What can we do for ALS patients with low vital capacity needing a digestive access for enteral nutrition?

Abstract

The recent publication by Loser et al. on ESPEN guidelines on artificial enteral nutrition is of great interest, as well in theory as in clinical practice. 1 Loser C. Aschl G. Hébuterne X. et al. ESPEN guidelines on artificial enteral nutrition—percutaneaous endoscopic gastrostomy (PEG). Clin Nutr. 2005; 24: 848-861 Abstract Full Text PDF PubMed Scopus (473) Google Scholar A paragraph is specially dedicated to amyotrophic lateral sclerosis (ALS) patients care. The authors note that a forced vital capacity (FVC) of more than 50% (predicted capacity) is recommended for the placement of percutaneous endoscopic gastrostomy (PEG). Indeed, American Academy of Neurology suggests that the risk of respiratory complications after PEG rises significantly when FVC drops below this value. 2 Miller R.G. Rosenberg J.A. Gelinas D.F. et al. Practice parameter: the care of the patient with amyotrophic lateral sclerosis (an evidence-based review). Neurology. 1999; 52: 1311-1323 Crossref PubMed Google Scholar Importance of respiratory status is based on several studies looking for the post-PEG survival factors, using percentage of FCV theoretical values, 3 Mazzini L. Corra T. Zaccala M. et al. Percutaneous endoscopic gastrostomy and enteral nutrition in amyotrophic lateral sclerosis. J Neurol. 1995; 242: 695-698 Crossref PubMed Scopus (307) Google Scholar , 4 Chio A. Finnochiaro E. Bottachi E. and the percutaneous endoscopic gastrostomy study groupStudy and factors related to survival after percutaneous endoscopic gastrostomy in ALS. Neurology. 1999; 53: 1123-1125 Crossref PubMed Google Scholar , 5 Kasarskis E.J. Scarlata D. Hill R. et al. A retrospective study of percutaneous endoscopic gastrostomy in ALS patients during the BDNF and CNTF trials. J Neurol Sci. 1999; 169: 118-125 Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar , 6 Desport J.C. Preux P.M. Truong C.T. et al. Nutritional assessment and survival in ALS patients. Amyotroph Lateral Scler. 2000; 1: 91-96 Crossref PubMed Scopus (162) Google Scholar or FVC measured in liters. 7 Mathus-Vliegen E.M.H. Louwerse L.S. Merkus M.P. Tytgat G.N.J. Vianney de Jong J.M.B. Percutaneous endoscopic gastrotomy in patients with amyotrophic lateral sclerosis and impaired pulmonary function. Gastrointest Endosc. 1994; 40: 436-439 Abstract Full Text Full Text PDF Scopus (119) Google Scholar Consequently, the question is: what can we do for ALS patients with altered FCV? In this circumstance, in our daily practice, at least two digestive accesses for enteral nutrition are discussed with the patient and the medical staff. The first is the classical nasogastric silicone fine-bore (7–9 French) tube, usually placed under nasal local anesthesia, but often badly tolerated. The second one is the use of radiologically inserted gastrostomy (RIG). RIG is an alternative approach which can be performed under local anesthesia of a very limited part of abdominal wall. It avoids the need to pass an endoscope, can be used if PEG is refused, and has been reported as successful in ALS patients when PEG insertion technically fails. 8 Alexander M.D. Gorman M. Corr B. et al. Nutritional management in ALS: radiologically inserted gastrostomy or percutaneous endoscopic gastrostomy. Amyotroph Lateral Scler. 2000; 1: 42-43 Google Scholar We have recently published a prospective study on complications and survival following 20 RIG and 30 PEG, comparable for age, gender ratio, duration of the disease before gastrostomy, neurological form and gravity, nutritional status, but different when considering vital capacity (67.4±26.7% versus 51.6±25% for PEG and RIG, respectively, P = 0.03 ). 9 Desport J.C. Mabrouk T. Bouillet P. Perna A. Preeux P.M. Couratier P. Complications and survival following radiologically and endoscopically guided gastrostomy in patients with amyotrophic lateral sclerosis. Amyotroph Lateral Scler. 2005; 6: 88-93 Crossref PubMed Scopus (13) Google Scholar RIG was proposed as first-line therapy when patients had a vital capacity below 50% and when PEG was refused. No difference between the two techniques was noted neither for the main complications during and after gastrostomy, nor for survival, clearly showing that RIG is feasible in patients who have significant ventilatory compromise. As a conclusion, we think that, if PEG remains in a large number of ALS patients a good technique, nasogastric tube and when possible RIG can be proposed when FCV is below 50% predicted.