Download PDF
Endoscopy 2011; 43(9): 752-758
DOI: 10.1055/s-0030-1256495
Original article

© Georg Thieme Verlag KG Stuttgart · New York

A new large-caliber trocar for percutaneous endoscopic gastrostomy by the introducer technique in head and neck cancer patients

J.  H.  Giordano-Nappi1 , F.  Maluf-Filho1 , S.  Ishioka1 , F.  Y.  Hondo1 , S.  E.  Matuguma1 , M.  Simas de Lima1 , M.  Lera dos Santos1 , F.  A.  Retes1 , P.  Sakai1
  • 1Department of Gastroenterology, Hospital das Clínicas, Medical School of São Paulo University, São Paulo, Brazil
Further Information

Publication History

submitted 19 August 2010

accepted after revision 6 March 2011

Publication Date:
07 June 2011 (online)

Also available at
    Permissions and Reprints

Background and study aims

In many patients, percutaneous endoscopic gastrostomy (PEG) can be limited by digestive tract stenosis. PEG placement using an introducer is the safest alternative for this group of patients, but the available devices are difficult to implement and require smaller-caliber tubes. The aim of this study was to evaluate the modification of an introducer technique device for PEG placement with regard to the following: procedure feasibility, possibility of using a 20-Fr balloon gastrostomy tube, tube-related function and problems, complications, procedure safety, and mortality.

Patients and methods

Between March 2007 and February 2008, 30 consecutive patients with head and neck malignancies underwent introducer PEG placement with the modified device and gastropexy. Each patient was evaluated for 60 days after the procedure for the success of the procedure, infection, pain, complications, mortality, and problems with the procedure.

Results

The procedure was successful in all cases with no perioperative complications. No signs of stomal infection were observed using the combined infection score. The majority of patients experienced mild-to-moderate pain both in the immediate postoperative period and at 72 hours. One major early complication (3.3 %) and two minor complications (6.7 %) were observed. No procedure-related deaths occurred during the first 60 days after the procedure.

Conclusion

The device modification for PEG using the introducer technique is feasible, safe, and efficient in outpatients with obstructive head and neck cancer. In this series, it allowed the use of a larger-caliber tube with low complication rates and no procedure-related mortality.

