HOME ENTERAL NUTRITION VIA GASTROSTOMY IN ADVANCED HEAD AND NECK CANCER PATIENTS Antonio Carlos L. Campos, MD, MS, Michael Butters, MD, and Michael M. Meguid, MD, PhD
We investigated whether home enteral feeding via a tube gastrostomy would enable patients with advanced malignant disease, who were unable to maintain themselves nutritionally via the oral route, to be independent of the hospital setting. Thirtynine patients with advanced upper gastrointestinal and head and neck cancer had a tube gastrostomy placed. Before discharge, the patient was trained in the care and use of the gastrostomy feeding tube. Ten patients died of their disease before they could be discharged. During the 6-month period before gastrostomy insertion, the mean weight loss of the remaining 29 patients was 12.8%, and the mean body weight was less than 90% of ideal body weight. Prior to operation, the mean serum albumin and total lymphocyte count were 3.7 g/L and l,087/mL, respectively. At discharge the mean caloric intake was 1.48 times resting energy expenditure. Home enteral nutrition was provided for a median of 94 days and resulted in stabilizationof nutritional indices. During their median survival of 176 days, the 29 patients were admitted a total of 52 times. Twenty-eight percent of the patients were never re-admitted after gastrostomy and were adequately maintained at home, whereas 24% needed to be re-admitted once. Only 48% were re-admitted twice to assist in their nutritional management. Twenty patients received temporary home nursing services to aid in their transition. Four patients eventually resumed oral intake, and their
Acknowledgment. The authors thank Mrs. Darlene Thompson for her editorial assistance. From the Department of Surgery, Nutrition Support Service, University Hospital, SUNY Health Science Center, Syracuse, New York. Address reprint requests to Dr. Meguid at Surgical Metabolism & Nutrition Laboratory, Department of Surgery, University Hospital, SUNY Health Science Center, 750 East Adarns Street, Syracuse, NY 13210. Accepted for publication July 17, 1989. CCC 0148-6403/90/020137-06 $04.00 0 1990 John Wiley & Sons, Inc.
Home Enteral Nutrition via Gastrostomy
feeding gastrostomies were removed. Home enteral nutritional support via gastrostomy enabled patients with advanced cancer to maintain their nutritional status and be independent from the hospital setting for extended periods, with the improved comfort and quality of their limited life at home in familiar surroundings in face of malignant disease. HEAD & NECK 12:137-142, 1990
Patients with head and neck cancer present nutritional problems similar to those of other cancer patients, but they also present special problems related to their frequent inability to consume adequate nutrition orally. In a recent survey of 50 head and neck cancer patients, Basset and Dobie’ found that 40% presented a poor nutritional status. Similarly, in a couple of series reporting on a large population with digestive tract carcinoma, 48% to 66% of the patients were considered malnourished on a d m i ~ s i o n . This ~’~ high incidence of malnutrition in cancer patients prior t o definitive treatment and the severe sequelae that may result from extensive cancer operations often leads t o prolonged periods of hospitalization for nutritional support4; the latter represents an additional burden for health services resources. When the oral feeding route is unable to meet the patients caloric requirements, two other ways of nutrient delivery remain: parenteral nutrition (PN)or enteral nutrition (EN). Both are equally effective in maintaining the patient’s nutritional status or treating protein calorie malHEAD & NECK
March/April 1990
137
However, in patients with an intact functional gastrointestinal tract, EN is preferable.7 The advantages of this feeding route are as follow: the maintenance of gastrointestinal mass and function by delivering nutrients in the physiological way'; maintenance of the patient's defense risk of infection is minimal as compared to PN'l; less expensive than PN12; relatively safe to administer; and easy to perform by patients and/or family. If long-term EN support is required, tube gastrostomy is preferable to nasogastric tubes because it has a low risk of long-term complithe discomfort and risks assoc a t i o n ~it, ~avoids ~ ciated with long-term use of the nasogastric tube,14 and it allows more mobility and produces less psychological distress than the nasogastric tube.15 The present study was undertaken to assess the efficacy of home feeding by tube gastrostomies as an alternative to an expensive hospitalbased nutritional program in patients with advanced but slowly progressing cancer in whom no further tumor-directed therapy was available. If possible, such a regimen would enable patients to return to their usual home environment and to be independent of the hospital setting. METHODS AND MATERIALS
