Percutaneous Endoscopic Gastrostomy (PEG) Is the Preferred Mode of Enteral Feeding in Amyotrophic Lateral Sclerosis (Als)

Abstract

Purpose: ALS is a rapidly progressive, fatal neuromuscular illness characterized by progressively severe dysphagia. Malnutrition is 2nd only to impaired vital capacity as an independent predictor of a poor prognosis. Correction of malnutrition can improve both muscle function and respiratory function. While some experts recommend radiographically inserted gastrostomy (RIG) over PEG, especially for pts with severe respiratory compromise, only a single study prospectively compared these techniques in ALS. In 50 pts studied, 2 died from tube placement, 1 with each technique. Furthermore, in another prospective study aspiration occurred nearly twice as often in RIG than in PEG. PEG may have advantages over radiographic placement by providing: close attention to protecting the airway from secretions, semi-upright positioning and the comfort of moderate sedation. We have an extensive experience providing multidisciplinary treatment for ALS patients in our MDS/ALS Center of Hope. Aim of study: 1. To evaluate the safety of PEG placement in a diverse population of ALS and 2. To identify risk factors for complications. Methods: Demographic factors, subtype ALS, FEV1, severity of ALS motor dysfunction (ALSFRS) and duration of ALS were evaluated (when available) in patients with ALS referred for PEG placement from 1998 to 2007. Procedures were characterized as successful if a functional feeding tube was placed. Complications were characterized as severe (mortality, major morbidity or intubation), major (resulting in prolonged admission) or minor. Mild discomfort < 48 hrs duration was not included. Results: 108 ALS pts were identified to have been referred for PEG. The procedure was successful in 101. In 7 pts, the PEG could not be performed: 1 had a surgically place J-tube and a severe complication, 1 refused and 5 underwent RIG. PEG was placed in 43 males and 58 females with a mean age of 60.8 years. Their mean FVC was 42% (range 15% to 80%). 77% had an FVC of < 50% predicted. The average length of hospital stay was 2.9 days. The 30-day survival was 100% and there were no severe complications. 3 pts had major complications: bleeding (stopped after transfusion and tamponade), unexplained pain and aspiration pneumonia (treated with IV antibiotics w/o intubation). 6 pts had minor complications including skin infection, pain, and low grade fever with normal chest x-ray. Thus the major complication rate was 3.4% and overall complication rate was 7%. No pt characteristics or measure of ALS severity was associated with an increase risk of complication, including FVC. Conclusion: PEGs can be placed safely, even in advanced ALS pts. A randomized prospective study is needed to determine the safest mode to provide enteral nutritional support for ALS pts.