The Use of Nasogastric Tubes Compared to Prophalytic Gastrostomy Tubes in Head and Neck Cancer Patients Undergoing Curative Radiotherapy +/- Concurrent Chemotherapy in the UK

Rebekah Smith, Senior Dietitian – ENT/ Max Facs, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, UK;
email: Rebekah.Smith@uhb.nhs.uk

Introduction

Head and neck cancer is the eighth most common cancer in UK. Over the past decade the incidence of oral cancer has increased by 92% since the 1970s. The incidence of oropharyngeal cancer has risen by 73%, and continues to increase due to the human papillomavirus (HPV), with more men being diagnosed than women. Most oral cancers (~91%) are linked to lifestyle choices, including smoking, increased alcohol consumption, betel quid/pann consumption, and a low intake of fruit and vegetables.¹

Head and neck tumours, surgery and chemoradiotherapy side effects may physically impair an individual’s ability to swallow which, in addition to cancer cachexia, can have a significant effect on an individual’s ability to meet their nutritional requirements and maintain a healthy nutritional status.

It is recognised that malnutrition negatively effects treatment outcomes in head and neck cancer patients. This is because those with significant weight loss are more likely to suffer major postoperative complications,² less tolerance to radiotherapy with more interruptions to treatment,³ decreased response to chemotherapy with increased toxicity and shortened survival times.⁴

Nutrition support during treatment is required to prevent malnutrition and can be provided with a texture modified and fortified diet along with oral nutritional supplements. However, when this is not sufficient artificial nutritional support may be required. Enteral feeding should be discussed at the multidisciplinary team (MDT) meeting when a treatment plan is agreed. This can be prospectively when a patient is offered a prophylactic gastrostomy tube, or reactively as nasogastric feeding. Parenteral nutrition is rarely used.

Radiotherapy

Enteral feeding tubes are frequently used in patients undergoing radiotherapy and there is much debate over which feeding tube should be used. Currently, there is no definitive answer within the published literature and the type of tube that is placed is often depend on baseline swallow, tumour location, the patient’s nutritional status pre-treatment and patient choice.

Advancements in radiotherapy treatment

Traditionally, conformal radiotherapy had been used bilaterally on the neck and a higher dose of radiotherapy had been given. As the radiotherapy treatment encompassed all of the neck, it was more likely that structures used for swallowing were affected by the radiotherapy regardless of tumour position. Therefore, it was more likely that a patient undergoing radiotherapy for head and neck cancer would need a feeding tube and would require this enteral feeding tube for longer.

With the introduction of intensity modulated radiotherapy (IMRT), where the tumour is targeted more precisely (parotid-sparing treatment), structures in the neck that are used for swallowing are either having a smaller dose of radiotherapy or are not within the radiation field. As a result, the side effects of radiotherapy may last for shorter periods of time. This means that some patients are now able to go through treatment without the need for an enteral feeding tube, with the caveat that if enteral feeding is required a nasogastric tube (NGT) can be placed. This means that the patient undergoing IMRT, as a single or dual modality treatment, are less likely to be considered for a prophylactic gastrostomy and avoid additional procedures pre radiotherapy. The following link provides further information on IMRT and different types of radiotherapy used for cancer treatment: www.macmillan.org.uk/information-and-support/treating/radiotherapy/external-beam-radiotherapy-explained/types-of-external-beam-radiotherapy.html

The effect on swallowing outcomes

Radiotherapy doses may also influence gastrostomy dependence and result in the patient only being able to tolerate a poor texture diet, e.g. pureed diet or a reduced oral intake depending on what the patient can tolerate. Guo et al.⁵ showed that radiotherapy doses in excess of 55 Gy to the supraglottis, 44 Gy to the glottis, 48 Gy to cricopharyngeal muscle and 44 Gy to oesophageal inlet muscle was associated with an increase in feeding tube dependence. This suggests that a reduced dose of radiotherapy to these muscles may improve swallowing function post radiotherapy, therefore reducing percutaneous endoscopic gastrostomy (PEG) tube feeding dependence. While a number of different papers, including the aforementioned, refer to PEG for enteral feeding, some centres may also use radiologically inserted gastrostomy tubes (RIGS), which are discussed later in this article.

In general, gastrostomy tubes stay in situ a lot longer during treatment and after treatment when compared to NGTs (771 days vs. 30.5 days).⁶ It is thought that the duration the enteral feeding tube is in situ for, combined with the toxicity of treatment, can lead to patients becoming more dependent on feeding tubes to meet their nutrition and hydration requirements and patients are, therefore, less like to swallow food or fluids. This can lead to increased fibrosis of the pharyngeal muscles and atrophy of the swallowing muscle, causing more difficulty swallowing and more hypopharyngeal and oesophageal strictures.⁷ It has been reported that patients with gastrostomy tubes have a poorer swallow at six months post treatment when compared to patients with a NGT.⁸

Conversely, a randomised controlled trial showed that at two years post treatment there was no significant difference between patients who had a PEG placed before treatment and those who had treatment with a reactive NGT and a cohort who had no enteral feeding tube placed.⁹ Also of note, in most studies swallowing management protocols are not detailed and there is a lack of consensus among clinicians regarding dysphagia management and PEG usage. This affected NICE recommendations, in 2013,¹⁰ which recommended that gastrostomy feeding in this patient group should be used in long-term feeding.

