Safety of Percutaneous Endoscopic Gastrostomy (PEG) Tube for Enteral Nutrition in Patients with Amyotrophic Lateral Sclerosis (ALS)

Abstract

Purpose: ALS is a fatal progressive neurodegenerative disease.In 25% of patients bulbar muscles are affected first. Eventually majority of patients develop bulbar symptoms that results in dysphagia and severe malnutrition increasing mortality 8 fold. It has shown that there is a correlation between the duration of bulbar symptoms and survival and a gastroenterologist is usually involved early with the placement of a PEG tube. Concerns exist that PEG placement in ALS patient has more complications compared to other patients. Our aim - evaluate safety of PEG tube insertion in ALS patients compared to patients with stroke. Methods: Retrospective data collection from Jan 2005-Dec 2009. 113 patients (35 ALS and 78 stroke) with dysphagia were compared with respect to major and minor complications relating to PEG tube insertion. Data included demographics, bulbar or spinal ALS, dysphagia grade, aspiration on swallow study, FVC (ALS pts) and complications which included apnea, intubation, bleeding, infection and migration. Complications were analyzed using a Fisher's exact test. 30 day and 1 year survival were reported for both groups and a log-rank test was used to test for significant difference in survival between the two groups. Logistic regressions was used to test for statistically significant group effect on mortality, major and minor complications after adjusting for patient characteristics. Results: Baseline characteristics were similar. The complications rate at PEG insertion and in the first month of follow-up was not significantly different between the two groups. 1 (2.8%) patient was intubated (major complication) during PEG placement in the ALS group vs. 3 (3.8%) major complications (2 bleeding episodes requiring transfusion and 1 abdominal wall abscess resulting in sepsis) in the stroke group (p=1.00). There were 3 (8.3%) minor complications in the ALS patients vs. 1 (1.3%) in the stroke patients. 1 year mortality post PEG placement in ALS patients was 53% vs. 26% in the stroke patients. 97% of ALS patients were alive at 30 days vs. 87% of stroke patients. The median survival after PEG was 423 days. When adjusting for age at PEG placement, sex and race, the odds of death in the ALS group was 2.8 times the odds in the stroke group (p = 0.037) and the odds of death in females was 2.97 times the odds in males (p = 0.014). Conclusion: PEG insertion in ALS patient is as safe as in stroke patients as there was no statistical difference in the incidence of major and minor complications and should be employed early in the course of ALS patients. 1 year mortality of ALS patients was 53% which was significantly higher than in stroke patients likely because ALS is a fatal progressive neurological diseases with high mortality usually from respiratory complications.Table 1: Incidence of major and minor complicationsTable 2: Group effect on mortality adjusting for patient characteristics