Keywords
head and neck malignancy - percutaneous endoscopic gastrostomy - T-PEG
Introduction
A 55-year-old male presented with difficulty in swallowing and weight loss for 1 month.
He was diagnosed to have carcinoma cervical esophagus 6 years ago and treated with
definite chemoradiation. He was under palliative care for carcinoma base of tongue
for the last 1 year. He has progressive dysphagia for 1 month and came to our center
for feeding procedure. Carcinoma base of tongue causing obstruction precluded the
use of oral gastroscope. Hence, he was planned for transnasal percutaneous endoscopic
gastrostomy (T-PEG). However, this was not easy as patient breathing would be difficult
with single nostril since oral cavity was compromised. Ventilation was secured with
nasopharyngeal airway ([Fig. 1]). Nasal endoscope was passed. Stomach was entered without much difficulty through
larynx and esophagus. Transillumination was noted in anterior abdominal wall and finger
indentation was noted in the distal body of stomach. At this point, skin incision
of 1 cm was made using scalpel. Large bore needle with cannula was introduced into
the stomach through this incision. Needle was removed keeping the cannula inside stomach.
PEG wire was introduced into the stomach through the cannula and was held with forceps
and pulled through the nose. Figure of eight knot was made and adequately lubricated.
24-Fr cook PEG tube was placed in the stomach using pull through technique. Mild resistance
was felt while pulling the internal bolster through nostril; however, there were no
intraprocedural or postprocedural complications. Postoperatively he did not develop
any fever, however, antibiotics were given for 5 days to prevent infection. PEG feeds
were started next day and patient was discharged in stable condition (Supplementary
[Video 1]; available in the online version).
Fig. 1 Image showing nasopharyngeal airway in left nostril and PEG tube in the right nostril.
PEG, percutaneous endoscopic gastrostomy.
Peroral endoscopic gastrostomy is the standard of care for patients requiring long-term
enteral nutritional support. However, it is not feasible in 4 to 7% of head and neck
cancer patients owing to underlying pathology.[1] T-PEG is a viable alternative for those patients. Counihan et al reported first
successful T-PEG using a pull method in a patient with intermaxillary fixation.[2] Other pragmatic indications include malignant oropharyngeal obstruction and trismus.
There are three techniques of PEG tube insertion: pull, push, and introducer. Pull
and push techniques are more popularized owing to low chance of dislodgement. Introducer
technique has higher chance of bleeding and catheter dislodgement.[3] Pseudomonas aeruginosa infection of stomal site has been reported in patients undergoing
T-PEG.[4] Securing ventilation with nasopharyngeal airway is of great importance as patient
can breathe only through one nostril. A specific concern is the fear of tumoral seeding
at the time of PEG placement. The risk of this adverse event is small and there have
been no reports of tract seeding using the transnasal approach. The safety of T-PEG
has been established and no significant differences between the transnasal and the
transoral approach in regard to hemodynamics, success, or adverse events. There are
studies on successful T-PEG placement, but this is the first report showing the intricate
steps of procedure.[5] To conclude, T-PEG is a safe and effective procedure, especially in patients where
oral endoscopy is not feasible due to various reasons.