Thirty-nine patients were studied; all had tube gastrostomies placed because adequate nutrition could not be maintained orally. Ten patients were close to the end-stage of their disease when the gastrostomy tube was placed. They died during the same hospitalization at 2 to 95 days after gastrostomy tube placement and were not evaluated further. The remaining 29 patients had advanced disease or therapeutic complications of cancer treatment which impaired maintenance of their nutritional status by the oral route but were otherwise not in preterminal stages of their disease. Sites of the primary cancers were head and neck (N = 26), esophagus (N = 2), and lung (N = 1). In 19 patients, indications for gastrostomy placement included dysphagia, anorexia, and inanition. In 10 patients with fistulas from head and neck cancer following radiotherapy and operation, tube gastrostomy was the only operation. One of these patients underwent a flap revision after head and neck surgery. Before discharge, the patient and/or a family member was trained by a nutritional team nurse
138
Home Enteral Nutrition via Gastrostomy
in the care and use of the gastrostomy feeding tube. The learning period ranged from 5 to 7 days. EN was administered via the bolus gravity method with the feeding formula at room temperature. Nutritional status was assessed according to previously established criteria. 16*17Factors monitored were percentage of ideal body weight, serum albumin, and total lymphocyte count. These values were noted on admission, on the day of surgery, at discharge, and just prior to demise. Patient's weight approximately 6 months prior t o admission for gastrostomy was noted. Patients were considered malnourished when at least two of these latter parameters were below the 90th percentile. The daily caloric intake shortly before discharge was determined using the HarrisBenedict formula, to determine the percentage of caloric requirements supplied by EN. Other factors scrutinized included: technique of gastrostomy tube placement, complications of tube placement, feeding formula used, length of hospitalization, number of times patients were rehospitalized, number of days patients were maintained at home after discharge, number of days patients survived after tube gastrostomy was placed, whether patients were discharged home or to an extended-care facility, and whether home nursing services were utilized. The results of nutritional assessment are expressed as mean & SE, and all other results are expressed as the median, with the provided range. The paired t test and the signed-rank test were used to evaluate the changes in the nutritional indices. RESULTS
Of the 39 patients, the majority of the gastrostomy tubes placed were Foley catheters; 10 were Malencot catheters and five were DePezzer catheters. The most commonly placed gastrostomies were either of the Witzel" or the Stammlg type. There were no complications related to gastrostomy tube placement. Ten patients who died during the same hospitalization, during which tube gastrostomy was performed, were in the preterminal stage of their malignant diseases; all deaths were attributed to their primary cancer diagnosis. Since these patients could not contribute to an assessment of the utility of tube gastrostomy for home care, they will not be included in the following results. Table 1lists the nutritional assessments performed on the remaining 29 patients at admis-
HEAD & NECK
March/April 1990
Table 1. Nutritional assessment of cancer patients receiving home enteral feeding vis gastrostomy." Indices (A! = 29) % ideal body weight
Serum albumin Total lymphocyte count
Admission
Operation
Discharge
Recent
83.5 f 2.6 4.07 f 0.18 1,148 f 153
85.6 f 2.6 3.74 f 0.09 1,060 2 167
84.2 f 2.8 3.53 f 0.11 1,246 f 91
82.0 f 3.6 3.47 f 0.14 1,026 f 144
Values are given as mean 2 SE. "Changes were not significant at p < 0.05.
sion, on the day of operation, at discharge, and at the most recent assessment available. During the 6-month period prior to gastrostomy placement, a n average weight loss of 12.8% (7.7 kg) had occurred. Mean body weight remained below 90%of ideal body weight throughout the postgastrostomy nutritional management period. Total lymphocyte counts and serum albumin levels also remained below normal throughout. The average changes in serum albumin from gastrostomy placement to discharge and from discharge to the most recent contact were not significant. The mean changes in weight from operation to discharge or from operation to 1year follow-up were not significant. At discharge, the mean caloric intake was 1.48 times the patient's resting energy expenditure (range, 0.9-2.1). The majority of patients used Ensure (Ross Labs, Dayton, OH) for their feeding formula. Osmolite (Ross Labs) was used in 2 patients who had unpleasant feelings of abdominal fullness and distress with Ensure; 1 patient used Ensure Plus (Ross Labs) to increase his caloric intake. There were no operative complications of tube placement. The mechanical complications associated with the use of the gastrointestinal tube fell into two groups: low-frequency complications and high-frequency complications, defined as ones which occurred with < 5% or > 5% of the number of gastrostomy tubes used, respectively. These complications are also classified as either high or low morbidity, according to their impact on the patient's well-being. There was one low-frequency-low-morbidity complication consisting of purulent drainage due to cellulitis noted around a gastrostomy insertion site. The tube was temporarily removed, while antibiotic therapy was given. There were seven high-frequency-low-morbidity complications. Three tubes became clogged and required replacement; four tubes were accidentally pulled out by the patient and also needed replacement.