References

  • 1 Tucker A T, Gourin C G et al. “Push” versus “pull” percutaneous endoscopic gastrostomy tube placement in patients with advance head and neck cancer.  Laringoscope. 2003;  113 1898-1902
    PubMedGoogle Scholar
  • 2 Foster J M, Filocamo P, Nava H et al. The introducer technique is the optimal method for placing percutaneous endoscopic gastrostomy tubes in head and neck cancer patients.  Surg Endosc. 2007;  21 897-901
    CrossrefPubMedGoogle Scholar
  • 3 Baredes S, Behin D, Deitch E. Percutaneous endoscopic gastrostomy tube feeding in patients with head and neck cancer.  Ear Nose Throat J. 2004;  83 417-419
    PubMedGoogle Scholar
  • 4 Nicholson F B, Korman M G, Richardson M A. Percutaneous endoscopic gastrostomy: a review of indications, complications and outcome.  J Gastroenterol Hepatol. 2000;  15 21-25
    CrossrefPubMedGoogle Scholar
  • 5 Hunter J G, Lauretano L, Shellito P C. Percutaneous endoscopic gastrostomy in head and neck cancer patients.  Ann Surg. 1989;  210 42-46
    CrossrefPubMedGoogle Scholar
  • 6 Riley D A, Strauss M. Airway and other complications of percutaneous endoscopic gastrostomy in head and neck cancer patients.  Ann Otol Rhinol Laryngol. 1992;  101 310-313
    CrossrefPubMedGoogle Scholar
  • 7 Sabnis A, Liu R, Chand B, Ponsky J. SLiC technique. A novel approach to percutaneous gastrostomy.  Surg Endosc. 2006;  20 256-262
    CrossrefPubMedGoogle Scholar
  • 8 Bhama J K, Haas M K, Fisher W E. Spread of pharyngeal cancer to the abdominal wall after percutaneous endoscopic gastrostomy.  Surg Laparosc Endosc Percutan Tech. 2001;  11 375-378
    CrossrefPubMedGoogle Scholar
  • 9 Dormann A J, Glosemeyer R, Leistner U et al. Modified percutaneous endoscopic (PEG) with gastropexy – early experience with a new introducer technique.  Z Gastroenterol. 2000;  38 933-938
    Google Scholar
  • 10 Dormann A J, Wejda B, Kahl S et al. Long-term result with a new introducer method with gastropexy for percutaneous endoscopic gastrostomy.  Am J Gastroenterol. 2006;  101 1229-1234
    CrossrefPubMedGoogle Scholar
  • 11 Potochny J D, Sataloff D M, Spiegel J R et al. Head and neck cancer implantation at the percutaneous endoscopic gastrostomy exit site. A case report and a review.  Surg Endosc. 1998;  12 1361-1365
    CrossrefPubMedGoogle Scholar
  • 12 Russell T R, Brotman M, Norris F. Percutaneous gastrostomy: a new simplified and cost-effective technique.  Am J Surg. 1984;  148 132-137
    CrossrefPubMedGoogle Scholar
  • 13 Lin H S, Ibrahim H Z, Kheng J W et al. Percutaneous endoscopic gastrostomy: strategies for prevention and management of complications.  Laryngoscope. 2001;  111 1847-1852
    CrossrefPubMedGoogle Scholar
  • 14 Cappell M S. 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
    CrossrefPubMedGoogle Scholar
  • 15 Miller R E, Kummer B A, Kotler D P, Tiszenkel H I. Percutaneous endoscopic gastrostomy. Procedure of choice.  Ann Surg. 1986;  204 543-545
    CrossrefPubMedGoogle Scholar
  • 16 Kozarek R A, Ball T J, Ryan J A. When push comes to shove: a comparison between two methods of percutaneous endoscopic gastrostomy.  Am J Gastroenterol. 1986;  81 642-646
    PubMedGoogle Scholar
  • 17 Cosentini E P, Sautner T, Gnant M et al. Outcomes of surgical, percutaneous endoscopic, and percutaneous radiologic gastrostomies.  Arch Surg. 1998;  133 1076-1083
    CrossrefPubMedGoogle Scholar
  • 18 Simon T, Fink A S. Recent experience with percutaneous endoscopic gastro/jejunostomy (PEG/J) for enteral nutrition.  Surg Endosc. 2000;  14 436-438
    CrossrefPubMedGoogle Scholar
  • 19 Sobreira R S, Lo Turco C M, Patrício C E et al. Gastrostomia endoscópica: indicações, técnicas e complicações.  GED. 2006;  25 37-41
    PubMedGoogle Scholar
  • 20 Giordano-Nappi J H, Ishioka S, Maluf-Filho F et al. A new device for the introducer technique for percutaneous endoscopic gastrostomy placement.  Endoscopy. 2007;  39 (Suppl 1) 274-275
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Jain N K, Larson D E, Schroeder K W et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy. A prospective, randomized, double – blind clinical trial.  Ann Intern Med. 1987;  107 824-828
    Google Scholar
  • 22 Ehrsson Y T, 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;  29 740-746
    PubMedGoogle Scholar
  • 23 Gauderer M WL, Ponsky J L, Izant R J. Gastrostomy without laparotomy: a percutaneous endoscopic technique.  J Pediatr Surg. 1980;  15 872-875
    CrossrefPubMedGoogle Scholar
