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The authors found a 0% complication rate with push PEGs compared to 30% in those undergoing pull PEGs. One patient undergoing pull technique PEG presented with a PEG site metastasis, but the small study population size and overall low rate of PEG metastasis makes this result difficult to interpret when comparing the two methods. Theoretically, however, the smaller caliber and maneuverability of the endoscope should allow less trauma to the tumor surface than a blindly passed feeding tube, as is required with pull techniques such as Gauderer Ponsky or Sacks-Vine. The same argument has been made regarding the percutaneous placement of feeding tubes under fluoroscopic guidance in cases of HNSCC requiring enteral feeding [50,53]. The paucity of published reports of PEG site metastasis from HNSCC using the percutaneous radiologic-assisted gastrostomy.