Home Enteral Nutrition via Gastrostomy
There was one low-frequency-high-morbidity complication consisting of migration of the Foley catheter balloon into the duodenum with signs of intermittent obstruction. After it was recognized radiologically, remedial action consisted of fixing the tube more securely to the abdominal wall to prevent the distal migration of the Foley catheter balloon with gastric peristalsis. The median time interval from admission to operation was 4 days (range, 1 to 64 days); from operation to discharge, 11 days (range, 5 to 82 days). The median length of hospitalization was 31 days (range: 6 to 108 days). The majority of patients were adequately maintained at home; 28% were never readmitted, whereas 24% were readmitted once during their course at home. Only 48% had to be readmitted twice. The reasons for readmission included the complications noted above, modification of nutritional therapy to allow better tolerance of formulae, and to provide temporary relief to the family by reassuring them and helping them cope with the progressive deteriorating clinical situation. Only 1 patient was discharged to an extended-care facility (his usual living situation); the others were discharged home to their family. Twenty patients received temporary home nursing services to aid in their transition home. Home enteral support in 25 patients was provided for a median of 94 days (18 to 1,149 days) and resulted in stabilization of nutritional indices. The median survival of these patients was 176 days (33 to 1,167 days). Four patients eventually resumed oral intake and their feeding gastrostomies were removed. The nutritional status of these patients was adequate at operation, at removal of gastrostomy tube, and at most recent contact; all were within their ideal body weight range. Their mean caloric intake at discharge from hospital was 1.78 (range, 1.19-2.16) times their resting energy expenditure. The median number of days at home with tube feeding for these patients was 136.2.
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139
Two of them were readmitted once. To date, all 4 patients are still alive. DISCUSSION
To evaluate the feasibility and the possible advantages of home EN using gastrostomy, patients with advanced but steady, progressive carcinoma (in whom no further tumor-directed therapy was available) had a gastrostomy tube placed in order to be given home enteral feeding so that their nutritional status could be maintained independent of the hospital setting. Ten patients died during hospitalization, for a mortality rate of 25.6%; the overall complication rate during the 1 year was 23%. All these patients presented terminal stages of their malignant diseases. Similar high mortality rates have been reported following feeding gastrostomy,20 although in that study the majority of patients who died were comatose. These results reflect the poor general condition of our patients and suggest that the indication of feeding gastrostomy to cachectic terminal cancer patients should be questioned. Twenty-nine patients were discharged a median of 11 days after gastrostomy tube insertion for maintaining their nutritional status. At discharge, they had a caloric intake of 1.48 times resting energy expenditure. From operation to the most recent contact, their mean weight gain was 1.8kg. "hey were followed with comfort care and without further anti-tumor therapy until their demise. During the 1 year follow-up, readmittance occurred a mean of 2.2 per patient; 52% of the patients were either never readmitted to the hospital or were readmitted only once. No significant complications (aspiration, perforation, uncontrolled diarrhea with resulting decubitii) were seen during the home-feeding period. Four of the 29 patients had the gastrostomy tube subsequently removed because they resumed adequate oral intake considered sufficient to meet their resting energy expenditure. They were on home tube feedings for a median period of 136.2 days with a mean caloric intake at discharge of 1.78 times resting energy expenditure. These data show that long-term home EN with a gastrostomy is a reasonable way of feeding cancer patients who are temporarily or definitively unable to swallow or eat, but whose gastrointestinal tract is intact. The nutritional considerations in the acute and chronic management of head and neck can-
140
Home Enteral Nutrition via Gastrostomy
cer were recently discussed.21 Over 30 different operative techniques have been described for tube gastrostomy placement. In the typical oncologic setting, a gastrostomy tube should be placed at the time of other operative procedures, when prolonged postoperative use of enteral feeding is anticipated. Alternatively, gastrostomies can be placed as a separate surgical procedure performed through a limited celiotomy under local anesthesia or light general anesthesia13; both these options were used in our patients. More recently, the options of placement have increased with the introduction of percutaneous endoscopic gastrostomy (PEG), initially described in 1980 by Gauderer and Ponsky22 for infants and subsequently for adults in 1983,23in which a gastrostomy tube is placed percutaneously with the aid of gastric endoscopy commonly using only light sedation, local anesthesia, and performed at the bedside. Numerous investigators have reported series emphasizing the ease of the procedure; its low morbidity, the virtual absence of mortality, and its cost-effecti~eness.~~ Whereas -~l it is incumbent for the surgeon to anticipate the need and make plans for gastrointestinal access prior to and during an oncologic operation, the option of a PEG has compensated for the occasional misjudgment. Thus, a PEG is now being increasingly used in our current patient population when the need for a gastrostomy arises in the postoperative period. From a review of the literature32, of 991 patients in whom a PEG had been placed, overall procedure related morbidity was 9.4% and mortality was 0.4%. In comparison, operatively placed gastrostomy in a series of 6 s t ~ d i e s ~car~ * ~ ~ ~ ~ ried a higher morbidity of up to 32% and procedure-related mortality ranging from 2% to 21%. Sufficient caloric delivery is possible by EN with the low risk of complication^.^^*^^ It is easy to administer and a short-training time to instruct the patient andlor the family is enough to assure successful nutritional care at home. By the use of feeding gastrostomy, patients with limited life expectancy, but conscious and not in a terminal stage, may be spared long and impersonal hospital stays. Readmittance was necessary only in a low percentage of our patients. Half of our patients were never or only once readmitted to the hospital to support and reassure the patient's family in the face of progressively deteriorating clinical situation, although the patients were nutritionally adequately maintained in their usual home setting. During this time the
