Background: Stomal metastasis to the percutaneous endoscopic gastrotomy (PEG) tube in head and neck cancer patients is a rare but serious complication of the procedure. Because of its rarity, this clinical entity does not yet have clear risk factors limiting our ability to prevent such a complication.
Objective: To systematically review all reported cases of stomal metastases after PEG placement in patients with head and neck cancer, identify clinical risk factors, and develop strategies to detect and prevent this serious complication.
Methods: Ovid MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were queried. Data on clinical presentation, detection of metastasis, type of gastrostomy tube, time to metastasis, and outcome measures were collected.
Results. The systematic review yielded 104 unique cases of stomal PEG site metastasis, including 37 case series. The mean patient age was 59.0 ±9.3 with 85% of the male gender. The majority of cases occurred in patients with pharyngoesophageal tumors (76.0%), at advanced (T3/T4) pathologic stage (77%), with pathological evidence of squamous cell carcinoma (87.8%), and at with histological evidence of poor or moderately differentiated grade. In all except one case, the PEG was administered via the “pull” mechanism. Average time from PEG placement to diagnosis of stomal PEG-site metastasis was 7.63 ± 4.80 months and average tumor size on detection was 4.5 ± 2.06 cm (range 1-9.6cm). Synchronous distant metastasis at the time of diagnosis was evident in 52.9% of cases. Average length of survival after detection of PEG disease was 7.49± 6.40 months.
Conclusions. PEG site metastasis is an uncommon complication with poor prognosis that occurs primarily in patients who have PEG placed by the pull-string technique. Risk factors for stomal metastases include advanced stage, pharyngoesophageal primary cancer, squamous cell histology, and moderately/poorly differentiated cancer. Risk of developing stomal metastasis may be reduced in this population through the substitution of the pull-string with the push-guidewire PEG placement technique.