Issues and problems with enteral feeding tube placement

As with any medical device, there are associated risks when it comes to an enteral feeding tube being inserted. Gastrostomy insertions are a more invasive procedure and as a result there is a greater potential for complications following its placement (see Table One). As with a NGT, there is the potential for both tube blockage and dislodgement.

Table One: Complications Associated with PEG Tube Placements

Minor complications	Major complications
Hernia	Ileus
Granuloma	Tumour seeding
Gastric Obstruction Outlet	Bleeding
Peristomal Leakage	Buried bumper syndrome
Persistant gastric fistula	Perforation of bowel
Wound infection	Aspiration pneumoina
Ulceration	Death

 

To prevent PEG-related complications it is recommended that the tube is placed by an experience gastroenterologist,¹¹ who is experienced in the anatomy of the gastrointestinal tract to avoid perforation of the small bowel.

Another concern with the placement of a PEG in patients with advanced head and neck disease is the risk of tumor seeding and the development of abdominal wall metastasis.¹² This has been shown to be a rare complication of PEG placement in this patient group, with 0.64% of the 777 participants studied having tumour seeding after approximately 27-months follow up.¹²

As previously mentioned, some centres use RIGs. The placement of a RIG avoids tumour seeding, as it is radiologically inserted using a NGT to guide the placement of the tube under X-ray and is carried out by an ‘interventional radiologist’. Buried bumper is also not a problem when using a RIG, as it is retained by a balloon (filled with water to hold it in place) rather than a disk.

Cost of tube and placement

Currently, in practice, NGT placement is perceived to be a cheaper alternative to gastrostomy placement. This is due to NGTs being cheaper and the fact that anyone who has completed competencies on how to pass a NGT can insert a tube. In some areas, district nurses will not repass tubes and, in addition, there are some who will not accept NGT feeding for home enteral nutrition (HEN) due to aspiration risks. It can be inserted in a ward or in a clinic room. This is drastically different to placing a PEG, where it can take a day to place and sometime an overnight stay in hospital is required.

An experienced gastroenterologist, as previously discussed, is usually required to place a gastrostomy tube, which requires space in theatre and prophylactic antibiotics. In addition, detailed advice needs to be provided by nursing staff on how to care for the PEG, which adds to the costs associated with this method of feeding.

Although NGTs can dislodge and may need to be replaced several times during treatment, increasing the cost of using this type of feeding tube, it is cheaper than having a gastrostomy placed.⁸ Some NGTs may need to be re-sited endoscopically, which will also increase the cost of placing a NGT due to the fact that this is a day case procedure.

Other factors to consider

With reference to weight and weight loss during treatment recent studies show that there is no significant difference between using a NGT or gastrostomy and both are just as effective in preventing further malnutrition.^{13, 14} However most journals look purely at weight as a whole and do not differentiate between muscle mass and fat free mass. Further studies are needed to look at anthropometric data regarding PEG placement and NGT insertion.

For patients being enterally fed in the community and looking after the enteral feeding tube themselves, NGTs tend not to be as safe as gastrostomy tubes to look after. This is because of the risk of the NGT moving and the potential for the enteral feed to go into the lung, causing chest infections and potentially pneumonia. In some areas there are not the services or support required for patients who have a NGT placed to be cared for in the community. This means that, for some patients, a NGT will mean that they spend the rest of their radiotherapy treatment as an inpatient. This was backed-up by a survey undertaken by the British Dietetic Association's¹⁵ head and neck sub group. The results showed that patients with an NGT either had to spend the remaining treatment time with their tube in situ as an inpatient, or, if they were fortunate enough to have the services to support them in their area, receiving their HEN at home.

Conclusion

Current practice on how and when these tubes are placed during treatment varies not only throughout the UK but around the world, due to the different healthcare systems that are in place. Enteral tube placement depends on the treatment being given, local polices and the support available to care for tube fed patients in the community. Some centres opt to use prophalytically place gastrostomy tubes, while other centres reactively place nasogastric tubes during treatment.

A lack of robust clinical trials to support the use of one enteral feeding method over another, with some studies showing no difference between feeding a patient with either and gastrostomy or a nasogastric tube, means that it is not possible to provide clinical guidance on the feeding route in relation to the diagnosis or recommended modality of treatment.

Acknowledgement: With thanks to Carole-Anne Fleming for her advice and help with writing this article.

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