HEAD & NECK
March/April 1990
opportunity was taken to fine tune their nutritional therapy and reaffirm the overall management goals. With the increasing availability of hospice facilities, such readmissions are anticipated to become less frequent. In the presence of a tumor and in the face of an increasing tumor burden, nutritional support has been shown experimentally to maintain the existing nutritional status.39 Albumin status does not improve even with the long-term provision of adequate nutrition4'; only following curative resection of tumor load does adequate nutrition improve the overall nutritional status.39i41 In a median of 176 days of home feeding, significant complications which are described to be as high as 30%,42 did not occur in our patients. This shows that in a group of conscious patients, without neurological diseases or mental disturbances, the event of aspiration is very rare. The
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_
_
_
_
_
aim of intensive instructions of the patient, while in hospital, was to make him function in basic procedures and t o become competent to recognize hazards before severe complications take place.43 In summary, our results show that EN of advanced cancer patients who are unable to maintain their nutritional status by eating can be efficiently maintained at home using tube gastrostomy with occasional readmission for family supportive care and reassurance, during which the opportunity is used to fine tune their nutritional support therapy. This represents a humane and kind means of managing these types of patients by allowing them to return to their usual home environment, thereby to be independent of the hospital setting for a prolonged period, which improves the quality of their limited life, in the face of stable or progressive malignant disease.
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REFERENCES
1. Basset MR, Dobie RA. Patterns of nutritional deficiency in head and neck cancer. Otolaryngol Head Neck Surg 1983; 91~119-125. 2. Muller JM, Dienst C, Brenner U, Pichlmaier H. Preoperative parenteral feeding in patients with gastrointestinal carcinoma. Lancet 1982; 1:68-71. 3. Meguid MM, Debonis D, Meguid V, Hill LR, Terz JJ. Complications of abdominal operations for malignant disease. A m J Surg 1988; 156341-345. 4. Meguid MM, Campos ACL, Meguid V, Debonis D, Ten JJ. IONIP A criterion of surgical outcome and patient selection for perioperative nutritional support. Br J Clin P m t 1988; 42% 14. 5. Heylen AM, Lybeer MB, Pennick FM, Kerremans RP, Frost PG. Parenteral versus needle jejunostomy nutrition after total gastredomy. Clin Nutr 1987; 6:131-136. 6. Lim STK, Choa RG, Lam KM, et al. Total parenteral nutrition versus gastrostamy in the preoperative preparation of patients with carcinoma of the esophagus. Br J Surg 1981; 68:69-72. 7. Shellito PC, Malt RA. Tube gastrostomy: Techniques and complications. Ann Surg 1985; 201:180-185. 8. Thompson JS, Vaughan WP, Forst CF, Jacobs DL, Weekly JS, Rikkers LF. The effect of the route of nutrient delivery on gut structure and diamine oxidase levels. JPEN 1987; 11:28-32. 9. Alverdy JC, Aoys E, Moss JS. Total parenteral nutrition promotes bacterial translocation from the gut. Surgery 1988; 104~185-190. 10. Border JR, Hasset J, LeDuce J, et al. The gut origin septic states in blunt multiple trauma (ISS=40) in the ICU. Ann Surg 1987; 206:427-445. 11. Torosian MH, Rombeau JL. Feeding by tube enterostomy. Surg Gynecol Obstet 1980; 150918-927. 12. Twomey PL, Patching SC. Cost-effectiveness of nutritional support. JPEN 1985; 9:3-10. 13. Meguid MM, Williams LF. The use of gastrostomy to correct malnutrition. Surg Gynecol Obstet 1979; 149:27-32. 14. Jordan GL Jr. Surgical approach to nutritional problems. Adv Surg 1974; 8:85. 15. Padilla GV, Grant M, Wong H, et al. Subjective dis-
Home Enteral Nutrition via Gastrostorny
tresses of nasogastric tube feeding. J Parent Ent Nutr 1979; 3:53. 16. Blackburn GL, Bistrian BR, Maini BS, Schlamm HT, Smith MF. Nutritional and metabolic assessment of the hospitalized patient. JPEN 1977; 1:ll-22. 17. Mughal MM, Meguid MM. The effect of nutritional status on morbidity afler elective surgery for benign gastrointestinal disease. JPEN 1987; 11:140- 143. 18. Witzel 0. Zur technik der magenfistelanlagen. Centmlbl Chir 1891;18:601- 604. 19. Stamm M. Gastrostomy: A new method. Med News 1894; 54~324-326. 20. Wilkinson WA, Pickleman J. Feeding gastrostomy. A reappraisal. A m Surg 1982; 48:273-275. 21. Williams EF III, Meguid MM. Nutritional concepts and considerations in head and neck surgery. Head Neck 1989; 11:393-399. 22. Gauderer MWL, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pedintr Surg 1980; 15:872-875. 23. Ponsky JL, Gauderer MWL, Stellato TA. Percutaneous endoscopic gastrostomy. Arch Surg 1983; 118:913-914. 24. Russell TR, Brotman M, Norris F. Percutaneous gastrostomy: A new simplified and cost-effective technique. A m J Surg 1984; 148:132-135. 25. Miller RE, Kummer BA, Kotlir DP, Tiszenkel HI. Percutaneous endoscopic gastrostomy: Procedure of choice. Ann Surg 1986; 204543-545. 26. Larson DE, Fleming CR, Ott BJ, Schroeder KW. Percutaneous endoscopic gastrostomy: Simplified access for enteral nutrition. Muyo CZin Proc 1983; 58:103-107. 27. Cohen NN, Plumer PA, Ockryoniek SB, Shah N. Percutaneous endoscopic gastrostomy: A pragmatic approach to nutrition in patients unable to swallow. Gastrointest Endosc 1983; 29:181. 28. Kirby DF, Craig RM, Tsang T, Plotnick BH. Percutaneous endoscopic gastrostomies: A prospective evaluation and review of the literature. JPEN 1986; 10:155-159. 29. Ponsky JL, Gauderer MW,Stellato TA, Aszodi A. Percutaneous approaches to enteral alimentation. A m J Surg 1985; 149102-105.
