Reactive versus prophylactic percutaneous gastrostomy: outcomes in a cohort of advanced oropharyngeal carcinoma patients
Keywords:Percutaneous gastrostomy, Head and neck cancer, Nutrition, Survival
Background: Dysphagia is a common complaint in patients with oropharyngeal tumors, both due to limitations of the underlying disease and the adverse effects of medical or surgical treatments. Percutaneous gastrostomy is used to prevent malnutrition, but there is currently no consensus on the best timing for its placement (prophylactic - pPEG or reactive - rPEG). The objective of this study was to analyze differences in nutritional and survival outcomes between patients who used pPEG and rPEG.
Methods: Retrospective analysis of a cohort of patients with advanced-stage oropharyngeal neoplasm undergoing chemoradiotherapy between January 2013 and December 2020. PEG placement was performed before (prophylactic - pPEG) or after (reactive - rPEG) initiation of treatment. Relevant demographic and clinical variables were analyzed.
Results: 49 patients received PEG during the studied period (age 57.6±8.2 years; 89.8% male). Of these, 32 (65.3%) received pPEG, while 17 (34.7%) placed rPEG. Device length of stay was significantly longer in patients with the pPEG strategy (205.5 vs 159.2 days; r=0.40; p=0.03). There was no difference in weight percentage at 3 (p=0.82) and 6 (p=0.08) months. Kaplan-Meyer analysis showed no difference in survival between the two strategies (log-rank p=0.49).
Conclusions: Nutritional and survival outcomes were not statistically different between the two analyzed subgroups. PEG dependence seems to be influenced by PEG timing strategy.
Hunter M, Kellett J, Toohey K, D’cunha NM, Isbel S, Naumovski N. Toxicities caused by head and neck cancer treatments and their influence on the development of malnutrition: Review of the literature. Eur J Investig Heal Psychol Educ. 2020;10:935-49.
Stechmiller JK. Understanding the role of nutrition and wound healing. Nutr Clin Pr. 2010;25(1):61-8.
Mueller SA, Mayer C, Bojaxhiu B. Effect of preoperative immunonutrition on complications after salvage surgery in head and neck cancer. J Otolaryngol Head Neck Surg. 2019;48(1):25.
Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World J Gastroenterol. 2014;20(24):7739-51.
Kohli DR, Kennedy KF, Desai M, Sharma P. Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment. Gastrointest Endosc. 2021;93(5):1067-85.
Gaziano JE. Evaluation and management of oropharyngeal dysphagia in head and neck cancer. Cancer Control. 2002;9(5):400-9.
Eisbruch A, Schwartz M, Rasch C, et al. Dysphagia and aspiration after chemoradiotherapy for head-and-neck cancer: Which anatomic structures are affected and can they be spared by IMRT? Int J Radiat Oncol Biol Phys. 2004;60(5):1425-39.
NICE. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition | Guidance and guidelines. NICE. Available at: Https://Www.Nice.Org.Uk/Guidance/Cg32. 2017. Accessed on 20 Janauary 2022.
Bese NS, Hendry J, Jeremic B. Effects of Prolongation of Overall Treatment Time Due To Unplanned Interruptions During Radiotherapy of Different Tumor Sites and Practical Methods for Compensation. Int J Radiat Oncol Biol Phys. 2007;68(3):654-61.
Chen AM, Li BQ, Lau DH. Evaluating the role of prophylactic gastrostomy tube placement prior to definitive chemoradiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys. 2010;78(4):1026-32.
Dave AA, Mozer MA, Zhang Y. Impact of reactive gastrostomy tube placement on clinical course of oropharynx cancer patients treated with chemoradiation. J Clin Oncol. 2019;37(15).
Brown TE, Banks MD, Hughes BGM, Lin CY, Kenny LM, Bauer JD. Comparison of Nutritional and Clinical Outcomes in Patients with Head and Neck Cancer Undergoing Chemoradiotherapy Utilizing Prophylactic versus Reactive Nutrition Support Approaches. J Acad Nutr Diet. 2018;118(4):627-36.
Madhoun MF, Blankenship MM, Blankenship DM, Krempl GA, Tierney WM. Prophylactic peg placement in head and neck cancer: How many feeding tubes are unused (and unnecessary)? World J Gastroenterol. 2011;17(8):1004-08.
Lawson JD, Gaultney J, Saba N, Grist W, Davis L, Johnstone PAS. Percutaneous feeding tubes in patients with head and neck cancer: rethinking prophylactic placement for patients undergoing chemoradiation. Am J Otolaryngol. 2009;30(4):244-9.
Langmore S, Krisciunas GP, Miloro KV, Evans SR, Cheng DM. Does PEG use cause dysphagia in head and neck cancer patients? Dysphagia. 2012;27(2):251-9.
Hutcheson KA, Bhayani MK, Beadle BM. Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers: Use it or lose it. JAMA Otolaryngol Head Neck Surg. 2013;139(11):1127-34.
Shaw SM, Flowers H, O’Sullivan B, Hope A, Liu LWC, Martino R. The Effect of Prophylactic Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement on Swallowing and Swallow-Related Outcomes in Patients Undergoing Radiotherapy for Head and Neck Cancer: A Systematic Review. Dysphagia. 2015;30:152-75.
Wiggenraad RGJ, Flierman L, Goossens A. Prophylactic gastrostomy placement and early tube feeding may limit loss of weight during chemoradiotherapy for advanced head and neck cancer, a preliminary study. Clin Otolaryngol. 2007;32(5):384-90.
Lang K, Elshafie RA, Akbaba S. Percutaneous endoscopic gastrostomy tube placement in patients with head and neck cancer treated with radiotherapy. Cancer Manag Res. 2020;12:127-136.
Strom T, Trotti AM, Kish J. Risk factors for percutaneous endoscopic gastrostomy tube placement during chemoradiotherapy for oropharyngeal cancer. JAMA Otolaryngol - Head Neck Surg. 2013.
Kramer S, Newcomb M, Hessler J, Siddiqui F. Prophylactic versus reactive PEG tube placement in head and neck cancer. Otolaryngol Head Neck Surg. 2014;150(3):407-12.
McClelland S, Andrews JZ, Chaudhry H, Teckie S, Goenka A. Prophylactic versus reactive gastrostomy tube placement in advanced head and neck cancer treated with definitive chemoradiotherapy: A systematic review. Oral Oncol. 2018;87:77-81.
Salas S, Baumstarck-Barrau K, Alfonsi M. Impact of the prophylactic gastrostomy for unresectable squamous cell head and neck carcinomas treated with radio-chemotherapy on quality of life: Prospective randomized trial. Radiother Oncol. 2009;93(3):503-9.