Gastrostomy - Seeing Beyond the Endoscope: Reply

We thank Dr. Laasch for his letter, and have some comments about his constructive criticisms and suggestions.

The objective of our study was to perform an unsedated transnasal percutaneous endoscopic gastrostomy (PEG) placement with an ultrathin endoscope in 12 patients in whom a transoral placement with a standard endoscope was not previously possible. An unsedated procedure was necessary because in all 12 patients their general clinical condition did not allow sedation. The use of an ultrathin endoscope (Olympus video gastroscope Evis Exera GIF-XP 160 Slim Sight; distal end 5.9 mm diameter) and a special PEG tube (Corflo-Max 16 Fr diameter) made the procedure possible and no patient required sedation. Moreover the completely collapsible internal bumper did not provoke any bleeding and/or trauma during passage through the nose and the oropharynx, as checked endoscopically, and no patient complained of pain.

We agree with Dr. Laasch that an endoscopic gastrostomy should be avoided in patients with head/neck tumors awaiting curative procedures, on account of the risk of tumor seeding at the stoma site [1] [2] [3], and in these cases the radiologically inserted gastrostomy (RIG) technique represents an effective alternative [4] [5]. In our study we decided to perform a PEG placement in five out of 12 patients because they had an unresectable cancer and the gastrostomy represented a palliative procedure. Regarding cooperation between radiologists and endoscopists, we think that it could be interesting to show the feasibility of a combined method (transnasal endoscopy and RIG technique) and to compare it with the transnasal endoscopic procedure.

References

• 1 Sinclair J J, Scolapio J S, Stark M E, Hinder R A. 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
• 2 Maccabee D, Sheppard B C. Prevention of percutaneous endoscopic gastrostomy before multimodality therapy in patients with esophageal cancer.  Ann Thorac Surg. 2003;  76 1694-1697
• 3 Adelson R T, Ducic Y. Metastatic head and neck carcinoma to a percutaneous endoscopic gastrostomy site.  Head Neck. 2005;  27 339-343
• 4 Ho S G, Marchinkow L O, Legeihn G M. et al . Radiological percutaneous gastrostomy.  Clin Radiol. 2001;  56 902-910
• 5 Laasch H U, Wilbraham L, Bullen K. et al . Gastrostomy insertion: comparing the options - PEG, RIG or PIG?.  Clin Radiol. 2003;  58 398-405