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S. Endoscopic vs. surgical gastrostomy for enteral nutrition. Surg Endosc 1987; 1:33-
30. Himal HS, Schumacher
35. 31. Stern JS. Comparison of percutaneous endoscopic gastrostomy with surgical gastrostomy at a community hospital. A m J Gastroenterol 1986; 81:1171-1173. 32. Sangster W, Cuddington GD, Bachulis BL. Percutaneous endoscopic gastrostomy. A m J Surg 1988; 155:677-682. 33. Heimbach DM. Surgical feeding procedures in patients with neurological disorders. Ann Surg 1970; 172:311314. 34. Pomerantz MA, Salomon J, Dunn R. Permanent gastrostomy as a solution to some nutritional problems in the elderly. J A m Geriatr Soc 1980; 28:104-107. 35. Swartzendruber FD, Laws HL. The superior feeding gastrostomy. Ann Surg 1982; 48:276-278. 36. Wasiljew BK, Ujiki GT, Beal JM. Feeding gastrostomy: Complications and mortality. A m J Surg 1982; 143:194195.
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Home Enteral Nutrition via Gastrostomy
37. Russell RJ. Home enteral nutrition with formula diets. J Gastroenterol 1985; 23:94- 97. 38. Rombeau JL, Barot LR. Enteral nutritional therapy. Surg Clin North A m 1981; 61:605-620. 39. Meguid MM, Landel AM, Lo C-C, Rivera D. Effect of tu-
mor and tumor removal on DNA, RNA, protein tissue content and survival of methylcholanthrene sarcomabearing rat. Surg Res Commun 1987; 1:261-271. 40. Gray GE, Meguid MM. Can TPN reverse hypoalbuminemia in oncology patients? Nutrition 1990 (in press). 41. Landel AM, Lo C-C, Meguid MM, Rivera D. Effect of methylcholanthrene-induced sarcoma and its removal on rat plasma and intracellular free amino acid content. Surg Res Commun 1987; 1:273-287. 42. Burtch GD, Shatney CH. Feeding jejunostomy vs gastrostomy passes the test of time. A m Surg 1987; 53:5457. 43. Jensen TG. Home enteral nutrition. Dietetic Contents 1982; 9:16-20.
HEAD & NECK
March/April 1990
We investigated whether home enteral feeding via a tube gastrostomy would enable patients with advanced malignant disease, who were unable to maintain themselves nutritionally via the oral route, to be independent of the hospital setting. Thirtynine patients with advanced upper gastrointestinal and head and neck cancer had a tube gastrostomy placed. Before discharge, the patient was trained in the care and use of the gastrostomy feeding tube. Ten patients died of their disease before they could be discharged. During the 6-month period before gastrostomy insertion, the mean weight loss of the remaining 29 patients was 12.8%, and the mean body weight was less than 90% of ideal body weight. Prior to operation, the mean serum albumin and total lymphocyte count were 3.7 g/L and l,087/mL, respectively. At discharge the mean caloric intake was 1.48 times resting energy expenditure. Home enteral nutrition was provided for a median of 94 days and resulted in stabilizationof nutritional indices. During their median survival of 176 days, the 29 patients were admitted a total of 52 times. Twenty-eight percent of the patients were never re-admitted after gastrostomy and were adequately maintained at home, whereas 24% needed to be re-admitted once. Only 48% were re-admitted twice to assist in their nutritional management. Twenty patients received temporary home nursing services to aid in their transition. Four patients eventually resumed oral intake, and their
Acknowledgment. The authors thank Mrs. Darlene Thompson for her editorial assistance. From the Department of Surgery, Nutrition Support Service, University Hospital, SUNY Health Science Center, Syracuse, New York. Address reprint requests to Dr. Meguid at Surgical Metabolism & Nutrition Laboratory, Department of Surgery, University Hospital, SUNY Health Science Center, 750 East Adarns Street, Syracuse, NY 13210. Accepted for publication July 17, 1989. CCC 0148-6403/90/020137-06 $04.00 0 1990 John Wiley & Sons, Inc.
