Oesophageal cancer causes dysphagia and weight loss. Malnutrition further worsens with multimodal treatment.

The aim of the study was to evaluate the impact of percutaneous endoscopic gastrostomy (PEG) placement in the nutritional status of patients with oesophageal cancer requiring chemoradiotherapy (CRT).

A comparative study with a prospective arm and a historical cohort was conducted. Oesophageal cancer patients undergoing CRT with dysphagia grade >2 and/or weight loss >10% were submitted to PEG-tube placement (pull method) before CRT. Stoma seeding was evaluated through a swab obtained after placement and, in surgical patients, the resected stoma. A matched historical cohort without PEG placement was used as control (trial ACTRN12616000697482).

Twenty-nine patients (intervention group, IG) were compared to 30 patients (control group, CG). Main outcomes did not differ in the IG and CG: weight loss during CRT 8.1 ± 5.5 kg versus 9.1 ± 4.2 kg (p = 0.503); 6-month mortality after CRT or surgery 17.2% versus 26.7% (p = 0.383); perioperative complication rate 54.5% versus 55.6% (p = 1.000); unplanned hospital admissions 34.5% versus 40.0% (p = 0.661). In the CG, during CRT, 14 (46.7%) patients presented with dysphagia grade 3-4, of whom 12 required nasogastric tube feeding (n = 10), surgical gastrostomy (n = 1), and oesophageal dilation (n = 1). In the IG, 89.7% used the PEG tube during CRT, sometimes exclusively in 51.7%. Adverse events were mainly minor (n = 12, 41.4%), mostly late peristomal infections, 1 major complication (exploratory laparotomy due to suspected colonic interposition, not confirmed). There was no cytological or histological evidence of stomal tumour seeding.

Weight loss, hospital admissions, surgical complications, and mortality were identical in oesophageal cancer patients referred for CRT, regardless of prophylactic PEG. However, half of the patients required exclusive enteral nutritional support, making PEG-tube placement an alternative to consider.

While surgical therapy for head and neck cancer (HNC) is showing improvement with the advancement of reconstruction techniques, the focus in these patients should also be shifting to supportive pre and aftercare. Due to the highly sensitive and anatomically complex region, these patients tend to exhibit malnutrition, which has a substantial impact on their recovery and quality of life. The complications and symptoms of both the disease and the therapy usually make these patients unable to orally intake food, hence, a strategy should be prepared for their nutritional management. Even though there are several possible nutritional modalities that can be administrated, these patients commonly have a functional gastrointestinal tract, and enteral nutrition is indicated over the parenteral option. However, after extensive research of the available literature, it seems that there is a limited number of studies that focus on this important issue. Furthermore, there are no recommendations or guidelines regarding the nutritional management of HNC patients, pre- or post-operatively. Henceforth, this narrative review summarizes the nutritional challenges and management modalities in this particular group of patients. Nonetheless, this issue should be addressed in future studies and an algorithm should be established for better nutritional care of these patients.

Gastroenterologists are frequently consulted for evaluation feeding tube placement, or for management of complications in an existing feeding tube. Though a frequent topic of consultation for GI Fellows, there are few comprehensive resources for feeding tube placement and troubleshooting available. In this review, we discuss different types of feeding tubes, when each should be considered, and various methods and techniques for placement. Considerations for when one type, method, technique, or specialty may be preferred over the other will be discussed. Additionally, we discuss management of the many complications of indwelling feeding tubes. Our goal is to create a comprehensive review for gastroenterologists to cover clinically relevant questions related to feeding tube placement and management.

Carotid endarterectomy (CEA) is a safe and effective procedure, with a low risk of complications when performed by experienced surgeons. Postoperative infections are particularly rare, reportedly affecting less than 1% of cases. Incisional metastases have not been described.

To describe a previously unreported complication, the incisional seeding of metastatic squamous cell carcinoma (SCC) during neck dissection, which presented and was treated as a presumed postoperative neck abscess.

