A

Comparison of Gastrostomy Techniques in Patients With Advanced Head and Neck Cancer

Colin E.

Bailey, MD;

Charles E. Lucas, MD; Anna M.

with advanced head and neck carcinomas often suffer from impaired deglutition and require prolonged enteral feedings during therapy. This retrospective study analyzed 75 patients managed with three different gastrostomy techniques. Thirty patients received a percutaneous endoscopic gastrostomy; 28 patients had an open tube gastrostomy using a Foley or Malecot catheter through a purse-string stay suture; and 17 patients received an open\x=req-\ tube gastrostomy with a 1-cm Dacron-cuffed Silastic catheter enclosed in a 3-cm Witzel tunnel with the cuff buried in the subperitoneal pocket. The complication rate for 100 days of tube use was 0.21 for cuffed Silastic gastrostomy, 0.35 for open tube gastrostomy, and 1.41 for the percutaneous endoscopic gastrostomy group. We conclude that the cuffed Silastic gastrostomy technique is superior in this patient population. (Arch Otolaryngol Head Neck Surg. 1992;118:124-126) \s=b\ Patients

malnourished patients Severel y benefit from nutritional support. cal

with malignant disease Patients with cervi¬ or upper gastrointestinal malignancies are often good candidates for extra-oral alimentation. The combination of cancer involving the mouth or pharynx and the effects of major extirpative surgery often impairs mastication and deglutition. The sequela of radiation therapy increases the need for supplemental nutrition.1 In patients with a func¬ tional gastrointestinal tract, the enterai route of nutri¬ tional support is preferred.2"4 There are many methods of enterai feeding, each with attendant advantages and disadvantages. The simplest and cheapest method is via a nasogastric tube. This mo¬ dality is effective in patients with a patent upper gas¬ trointestinal tract, a functional pylorus, and a competent gastroesophageal sphincter mechanism. When altered anatomy or patient discomfort precludes long-term nu¬ tritional supplement via a nasogastric tube, a jejunostomy or gastrostomy feeding tube is indicated. A feeding jejunostomy is required in patients with cardioesophageal reflex to avoid aspiration. The main difficulty with a

Accepted

publication May 29, 1991. of Surgery (Drs Bailey, Lucas, and Ledgerwood) and Otolaryngology (Dr Jacobs), Wayne State University, From the

for

Departments

Detroit, Mich. Reprint requests

University, 4201

cas).

to the Department of Surgery, Wayne State St Antoine, Room 4S-13, Detroit, MI 48201 (Dr Lu-

Ledgerwood, MD; John

R.

Jacobs,

MD

jejunostomy, however, is the need for a constant infusion of nutrients to provide adequate calories without exces¬ sive diarrhea. This severely limits the patient's mobility and independence. The feeding gastrostomy is preferred in patients with¬ out cardioesophageal reflux or gastric disease. The ideal patient should also have normal gastric and duodenal emptying. A feeding gastrostomy is desirable because the reservoir capacity of the stomach allows for intermittent bolus feeding. Eliminating the need for a constant infusion of nutrients facilitates the patient's independence from the hospital setting.5 The purpose of this article is to compare the efficacy of a new cuffed Silastic gastrostomy (CSG) technique with the traditional Stamm technique and the

percutaneous endoscopie gastrostomy (PEG) technique.6 First, we describe the CSG technique, after which compar¬ ison with the Stamm and PEG

Cuffed Silastic

techniques is made.

Gastrostomy

The CSG can be performed under local or general an¬ esthesia. A 7.5-cm upper midline incision provides excel¬ lent exposure to the anterior stomach wall. A single cuffed Tenckhoff catheter (Quinton Industries) with additional holes (4 to 5) cut in the distal end is inserted within a single 3-0 absorbable purse-string suture placed in the middle as¬ pect of the anterior gastric wall just superior to the incisura angularis (Figure). Before insertion, the catheter length is shortened to prevent passage of the catheter across the py¬ lorus and subsequent gastric outlet obstruction. The cath¬ eter is positioned with the cuff 3 cm from the purse-string suture. This 3-cm segment is then incorporated into a Witzel tunnel. After positioning the catheter within the stom¬ ach, a guide wire is passed through a 14-gauge needle in¬ serted into the abdominal wall at the lateral border of the rectus abdominis muscle. The needle is withdrawn and a 1.5-mm incision is made at the skin entry site of the guide wire. At this point, a 16-F introducer and sheath are passed over the wire, dilating the skin incision to match the diameter of the Tenckhoff catheter. The wire and intro¬ ducer are removed and the Tenckhoff catheter is passed from the peritoneal cavity through the sheath. The sheath is then withdrawn over the catheter. At this point the stomach is secured to the peritoneum around the internal exit site of the Witzel tunnel with four stay sutures. The catheter is then secured to the skin with a 4-0 nylon suture, which is removed in 1 week.