Home Enteral Nutrition via Gastrostomy
feeding gastrostomies were removed. Home enteral nutritional support via gastrostomy enabled patients with advanced cancer to maintain their nutritional status and be independent from the hospital setting for extended periods, with the improved comfort and quality of their limited life at home in familiar surroundings in face of malignant disease. HEAD & NECK 12:137-142, 1990
Patients with head and neck cancer present nutritional problems similar to those of other cancer patients, but they also present special problems related to their frequent inability to consume adequate nutrition orally. In a recent survey of 50 head and neck cancer patients, Basset and Dobie’ found that 40% presented a poor nutritional status. Similarly, in a couple of series reporting on a large population with digestive tract carcinoma, 48% to 66% of the patients were considered malnourished on a d m i ~ s i o n . This ~’~ high incidence of malnutrition in cancer patients prior t o definitive treatment and the severe sequelae that may result from extensive cancer operations often leads t o prolonged periods of hospitalization for nutritional support4; the latter represents an additional burden for health services resources. When the oral feeding route is unable to meet the patients caloric requirements, two other ways of nutrient delivery remain: parenteral nutrition (PN)or enteral nutrition (EN). Both are equally effective in maintaining the patient’s nutritional status or treating protein calorie malHEAD & NECK
March/April 1990
137
However, in patients with an intact functional gastrointestinal tract, EN is preferable.7 The advantages of this feeding route are as follow: the maintenance of gastrointestinal mass and function by delivering nutrients in the physiological way'; maintenance of the patient's defense risk of infection is minimal as compared to PN'l; less expensive than PN12; relatively safe to administer; and easy to perform by patients and/or family. If long-term EN support is required, tube gastrostomy is preferable to nasogastric tubes because it has a low risk of long-term complithe discomfort and risks assoc a t i o n ~it, ~avoids ~ ciated with long-term use of the nasogastric tube,14 and it allows more mobility and produces less psychological distress than the nasogastric tube.15 The present study was undertaken to assess the efficacy of home feeding by tube gastrostomies as an alternative to an expensive hospitalbased nutritional program in patients with advanced but slowly progressing cancer in whom no further tumor-directed therapy was available. If possible, such a regimen would enable patients to return to their usual home environment and to be independent of the hospital setting. METHODS AND MATERIALS
Thirty-nine patients were studied; all had tube gastrostomies placed because adequate nutrition could not be maintained orally. Ten patients were close to the end-stage of their disease when the gastrostomy tube was placed. They died during the same hospitalization at 2 to 95 days after gastrostomy tube placement and were not evaluated further. The remaining 29 patients had advanced disease or therapeutic complications of cancer treatment which impaired maintenance of their nutritional status by the oral route but were otherwise not in preterminal stages of their disease. Sites of the primary cancers were head and neck (N = 26), esophagus (N = 2), and lung (N = 1). In 19 patients, indications for gastrostomy placement included dysphagia, anorexia, and inanition. In 10 patients with fistulas from head and neck cancer following radiotherapy and operation, tube gastrostomy was the only operation. One of these patients underwent a flap revision after head and neck surgery. Before discharge, the patient and/or a family member was trained by a nutritional team nurse
138
Home Enteral Nutrition via Gastrostomy
in the care and use of the gastrostomy feeding tube. The learning period ranged from 5 to 7 days. EN was administered via the bolus gravity method with the feeding formula at room temperature. Nutritional status was assessed according to previously established criteria. 16*17Factors monitored were percentage of ideal body weight, serum albumin, and total lymphocyte count. These values were noted on admission, on the day of surgery, at discharge, and just prior to demise. Patient's weight approximately 6 months prior t o admission for gastrostomy was noted. Patients were considered malnourished when at least two of these latter parameters were below the 90th percentile. The daily caloric intake shortly before discharge was determined using the HarrisBenedict formula, to determine the percentage of caloric requirements supplied by EN. Other factors scrutinized included: technique of gastrostomy tube placement, complications of tube placement, feeding formula used, length of hospitalization, number of times patients were rehospitalized, number of days patients were maintained at home after discharge, number of days patients survived after tube gastrostomy was placed, whether patients were discharged home or to an extended-care facility, and whether home nursing services were utilized. The results of nutritional assessment are expressed as mean & SE, and all other results are expressed as the median, with the provided range. The paired t test and the signed-rank test were used to evaluate the changes in the nutritional indices. RESULTS
Of the 39 patients, the majority of the gastrostomy tubes placed were Foley catheters; 10 were Malencot catheters and five were DePezzer catheters. The most commonly placed gastrostomies were either of the Witzel" or the Stammlg type. There were no complications related to gastrostomy tube placement. Ten patients who died during the same hospitalization, during which tube gastrostomy was performed, were in the preterminal stage of their malignant diseases; all deaths were attributed to their primary cancer diagnosis. Since these patients could not contribute to an assessment of the utility of tube gastrostomy for home care, they will not be included in the following results. Table 1lists the nutritional assessments performed on the remaining 29 patients at admis-
HEAD & NECK
March/April 1990
Table 1. Nutritional assessment of cancer patients receiving home enteral feeding vis gastrostomy." Indices (A! = 29) % ideal body weight
Serum albumin Total lymphocyte count
Admission
Operation
Discharge
Recent
83.5 f 2.6 4.07 f 0.18 1,148 f 153
85.6 f 2.6 3.74 f 0.09 1,060 2 167
84.2 f 2.8 3.53 f 0.11 1,246 f 91
82.0 f 3.6 3.47 f 0.14 1,026 f 144
Values are given as mean 2 SE. "Changes were not significant at p < 0.05.
