Does PEG Use Cause Dysphagia in Head and Neck Cancer Patients?

Abstract

Percutaneous endoscopic gastrostomy (PEG) use is common in patients who undergo radiotherapy (RT) for head and neck cancer to maintain weight and nutrition during treatment. However, the true effect of PEG use on weight maintenance and its potential impact on long-term dysphagia outcomes have not been adequately studied. This retrospective study looked at swallowing-related outcomes among patients who received prophylactic PEG vs. those who did not, and among patients who maintained oral diets vs. partial oral diets vs. those who were nil per os (NPO). Outcomes were assessed at the end of RT and at 3, 6, and 12 months post RT. A comprehensive review of patients’ medical charts for a 6-year period yielded 59 subjects with complete data. Results showed no difference in long-term percent weight change between the prophylactic PEG patients vs. all others, or between patients who, during RT, had oral diets vs. partial oral diets vs. NPO. However, those who did not receive prophylactic PEGs and those who maintained an oral or a partial oral diet during RT had significantly better diet outcomes at all times post RT. Dependence on a PEG may lead to adverse swallowing ability in post-irradiated head and neck cancer patients possibly due to decreased use of the swallowing musculature.

A review of weight loss and sarcopenia in patients with head and neck cancer treated with chemoradiation

“…One explanation for this discrepancy is that in some patients the weight loss is caused of decreased caloric intake, while in others weight loss is a manifestation of cachexia, or a syndrome of dysregulated catabolism and anabolism [17]. Historically, high-risk patients would have a percutaneous endoscopic gastrostomy (PEG) placed prior to starting treatment in order to prevent decreased caloric intake, but more recently there has been movement away from using feeding tubes due to concerns about delayed recovery of swallowing post-CTRT [18][19][20]. Interestingly, the placement of a PEG, or increased caloric intake alone, does not alleviate all the weight loss experienced during CTRT [12,19,21].…”

Prospective clinical study on long-term swallowing function and voice quality in advanced head and neck cancer patients treated with concurrent chemoradiotherapy and preventive swallowing exercises

“…Preventive rehabilitation programs have been associated with a long list of positive effects: improved QoL [20], better base of tongue retraction and better maintained epiglottic inversion [21], superior muscle maintenance and functional swallowing ability [22], better oral intake and clinician-rated swallowing function at three and 6 months [23], reduced extent and severity of penetration and/or aspiration, less trismus, less weight loss, and less pain (both short term [24] and at oneand two-years post-treatment [25]), and better oral intake and shorter duration of feeding tube dependency [26] posttreatment. Also maintained oral intake (no feeding tube dependency) has been shown to lead to better swallowing function after CCRT, possibly due to continued use of the swallowing musculature [26][27][28]. Benefits from preventive (swallowing) exercises have been reported in particular on the short term (up to 2 years) [19].…”

Optimising nutrition support in patients with head and neck cancer

“…There are concerns in the literature that gastrostomy insertion can lead to dysphagia and tube dependency (Chen et al, 2010;Corry et al, 2008;Langmore et al, 2012;Mekhail et al, 2001), although other studies have shown no detrimental impact on swallowing function (Crombie et al, 2015;Silander et al, 2010) and the body of literature remains inconclusive from a recent systematic review (Shaw et al, 2015). Whilst the data from this current study suggests there may have been more tendency for the intervention group to use the tube for supplementary feeding for longer, with an increased use at four months post-treatment, there were no other statistical differences at any other time point.…”

“…Prophylactic gastrostomy tube (PGT) placement is a common method of nutrition support in patients with mucosal head and neck cancer (HNSCC), however there are concerns this leads to dysphagia and long term tube dependency (Chen et al, 2010;Corry et al, 2008;Langmore et al, 2012;Mekhail et al, 2001). Some studies have reported nil impact on swallowing function (Crombie et al, 2015;Silander et al, 2010), and the most recent systematic review on this topic remains inconclusive (Shaw et al, 2015).…”

“…Prophylactic placement of a gastrostomy, in anticipation of its use during and after treatment, is common practice. Consideration must be given to the risks associated with the procedure of gastrostomy placement (Grant et al, 2009) and there is increasing concern that gastrostomy placement leads to prolonged tube dependency and long-term dysphagia (Corry et al, 2008;Langmore, Krisciunas, Miloro, Evans, & Cheng, 2012;Mekhail et al, 2001). Although one additional study comparing two different centre's approaches with reactive gastrostomy placement versus proactive gastrostomy placement found a higher rate of gastrostomy dependency in the proactive placement group at three months there was no difference at six or 12 months (Olson et al, 2013).…”