Clinical records were reviewed regarding a 73-yr-old female who underwent routine CEA and presented 2 mo postoperatively with neck induration and erythema. Tissue submitted during the initial CEA was reexamined given the updated clinical history.

Postoperatively, a complex, multi-cystic fluid collection beneath the incision was identified and percutaneously drained. Although cultures were negative, an infection was favored and antibiotic therapy initiated. The patient's symptoms worsened prompting surgical exploration, and tissue sent for pathological examination was consistent with metastatic SCC. Retrospective analysis of a lymph node excised during the initial dissection also revealed tumor deposits, indicating that the surgical site had been seeded during exposure. A primary origin was not identified.

The time from initial presentation of postoperative complications to a final diagnosis of metastatic SCC was 2 mo, during which time the patient was treated as having a postoperative infection. Further investigations were consistent with diffuse and incurable metastatic disease. This report highlights the diagnostic challenges and potential avoidance strategies when dealing with rare complications following CEA.

Gastrostomy site metastization is considered an uncommon complication of percutaneous endoscopic gastrostomy (PEG) placement in patients with head and neck tumours, but it is important to consider this possibility when evaluating gastrostomy-related symptoms. The authors present the case of a 40-year-old male with excessive alcohol consumption and active smoking, diagnosed with a stage IV oropharyngeal squamous cell carcinoma. The patient developed a paraneoplastic demyelinating motor polyneuropathy that, associated with tumour mass effect, caused dysphagia with need for nasogastric tube feeding. Treatment with radiotherapy and then chemoradiotherapy was administered and a PEG was placed with the pull method. Cancer remission and resolution of polyneuropathy was achieved, so PEG was removed. Two weeks later, the patient presented with pain and swelling at the gastrostomy site suggesting a local abscess, with improvement after drainage and antibiotic therapy. After 1 month, there was a tumour mass at the gastrostomy site and an oropharyngeal cancer metastasis was diagnosed. The patient underwent surgical excision of abdominal wall metastasis and abdominal disease was controlled. Nevertheless, there was subsequent oropharyngeal neoplasia recurrence and the patient died 6 months later. This case raises the discussion about gastrostomy placement methods that could avoid gastrostomy site metastization, the possible differential diagnosis, and diagnostic workout. Surgical resection may allow metastatic disease control, but by primary disease evolution greatly affects prognosis.

Head and neck cancer (HNC) patients often require percutaneous gastrostomy (PEG) tube placement due to malnutrition and dysphagia. While beneficial, PEG tube placement can cause a rare but reportable complication of metastasis of the original tumor to the gastrostomy exit site. The objectives of this case series were to present HNC patients at a single institution that developed PEG tube metastases, their subsequent treatment, and review of the literature for similar cases.

We describe three HNC patients who underwent PEG tube placement and developed metastasis at their tube site. We also describe their metastatic disease treatment and compare these cases with similar cases in the literature.

All three cases' initial staging were node positive and all three cases had their PEG tubes placed by the "pull" method. Two patients presented with masses at their PEG site while one patient had a site mass on surveillance positron emission topography (PET) imaging. Biopsy showed the original HNC metastasized to the gastrostomy site. Two patients were treated with surgical resection while one patient was treated with palliative chemotherapy. The "pull" method has been most associated with cases of metastasis in the literature. In the literature, risk factors for metastasis include initial tumor clinical and pathological staging.

PEG site metastasis should be suspected in patients with skin changes at the PEG site. "Pull" procedures may cause metastasis through physical contact with the primary tumor causing tumor seeding at the PEG site. Surgical resection of metastasis has been shown to be an effective treatment strategy for PEG site metastasis. In patients with higher stage cancers, tube insertion methods that avoid contact with the primary tumor should be considered.

NA.

Percutaneous endoscopic gastrostomy (PEG) tubes are an effective modality for enteral nutrition in patients with head and neck cancer; however, there have been documented case reports of "seeding" of the abdominal wall by the theoretic risk of dragging the tube along the tumor during PEG placement. The objective of this study is to determine the incidence and contributing risk factors leading to metastasis to the abdominal wall following PEG placement in patients with head and neck cancer.

