Usage characteristics and adverse event rates of the direct puncture and pull techniques for percutaneous endoscopic gastrostomy in patients with malignant tumors of the upper aerodigestive tract
submitted 14 May 2017
accepted after revision 12 September 2017
12 January 2018 (online)
Background and study aims Patients with malignant tumors of the upper gastrointestinal tract are at risk of weight loss. Early supportive nutrition therapy is therefore recommended and usually requires placement of a percutaneous endoscopic gastrostomy (PEG). The aim of this study was to compare adverse events and usage characteristics of the direct puncture technique with those of the traditional pull technique when used in patients with endoscopically passable tumors. The primary endpoint was the rate of inflammatory adverse events (AEs) at the gastrostomy fistula. The secondary endpoint was the long-term rate of puncture-site metastases.
Patients and methods One hundred twenty patients (median age 56; IQR 36, 86 years) were randomized and treated per protocol in this prospective open randomized single-center study. Follow-ups were conducted on the third and seventh post-interventional days, after 1, 3 and 6 months and the last follow-up 5 years after intervention.
Results Within the short-term follow-up period of 6 months after PEG placement, AEs were noted in 47 patients (39.2 %). These included 22 inflammations and 16 device dislocations and were mainly found in the puncture group (33 vs. 14 in the pull group) with a significantly increased incidence in the first month after PEG insertion (P = 0.001). Evaluation of the 5-year data did not reveal any significant differences. The gastrostomy tube was used in 101 patients (84.2 %) (range 18 days to 5 years).
Conclusions Our results favor the pull technique for patients with endoscopically passable tumors of the upper gastrointestinal tract due to less short-term adverse events. Both systems contributed equally to secure long-term use.
- 1 Datema FR, Ferrier MB, Baatenburg de Jong RJ. Impact of severe malnutrition on short-term mortality and overall survival in head and neck cancer. Oral Oncol 2011; 47: 910-914
- 2 Arends J, Bodoky G, Bozzetti F. et al. ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology. Clin Nutr 2006; 25: 245-259
- 3 Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980; 15: 872-875
- 4 Preyer S, Thul P. Gastric metastasis of squamous cell carcinoma of the head and neck after percutaneous endoscopic gastrostomy: report of a case. Endoscopy 1989; 21: 295
- 5 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: 1307-1311
- 6 Ananth S, Amin M. Implantation of oral squamous cell carcinoma at the site of a percutaneous endoscopic gastrostomy: a case report. Br J Oral Maxillofac Surg 2002; 40: 125-130
- 7 Russell TR, Brotman M, Norris F. Percutaneous gastrostomy. A new simplified and cost-effective technique. Am J Surg 1984; 148: 132-137
- 8 Tucker AT, Gourin CG, Ghegan MD. et al. 'Push' versus 'pull' percutaneous endoscopic gastrostomy tube placement in patients with advanced head and neck cancer. Laryngoscope 2003; 113: 1898-1902
- 9 Maetani I, Tada T, Ukita T. et al. PEG with introducer or pull method: a prospective randomized comparison. Gastrointest Endosc 2003; 57: 837-841
- 10 Maetani I, Yasuda M, Seike M. et al. Efficacy of an overtube for reducing the risk of peristomal infection after PEG placement: a prospective, randomized comparison study. Gastrointest Endosc 2005; 61: 522-527
- 11 Toyama Y, Usuba T, Son K. et al. Successful new method of extracorporeal percutaneous endoscopic gastrostomy (E-PEG). Surg Endosc 2007; 21: 2034-2038
- 12 Horiuchi A, Nakayama Y, Tanaka N. et al. Prospective randomized trial comparing the direct method using a 24 Fr bumper-button-type device with the pull method for percutaneous endoscopic gastrostomy. Endoscopy 2008; 40: 722-726
- 13 Hiki N, Maetani I, Suzuki Y. et al. Reduced risk of peristomal infection of direct percutaneous endoscopic gastrostomy in cancer patients: comparison with the pull percutaneous endoscopic gastrostomy procedure. J Am Coll Surg 2008; 207: 737-744
- 14 Van Dyck E, Macken EJ, Roth B. et al. Safety of pull-type and introducer percutaneous endoscopic gastrostomy tubes in oncology patients: a retrospective analysis. BMC Gastroenterol 2011; 11: 23
- 15 Lim JH, Choi SH, Lee C. et al. Thirty-day mortality after percutaneous gastrostomy by endoscopic versus radiologic placement: a systematic review and meta-analysis. Intest Res 2016; 14: 333-342
- 16 Lee C, Im JP, Kim JW. et al. Risk factors for adverse events and mortality of percutaneous endoscopic gastrostomy: a multicenter, retrospective study. Surg Endosc 2013; 27: 3806-3815
- 17 Ahmad I, Mouncher A, Abdoolah A. et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy – a prospective, randomised, double-blind trial. Aliment Pharmacol Ther 2003; 18: 209-215
- 18 Ohno T, Ogawa A, Yanai M. et al. The usefulness and safety of the introducer technique using a bumper-button-type device as compared with the pull method for percutaneous endoscopic gastrostomy. Surg Laparosc Endosc Percutan Tech 2015; 25: e1-4
- 19 Teh JL, Wong RK, Gowans M. et al. Gastric metastases of oral carcinoma resulting from percutaneous endoscopic gastrostomy placement via the introducer technique. Gastroenterol Rep (Oxf) 2013; 1: 211-213
- 20 Sartori S, Trevisani L, Nielsen I. et al. Longevity of silicone and polyurethane catheters in long-term enteral feeding via percutaneous endoscopic gastrostomy. Aliment Pharmacol Ther 2003; 17: 853-856
- 21 Blacka J, Donoghue J, Sutherland M. et al. Dwell time and functional failure in percutaneous endoscopic gastrostomy tubes: a prospective randomized-controlled comparison between silicon polymer and polyurethane percutaneous endoscopic gastrostomy tubes. Aliment Pharmacol Ther 2004; 20: 875-882