Percutaneous Endoscopic Pharyngostomy (PEP) Tube Placement for Gastrointestinal Diversion: A PEP in Your Palliative Step

Key Takeaways

• Percutaneous endoscopic pharyngostomy tube placement is a safe and minimally invasive approach to gastrointestinal diversion when alternative options are limited.

Introduction

In patients with advanced malignancy or prolonged gastrointestinal discontinuity that require long-term gastrointestinal diversion (GID), we have utilized a percutaneous endoscopic pharyngostomy (PEP) technique as a minimally invasive approach for placing a cervical pharyngostomy in order to achieve long-term GID. This technique mitigates the complications and impacts to quality of life that long-term nasogastric tube decompression carry. It enables the progression of care to home, which is preferred by people facing a poor survival prognosis, and can soften the ever rising burden on the health care system.^1-6

Cervical pharyngostomy placement has been described as early as 1968 by Royster et al for feeding after maxillofacial surgery, as well as for GID as early as 1974 by Lyons, and percutaneous approaches were described by Meehan et al in 1984 and Bucklin and Gilsdorf in 1985.^7-10 We believe this to be the first description of a percutaneous endoscopic technique for pharyngostomy placement, as this technique utilizes the advantages of endoscopic visualization in addition to common percutaneous access and ultrasound imaging skills.

Methods

In order to identify the indications and outcomes of patients who had PEP placement, case logs from the Acute Care Surgery service-line at a single institution were reviewed, and all patients who underwent PEP placement were included. Our Institutional Review Board’s policies consider this study exempt from requiring approval or review. 10 patients were identified who, in-total, underwent 13 operations. Chart review of each patient identified the indication for surgery and outcomes, including any complications. A complication was considered to be any inadvertent outcome which led or could lead to increased morbidity, return to OR, hospital readmission, or mortality not related to the already present disease process. No patients identified in our search were excluded from the study.

Results

A total of 10 patients were identified, which accounted for 13 operations. Patients ranged from ages 39 to 81. The treatment goal was palliative for nine of the ten patients due to malignant obstruction. The remaining patient required decompression of an esophageal pouch, following a gastrectomy without reconstruction for ischemia, to facilitate discharge home while awaiting staged reconstruction after recovery. Nine of the ten patients were discharged home, with an average discharge of 3.4 days postoperatively. The 10th patient withdrew care after an extended hospital course. Two patients were discharged the same day of surgery with no complications. Three patients were discharged the day after surgery. Complications included the dislodgement of five PEP tubes, ranging from post-op days 12 to 42; three dislodgements occurred at home and were replaced, and the remaining 2 dislodgements occurred at a health care facility and were not replaced. Three patients were lost to follow-up; however, all three patients were discharged to home hospice as per the patient’s preoperative goals of care.

Discussion

We have found this technique to be a safe, effective, and minimally invasive approach to long-term GID in situations when gastrostomy is not appropriate, and it has helped to alleviate barriers to discharge by allowing patients to meet their goal of discharge to home with minimal postoperative recovery time. Given the high dislodgement rate, a second non-absorbable suture to secure the tube was adopted in order to reduce tube dislodgements. When patients returned to the hospital for tube dislodgements, these hospitalizations were short. Two out of three patients were discharged the same day as the replacement operation, and the third patient was discharged the day after. After reviewing the patients with outcomes of longer length of stay or in-hospital morbidity, we propose that these outcomes were more likely related to the patient’s underlying complex pathology and not as a result of the operation, as the operation often alleviated barriers to discharge.

Given the success to meet palliative goals of long-term GID, we have begun to utilize broader applications of this technique. In a patient with a complex surgical history and disease pathology in long-term gastrointestinal discontinuity due to need for delay in reconstruction, PEP placement was used for esophageal pouch drainage which facilitated discharge to home while they awaited staged reconstruction.

In conclusion, we have had early success with the PEP technique and found this minimally invasive approach to be safe and effective. We suggest this technique for long-term GID, which utilizes the advantages of endoscopic visualization and common percutaneous access skills, to be a useful skill for acute care surgeons.