guide

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Table 1. —Underlying Patients Receiving a

Malignancy

Larynx Tongue

16

Pharynx

12

13

Tonsil

9

Floor of mouth

6

Retromolar trigone Pyriform sinus

5

Nasopharynx palate Maxillary sinus

4

Parotid

1

Thyroid

1

5 2

Soft

1

Total

single, cuffed Tenckhoff catheter (Quinton Industries) with addi¬ tional holes cut in the distal end is advanced through the pursestring suture. Care is taken to avoid passage of the catheter through the pylorus. Next, a 3-cm segment of catheter between the pursestring suture and the Dacron cuff is enclosed within a Witzel tun¬ nel.

in

Gastrostomy

75

A

Clinical Material The hospital records of 75 randomly selected patients with head and neck cancer who received feeding gastrostomies in the Detroit (Mich) Medical Center over a period of 6 years were retrospectively reviewed (Table 1). The mean age was 61 years and this was similar in all three groups. Fifty-six patients were male and 19 were female. The patients were compared for age, outcome, number of

days a feeding tube was in place (tube days), and compli¬ cations per 100 days of tube use. Thirty patients had a PEG; 28 patients received a Stamm gastrostomy; 17 patients had the new CSG. The Stamm gastrostomy was performed with either a Malecot (10 patients), Foley (14 patients), or DePezzor (four patients) catheter. The choice of gastrostomy reflected surgeon bias independent of

disease

stage.

RESULTS The advanced stage of the underlying disease is re¬ flected by the inhospital mortality rate; 19 (25%) of 75 pa¬ tients died. The deaths included nine patients (30%) who underwent PEG placement, six patients (21%) who re¬ ceived a Stamm gastrostomy, and three patients (17.6%) who had a CSG placed. The cause of death was aspiration pneumonia in four patients, while the remaining 15 died of their underlying disease. There were no intraoperative surgical or anesthetic complications. Postoperative aspiration with feeding led to a lethal pneumonia in two patients after PEG, in one patient after Stamm gastrostomy, and in one patient after CSG. The incidence of nonaspiration complications var¬ ied directly with the type of gastrostomy (Table 2). The patients who experienced the greatest number of compli¬ cations per 100 tube days received PEGs. A total of 1707 tube days were documented in these 30 patients. During these days, a total of 22 nonaspiration complications were noted. These included three episodes of plugging, seven tubes accidentally removed, and one tube that migrated

Table

2.—Morbidity and Mortality After Gastrostomy* CSG

Stamm

PEG

Prolapse/retraction

0

0/7

Tube-site infection

0

3

0

pulled

2 (1/1)

1

13

7

Dehiscence

1

1

1

Failure to function External leak Death associated with

0

5

3

0

15

Tube

out

procedure

1

(asp)

1

(asp)

2

(asp)

Other (skin and stomach

necrosis)

complications patients Patients without complications,

Total

Total No. of No.

(%)

Patients with No. (%)

complications,

days Complications days

Tube

per 100 tube

0

0

2

3

45

24

17

28

30

14/7 (82) 10/28 (36) 13/30

(43)

3/17 (18) 18/28 (64) 17/30

(57)

1420

13 613

1707

0.21

0.33

1.41

"CSG indicates cuffed Silastic gastrostomy; asp, aspiration.

endoscopie gastrostomy;

PEC, percutaneous

into the pylorus causing gastric outlet obstruction. Skin excoriation from external leakage occurred in eight pa¬

tients,

including two patients who developed fullthickness abdominal wall necrosis around the tube site. The skin excoriation in one patient necessitated tube re¬ moval to allow the stoma to close. Another patient devel¬ oped prolapse of his stomach through the PEG site, pre¬ sumably from an accidental tug on the PEG tube. Some type of complication occurred in 60% of patients with PEG and there were 1.41 complications per 100 tube days with the PEG (Table 2). In the 28 patients with a Stamm gastrostomy, a total of 13613 tube days were documented (Table 2). During this time there were 44 nonaspiration complications. These included five episodes of catheter plugging, three patients

