Percutaneous endoscopic gastrostomy before multimodality therapy in patients with esophageal cancer.
BACKGROUND
Percutaneous endoscopic gastrostomy (PEG) has not been widely used in esophageal cancer because of concerns about safety of dilatation, suitability of the stomach as an esophageal replacement, and potential for inoculation metastasis.


METHODS
Experience with PEG in consecutive patients presenting with new esophageal cancer from March 1991 to March 2001 was reviewed retrospectively. PEG was planned in 119 of 179 (66%) of these patients excluding those presenting moribund and those for whom early resection was planned. The PEG was placed using an endoscopic method with wire-guided endoscopic bougienage or laser ablation or both as needed. Success of placement, requirement for dilatation and ablation, PEG-related complications, tolerance of enteral feeds, and impact on therapy were evaluated.


RESULTS
PEG placement was possible in 87% of patients (103 of 119). Dilatation or laser ablation or both was required in 46% (47 of 103). There was no procedure-related mortality. Thirty-day mortality was 13.5%. Major PEG-related complications were observed in 4% (4 of 103) and minor PEG-related complications in 12% (12 of 103). PEG removal was required in 4 patients and interruption of enteral feeds required in 33 (32%). No instances of esophageal disruption or tumor inoculation metastasis were noted. PEG takedown and site closure at the time of operation was uncomplicated and use of the stomach as an esophageal substitute was possible in all 61 resected patients. Rates of anastomotic leak, stricture, and gastric emptying delay were similar to those for patients proceeding to resection without prior PEG (leak: PEG = 8% [5 of 61] versus non-PEG = 10.5% [2 of 19]), (stricture: PEG = 37% [22 of 61] versus non-PEG = 32.5% [6 of 19]), (delay: PEG = 9.8% [6 of 61] versus non-PEG = 10.5% [2 of 19]). Analysis of variables showed PEG to be significantly related to attainment of target doses of chemoradiotherapy (p = 0.034), and survival at 12 months (p = 0.02).


CONCLUSIONS
PEG in esophageal cancer is safe and useful and does not compromise the stomach or esophagogastric anastomosis. Further study is required to define the efficacy of PEG as a means of nutritional support and its impact on survival.
Margolis
Marc
M
Division of Cardiothoracic Surgery, VAMC, Washington, DC, USA.
Alexander
Pendleton
P
Trachiotis
Gregory D
GD
Gharagozloo
Farid
F
Lipman
Timothy
T
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D015331:Cohort Studies; D004750:Enteral Nutrition / Q000379:methods; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005773:Gastroscopy; D005774:Gastrostomy / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D016896:Treatment Outcome