Patients with advanced oesophageal cancer have significant dysphagia, weight loss, and malnutrition.[3, 15, 16] The goal of enteral feeding for patients, mainly in the last period of life, may relieve hunger and thirst, provide oral medications, and preserve nutritional status and daily functional activity.
Each patient with advanced oesophageal might have a different cancer stage, tumour location and size, natural course of the disease, and tolerability of NGT placement.[18, 19] The palliative NGT placement in hospital settings may be affected by the feasibility of technique, financial limitation, or lack of available medical services. The need for palliative NGT placement should not only focus on the success rate, but also understand whether the palliative NGT placement is feasible in the hospital setting, and is acceptable to the patients and families. Our study confirmed that palliative NGT placement, designed for direct visualization under endoscopy or fluoroscopy and focused on personalized support service, was a useful alternative if the conventional bedside blind NGT placement failed (Table 4).
Guidewire method: Advantages and limitations
The guidewire method for placing NGT required a mouth-to-nose wire transfer after the placement of guidewires.[21, 22] Mouth-to-nose wire transfer caused technical difficulties, consumed more time, and increased patient suffering. Different from the traditional guidewire method, the NGT and the guidewire were passed through the nose down into the oesophagus. Under fluoroscopic guidance, the guidewire was inserted and passed through the obstructive tumour region into the stomach. NGT established ‘‘through-and-through’’ access, which provided one-step NGT placement without the need for cumbersome wire transfer.
However, NGT often dislodged when the advancing through the nearly oesophageal obstruction segment. This could be overcome by utilizing a fully lubricated fine-bore NGT, and advancing the NGT slowly along the obstructing lesion.11 However, since the fine-bore NGT has a tendency to clog, routine flushing with water and adherence to protocol when administering medications are necessary.[23, 24] The guidewire method for NGT placement is simple, safe, one-step and does not require wire transfer; it has lesser procedure-related complications, and yielded a success rate of approximately 75% (Table 2).
Drag method: Advantages and limitations
Upper gastrointestinal endoscopy is the most common procedure performed in patients with oesophageal cancer to obtain tissue samples and diagnose the structural abnormalities.[25, 26] The first endoscopic procedure provides information on the tumour lesion, and ensures that the endoscope can pass beyond the obstructing lesion. The second endoscopy can then easily drag the standard bore NGT through the oesophageal tumour lesion, down to the stomach.
Under direct endoscopic vision, NGT placement is simple, less time consuming, less difficult technique, and requires an experienced endoscopist. We demonstrated that the drag method is a one-step tube placement without the need for wire transfer, established a standard bore NGT feeding route, and yielded the success rate of 100% in patients with advanced oesophageal cancer.
Push method: Advantages and limitations
The oesophageal obstruction segment comprises mucosal oedema, swelling, fibrosis, and tumour mass. A fissure-like obstruction lumen was opened by pressing the tip of the stylet or guidewire stiffened NGT. Under fluoroscopic guidance, the NGT was slowly squeezed and advanced through an irregular and long oesophageal stricture lumen. NGT squeezing through the tumour lesion may cause mucosal damage, resulting in haemorrhage.
Nevertheless, NGT placement with the push methods was a simple, rapid, one-step procedure, without the need the wire transfer, which established a standard bore NGT feeding route and yielded a high success rate of 93%.
First, owing to the retrospective study design and small sample size, the study could not fully detect small increases in success rates, complications, and mortality. The impact on clinical practice needs to be confirmed with larger prospective cohort studies. Second, the study was performed at a single centre, which may have resulted in selection bias and referral bias. This may not be true in other hospitals. Third, the success rate and complications may have been influenced by experience of the operator because palliative NGT placement is an operator-dependent procedure.