Multidisciplinary meetings (MDMs) are an essential part of the management of head and neck cancer. Practice care guidance set up by the British Association of Head and Neck Oncologists has recommended that MDMs should have appropriate projection equipment for computer-generated images so that all members of group have access to the same information. The aim of this paper is to review our experience with the integrated visual presentation of head and neck oncology patients and to demonstrate its advantages over conventional approaches. Digital photographs are taken of patients and of their index tumour at presentation or at the time of diagnostic endoscopy. All relevant pre-treatment digitised images from tumour sites and radiological images and histological slides are incorporated into a single presentation using Microsoft PowerPoint software. During the past 2 years, on-line radiological scans have also become accessible for the meeting to aid treatment planning. Subsequently, all peri-operative pictures and post-surgical macroscopic and microscopic histopathological images are added to each patient's presentation, which is then hyperlinked into the agenda. The Guy's and St Thomas' Head and Neck Cancer Centre treats over 400 patients a year, and since 2002, all new cancer diagnoses have been discussed in the weekly MDM as described above. A total of 1,638 presentations have been incorporated in a centralized database that is updated in the event of recurrence, further primary tumours or other clinical developments. Satisfactory documentation and staging of head and neck tumours must include a verbal description, accurate measurement, diagrammatic representation, photographic recording and appropriate radiological imaging. Integrated presentation at MDM collates all relevant findings for clinical management decisions on patients with head and neck cancer. This approach is also an extremely valuable adjunct to long-term clinical monitoring.

INTRODUCTIONThe 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.PATIENTS AND METHODS 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.RESULTS 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.CONCLUSIONS 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.

In 2001 a retrospective audit was performed of mortality and morbidity of percutaneous endoscopic gastrostomy (PEG) inserted over a 2-year period at a single unit (McCarthy, unpublished results). At that time the infection rate was found to be high at 32 % and there was an overall high morbidity rate of 36 %. PEG-related mortality was 3.4%. Following the audit, changes were implemented in clinical practice that it was hoped would improve clinical outcome in these patients. These changes included review of all patients by a nutrition nurse specialist or member of the gastroenterology team (registrar or consultant) before referral to the endoscopy department. Use of prophylactic antibiotics in all patients and all patients with head-and-neck cancer receive an airway assessment before undergoing the procedure. All PEG were inspected at days-3 post insertion to look for early complications. On discharge, any early problems were assessed in a rapid access clinic. The aim of this current audit was to assess if these changes have led to less morbidity and mortality. The second audit looked at PEG insertions from November 2006 to November 2007 and compared the data with that of January 1999-January 2001. Information was collected retrospectively using endoscopy software, electronic patient records and contemporaneous records kept by the nutrition nurse specialist and dietitians.