sion, on the day of operation, at discharge, and at the most recent assessment available. During the 6-month period prior to gastrostomy placement, a n average weight loss of 12.8% (7.7 kg) had occurred. Mean body weight remained below 90%of ideal body weight throughout the postgastrostomy nutritional management period. Total lymphocyte counts and serum albumin levels also remained below normal throughout. The average changes in serum albumin from gastrostomy placement to discharge and from discharge to the most recent contact were not significant. The mean changes in weight from operation to discharge or from operation to 1year follow-up were not significant. At discharge, the mean caloric intake was 1.48 times the patient's resting energy expenditure (range, 0.9-2.1). The majority of patients used Ensure (Ross Labs, Dayton, OH) for their feeding formula. Osmolite (Ross Labs) was used in 2 patients who had unpleasant feelings of abdominal fullness and distress with Ensure; 1 patient used Ensure Plus (Ross Labs) to increase his caloric intake. There were no operative complications of tube placement. The mechanical complications associated with the use of the gastrointestinal tube fell into two groups: low-frequency complications and high-frequency complications, defined as ones which occurred with < 5% or > 5% of the number of gastrostomy tubes used, respectively. These complications are also classified as either high or low morbidity, according to their impact on the patient's well-being. There was one low-frequency-low-morbidity complication consisting of purulent drainage due to cellulitis noted around a gastrostomy insertion site. The tube was temporarily removed, while antibiotic therapy was given. There were seven high-frequency-low-morbidity complications. Three tubes became clogged and required replacement; four tubes were accidentally pulled out by the patient and also needed replacement.
Home Enteral Nutrition via Gastrostomy
There was one low-frequency-high-morbidity complication consisting of migration of the Foley catheter balloon into the duodenum with signs of intermittent obstruction. After it was recognized radiologically, remedial action consisted of fixing the tube more securely to the abdominal wall to prevent the distal migration of the Foley catheter balloon with gastric peristalsis. The median time interval from admission to operation was 4 days (range, 1 to 64 days); from operation to discharge, 11 days (range, 5 to 82 days). The median length of hospitalization was 31 days (range: 6 to 108 days). The majority of patients were adequately maintained at home; 28% were never readmitted, whereas 24% were readmitted once during their course at home. Only 48% had to be readmitted twice. The reasons for readmission included the complications noted above, modification of nutritional therapy to allow better tolerance of formulae, and to provide temporary relief to the family by reassuring them and helping them cope with the progressive deteriorating clinical situation. Only 1 patient was discharged to an extended-care facility (his usual living situation); the others were discharged home to their family. Twenty patients received temporary home nursing services to aid in their transition home. Home enteral support in 25 patients was provided for a median of 94 days (18 to 1,149 days) and resulted in stabilization of nutritional indices. The median survival of these patients was 176 days (33 to 1,167 days). Four patients eventually resumed oral intake and their feeding gastrostomies were removed. The nutritional status of these patients was adequate at operation, at removal of gastrostomy tube, and at most recent contact; all were within their ideal body weight range. Their mean caloric intake at discharge from hospital was 1.78 (range, 1.19-2.16) times their resting energy expenditure. The median number of days at home with tube feeding for these patients was 136.2.