A retrospective chart review was performed on patients diagnosed with head and neck malignancy who underwent PEG placement between 1/5/2009 and 12/22/2014. Variables collected included development of abdominal wall metastases, type of malignancy and tumor characteristics, smoking history, PEG placement technique, and survival following recurrence. Data were then analyzed for overall trends.

Out of 777 patients analyzed, a total of five patients with head and neck malignancy were identified with abdominal wall metastasis following PEG tube placement with an overall incidence of 0.64% over an average follow-up of 27.55 months. All of these patients underwent PEG tube insertion via a Pull technique. One patient was found to have a clinically evident and symptomatic stomal metastasis, while the other four patients had radiologically detected metastases either on CT or PET scan. All of the identified patients were found to have stage IV oral cancer at time of initial diagnosis of their head and neck malignancy, followed by widespread distant metastatic disease at time of presentation with their PEG site stomal metastasis.

Abdominal wall metastases following PEG placement are a rare but serious complication in patients with head and neck malignancy.

Nutritional management is important throughout the treatment period for esophageal cancer patients. This study aimed to evaluate the feasibility of percutaneous radiologic gastrostomy (PRG) and to investigate whether PRG can be applied for patients with advanced esophageal cancer.

In this study, 89 patients (74 men and 15 women) with advanced esophageal cancer underwent PRG using computed tomography and fluoroscopic guidance. These patients were unsuitable candidates for endoscopic intervention because of esophageal stricture. Primary placement of a mushroom-retained gastrostomy catheter was intended. The end points were technical success and complications after PRG as well as clinical outcomes and survival of the patients. These end points also were compared between the pre-chemoradiotherapy (pre-CRT) and post-CRT groups using the Chi square test, Fisher's exact test, and the Wilcoxon rank sum test. The survival rate was calculated using the Kaplan-Meier method and compared using the log-rank test.

All the patients had a successful PRG. The mushroom-tip gastrostomy catheter was primarily inserted in 77 patients (86.5 %) and finally achieved for all the patients. Complications occurred for 14 patients (15.7 %) including Dindo-Clavien classification grade 3 (1 catheter dislodgement), grade 2 (2 gastric hemorrhages), and grade 1 (7 skin infections and 4 oozing hemorrhages) complications. During the follow-up period (median, 6 months), 60 patients (67.4 %) died, giving a 12-month survival rate of 37.7 %. Gastrostomy removal was more common in the pre-CRT group (P = 0.011). The pre-CRT group had higher survival rates than the post-CRT group (P = 0.021).

Because PRG provided high technical success with limited complications, it can be used for patients with advanced esophageal cancer whose treatment plan involves multimodal therapy.

Esophageal cancers account for majority of synchronous or metachronous head and neck cancers. This study examined the risk of esophageal cancer following percutaneous endoscopic gastrostomy (PEG) in head and neck cancer patients using the Taiwan National Health Insurance Research Database. From 1997 to 2010, we identified and analyzed 1851 PEG patients and 3702 sex-, age-, and index date-matched controls. After adjusting for esophagitis, esophagus stricture, esophageal reflux, and primary sites, the PEG cohort had a higher adjusted hazard ratio (2.31, 95% confidence interval [CI] = 1.09-4.09) of developing esophageal cancer than the controls. Primary tumors in the oropharynx, hypopharynx, and larynx were associated with higher incidence of esophageal cancer. The adjusted hazard ratios were 1.49 (95% CI = 1.01-1.88), 3.99 (95% CI = 2.76-4.98), and 1.98 (95% CI = 1.11-2.76), respectively. Head and neck cancer patients treated with PEG were associated with a higher risk of developing esophageal cancer, which could be fixed by surgically placed tubes.

Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the "pull" technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.