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with tube site infections, and 13 episodes of accidental tube removal. Seven patients had migration of the tube into the pylorus causing gastric outlet obstruction. One patient had operative repair of a fasciai dehiscence. Skin excoriation from leakage around the tube was the most common complication in this group and was seen in 15 patients. Severe skin excoriation necessitated emergency admission in two patients, whereas one patient under¬ went gastrostomy tube removal to allow the stoma to heal. Some type of complication occurred in 57% of patients with the Stamm gastrostomy and there were 0.33 complications per 100 tube days (Table 2). A total of 1420 tube days were documented in the 17 patients with CSG (Table 2). Two nonaspiration compli¬ cations were experienced during these days. One tube was accidentally dislodged and one patient had a fasciai dehiscence. Some type of complication occurred in 18% of the CSG patients, including 0.21 complications per 100 tube days (Table 2). The cost of the three gastrostomy techniques are sim¬ ilar. Regardless of whether the operation was performed with sedation plus local anesthesia or under general an¬ esthesia, the average operating room time for each proce¬ dure was between 60 and 70 minutes, thereby making the anesthesia costs and hospital costs similar. The surgical charges, made through the same billing office, were identical for all three procedures unless two teams were used for the PEG, in which case the charge was greater for the PEG. The only measurable difference in cost was catheter cost, which equaled $2.04 for the Stamm tube, $107 for the PEG kit, and $74.50 for the CSG kit. The ma¬ jor unmeasurable difference in cost reflects the expendi¬ tures needed to correct and treat complications, especially infectious complications that were more frequent with the Stamm and PEG techniques. COMMENT The feeding gastrostomy is a popular method for maintaining enterai nutrition in patients with difficulty swallowing. The efficacy of this procedure in providing proper nutrition and in reversing malnutrition has been well established.7 Two of the most common techniques used today are the PEG described by Gauderer et al in 1980 and the Stamm gastrostomy that was first described ir ie late 1800s.5-8"10 Our study, to our knowledge, pre¬ sents the first published data comparing the complica-

tions of the

new

CSG technique with the PEG and Stamm

gastrostomy techniques.

Because this technique used both a Dacron cuff and a Witzel tunnel, the problems of leakage, tube-site infec¬ tion, abdominal wall necrosis around a leaking catheter, accidental removal, and gastric outlet obstruction are dramatically reduced. Inspissated feeding causing tem¬ porary tube occlusion seldom occurs; a bolus infusion of water through a 10-mL syringe quickly corrects this prob¬ lem. Complications after CSG generally are related to the abdominal incision, intraoperative dissection, or aspira¬ tion pneumonia. Based on the results of this study, we recommend the CSG in those patients expected to require a

long-term feeding gastrostomy. This

study was supported by the Interstitial Fluid Fund, Account

4-44966.

References 1. Meguid MM, Gray GE, Debonis D. The use of enteral nutrition in the patient with cancer. In: Rombeau JL, Caldwell MD, eds. Enteral and Tube Feeding. Philadelphia, Pa: WB Saunders Co; 1984:303-333. 2. Gardine RL, Kokal WA, Beatty JD, Rihimaki DU, Wagman LD, Terz JJ. Predicting the need for prolonged enteral supplementation in the patient with head and neck cancer. Am J Surg.

1988;156:63-65. 3. McArdle AH, Palmason C, Morency I, Brown

RA. A radionale for enteral feeding as the preferable route for hyperalimentation. Surgery. 1981;90:616-623. 4. Andrassy RJ. Preserving the gut mucosal barrier and enhancing immune response. Contemp Surg. 1988;32:1-7. 5. Rombeau JL, Barot LR, Low DW, Twomey PL. Feeding by tube enterostomy. In: Rombeau JL, Caldwell MD, eds. Enteral and Tube Feeding. Philadelphia, Pa: WB Saunders Co; 1984:275-291. 6. McGonigal MD, Lucas CE, Ledgerwood AM. Feeding jejunostomy in patients who are critically ill. Surg Gynecol Obstet. 1984;168:275-277. 7. Hinsdale JG, Lipkowitz

GS, Pollock TW, Hoover EL, Jaffe

Prolonged enteral nutrition in malnourished patients with nonelemental feeding. Am J Surg. 1985;149:334-338. 8. Torosian MH, Rombeau JL. Feeding by tube enterostomy. Surg Gynecol Obstet. 1980;150:918. 9. Heymsfeld SB, Bethel RA, Ansley JD. Enteral hyperalimenBM.

tation. Ann Intern Med. 1979;90:63. 10. Gauderer NW, Ponsky JL, Izant RJ, et al. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980;15:872-875.

1992 Third International

Meeting

Call for Abstracts

Preparations are well under way for the Third International Conference

Head and Neck Cancer to be held at the beautiful Marriott Hotel in San Francisco from July 26-31, 1992. The overall format of the meeting will be similar to that of the Boston meeting held in 1988. Abstract forms for the proffered paper section can be obtained from Ernest Weymuller, M.D., Department of Otolaryngology, University of Washington, Seattle, WA 98195. The Deadline for abstracts is February 1, 1992. on

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A comparison of gastrostomy techniques in patients with advanced head and neck cancer.

Patients with advanced head and neck carcinomas often suffer from impaired deglutition and require prolonged enteral feedings during therapy. This ret...
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