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Two of them were readmitted once. To date, all 4 patients are still alive. DISCUSSION
To evaluate the feasibility and the possible advantages of home EN using gastrostomy, patients with advanced but steady, progressive carcinoma (in whom no further tumor-directed therapy was available) had a gastrostomy tube placed in order to be given home enteral feeding so that their nutritional status could be maintained independent of the hospital setting. Ten patients died during hospitalization, for a mortality rate of 25.6%; the overall complication rate during the 1 year was 23%. All these patients presented terminal stages of their malignant diseases. Similar high mortality rates have been reported following feeding gastrostomy,20 although in that study the majority of patients who died were comatose. These results reflect the poor general condition of our patients and suggest that the indication of feeding gastrostomy to cachectic terminal cancer patients should be questioned. Twenty-nine patients were discharged a median of 11 days after gastrostomy tube insertion for maintaining their nutritional status. At discharge, they had a caloric intake of 1.48 times resting energy expenditure. From operation to the most recent contact, their mean weight gain was 1.8kg. "hey were followed with comfort care and without further anti-tumor therapy until their demise. During the 1 year follow-up, readmittance occurred a mean of 2.2 per patient; 52% of the patients were either never readmitted to the hospital or were readmitted only once. No significant complications (aspiration, perforation, uncontrolled diarrhea with resulting decubitii) were seen during the home-feeding period. Four of the 29 patients had the gastrostomy tube subsequently removed because they resumed adequate oral intake considered sufficient to meet their resting energy expenditure. They were on home tube feedings for a median period of 136.2 days with a mean caloric intake at discharge of 1.78 times resting energy expenditure. These data show that long-term home EN with a gastrostomy is a reasonable way of feeding cancer patients who are temporarily or definitively unable to swallow or eat, but whose gastrointestinal tract is intact. The nutritional considerations in the acute and chronic management of head and neck can-
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cer were recently discussed.21 Over 30 different operative techniques have been described for tube gastrostomy placement. In the typical oncologic setting, a gastrostomy tube should be placed at the time of other operative procedures, when prolonged postoperative use of enteral feeding is anticipated. Alternatively, gastrostomies can be placed as a separate surgical procedure performed through a limited celiotomy under local anesthesia or light general anesthesia13; both these options were used in our patients. More recently, the options of placement have increased with the introduction of percutaneous endoscopic gastrostomy (PEG), initially described in 1980 by Gauderer and Ponsky22 for infants and subsequently for adults in 1983,23in which a gastrostomy tube is placed percutaneously with the aid of gastric endoscopy commonly using only light sedation, local anesthesia, and performed at the bedside. Numerous investigators have reported series emphasizing the ease of the procedure; its low morbidity, the virtual absence of mortality, and its cost-effecti~eness.~~ Whereas -~l it is incumbent for the surgeon to anticipate the need and make plans for gastrointestinal access prior to and during an oncologic operation, the option of a PEG has compensated for the occasional misjudgment. Thus, a PEG is now being increasingly used in our current patient population when the need for a gastrostomy arises in the postoperative period. From a review of the literature32, of 991 patients in whom a PEG had been placed, overall procedure related morbidity was 9.4% and mortality was 0.4%. In comparison, operatively placed gastrostomy in a series of 6 s t ~ d i e s ~car~ * ~ ~ ~ ~ ried a higher morbidity of up to 32% and procedure-related mortality ranging from 2% to 21%. Sufficient caloric delivery is possible by EN with the low risk of complication^.^^*^^ It is easy to administer and a short-training time to instruct the patient andlor the family is enough to assure successful nutritional care at home. By the use of feeding gastrostomy, patients with limited life expectancy, but conscious and not in a terminal stage, may be spared long and impersonal hospital stays. Readmittance was necessary only in a low percentage of our patients. Half of our patients were never or only once readmitted to the hospital to support and reassure the patient's family in the face of progressively deteriorating clinical situation, although the patients were nutritionally adequately maintained in their usual home setting. During this time the
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March/April 1990
opportunity was taken to fine tune their nutritional therapy and reaffirm the overall management goals. With the increasing availability of hospice facilities, such readmissions are anticipated to become less frequent. In the presence of a tumor and in the face of an increasing tumor burden, nutritional support has been shown experimentally to maintain the existing nutritional status.39 Albumin status does not improve even with the long-term provision of adequate nutrition4'; only following curative resection of tumor load does adequate nutrition improve the overall nutritional status.39i41 In a median of 176 days of home feeding, significant complications which are described to be as high as 30%,42 did not occur in our patients. This shows that in a group of conscious patients, without neurological diseases or mental disturbances, the event of aspiration is very rare. The
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aim of intensive instructions of the patient, while in hospital, was to make him function in basic procedures and t o become competent to recognize hazards before severe complications take place.43 In summary, our results show that EN of advanced cancer patients who are unable to maintain their nutritional status by eating can be efficiently maintained at home using tube gastrostomy with occasional readmission for family supportive care and reassurance, during which the opportunity is used to fine tune their nutritional support therapy. This represents a humane and kind means of managing these types of patients by allowing them to return to their usual home environment, thereby to be independent of the hospital setting for a prolonged period, which improves the quality of their limited life, in the face of stable or progressive malignant disease.
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REFERENCES
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