Pharyngocutaneous fistula as an alternative access route for inserting a percutaneous endoscopic gastrostomy tube in head and neck cancer patients

Abstract

Background and study aims Performing a percutaneous endoscopic gastrostomy (PEG) in head and neck cancer (HNC) patients can be challenging because of the presence of trismus, pharyngeal obstruction by tumor, and pharyngoesophageal strictures or fistula. Pharyngocutaneous fistula (PCF) is a major postoperative concern in patients submitted to total laryngectomy (TL). In the medical literature to date, the cervical fistula has been used as an access to PEG in only four reports. The aim of this study was to evaluate the safety of cervical fistula for insertion of a PEG tube.

Patients and methods Retrospective study at a single tertiary referral center, regarding the technical feasibility, safety and outcomes of a PEG tube introduced by a cervical fistula in HNC patients with obstructive lesions of the oropharynx.

Results The procedure was technically successful in all 21 patients. A PEG tube was used for a minimum of 1 month and a maximum of 120 months. Twelve patients died while using the PEG tube, 8 had it taken out because it was no longer needed, and only 1 had the tube still in use. Adverse events occurred in 8 patients: granuloma (19 %), dermatitis (9.5 %), accidental late removal of the tube (9.5 %), periprocedural gastric wall hematoma (9.5 %), peristomal wound infection (4.7 %), buried bumper syndrome (4.7 %), and traumatic gastric ulcer (4.7 %).

Conclusion A postoperative cervical fistula can successfully work as a reliable and safe access for a PEG tube procedure in HNC patients, avoiding unnecessary surgery and reducing costs.

• References

• 1 Hunter JG, Lauretano L, Shellito PC. Percutaneous endoscopic gastrostomy in head and neck cancer patients. Ann Surg 1989; 210: 42-46
• 2 Pearce CB, Duncan HD. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad Med J 2002; 78: 198-204
• 3 Gauderer MWL, Ponsky JL, Izant Jr RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980; 15: 872-875
• 4 Moran BJ, Taylor MB, Johnson CD. Percutaneous endoscopic gastrostomy. Br J Surg 1990; 77: 858-862
• 5 Rustom IK, Jebreel A, Tayyab M. et al. Percutaneous endoscopic, radiological and surgical gastrostomy tubes: a comparison study in head and neck cancer patients. J Laryngol Otol 2006; 120: 463-466
• 6 Nevah MI, Lamberth JR, Dekovich AA. Transnasal PEG tube placement in patients with head and neck cancer. Gastrointest Endosc 2014; 79: 599-604
• 7 Miller RE, Kummer BA, Kotler DP. et al. Percutaneous endoscopic gastrostomy: procedure of choice. Ann Surg 1986; 204: 543-545
• 8 Paydarfar J, Birkmeyer NJ. Complications in head and neck surgery: a meta-analysis of postlaryngectomy pharyngocutaneous fistula. Arch Otolaryngol Head Neck Surg 2006; 132: 67-72
• 9 Genden EM, Rinaldo A, Shaha AR. et al. Pharyngocutaneous fistula following laryngectomy. Acta Otolaryngol 2004; 124: 117-120
• 10 Galli J, Corso ED, Volante M. et al. Postlaryngectomy pharyngocutaneous fistula: incidence, predisposing factors, and therapy. Otolaryngology–Head and Neck Surg 2005; 133: 689-694
• 11 Grant DG, Bradley PT, Pothier DD. et al. Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis. Clin Otolaryngol 2009; 34: 103-112
• 12 Taller A, Horvath E, Iliás L. et al. Technical modifications for improving the success rate of PEG tube placement in patients with head and neck cancer. Gastrointest Endosc 2001; 54: 633-636
• 13 Grier JF, Goldman DE, Gholson CF. Transmaxillary percutaneous endoscopic gastrostomy. Gastrointest Endosc 1994; 40: 778-779
• 14 Lujber L, Fábián G, Pytel J. Inserting a percutaneous endoscopic gastrostomy tube via a cervical fistula formed after major surgery on a patient with a head and neck tumor. Surg Laparosc Endosc Percutaneous Techn 2001; 11: 327-329
• 15 Lujber L. Placement of a percutaneous endoscopic gastrostomy feeding tube via a cervical pharyngocutaneous fistula. Endoscopy 2006; 38: E57
• 16 Mello GFS, Lukashok HP, Meine GC. et al. Outpatient percutaneous endoscopic gastrostomy in selected head and neck cancer patients. Surg Endosc 2009; 23: 1487-1493
• 17 Ehrsson YT, Langius-Eklof A, Bark T. et al. Percutaneous endoscopic gastrostomy (PEG) – a long-term follow-up study in head and neck cancer patients. Clin Otolaryngol 2004; 29: 740-746
• 18 Raynor EM, Williams MF, Martindale RG. et al. Timing of percutaneous endoscopic gastrostomy tube placement in head and neck cancer patients. Otolaryngol Head Neck Surg 1999; 120: 479-482
• 19 Walton GM. Complications of percutaneous endoscopic gastrostomy in patients with head and neck cancer – an anatysis of 42 consecutive patients. Ann R Coll Surg Engl 1999; 81: 272-276
• 20 Ruston IK, Jebreel A, Tayyab M. et al. Percutaneous endoscopic, radiological and surgical gastrostomy tubes: a comparison study in head and neck cancer patients. J Laryngol Otology 2006; 120: 463-466