Percutaneous endoscopic gastrostomy (PEG) has become a mainstay in providing enteral access for patients with obstructive head and neck tumors. PEG tube placement is considered safe and complications are infrequent.

A comprehensive review of the literature in MEDLINE (1962-2011) was performed. We report herein 3 new cases.

The literature search revealed 43 previous cases. The interval between PEG placement and diagnosis of metastasis ranged from 1 to 24 months.

Metastatic cancer should be considered in patients with head and neck cancer that have persistent, unexplained skin changes at PEG site, anemia, or guaiac positive stools without a clear etiology. The direct implantation of tumor cells through instrumentation is the most likely explanation, although hematogenous and/or lymphatic seeding is also a possibility. Our review of the literature and clinical experience indicate that the "pull" technique of PEG placement may directly implant tumor cells at the gastrostomy site.

Skin metastases occur in 0.6%-10.4% of all patients with cancer and represent 2% of all skin tumors. Skin metastases from visceral malignancies are important for dermatologists and dermatopathologists because of their variable clinical appearance and presentation, frequent delay and failure in their diagnosis, relative proportion of different internal malignancies metastasizing to the skin, and impact on morbidity, prognosis, and treatment. Another factor to take into account is that cutaneous metastasis may be the first sign of clinically silent visceral cancer. The relative frequencies of metastatic skin disease tend to correlate with the frequency of the different types of primary cancer in each sex. Thus, women with skin metastases have the following distribution in decreasing order of frequency of primary malignancies: breast, ovary, oral cavity, lung, and large intestine. In men, the distribution is as follows: lung, large intestine, oral cavity, kidney, breast, esophagus, pancreas, stomach, and liver. A wide morphologic spectrum of clinical appearances has been described in cutaneous metastases. This variable clinical morphology included nodules, papules, plaques, tumors, and ulcers. From a histopathologic point of view, there are 4 main morphologic patterns of cutaneous metastases involving the dermis, namely, nodular, infiltrative, diffuse, and intravascular. Generally, cutaneous metastases herald a poor prognosis. The average survival time of patients with skin metastases is a few months. In this article, we review the clinicopathologic and immunohistochemical characteristics of cutaneous metastases from internal malignancies, classify the most common cutaneous metastases, and identify studies that may assist in diagnosing the origin of a cutaneous metastasis.

Many patients with advanced head and neck cancer are already in a poor nutritional status and need supportive nutritional therapy at the time of initial diagnosis. Malnutrition is associated with delayed recovery, prolonged hospital stay and unfavorable prognosis. By using percutaneous endoscopic gastrostomy (PEG), the social stigmatization for the patient resulting from the conspicuous nasal feeding tube is avoided. The PEG can be easily implemented at the time of diagnosis by head and neck surgeons in patients suffering from massive tumor-associated weight loss, when definitive or adjuvant radiochemotherapy is anticipated, or prior to tumor surgery likely to be followed by prolonged significant dysphagia and protracted swallowing rehabilitation. Analgesics can be administered via the PEG tube, thus simplifying adequate pain management, which plays a central role in the care of head and neck cancer patients.

Endoscopic ultrasound (EUS) fine needle aspiration (FNA) can result in false-positive cytology and can also cause needle tract seeding. Our goal was to evaluate a potential cause, namely, the presence of malignant cells within gastrointestinal (GI) luminal fluid, either as a result of tumor sloughing from luminal cancers or secondary to FNA of extraluminal sites.

During EUS, luminal fluid that is usually aspirated through the echoendoscope suction channel and discarded was instead submitted for cytological analysis among patients with cancer and benign disease. Pre- and post-FNA luminal fluid samples were collected to discern the role of FNA in inducing a positive cytology. When not performing FNA, one sample was collected for the entire examination. The final diagnosis was based on strict clinicopathological criteria and >or=2-year follow-up. This study was conducted in a tertiary referral center.

