PEG placement for patients with oropharyngeal/oeosphageal cancers

Editor – I recently read and completed the CME gastroenterology self-assessment questionnaire (Clin Med Dec 2012 pp 572–95). Question 3 asks about nutritional support for a patient with a pharyngeal tumour due to undergo radiotherapy and surgery. The answer given is that he should have a percutaneous endoscopic gastrostomy (PEG) sited for feeding.

Endoscopic siting of a PEG tube involves pulling the feeding tube and plastic ‘bumper’ through the oropharynx, oeosphagus, into the stomach and out through the gastrostomy site. This procedure potentially brings the tube and bumper into direct contact with tumours at these sites. Tumour seeding with development of metastases at the PEG site has been reported in numerous case reports^1,2 and metastases of this nature can have devastating consequences for patients.

National guidelines³ highlight this issue and state that the alternative, direct ­puncture technique, has not been demonstrated to result in metastases, but they do not go as far as to make recommendations for clinical practice. Most recently a prospective trial has attempted to address this question.⁴ Ellrichmann et al performed immediate and delayed (after 3–6 months) cytology from PEG tubing and at the ­transcutaneous incision site of 40 patients undergoing pull-through PEG for ear nose and throat (ENT)/oeosphageal cancer. The results were concerning, demonstrating malignant cells on cytology of 22.5% of patients immediately after pull-through PEG placement, and 9.4% of patients with local metastases at follow up. While the authors admit the sample size was small (n = 7 studied at follow up), the study demonstrated a shorter median overall survival in those with proof of malignant cells at follow up (16.1 weeks vs 26.8 weeks, p = 0.08). The authors note that risk of malignant seeding was highest in older patients and in those with higher tumour stages and concluded that pull-through PEG should be avoided in these groups and direct access gastrostomy favoured instead.

• © 2013 Royal College of Physicians