PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN PATIENTS WITH AMYOTROPHIC-LATERAL-SCLEROSIS AND IMPAIRED PULMONARY-FUNCTION

Amyotrophic lateral sclerosis is a rapidly progressive disease of unknown etiology resulting in tetraparalysis, dysarthria, dysphagia, and ultimately death from respiratory insufficiency. In the course of the disease, recurrent episodes of aspiration, pneumonia, dehydration, and malnutrition may necessitate nasoenteral tube placement, an inconvenient and unattractive arrangement in patients with dribbling and impaired swallowing. A percutaneous endoscopic gastrostomy seemed a better, though potentially hazardous, alternative in view of the often severely restricted pulmonary function of these patients. Therefore, we prospectively investigated the use of percutaneous endoscopic gastrostomy in 68 consecutive patients with amyotrophic lateral sclerosis. Minimum required pulmonary function was defined as forced vital capacity (FVC) of 1 L or more and CO2 gas exchange capability as pCO(2) of 45 mm Hg or less. The methodology of insertion was adapted to facilitate the early removal of gastric air. Fifty-five patients (median FVC, 1.7 L; pCO(2), 40 mm Hg) were eligible for the gastrostomy procedure, and 13 patients (median FVC, 0.8 L; pCO(2), 47 mm Hg) were not. Despite the fact that modification of the method of insertion rendered the procedure more difficult, the success rate was 89% (49/55); it was 96% (49/51) when failures related to distorted anatomy were excluded. The procedure-related mortality rate was 1.8% and the 24-hour in-hospital mortality rate was 3.6%, mainly related to respiratory insufficiency. The 30-day out-of-hospital mortality rate was 11.5%. Major complications (3.6%) consisted of a spontaneously draining cutaneous abscess in 2 cases. Peristomal redness was present in 6 cases, and 5 patients required analgesics for wound pain. Median survival (122 days) in gastrostomy-eligible patients was not different from median survival in the group that did not receive a gastrostomy (92.5 days), but in the latter group, tube-related complaints (3 out of 6 patients) and repeated episodes of choking on foods and drinks interfered with quality of life. Provided the gastrostomy placement technique minimizes air insufflation, facilitates adequate and early removal of gastric air, and avoids intravenous sedation, the method appears to be successful and safe in a subset of highly disabled patients with respiratory compromise and far-advanced neurologic disease.