We assessed the prevalence of luminal fluid-positive cytology among patients with luminal (e.g., esophageal), extraluminal (e.g., pancreatic), and benign disease. Among the 140 patients prospectively enrolled with sufficient sampling and follow-up, an examination of luminal fluid cytology showed positive results for malignancy in luminal and extraluminal cancer patients, 48 and 10%, respectively. This included 8 out of 23 esophageal, 4 of 5 gastric, and 9 of 15 rectal cancers. The positive luminal fluid cytology rate with luminal cancers was not affected by performing FNA. Post-FNA luminal fluid cytology was positive in 3 out of 26 with pancreatic cancers. Cytological examination of luminal fluid aspirates did not demonstrate malignant cells in any patient with nonmalignant disease.

Malignant cells are commonly present in the GI luminal fluid of patients with luminal cancers and can also be found in patients with pancreatic cancer after EUS FNA. Further study is needed to determine the impact of these findings on cytological interpretation, staging, risk of needle tract seeding, and patient care and outcomes.

The presence of a malignancy of the upper aerodigestive tract introduces the potential for iatrogenic complications additional to those usually associated with percutaneous endoscopic gastrostomy. Specifically, seeding of tumour from the upper aerodigestive tract creating abdominal wall metastases, and airway obstruction due to tumour directly occluding the airway when a patient is sedated for percutaneous endoscopic gastrostomy.

We report an audit of our experience of gastrostomy placement for patients under going treatment for head and neck cancer in our institution from September 2003 to October 2006.

Of 33 patients who had percutaneous endoscopic gastrostomy insertion under sedation in the first cycle of the audit, two (6%) experienced major airway complications resulting in one fatality. A tumour assessment protocol was introduced. In the second cycle, 96 patients had percutaneous endoscopic gastrostomies, of whom 16 (13%) underwent gastrostomy insertion under general anaesthetic and five (4.5%) under radiological guidance. No patients had airway complications or abdominal wall metastases.

A formal tumour assessment protocol eliminated airway obstruction as a complication of percutaneous endoscopic gastrostomy insertion and may reduce the potential for abdominal wall metastases at the gastrostomy site when using the pull technique.

Metastases to gastrostomy sites are a rare but significant complication of percutaneous endoscopic gastrotomy (PEG) placement in cancer patients. Both direct seeding and hematogenous spread have been suggested as possible mechanisms. This article outlines the incidence, presentation, pathogenesis, and management of PEG-site metastases.

Innovation in endoscope design and application of lessons and techniques from minimally invasive surgery is allowing endoscopists to explore new frontiers in enteral access and meet the demands of an increasingly savvy and aging 'baby boomer' population that has high health care expectations. Another small but very labor intensive group of patients that is contributing both to increased awareness and to the demand for specialized nutrition support services, is made up of patients with intestinal failure. With steadily accruing experience in the care of these patients on long term home parenteral and enteral nutrition, as well as the improved outcomes for intestinal transplantation, these services are poised for exponential growth in coming years. The endoscopist whose practice involves enteral access should be capable of providing the whole gamut of enteral access services allowing individualization of approach to ensure the best possible outcomes for a given patient and indication. Experience with management of the many common complications of enteral access is a pre-requisite for successful long-term outcomes. While it would be desirable that such enteral access be provided within a broader multi-disciplinary model of specialized nutrition support, in the current climate of a tightening health care economy that may be counsel for perfection.

To comprehensively review all known reported cases of stomal metastases after percutaneous endoscopic gastrostomy (PEG) to systematically identify risk factors for this complication and to develop strategies for reducing this risk.

Reported cases were identified by computerized literature searches. Criteria for risk factors for stomal metastases included: a substantially higher relative rate of this factor in patients with stomal metastases than expected from pharyngoesophageal malignancy in general, and biologic plausibility of this phenomenon.

