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To the Editor:

University of Alberta Alberta, Edmonton, Canada

In their February 2007 article, Rayykher et al¹ have provided us with a thorough and useful review of the area of nutrition support for head and neck cancer patients. Still, I must disagree with a generalization made in the section entitled "Enteral Access."

Regarding enteral access methods for head and neck cancer patients, Raykher notes that, "Percutaneous endoscopic gastrostomy (PEG) placement is the preferred method for establishing access for enteral feeding in this population."^2–7 In focusing solely on PEG insertion, Raykher overlooks the many reviews describing percutaneous radiologic gastrostomy (PRG) as a successful and safe method of enteral access for this same group. Raykher supports this view by noting, "compared with PEG tubes, radiologically placed gastrostomies often have inferior tube function,"¹ information referenced from a paper by Cosentini et al.²

First, the reported difference in tube function rates between PEG and PRG in the Cosentini study was found to be "not statistically significant." I would also be wary of making such firm conclusions based on the Cosentini study given its initial small sample size with a further reduction due to death from disease progression.

Second, the Raykher paper is making recommendations for the head and neck cancer population, yet in the Cosentini study only 38% of patients undergoing PEG insertion had head and neck cancer.

This review also fails to acknowledge the difficulty endoscopists often encounter in attempting to traverse obstructing lesions of the upper pharyngeal or digestive tract during PEG insertion for head and neck cancer patients.

Finally, there have been numerous case reports of gastrostomy site tumor seeding with the PEG insertion method for this population.^9–15

For the head and neck cancer population, both PEG and PRG have a high rate of successful placement.^{2–7,16–18} With regard to procedure-related complications, Cosentini found no major differences between the 2 methods. In addition, a meta-analysis of the literature comparing gastrostomy insertion methods in a similar set of patients found the least number of major complications with the radiologic insertion method (5.9% vs 9.4% vs 19.9% for PRG, PEG, and surgical insertion, respectively).¹⁶

In summary, declaring PEG insertion as the preferred method of achieving enteral access for head and neck cancer patients may mislead clinicians. PRG remains a useful insertion technique, and evidence to support a conclusive statement regarding the preferred means of gastrostomy tube placement for head and neck cancer patients is not currently available in the literature.

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Note from the Editor: The authors of the subject paper have reviewed this letter and have elected not to respond.

1. Raykher A, Russo L, Schattner M, Schwartz L, Scott B, Shike M. Enteral nutrition support of head and neck cancer patients. Nutr Clin Pract. 2007;22:68 –73.[Abstract/Free Full Text]
2. Tyldesley S, Sheehan F, Munk P, et al. The use of radiologically placed gastrostomy tubes in head and neck cancer patients receiving radiotherapy. Int J Radiat Oncol Biol Phys.1996; 36:1205 –1209.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
3. Beaver ME, Myers JN, Griffenberg L, Waugh K. Percutaneous fluoroscopic gastrostomy tube placement in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg.1998; 124:1141 –1144.[Abstract/Free Full Text]
4. O'Dwyer TP, Gullane PJ, Awerbuch D, Ho CS. Percutaneous feeding gastrostomy in patients with head and neck tumors: a 5-year review. Larynogoscope.1990; 100:29 –32.
5. De Baere T, Chapot R, Kuoch V, et al. Percutaneous gastrostomy with fluoroscopic guidance: single-center experience in 500 consecutive cancer patients. Radiology.1999; 210:651 –654.[Abstract/Free Full Text]
6. Deurloo EE, Schultze Kool LJ, Kroger R, van Coevorden F, Balm AJ. Percutaneous radiological gastrostomy in patients with head and neck cancer. Eur J Surg Oncol.2001; 27:94 –97.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
7. Marcy PY, Magne N, Bensadoun RJ, et al. Systematic percutaneous fluoroscopic gastrostomy for concomitant radiochemotherapy of advanced head and neck cancer: optimization of therapy. Support Care Cancer. 2000;8:410 –413.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
8. Cosentini EP, Sautner T, Gnant M, Winkelbauer F, Teleky B, Jakesz R. Outcomes of surgical, percutaneous endoscopic, and percutaneous radiologic gastrostomies. Arch Surg.1998; 133:1076 –1083.[Abstract/Free Full Text]
9. Ananth S, Amin M. Implantation or oral squamous cell carcinoma at the site of a percutaneous endoscopic gastrostomy: a case report. Br J Oral Maxillofac Surg.2002; 40:125 –130.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
10. Cossentino MJ, Fukuda MM, Butler JA, Sanders JW. Cancer metastasis to a percutaneous gastrostomy site. Head Neck.2001; 23:1080 –1083.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
11. Sinclair JJ, Scolapio JS, Stark MR, Hinder RA. Metastasis of head and neck carcinoma to the site of percutaneous endoscopic gastrostomy: case report and literature review. JPEN J Parenter Enteral Nutr. 2001;25:282 –285.[Abstract/Free Full Text]
12. Potochny JD, Sataloff DM, Spiegel JR, Lieber CP, Siskind B, Sataloff RT. Head and neck cancer implantation at the percutaneous endoscopic gastrostomy exit site. A case report and a review. Surg Endosc. 1998;12:1361 –1365.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
13. Schneider AM, Loggie BW. Metastatic head and neck cancer to the percutaneous endoscopic gastrostomy exit site: a case report and review of the literature. Am Surg.1997; 63:481 –486.[Web of Science][Medline] [Order article via Infotrieve]
14. Strodel WE, Kenady DE. Stomal seeding of head and neck cancer by percutaneous endoscopic gastrostomy (PEG) tube. Ann Surg Oncol. 1995;2:462 –463.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
15. Lee DS, Mohit-Tabatabai MS, Rush BF Jr, Levine C. Stomal seeding of head and neck cancer by percutaneous endoscopic gastrostomy tube placement. Ann Surg Oncoil.1995; 2:170 –173.[CrossRef]
16. Wollman B, D'Agostino HB, Walus-Wigle JR, Easter DW, Beale A. Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature. Radiology.1995; 197:699 –704.[Abstract/Free Full Text]
17. Saunders JR Jr, Brown MS, Hirata RM, Jaques DA. Percutaneous endoscopic gastrostomy in patients with head and neck malignancies. Am J Surg.1991; 162:381 –383.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
18. Hunter JG, Lauretano L, Shellito PC. Percutaneous endoscopic gastrostomy in head and neck cancer patients. Ann Surg. 1989;210:42 –46.[Web of Science][Medline] [Order article via Infotrieve]

Nutrition in Clinical Practice, Vol. 22, No. 6, 689-690 (2007)
DOI: 10.1177/0115426507022006689


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