Metastasis to gastrostomy sites from upper aerodigestive tract malignancies: a systematic review and meta-analysis

Siu, Jennifer; Fuller, Kaitlin; Nadler, Ashlie; Pugash, Robyn; Cohen, Lawrence E.; Deutsch, Konrado Massing; Enepekides, Danny; Karam, Irene; Husain, Zain; Chan, Kelvin K.; Singh, Simron; Poon, Ian; Higgins, Kevin; Xu, Bin; Eskander, Antoine

doi:10.1016/j.gie.2019.12.045

Cited by 29 publications

(35 citation statements)

References 91 publications

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“…A recent meta-analysis including 121 cases, calculated the overall rate for this event to be of the order of 0.5 % (95 %CI 0.4 % -0.7 %). Subgroup analysis showed event rates of 0.56 % (95 %CI 0.40 % -0.79 %) with the "pull" technique and 0.29 % (95 %CI, 0.15 % -0.55 %) with the "push" technique [81]. Late-stage disease (T3 /T4) and lymph node involvement are additional risk factors.…”

Section: Recommendationmentioning

confidence: 95%

“…Although rare, metastasis to the PEG site in patients with upper aerodigestive tract malignancies is a dramatic adverse effect, especially in patients who have achieved remission with initial oncological treatment [81]. A recent meta-analysis including 121 cases, calculated the overall rate for this event to be of the order of 0.5 % (95 %CI 0.4 % -0.7 %).…”

Section: Recommendationmentioning

confidence: 99%

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Endoscopic management of enteral tubes in adult patients – Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2020

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Main recommendationsESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.

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Section: Recommendationmentioning

confidence: 95%

Section: Recommendationmentioning

confidence: 99%

Endoscopic management of enteral tubes in adult patients – Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2020

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“…for patients in whom the standard "pull" technique either cannot be used (e. g. because of presence of an esophageal stricture) or would involve an increased risk during passage of the internal bumper (e. g. risk of implantation metastasis in malignant diseases, mainly in primary squamous cell pharyngoesophageal cancer) [15]. The main problem initially associated with this technique was deflection of the stomach wall during puncture, combined with the risk of tube misplacement.…”

Section: Recommendationmentioning

confidence: 99%

Endoscopic management of enteral tubes in adult patients – Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2020

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Main recommendationsESGE recommends the “pull” technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer (“push”) technique for PEG placement in cases where the “pull” method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed “blindly” at the patient’s bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 – 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 – 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.

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“…The most commonly reported theory is that gastrostomy site seeding is a direct consequence of endoscopic instrumentation and the PEG tube passing the tumor, causing mucosal disruption, contaminating the instrumentation and PEG tube, and thus allowing cancer cells to be inserted into the new gastrostomy site 2,11,15,16 . This theory is supported from other cancer diagnostic surgical interventions, such as needle biopsies that can result in cancer cells being translocated, implanted, and metastasized to other locations 17 . According to a systematic review by Siu et al (2020), there are 121 case reports of gastrostomy site metastases in patients with HNC or esophageal cancer that exist in the literature 14 .…”

Section: Discussionmentioning

confidence: 99%

“…Cancer characteristics, including primary site location, tumor stage at diagnosis, and histology, have demonstrated trends in the cases reports. The location of the primary cancer site is predominately found in the head and neck vs the esophagous, without significant difference among head and neck locations from either the oral cavity, tongue, base of the tongue, oropharynx, hypopharynx, or larynx 10,11,17 . SCC has been overwhelmingly associated with increased risk of gastrostomy site seeding, with SCC diagnosis in >95% of cases 2,10,11,14,18 .…”

Section: Discussionmentioning

confidence: 99%

Seeding of Gastrostomy Tube Site in Patient With Squamous Cell Carcinoma of the Tongue: A Case Report

et al. 2020

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Enteral nutrition (EN) is a widely used therapeutic tool to provide nutrition support for patients with various clinical conditions, including different types of cancer. Head and neck cancers, often complicated by dysphagia, are among leading indications for enteral feeding. Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) tubes are typically used to deliver EN. This article presents a case report of a young male with squamous cell carcinoma of the tongue. Unfortunately, he developed metastasis of his cancer at the right lateral side of the PEG placement site, requiring surgical resection of seeded growth at the PEG site. This rare complication can be challenging, as it requires a high index of suspicion to diagnose and can potentially limit nutrition support options. A number of theories have been proposed to explain seeding during PEG/PEJ placement, including direct repositioning of malignant cells during instrumentation. A specific placement technique has not been shown to be superior, as seeding was reported with all placement techniques. However, given the lack of statistically powerful studies to describe this entity, there are still gaps we need to explore to better understand seeding of feeding tubes and best practices around diagnosis and early treatment. EN continues to be an important part of caring for patients with cancer during active or palliative treatments. Understanding potential risks in the setting of cancer metastasis is beneficial to the patients and multidisciplinary teams involved. Early recognition of possible seeding of feeding tube sites is necessary to ensure subsequent timely surgical intervention.

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Metastasis to gastrostomy sites from upper aerodigestive tract malignancies: a systematic review and meta-analysis

Cited by 29 publications

References 91 publications

Endoscopic management of enteral tubes in adult patients – Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopic management of enteral tubes in adult patients – Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopic management of enteral tubes in adult patients – Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Seeding of Gastrostomy Tube Site in Patient With Squamous Cell Carcinoma of the Tongue: A Case Report

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