Percutaneous gastrojejunostomy in amyotrophic lateral sclerosis

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Abstract

We have performed a retrospective review of the use of a percutaneous gastrojejunostomy in patients with amyotrophic lateral sclerosis (ALS). Forty-one patients with initial bulbar manifestations of ALS and 32 patients with initial limb manifestations underwent a percutaneous gastrojejunostomy under fluoroscopic control using the Rankin gastrojejunostomy tube. Survival characteristics were compared with 86 bulbar onsetting and 207 limb onsetting ALS patients who did not require nutritional support. The 30-day mortality rate was 9.6% (respiratory death in three bulbar onsetting patients and four limb onsetting patients) and the 30 day morbidity rate was 4.1% (one operative site infection and intraperitoneal leakage in two patients). The most frequent long-term complication was the requirement for tube changing (blockage in six; dislodgment in two). Gastric reflux was not described amongst the treated patients. Overall survivorship (symptom onset to death) was less in the bulbar onsetting patients receiving a gastrojejunostomy tube than in the control population (median survival 22.0 vs. 33.7 months, respectively, P=0.005). As a group, the median survivorship for limb onsetting patients was not different for those receiving a gastrojejunostomy than for those who did not. However, a significant reduction in survival was observed in limb onsetting patients receiving a gastrojejunostomy early in the course of their disease (P=0.001) compared to those with a longer duration prior to the procedure. This was not observed in the bulbar onsetting patients. In both patient populations, no relationship was observed between survival post-gastrojejunostomy and the severity of pulmonary involvement at the time of the intervention, serum chloride, or age at onset. These studies demonstrate that a percutaneous gastrojejunostomy is a well-tolerated and safe alternative technique for enteral nutritional support in ALS patients. It also offers the advantage of not requiring either a general anaesthetic at the time of the procedure or instrumentation through the oropharynx. We have also observed that limb onsetting patients requiring a gastrojejunostomy early in the course of their illness are in a distinctive, less favorable, prognostic group.

Introduction

The requirement for enteral nutritional supplementation in amyotrophic lateral sclerosis (ALS) is a common occurrence in the final stages of the disease process when severe bulbar compromise prohibits the oral ingestion of foodstuffs. However, patients with ALS are at risk for the development of malnutrition early in the course of their illness and may require supplementation even before significant bulbar compromise is evident [1], [2], [3]. Traditionally, when oral supplementation can no longer be tolerated, enteral nutritional support is provided by a nasogastric tube, percutaneous endoscopic gastrostomy (PEG) or jejunostomy (PEJ). Nasogastric tubes have been largely supplanted by either the PEG or PEJ because of greater patient comfort, less frequent displacement, reduced risk of aspiration and improved anchoring distally [4], [5]. Prolonged usage of a nasogastric tube is also associated with nasopharyngeal ulceration and a higher incidence of aspiration pneumonia [6]. In a prospective comparison of the nasogastric tube to PEG in 90 patients, no increase in the incidence of aspiration was observed between the two groups, but a higher incidence of nasal ulceration was found in the nasogastric group [7]. Although a greater rate of complications in those utilizing a PEG (abdominal pain in five, peritoneal sepsis in one, 27% rate of mild inflammation at the site of the tube insertion) was observed, health care providers rated PEG superior to the nasogastric tube. Both endoscopic procedures can be associated with increased complications in the elderly population (that which is most commonly afflicted with ALS), including peritonitis and reflux with persistent aspiration [4]. The later complication is of specific concern in the elderly population in whom an increased risk of gastroesophageal reflux and esophageal motility disorders has been observed [8], [9].

Hence, there is a need for an alternate technique for enteral nutritional support for ALS patients. In this paper, we report our experience with the use of a percutaneous gastrojejunostomy in patients with ALS. Compared to conventional procedures, this technique offers several advantages, including the lack of requirement for a general anesthetic, the absence of instrumentation in the oropharynx, and the ability to utilize the feeding tube within hours of its implantation, thereby reducing hospitalization time.

Section snippets

Patients and methods

Seventy three patients with clinically definite ALS (El Escorial criteria) underwent a percutaneous gastrojejunostomy, consisting of 41 patients (M:F 1.1:1) with initial bulbar manifestations and 32 (M:F 1.3:1) with limb onsetting symptoms [10]. No significant differences in the age at symptom onset were observed between the bulbar onset control (n=86; M:F 0.76:1) and gastrojejunostomy patients, or between limb onset control (n=72; M:F 1.5:1) and gastrojejunostomy patients (Table 1). Control

Complications

The 30-day mortality rate following the gastrojejunostomy was 9.6% and consisted of seven deaths (three bulbar, four limb onset). The cause of death was respiratory failure in six and a myocardial infarction in one. There were no deaths in the immediate peri-operative time period. The 30-day morbidity rate was 4.1% and consisted of incision site infections in four patients (one with multiple infections), intraperitoneal leakage in two (not requiring antibiotic therapy). The most frequent

Discussion

We have observed that a percutaneous gastrojejunostomy is a safe and well-tolerated alternative to the traditional use of a PEG or PEJ in ALS. The use of a percutaneous gastrojejunostomy also presents several distinct advantages, including the lack of requirement of anesthesia or instrumentation of the oropharynx. Peri-operative aspiration pneumonia was not observed.

Our analysis compares favorably to the report of Mathus-Vliegen et al. [12] in which 55 ALS patients, selected for a FVC of 1 l or

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