**3. Introducer percutaneous endoscopic gastrostomy in palliative care**

In palliative care, advanced esophageal cancer patients have suffered from many symptoms such as pain, dysphagia, malnutrition, and psychological problems that depend on the tumor location with staging and the cancer current treatments [44]. Nutritional support is one of the critical roles for symptom management, especially for dysphagia and malnutrition. Also, nausea and vomiting might be the other symptom caused by chemotherapy, radiation, medication, and psychiatric issues that affected the patients' nutritional status [44, 45].

Enteral nutrition is a suitable option for managing these conditions for improving nutritional status, increasing tolerating for chemoradiation therapy, and enhancing the patients' quality of life. The preference for enteral nutrition of advanced esophageal cancer should be safe, minimally invasive with the ability to help in nutritional status. The introducer PEG is a practical choice for advanced esophageal cancer patients who had been included in palliative care [46–48].

#### **4. Indications and contraindications**

Clinical assessment to create accurate clinical staging is a crucial step for guiding the optimal management of esophageal cancer patients. Endoscopic resection is an option for the treatment of early esophageal cancer. Tri-modality therapy is an alternative for patients who have more advanced local disease and for patients with metastases group, palliative and supportive care are indicated to improve quality of life [49–51].

Esophageal cancer is often cause anorexia and dysphagia that lead to decreased oral intake and poor nutritional status, dehydration, imbalance of blood chemistry, and malnutrition. Assessing patient's performance status is a crucial for drawing up the treatment plan, irrespective of stage of the disease. Nutrition support is a key element and is indicated in patients whose nutritional status is compromised who cannot be adequately supported by eating and drinking normally. Enteral feeding is the route of first choice and preserves intestinal integrity, has a low risk of complications, and is more cost effective than the parenteral route [2, 52, 53].

NGT is a common practice for enteral nutrition. Passing a nasojejunal tube (NJT) is another enteral nutrition technique but this is technically more challenging [54]. Both NGT and NJT are intended for short-term nutritional support, usually up to four weeks [8, 9], and both require that the esophageal lumen is patent enough to accept the tubes.

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

**2. History and concept of the development of the introducer** 

**percutaneous endoscopic gastrostomy**

surgical gastrostomy, and PEG.

skillful surgeon, and experience [34, 35].

Percutaneous endoscopic gastrostomy (PEG)

Percutaneous endoscopic transgastric jejunostomy

*Methods for enteral nutrition in esophageal cancer patients.*

**Enteral nutrition methods Pre-pyloric** 

concern disadvantage [11–15]. Refining the pull technique led to the development of the push or introducer technique to avoid tumor seeding to the stroma [9, 16–18].

Alimentation for esophageal cancer patients can be provided via the enteral or parenteral routes [2, 19, 20]; the enteral route is preferred because it utilizes the gastrointestinal tract and avoids the complications of parenteral nutrition [21, 22]. Placing the feeding tube distally to the location of the cancer is the strategy. Enteral nutrition can be provided by pre-pyloric or post-pyloric feeding (**Table 1**). Intragastric feeding is easier and might provide greater physiologic benefits than the small bowel [23, 24]. The technical approaches of pre-pyloric nutrition include a nasogastric tube (NGT),

NGT is a classic approach for the patient with swallowing difficulties [25]. For early esophageal cancer, when patients may have mild dysphagia and limited luminal obstruction, a NGT should be able to pass easily. However, with advanced disease, the passing of a NGT requires endoscopic or fluoroscopic guidance to confirm the correct position of NGT before start the feeding process [8].

A surgical gastrostomy may be performed by an open approach whereby the feeding tube is placed in the stomach via an upper midline incision. This approach is associated with potential complications such as wound infection [26–29] and respiratory compromise [27, 30–33]. The laparoscopic gastrostomy was developed to minimize the risks of the open technique but it requires substantial training, a

PEG was first performed in 1979, using the pull-type technique [36]. This approach was associated with fewer procedural complications than surgical gastrostomy [37–40]. The pull method involves inserting a string into the intragastric space through the abdominal wall. The forceps from an endoscopy grasps the string and pulls it up to the oral cavity. A feeding tube is then passed over the guide string and pushed back down the esophagus, stomach, and then out through the abdominal wall. The pull-type technique is the most commonly used method in clinical

Nasogastric tube (NGT) + — — Nasojejunal tube (NJT) — + —

Gastrostomy + — — Jejunostomy — + —

Pull technique + — + Push or Introducer technique + — —

**feeding**

**Post-pyloric feeding**

— + —

**Risk of cancer seeding**

**52**

Surgical approach

(PEG-J)

*+ yes;* − *no.*

**Table 1.**


#### **Table 2.**

*Indications and contraindications.*

Although surgery plays a long history of enteral nutrition, the various procedures have developed to reduce complications, pain, and additional cosmetic results. Pull-type or introducer PEG is a favored method for a minimally invasive procedure, avoiding the risk of cancer seeding compared to surgical gastrostomy [17, 18]. In addition to patients with esophageal cancer, the introducer PEG could also use in patients who indicated enteral nutrition support with pre-pyloric feeding, demand for long-term enteral feeding, the patients with head and neck cancer that could diminish the risk of cancer seeding from PEG procedure, and apply for gastric decompression [9, 25, 55, 56].

The contraindications for a PEG include: patients with unstable vital signs, sepsis, uncorrected coagulopathy, gastric outlet obstruction or intestinal obstruction as well as patients who have endoscopic contraindications such as a viscus perforation, gastric pathology or severe abdominal wall infection especially at the site for the feeding tube, massive ascites, pregnancy, caustic esophageal or gastric injuries, and previous gastric or intra-abdominal surgery (**Table 2**) [9, 57].
