Amyotrophic lateral sclerosis: enteral nutrition provision--endoscopic or radiologic gastrostomy?

Abstract

Purpose: To retrospectively evaluate gastrostomy placement in patients with amyotrophic lateral sclerosis (ALS) to determine the insertion method of choice.

Materials and methods: During 3(1/2) years, 36 patients with ALS (19 men, 17 women; mean age, 54 years; age range, 37-69 years) underwent gastrostomy. Twenty patients were primarily referred for percutaneous endoscopic gastrostomy (PEG) and 16 for percutaneous radiologic gastrostomy (PRG). Gastrostomy method, success rate of each technique, and reason for procedure failure were reviewed in each patient. Forced vital capacity (FVC) prior to gastrostomy was recorded. PEG was performed with a pull-through technique after transillumination of the abdominal wall. PRG was performed with fluoroscopic guidance and T-fastener gastropexy. A log-rank test was used to compare survival rates after PRG and PEG, and a Wilcoxon rank sum test was used to evaluate the influence of declining FVC on PEG success. The Kaplan-Meier product limit method was used to estimate survival probabilities.

Results: Of the 20 patients referred for PEG, 11 had successful results. The nine failures (45%) resulted from failure to transilluminate the abdominal wall. All 16 patients primarily referred for PRG underwent successful gastrostomy. The nine patients in whom PEG failed underwent subsequent successful PRG. In patients with diaphragmatic palsy and a high subcostal stomach, an angled subcostal approach (n = 6) or intercostal approach (n = 2) was required at PRG. One death occurred in the PEG group (9%) because of procedure-related aspiration, and a second patient from the PEG group required laparotomy for postprocedural peritonitis. One death occurred in the PRG group (4%) because of inadvertent placement of the feeding tube in the peritoneal cavity. There was no significant difference between PEG and PRG in patient survival. FVC did not have a statistically significant influence on PEG failure.

Conclusion: Results show PRG to be the method of choice.