Review of all 44 known stomal metastases revealed the following. The mean patient age was 59.0+/-10.0 (SD) yr, and 79% of patients were male. Pathologically proven stomal metastases were located in the abdominal wall (PEG exit site) in 63%, in the gastric wall (PEG entrance site) in 7%, and in both walls in 30%. Mean survival after diagnosis was only 4.3+/-3.8 months. Pathologic risk factors for stomal metastases included: (a) pharyngoesophageal location of primary cancer (in 100% of cases, 0% other locations); (b) squamous cell histology (in 98%, adenocarcinoma in 2%); (c) poorly or moderately differentiated histology (in 92%, well differentiated in 8%); (d) advanced pathologic stage (in 97%, early stage in 3%); and (e) large primary cancer size at diagnosis (mean diameter 4.2+/-2.3 cm). These risk factors appeared to be quantitatively large (e.g., 98% of cases had squamous histology vs 50% expected rate, odds ratio 40.1, OR CI 6.31-246.4, P<0.0001). Therapeutic risk factors for stomal metastases included: (a) endoscopic PEG placement (in 98%, surgical gastrostomy in 2%); (b) pull-string PEG technique (in 98%, push-guidewire in 2%, direct-introducer in 0%); (c) primary cancer untreated or known local recurrence after treatment before PEG (in 87%); and (d) time>or=3 months after PEG insertion (in 100%, <3 months in 0%; mean interval 7.8+/-5.2 months after PEG). Four of the currently reported risk factors are novel (pathologic factors d,e; therapeutic factors a,d).

Strong risk factors for stomal metastases include: pharyngoesophageal primary cancer, squamous cell histology, less well-differentiated cancer, large size, and advanced cancer stage. The risk may be reduced in patients with risk factors by radiotherapy, chemotherapy, or cancer surgery before PEG; by substituting the push-guidewire for the pull-string technique for PEG; and possibly by use of a sheath with the pull-string technique.

Placement of a percutaneous endoscopic gastrostomy (PEG) tube creates a controlled perforation of a hollow viscous organ and an acute surgical wound. Physicians who place PEG tubes endoscopically or fluoroscopically often do not have the opportunity to provide these patients with long-term follow-up care. Thus, nutrition support specialists who do treat these patients may be the one member of the health care team who is in the most advantageous position for ongoing inspection and maintenance of the access device. Carefully monitored surveillance and adherence to routine principles of wound care assure the health of the skin, the underlying tissue, and the tract into the abdominal cavity through which the PEG passes. Having knowledge of the types of tubes placed, performing a regular physical examination of the PEG site, and maintaining good communication with the endoscopist results in early identification of problems, promotes rapid simple strategies to correct deficiencies, and the opportunity to minimize long-term complications. Dietitians, wound-care ostomy nurses, and other nutrition support specialists are encouraged to be more proactive with their participation in the care and management of the PEG site.

The minimally invasive nature of endoscopically placed gastrostomy tubes makes them a viable consideration in palliative care. Complications related to the procedure appear to correlate with age and underlying comorbidities.However, in many instances, the scientific basis for establishing benefit or harm from tube placement is methodologically inadequate. Decisions must be preceded by a discussion of the value and potential risk of artificial nutrition in a particular setting, respecting the wishes and beliefs of each patient and his or her family. The decision to use PEG placement for any reason should be consistent with legal and ethical principles, reflect patient autonomy over any other consideration (including beneficence), and arise from a clear determination of the goals of care (and whether the PEG placement will truly help meet those goals). Whenever possible, further studies with better design are needed to evaluate whether the use of PEG truly affects quality of life and patient outcome in palliative care. PEG tubes for decompression are placed successfully most of the time. Symptom relief occurs usually within 7 days of the procedure. Overall, the morbidity related to the PEG procedure for decompression is only slightly higher than when the same technique is used for nutritional purposes. The appropriate timing for PEG tube placement for nutritional support and for decompression throughout the course of disease progression may be difficult to determine and yet may be a factor in its overall efficiency. Only minor modifications of the basic technique used for PEG placement for nutritional purposes are required to adapt the technique to a variety of other applications in palliative care.