  • 24 Gibson S E, Wenig B L, Watkins J L. Complications of percutaneous endoscopic gastrostomy in head and neck cancer patients.  Ann Otol Rhinol Laryngol. 1992;  101 46-50
    PubMedGoogle Scholar
  • 25 Adler D G, Baron T H, Geels W et al. Placement of PEG tubes through previously placed self-expanding esophageal metal stents.  Gastrointest Endosc. 2001;  54 237-241
    CrossrefPubMedGoogle Scholar
  • 26 Stockeld D, Fagerberg J, Granström L, Backman L. Percutaneous endoscopic gastrostomy for nutrition in patients with oesophageal cancer.  Eur J Surg. 2001;  167 839-844
    CrossrefPubMedGoogle Scholar
  • 27 Shastri Y M, Hoepffner N, Tessmer A et al. New introducer PEG gastropexy does not require prophylactic antibiotics: multicenter prospective randomized double-blind placebo-controlled study.  Gastrointest Endosc. 2008;  67 620-628
    CrossrefPubMedGoogle Scholar
  • 28 Toyama Y, Usuba T, Son K et al. Successful new method of extracorporeal percutaneous endoscopic gastrostomy (E-PEG).  Surg Endosc. 2007;  21 2034-2038
    CrossrefPubMedGoogle Scholar
  • 29 Taller A, Horvath E, Iliás L et al. Technical modifications for improving the success rate of PEG tube placement in patients with head and neck cancer.  Gastrointest Endosc. 2001;  54 633-636
    CrossrefPubMedGoogle Scholar
  • 30 Pisano G, Calò P G, Tatti A et al. Surgical gastrostomy when percutaneous endoscopic gastrostomy is not feasible: indications, results and comparison between the two procedures.  Chir Ital. 2008;  60 261-266
    PubMedGoogle Scholar
  • 31 Petersen T I, Kruse A. Complications of percutaneous endoscopic gastrostomy.  Eur J Surg. 1997;  163 351-356
    PubMedGoogle Scholar
  • 32 Löser C, Wolters S, Fölsch U R. Enteral long-term nutrition via percutaneous endoscopic gastrostomy (PEG) in 210 patients: a four-year prospective study.  Dig Dis Sci. 1998;  43 2549-2557
    CrossrefPubMedGoogle Scholar
  • 33 Tsai J K, Schattner M. Percutaneous endoscopic gastrostomy site metastasis.  Gastrointest Endosc Clin N Am. 2007;  17 777-786
    CrossrefPubMedGoogle Scholar
  • 34 Cruz I, Mamel J J, Brady P G, Cass-Garcia M. Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head and neck cancer.  Gastrointest Endosc. 2005;  62 708-711
    CrossrefPubMedGoogle Scholar
  • 35 Schneider A M, Loggie B W. Metastatic head and neck cancer to the percutaneous endoscopic gastrostomy exit site: a case report and review of the literature.  Am Surg. 1997;  63 481-486
    PubMedGoogle Scholar
  • 36 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Campoli P MO, Ejima F H, Cardoso D MM et al. Percutaneous endoscopic gastrostomy in advanced head and neck cancer.  ABCD Arquivos Brasileiros de Cirurgia Digestive (ILMA Index). 2007;  20 97-101
    PubMedGoogle Scholar
  • 38 Wiesen A J, Sideridis K, Fernandes A et al. True incidence and clinical significance of pneumoperitoneum after PEG placement: a prospective study.  Gastrointest Endosc. 2006;  64 886-889
    CrossrefPubMedGoogle Scholar
  • 39 Blum C A, Selander C, Ruddy J M, Leon S. The incidence and clinical significance of pneumoperitoneum after percutaneous endoscopic gastrostomy: a review of 722 cases.  Am Surg. 2009;  75 39-43
    PubMedGoogle Scholar
  • 40 Wojtowycz M M, Arata J A, Micklos T J, Miller F J. CT findings after uncomplicated percutaneous gastrostomy.  AJR Am J Roentgenol. 1988;  151 307-309
    CrossrefPubMedGoogle Scholar
  • 41 Miller R E, Castlemain B, Lacqua F J, Kotler D P. Percutaneous endoscopic gastrostomy. Results in 316 patients and review of literature.  Surg Endosc. 1989;  3 186-190
    CrossrefPubMedGoogle Scholar
  • 42 Terry N E, Boswell W C, Carney D E et al. Percutaneous endoscopic gastrostomy with T-bar fixation in children and infants.  Surg Endosc. 2008;  22 167-170
    CrossrefPubMedGoogle Scholar
  • 43 Pofahl W E, Ringold F. Management of early dislodgment of percutaneous endoscopic gastrostomy tubes.  Surg Laparosc Endosc Percutan Tech. 1999;  9 253-256
    CrossrefPubMedGoogle Scholar
  • 44 Grant D G, Bradley P T, Pothier D D et al. Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis.  Clin Otolaryngol. 2009;  34 103-112
    CrossrefPubMedGoogle Scholar

J. H. Giordano-NappiMD, PhD 

Department of Gastroenterology
Gastrointestinal Endoscopy Unit
Hospital das Clínicas
Medical School of São Paulo University

Av. Dr Eneas Carvalho de Aguiar 255
6 ° Andar, Bloco C
São Paulo
Brazil

Fax: 55-11-30697579

Email: drgiordano@hotmail.com

      >