Gastrostomy in patients with amyotrophic lateral sclerosis (ProGas): a prospective cohort study

Abstract

SummaryBackgroundGastrostomy feeding is commonly used to support patients with amyotrophic lateral sclerosis who develop severe dysphagia. Although recommended by both the American Academy of Neurology and the European Federation of Neurological Societies, currently little evidence indicates the optimum method and timing for gastrostomy insertion. We aimed to compare gastrostomy insertion approaches in terms of safety and clinical outcomes.MethodsIn this large, longitudinal, prospective cohort study (ProGas), we enrolled patients with a diagnosis of definite, probable, laboratory supported, or possible amyotrophic lateral sclerosis who had agreed with their treating clinicians to undergo gastrostomy at 24 motor neuron disease care centres or clinics in the UK. The primary outcome was 30-day mortality after gastrostomy. This study was registered on the UK Clinical Research Network database, identification number 9923.FindingsBetween Nov 2, 2010, and Jan 31, 2014, 345 patients were recruited of whom 330 had gastrostomy. 163 (49%) patients underwent percutaneous endoscopic gastrostomy, 121 (37%) underwent radiologically inserted gastrostomy, 43 (13%) underwent per-oral image-guided gastrostomy, and three (1%) underwent surgical gastrostomy. 12 patients (4%, 95% CI 2·1–6·2) died within the first 30 days after gastrostomy: five (3%) of 163 after percutaneous endoscopic gastrostomy, four (3%) of 121 after radiologically inserted gastrostomy, and three (7%) of 43 after per-oral image-guided gastrostomy (p=0·46). Including repeat attempts in 14 patients, 21 (6%) of 344 gastrostomy procedures could not be completed: 11 (6%) of 171 percutaneous endoscopic gastrostomies, seven (6%) of 121 radiologically inserted gastrostomies, and three (6%) of 45 per-oral image-guided gastrostomies (p=0·947).InterpretationThe three methods of gastrostomy seemed to be as safe as each other in relation to survival and procedural complications. In the absence of data from randomised trials, our findings could inform clinicians and patients in reaching decisions about gastrostomy and will stimulate further research into the nutritional management in patients with amyotrophic lateral sclerosis.FundingMotor Neurone Disease Association of Great Britain and Northern Ireland (MNDA) and the Sheffield Institute for Translational Neuroscience (SITraN).

Thirty-day mortality after percutaneous gastrostomy by endoscopic versus radiologic placement: a systematic review and meta-analysis

“…PEG and RIG placement are generally known as safe and feasible procedures with low mortality rates 9. In this meta-analysis, the pooled 30-day mortality rate of the PEG group was 5.5% (95% 4.0%-6.9%) and that of the RIG group was 10.5% (95% CI, 6.8%-14.3%).…”

“…We identified 828 citations through the electronic database search, and 445 citations remained after duplicates were removed. Initial screening of the titles and abstracts resulted in the exclusion of 414 citations, and full texts of the remaining 31 citations were reviewed in detail 891617181920212223242526272829303132333435363738394041424344. An additional 16 citations were excluded after reviewing the full articles, for the following reasons: duplicated reports,424344 noncomparative studies,37 studies with RIG placement after failure of PEG,2535 no data present on 30-day mortality,294041 no reported case of 30-day mortality,192730343638 and review articles 1721.…”

“…An additional 16 citations were excluded after reviewing the full articles, for the following reasons: duplicated reports,424344 noncomparative studies,37 studies with RIG placement after failure of PEG,2535 no data present on 30-day mortality,294041 no reported case of 30-day mortality,192730343638 and review articles 1721. Fifteen published studies including two RCTs1639 and 13 NRCTs891920222324262831323342 were included in the final analysis.…”

“…A total of five studies919222432 were performed in patients with motor neuron disease. Pooled analysis of the ORs showed no significant difference in 30-day mortality between the PEG group and RIG group (OR, 0.84; 95% CI, 0.43-1.69; P =0.637) (Fig.…”

“…Radiologically-inserted gastrostomy (RIG) was also introduced in 1981 and has been used as an alternative to PEG for enteral feeding with a high rate of technical success under local anesthesia 3. Although PEG and RIG are both considered minimally invasive, they are associated with considerable early mortality (30-day mortality), which has been reported as 5.8% to 28% for PEG and 1% to 40% for RIG 456789. Furthermore, various complications such as wound infections, hemorrhage, hematoma formation, aspiration pneumonia, or gastric perforation may develop after gastrostomy.…”