An interesting case of gastric metastasis of head and neck cancer after percutaneous endoscopic gastrostomy (PEG) placement is presented. Gastric metastases may appear in 3 morphologic varieties endoscopically. They may be multiple nodules of varying size, submucosal tumor masses with tip ulceration, or nonulcerated masses. Histologically, they may be seen as microscopic infiltration, a gross nodule, gross ulceration, or a gross hypertrophied wall. A case of PEG associated gastric metastasis has been reported almost every year since 1989. Even then, PEG placement by pull method continues to be a common procedure for patients diagnosed with head and neck cancer. The mechanism of gastric metastasis in patients with PEG is unclear. Seeding as well as hematogenous and lymphatic spread to traumatized tissue may be the cause.

To compare percutaneous endoscopic gastrostomy (PEG) with radiologically inserted gastrostomy (RIG) and assess a hybrid gastrostomy technique (per-oral image-guided gastrostomy, PIG).

Fifty PEGs and 50 RIGs performed in three centres were prospectively compared and the endoscopic findings of 200 PEGs reviewed. A fluoroscopy-guided technique was modified to place 20 F over-the-wire PEG-tubes in 60 consecutive patients.

Technical success was 98%, 100% and 100% for PEG, RIG and PIG, respectively. Antibiotic prophylaxis significantly reduced stoma infection for orally placed tubes (p=0.02). Ten out of 50 (20%) small-bore RIG tubes blocked. Replacement tubes were required in six out of 50 PEGs (12%), 10 out of 50 RIGs (20%), but no PIGs (p<0.001). No procedure-related complications occurred. The function of radiologically placed tubes was significantly improved with the larger PIG (p<0.001), with similar wound infection rates. PIG was successful in 24 patients where endoscopic insertion could not be performed. Significant endoscopic abnormalities were found in 42 out of 200 PEG patients (21%), all related to peptic disease. Insignificant pathology was found in 8.5%.

PIG combines advantages of both traditional methods with a higher success and lower re-intervention rate. Endoscopy is unlikely to detect clinically relevant pathology other than peptic disease. PIG is a very effective gastrostomy method; it has better long-term results than RIG and is successful where conventional PEG has failed.

Malnutrition is a common and significant problem in patients with cancer. Enteral nutrition support is an important therapy and is preferred over parenteral nutrition in the setting of a functional gastrointestinal tract. Familiarity with the indications for enteral support, the choice of an enteral access device, and the selection of an enteral formula are critical for the care of patients with cancer and malnutrition. Enteral nutrition has proven efficacy in patients receiving radiation to the head and neck, those with persistent dysphagia, and critically ill patients with impaired gastric emptying. Placement of feeding tubes through the nose or percutaneously provides a mechanism to deliver nutrients when proximal obstructions or oropharyngeal dysphagia prevent adequate oral intake. Direct access to the jejunum can be safely obtained endoscopically and is very useful in patients who require enteral nutrition support following a gastrectomy or esophagectomy or have impaired gastric emptying. Standard polymeric formulas are appropriate for most patients. Specialized formulas designed to enhance immune function may decrease infectious complications but do not improve survival.

This article describes the CT appearance of metastatic implantation at the percutaneous endoscopic gastrostomy (PEG) tract in patients with malignancy of the upper aerodigestive tract. Cumulative data from previous case reports are also considered for insight into causes of metastasis and the implications for gastrostomy placement in these patients.

CT showed lobulated soft tissue involving the entire abdominal wall PEG tract in all proven cases. CT is an effective method for evaluation because the tumor burden lies predominately in the abdominal wall and not at the entry or exit site. The stomal implant is often the only site of metastatic disease at presentation. In general, CT findings of mildly increased soft tissue along the PEG tract are nonspecific, but a lobulated mass is highly suspicious for tumor implantation, especially if the one-sided thickness exceeds 1 cm. The preponderance of evidence from the existing literature points to direct tumor implantation during endoscopic placement as the likely cause (rather than hematogenous spread). This conclusion would support the alternative of radiologic tube placement in these patients.