Background Conventional percutaneous endoscopic gastrostomy (PEG) in patients with upper aerodigestive malignancies inevitably carries a risk of stomal metastasis that could be avoided by the direct insertion of the gastrostomy tube through the abdomen. This study compared the efficacy and safety between surgical gastrostomy (SG) and Introducer PEG in patients with upper aerodigestive malignancies. Methods We retrospectively reviewed patients with upper aerodigestive malignancies undergoing SG or Introducer PEG. Procedure data, postprocedural clinical outcomes and 30-day mortality were assessed. Results In total, 99 patients were feasible to analysis: 53 were in the SG group, and 46 were in the Introducer PEG group. The SG group had a higher incidence of (in-hospital) major complications [28.3% VS 4.3%, p = 0.002], a longer procedure duration [52.02 ± 21.30 VS 21.46 ± 8.22 min, p \ 0.001], higher pain scores at 24 h [median (interquartile range, IQR); 5(3-8) VS 1(0-5), p \ 0.001] and longer length of hospitalization (LOH) [median (IQR); 5(4-6) days VS 3(2-4) days, p \ 0.001)]. In-hospital (3.8% VS 0%, p = 0.493) and 30-day mortality (17.0% VS 13.0%, p = 0.586) were not different between the two groups. In univariate analysis, high BMI, anemia (hemoglobin \11 g/dL), normal nutritional status (serum albumin [3 g/dL) and procedural type were found to be predicting factors for complications. Procedural type (Introducer PEG) was an independent factor for major complications in multivariate analysis [OR = 0.12, 95% CI 0.02-0.61, p= 0.011]. Conclusions In patients with upper aerodigestive malignancies, Introducer PEG was associated with lower rate of (in-hospital) major complications, faster operative time, lower pain scores and shorter LOH.

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