic and fluoroscopic guidance: experience in 154 patients. Acta Radiol 2007 Feb;48(1):13-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17325919.
  22. ↑ Hsieh JS, Wu CF, Chen FM, Wang JY, Huang TJ. Laparoscopic Witzel gastrostomy--a reappraised technique. Surg Endosc 2007 May;21(5):793-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17180291.
  23. ↑ 23.0 23.1 Faias S, Cravo M, Claro I, Lage P, Nobre-Leitão C. High rate of percutaneous endoscopic gastrostomy site infections due to oropharyngeal colonization. Dig Dis Sci 2006 Dec;51(12):2384-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17078008.
  24. ↑ 24.0 24.1 Cruz I, Mamel JJ, Brady PG, Cass-Garcia M. Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head and neck cancer. Gastrointest Endosc 2005 Nov;62(5):708-11; quiz 752, 753 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16246684.
  25. ↑ Ehrsson YT, Langius-Eklöf A, Bark T, Laurell G. Percutaneous endoscopic gastrostomy (PEG) - a long-term follow-up study in head and neck cancer patients. Clin Otolaryngol Allied Sci 2004 Dec;29(6):740-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15533171.
  26. ↑ Shand AG, Wild SR, Grieve DC, Evans J, Pendlebury J, Ghosh S. Radiological insertion of gastrostomy in patients in whom endoscopy was unsuccessful. Dig Liver Dis 2002 Apr;34(4):298-301 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12038815.
  27. ↑ .
  28. ↑ Luman W, Kwek KR, Loi KL, Chiam MA, Cheung WK, Ng HS. Percutaneous endoscopic gastrostomy--indications and outcome of our experience at the Singapore General Hospital. Singapore Med J 2001 Oct;42(10):460-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11874149.
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  30. ↑ Cunliffe DR, Swanton C, White C, Watt-Smith SR, Cook TA, George BD. Percutaneous endoscopic gastrostomy at the time of tumour resection in advanced oral cancer. Oral Oncol 2000 Sep;36(5):471-3 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10964056.
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  33. ↑ 33.0 33.1 Raynor EM, Williams MF, Martindale RG, Porubsky ES. Timing of percutaneous endoscopic gastrostomy tube placement in head and neck cancer patients. Otolaryngol Head Neck Surg 1999 Apr;120(4):479-82 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10187937.
  34. ↑ .
  35. ↑ .
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  42. ↑ Atasoy BM, Yonal O, Demirel B, Dane F, Yilmaz Y, Kalayci C, et al. The impact of early percutaneous endoscopic gastrostomy placement on treatment completeness and nutritional status in locally advanced head and neck cancer patients receiving chemoradiotherapy. Eur Arch Otorhinolaryngol 2012 Jan;269(1):275-82 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21472468.
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  49. ↑ .
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