Gastrostomy tube placement is a procedure that achieves enteral access for nutrition, decompression, and medication administration. Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events (AEs). Appropriate indications, contraindications, ethical considerations, and comorbidities of patients referred for gastrostomy placement should be weighed and balanced. Additionally, endoscopist should consider either a transoral or transabdominal approach is appropriate, and radiologic or surgical gastrostomy tube placement is needed. However, medical history, physical examination, and imaging prior to the procedure should be considered to tailor the appropriate approach and reduce the risk of AEs.

Metastasis to the gastrostomy site in patients with upper aerodigestive tract (UADT) malignancies is a rare but devastating adverse event that has been poorly described. Our aim was to determine the overall incidence and clinicopathologic characteristics observed with development of gastrostomy site metastasis in patients with UADT cancers.

This was a systematic review and meta-analysis of 6138 studies retrieved from Medline, EMBASE, CINAHL, and the Cochrane Register after being queried for studies including gastrostomy site metastasis in patients with UADT malignancies.

The final analysis included 121 studies. Pooled analysis showed an overall event rate gastrostomy site metastasis of .5% (95% confidence interval [CI], .4%-.7%). Subgroup analysis showed an event rate of .56% (95% CI, .40%-.79%) with the pull technique and .29% (95% CI, .15%-.55%) with the push technique. Clinicopathologic characteristics observed with gastrostomy site metastasis were late-stage disease (T3/T4) (57.8%), positive lymph node status (51.2%), and no evidence of systemic disease (M0) (62.8%) at initial presentation. The average time from gastrostomy placement to diagnosis of metastasis was 7.78 ± 4.9 months, average tumor size on detection was 4.65 cm (standard deviation, 2.02), and average length of survival was 7.26 months (standard deviation, 6.23).

Gastrostomy site metastasis is a rare but serious adverse event that occurs at an overall rate of .5%, particularly in patients with advanced-stage disease, and is observed with a very poor prognosis. These findings emphasize a need for clinical practice guidelines to include a regular assessment of the PEG site and highlight the importance of detection and management of gastrostomy site metastasis by the multidisciplinary care oncology team.

Because of publication bias, there is uncertainty about the true incidence of tumor seeding or implantation in patients with head and neck or oesophageal cancer undergoing percutaneous endoscopic gastrostomy (PEG) insertion.

In order to obtain a more reliable estimate of risk, a systematic review was undertaken. Randomized or non-randomized studies and case reports were identified by electronic searching. A risk of bias assessment was carried out for each study.

Ninety-eight cases from 74 published case reports and 1 unpublished case were identified. Synchronous distant metastases were present in 37%. Analysis of case series (6192 patients) considered to carry a moderate risk of bias suggests an incidence of seeding after PEG insertion of 0.32%. Studies carrying a lower risk of bias indicate a risk of seeding closer to 1 in 2000.

The true risk of seeding after PEG insertion is probably less than 1 in 1000.

Percutaneous endoscopic gastrostomy (PEG) enables enteral nutrition for patients with inadequate oral intake. Laparoscopic guidance of PEG insertion is used for high-risk populations, including in infants less than 5kg at insertion. This study aimed to assess complication rates with traditional PEG tube insertion in infants less than 5kg at a single tertiary care center.

A retrospective review of patients less than 5kg who underwent PEG insertion was conducted. PEG insertion-related complications, up to four years following insertion, were collected. Outcomes were reported as counts and percentages, or median with minimum and maximum values.

480 pediatric gastrostomy procedures between January 1, 2009 and February 1, 2017, were screened, with 129 included for analysis. Median weight at PEG insertion was 3800g. Superficial surgical site infection (SSI) occurred in 6 (4.7%) patients, and 1 (0.8%) required readmission for intravenous antibiotics. One (0.8%) required endoscopic management for retained foreign body, 1 (0.8%) required operative management for gastrocolic fistula, and 1 (0.8%) for persistent gastrocutaneous fistula. No deep space SSI, procedure-related hemorrhage requiring readmission or transfusion, buried bumper syndrome, or procedure-related mortality occurred.

Traditional PEG tube insertion in infants less than 5kg results in complication rates comparable to pediatric literature standards.

Level II, retrospective prognosis study.

Peristomal infection is a main complication of PEG. The pull technique appears to be associated with higher infection rates compared with the introducer technique, although published results are controversial.

To determine which technique is associated with a higher risk of infection.

Systematic review and meta-analysis.

Studies reporting rates of peristomal infection after PEG performed by either the pull or introducer technique.

This study involved 2336 patients from 6 comparative and 10 observational studies.

Public MEDLINE (National Library of Medicine journal articles database), Excerpta Medica Database, Cochrane Central Register of Controlled Trials, and Latin American and Caribbean Center on Health Sciences Information databases and proceedings of two meetings, Digestive Disease Week and United European Gastroenterology Week, were searched. Both comparative and observational studies were included and analyzed separately.

Effect measures from each comparative study were reported as the odds ratio (OR). The pooled effect was then calculated. The infection rate in each observational study was also calculated, and a summary effect was then determined.

In comparative studies, the risk of infection was significantly higher with the pull technique (OR 13.0; 95% confidence interval [CI], 4.6-36.8; P < .0001). Similarly, observational studies also reported higher infection rates with the pull technique (10.7%; 95% CI, 4.9-21.8 with the pull technique vs 0.9%; 95% CI, 0.2-4.5 with the introducer technique).

Few studies were available for inclusion, and there was a high risk of bias among the comparative studies.

The pull technique appears to be associated with a significantly higher risk of infection compared with the introducer technique.

The importance of adequate nutrition has long been established in the surgical patient population. Enteral nutrition provides the safest, most cost-effective approach with endoscopic and surgical options for permanent access. Parenteral nutrition should be reserved for patients in whom enteral nutrition is contradicted. This article summarizes the routes of access for both enteral and parenteral nutrition as well as the indications, procedural pearls, and complications associated with each approach.

Percutaneous endoscopic gastrostomy (PEG) tubes are often placed in head and neck cancer patients to provide nutritional support, but studies have found the complication rates to be higher than other subsets of patients who undergo PEG placement. Complication rates as high as 50% have been reported, with the bulk of these complications being PEG site issues (i.e., cellulitis, abscess, fascitis, and tumor implantation). Because the pull technique has been the primary technique used, the theory is that the transoral tube passage is the source of the complications in these patients. Alternatively, the introducer technique uses a transabdominal approach to place the device, avoiding any tube contamination by upper aerodigestive organisms or tumor cells. At our institution, this technique has been used exclusively for head and neck cancer patients and this article reports our experience.

One hundred forty-nine head and neck cancer patients who had a prophylactic PEG tube placed were reviewed from January 1, 1999 to December 31, 2003. The rates of placement success, morbidity, and complications were determined.

Successful placement was achieved in 148 (99%) patients without any PEG-related deaths. Overall, 17 complications (11%) occurred, with only one major complication (0.7%) identified. PEG site infections were uncommon with only five cases (3.4%) and all were mild cellulitis.

The introducer technique is the safest method for PEG tube placement in head and neck cancer patients. The overall rate of complications is low and PEG site infectious complications are rare. The introducer technique should be the method of choice for PEG tubes in head and neck cancer patients.