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• W2016382822 abstract "We thank Drs. Laasch and Martin for their interest in our recently published article.1Taller A Horváth E Iliás L Kótai ZS Simig M Élö J et al.Technical modifications for improving the success rate of PEG tube placement in patients with head and neck cancer.Gastrointest Endosc. 2001; 54: 633-636Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar The success rate for percutaneous radiologically inserted gastrostomy (PRG, or RIG as preferred by Drs. Laasch and Martin) tube placement in patients with cancer in larger series and a meta-analysis is higher than that of the standard PEG procedure.2Wollman B D'Agostino HB Walus-Wigle JR Easter DW Beale A Radiologic, endoscopic and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature.Radiology. 1995; 197: 699-704PubMed Google Scholar, 3De Baere TH Chapot R Kuoch V Chevallier P Delille JP Domenge CH et al.Percutaneous gastrostomy with fluoroscopic guidance: single-center experience in 500 consecutive cancer patients.Radiology. 1999; 210: 651-654Crossref PubMed Scopus (131) Google Scholar, 4Dewald CHL Hiette PO Sewall LE Fredenberg PG Palestrant AM Percutaneous gastrostomy and gastrojejunostomy with gastropexy: experience in 701 procedures.Radiology. 1999; 211: 651-656Crossref PubMed Scopus (94) Google Scholar Obviously, further efforts are required to develop methods that will improve the success rate of PEG tube placement in these patients. Our report dealt only with new endoscopic solutions when access to the esophagus is compromised. Therefore, we intentionally did not mention any other techniques. Thus, the remark concerning the PRG method seems like looking for oranges on an apple tree. We conducted another search for publications on alternative PEG procedures and found no article that was more recent than those cited at the time our manuscript was submitted to Gastrointestinal Endoscopy. However, since then, 2 articles have appeared on alternate PEG procedures.5Lustberg A Fleisher AS Darwin PE Transnasal placement of percutaneous endoscopic gastrostomy with a pediatric endoscope in oropharyngeal obstruction.Am J Gastroenterol. 2001; 96: 936-937Crossref PubMed Google Scholar, 6Lujber L Fabian G Pytel J Inserting a percutaneous endoscopic gastrostomy tube via a cervical fistula formed after major surgery on a patient with a head and neck tumor.Surg Laparosc Endosc Percutan Tech. 2001; 11: 327-329Crossref PubMed Google Scholar There is only a single sentence in our report that refers to gastrostomy procedures other than PEG. We agree that if we had mentioned other types it would have been advisable to mention not only surgical procedures but also nonsurgical methods, and most importantly the PRG technique. Gastrostomy feeding tubes may be placed by an open surgical approach or percutaneously under endoscopic, radiologic, US, CT, or laparoscopic guidance, or PEG with magnetic positional imaging.7Gauderer MWL Ponsky JL Izant RJ Gastrostomy without laparotomy: A percutaneous endoscopic technique.J Pediatr Surg. 1980; 15: 872-875Abstract Full Text PDF PubMed Scopus (1747) Google Scholar, 8Wills JS Oglesby JT Percutaneous gastrostomy.Radiology. 1983; 149: 449-453Crossref PubMed Scopus (114) Google Scholar, 9Bleck JS Reiss B Gebel M Wagner S Strassburg CP Meier PN et al.Percutaneous sonographic gastrostomy: method, indications, and problems.Am J Gastroenterol. 1998; 93: 941-945Crossref PubMed Scopus (48) Google Scholar, 10Vogt W Messmann H Lock G Gmeinwieser J Feuerbach S Schölmerich J et al.CT-guided PEG in patients with unsuccessful endoscopic transillumination.Gastrointest Endosc. 1996; 43: 138-140Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 11Stringel G Robinson E Maisel S Laparoscopic gastrostomy.Pediatr Surg Int. 1993; 8: 382-384Crossref Scopus (4) Google Scholar, 12Stringel G Geller ER Lowenheim MS Laparoscopic-assisted percutaneous endoscopic gastrostomy.J Pediatr Surg. 1995; 30: 1209-1210Abstract Full Text PDF PubMed Scopus (27) Google Scholar, 13Kitchen PA Saunders B Halligan S Bladen J Bell DG Williams CB Accurate PEG tube placement with magnetic positional imaging.Gastrointest Endosc. 1999; 50: 83-85Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The two most frequently used methods are PEG and PRG. In a small percentage of cases, PEG tube placement may not be possible. Should PEG tube placement be unsuccessful, the alternative of choice is undoubtedly PRG. On the other hand, the method chosen should depend on local expertise and circumstances. From July 1995 until January 2002, we placed PEG tubes in 446 patients with head and neck cancer. Percutaneous ultrasonographic gastrostomy (PUG) was carried out in 6 patients, and laparoscopic technique was used successfully in 2 patients. With these 3 techniques, it was possible to place a gastrostomy tube in almost every patient. Placement of a gastrostomy tube by means of a straight laryngoscope, the open pharynx method, or the transnasal route are not increasingly invasive techniques. Premedication for transnasal PEG tube placement does not differ from that for standard routes. The straight laryngoscope and open pharynx methods are carried out in the operating room with the patient under general anesthesia, almost always in conjunction with other necessary surgical procedures. A large proportion of patients with malignancies in the head and neck region need only temporary tube feeding. The alternative methods mentioned are used when a bulky, advanced-stage cancer is present, cases in which it is highly unlikely that the requirement for nutritional support will be only temporary. Furthermore, the advantage of the PEG procedure is that a larger-diameter tube can be inserted, as acknowledged by Drs. Laasch and Martin. All currently used procedures for gastrostomy tube insertion are safe and well-tolerated and have few associated complications as well as a low procedure-related mortality rate.14Moller P Lindberg CG Zilling T Gastrostomy by various techniques: evaluation of indications, outcome, and complications.Scand J Gastroenterol. 1999; 34: 1050-1054Crossref PubMed Scopus (67) Google Scholar In the best interest of the patient, established techniques can be modified and adapted to special situations.15Zickler RW Barbagiovanni JT Swan KG A simplified open gastrostomy under local anesthesia.Am Surg. 2001; 67: 806-808PubMed Google Scholar Should the well-established, highly successful PEG procedure be discarded simply because a modification in the standard technique is required? The best and ethically justified gastrostomy is the successful gastrostomy, independent of the technique used. We submit that the alternative methods as described in our report will not cause tunnel vision, but will broaden the view for new endoscopic possibilities." @default.
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• W2016382822 title "Response: Why look for oranges on an apple tree?" @default.
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