Serious sequelae of nasopharyngeal cancer patients after radiotherapy include.
(1) Bilateral mandibular joint dysfunction and damage to the open and closed mouth muscle groups resulting in restricted mouth opening.
(2) Posterior group cranial nerve injury resulting in abnormal swallowing. These sequelae can cause difficulty in eating, or chronic malnutrition and recurrent aspiration respiratory infections due to choking and aspiration during feeding. In this case, percutaneous endoscopic gastrostomy is performed to solve the patient’s feeding problems and prevent chronic malnutrition and aspiration respiratory infections.
Percutaneous endoscopic gastrostomy (PEG) is an endoscopically guided, percutaneous puncture to place a gastrostomy tube for gastrointestinal nutrition and other therapeutic purposes, and PEG provides a safe, effective, non-surgical way to establish long-term enteral nutrition access. During the operation, a feeding tube is placed through the skin into the stomach using endoscopic guidance, and nutrient solution is infused directly into the stomach through the PEG feeding tube for gastrointestinal nutrition and other therapeutic purposes. Compared with traditional caesarean gastrostomy, PEG is less invasive, easier to operate, shorter operation time, safe, economical, widely used, and has significantly lower complications and mortality, and has now replaced the traditional surgical gastrostomy. Currently the procedure is very widely used in developed countries, and certain hospitals in China are also starting to apply it.
The indications for PEG are as follows: central nervous system diseases leading to swallowing disorders (e.g. stroke, traumatic brain injury, vegetative state, etc.); head and neck tumors (nasopharynx, oral cavity) before and after radiotherapy or surgery; esophageal perforation, esophageal fistula, extensive scar formation in the esophagus; esophageal cancer obstruction and inoperable; treatment of gastric torsion; tracheotomy, tracheal intubation requiring prolonged tube feeding; insufficient intake (e.g. burn, AIDS anorexia, bone marrow transplantation); chronic diseases (such as cystic fibrosis, congenital heart disease); acute oral poisoning gastric lavage rescue; extra-biliary fistula, bile external drainage; abdominal surgery after gastroparesis, gastrointestinal depression; severe pancreatitis, pancreatic cyst, gastric emptying disorder (jejunal nutrition tube); various causes of persistent, persistent vomiting (tumor chemotherapy, etc.)
Contraindications to PEG surgery: divided into absolute contraindications and relative contraindications. Absolute contraindications include: coagulation dysfunction, peritonitis, peritoneal dialysis, varicose veins of the gastric wall, absence of stomach and any disease that cannot be examined by gastroscopy. Relative contraindications such as patients with massive ascites, patients who cannot see the transillumination point from the abdominal wall during PEG, usually because of morbid obesity or the presence of other structures between the stomach and the abdominal wall. The absence of other tissue structures between the two can be clarified by endoscopy and abdominal ultrasound and CT scan, and the puncture can be performed under their guidance. In obese patients, the skin and subcutaneous tissue can be incised under local anesthesia, and then the PEG operation can be performed safely.
The operation of PEG is safe and quick, and its main operation steps (drag-out method) are as follows.
1, Routine method into the gastroscope, using the gastroscope light source to determine the puncture point.
2, Routine skin disinfection, towel laying, local anesthesia, skin incision, and vertical puncture into the stomach with a 16-gauge trocar needle.
3.Pull out the needle core and send in the loop guide wire.
4.Insert the loop sleeve, tighten the loop guide wire, and withdraw it with the gastroscope.
5.Pull out the oral loop guidewire and the loop guidewire at the end of the fistula in an “8”-shaped loop and fasten it.
6.Pull the loop guide wire on the abdominal wall side, and pull the fistula through the oral cavity, esophagus and cardia to reach the stomach, and pull it out through the abdominal wall fistula.
7, re-enter the scope, observe whether the contact between the fistula head and the gastric wall is appropriate, and fix the fistula and the connector.
Intermittent feeding can be performed after the PEG tube is placed, which has the advantages of easy implementation, good tolerance and physiological compliance. The right amount of enteral nutrients should be injected each time to avoid gastroesophageal reflux due to rapid and large infusion. In addition, the patient should be kept in a semi-recumbent position to reduce the risk of accidental aspiration. After the patient is discharged from the hospital, continuous enteral nutrition support can be continued at home using PEG to maintain normal nutrition status. PEG can play the role of long-term enteral nutrition and should be replaced promptly if the PEG tube becomes worn, ruptured or obstructed.
Given that most patients need tube feeding at home, it is important that patients and their families receive proper instructions on the use of.
1.Tube-feeding instruction: instruct patients how to perform tube feeding properly, including some precautions.
2, nutrition guidance: according to the actual situation of each patient, a reasonable and scientific mix of nutritional components to ensure the quantity and quality of demand.
3.Guidance on clean care of the fistula and fistula tube.
4.Complication prevention guidance: inform the relevant complications, if any occurrence can promptly seek medical attention.
5.Regular follow-up.
At least one complication occurs in 10-16% of patients after PEG surgery. Minor complications include: incisional infection, slipped and displaced fistula, parastomal leakage, fistula blockage, incisional hematoma, etc. Wound infections are more common. Serious complications include: bleeding, aspiration, peritonitis, endogastric pad syndrome, and gastric fistula. Complications can be effectively avoided through infection prevention, aseptic operation, strict compliance with operating procedures, and careful postoperative care.