Our trainees for May appeared to win the best-weather-during-traineeship jackpot, with blue skies and warm weather all week. This month our nutrition support trainees hailed from Kuwait, Jordan and Philadelphia, PA. The diversity of our group was a real treat! Our journal article this month dealt with the topic of the best method for gastrostomy placement in patients with ALS.
Allen JA, Chen R, Ajroud-Driss S, et al. Gastrostomy tube placement by endoscopy versus radiologic methods in patients with ALS: a retrospective study of complications and outcome. Amyotroph Lateral Scler Frontotemporal Degener. 2013;14(4):308-314.
This was a single center, retrospective, observational study of 100 patients with amyotrophic lateral sclerosis that compared outcomes of patients who received percutaneous endoscopic gastrostomy (PEG) or radiologically inserted gastrostomy (RIG). The choice of endoscopic versus radiologically placed feeding tube was based on the referral practice of ALS physicians, and the evolution of their referral practice over time. Prior to 2010 most patients were referred to gastroenterology, but after 2011 most ALS patients were referred to radiology.
Complications during and after gastrostomy placement, with an emphasis on aspiration pneumonia and post-procedure pain, were compared between the two types of G-tube placement.
Inclusion and Exclusion Criteria were:
Patients with a diagnosis of ALS at a single academic medical center who were referred for gastrostomy placement and a procedural attempt was made.
Patients who received their gastrostomy placement at a different institution, those with data missing from the medical record, or with limited clinical follow up.
A total of 283 patient charts were reviewed, and data from 75 patients were excluded due to primary evaluation done at a different facility, data was missing, or follow up was limited. Other exclusions included 11 patients because of incomplete documentation, and 17 patients because their gastrostomy was placed at an outside facility.
Ultimately, 180 patients with ALS were referred for gastrostomy placement. One hundred patients opted to attempt G-tube placement, while 80 patients declined. A total of 108 gastrostomy attempts were made in the 100 patients, with 57 PEGs and 51 RIGs attempted. Among the RIG placements, 37 used the “push” method and 14 the “pull” method.
Gastrostomies were completed by 10 different gastroenterologists and 15 different interventional radiologists. The choice of attending physician for gastrostomy placement was left to the gastroenterology and radiology scheduling process and not influenced by the referring physician.
Demographic and clinical characteristics, including type and location of ALS onset were similar between the PEG and RIG groups.
G-tube placements were not successful in 9 PEG and 1 RIG attempts. PEG attempts were not successful in 5 patients due to failure of transillumination, and in 4 patients due to respiratory compromise. The unsuccessful RIG attempt was due to high stomach position with no window for safe placement below the costal margin. Of the 9 aborted PEG attempts, 7 received a RIG; 1 failed RIG placement and 1 declined further attempts.
Outcomes from the procedures included: 1 RIG attempt resulted in respiratory failure, intubation, and G-tube placement under general anesthesia. Respiratory failure occurred in 4 patients undergoing PEG
procedure. Analysis of systemic or life threatening events revealed
major PEG complication rates of 7.0% for PEG and 1.9% for RIG, but this was not significantly different. Minor complications occurred at a similar frequency in both groups. Minor PEG complications included difficulty penetrating the gastric mucosa (2) and transient hypoxia (2). Minor RIG complications included difficulty dilating the G-tube tract and placement of a temporary 10-F catheter (1), transient hypoxia and agitation (1), and dislodged tooth crown (1).
Post-procedure aspiration was diagnosed in 6 patients (10.5%) after PEG and none after RIG attempts (p = 0.02). Length of hospital stay was significantly longer after RIG (4 days) compared with PEG (3.1 days) (p =0.02). Day 0 pain was significantly greater after RIG (pain scale 6.2/10) compared with PEG (pain scale 5.1/10) (p= 0.03). There was no significant difference in pain between groups on post procedure day 1.
There was no difference in post-procedure survival between the groups, with average time to death after gastrostomy placement of 9.4 months and six month mortality of 37% (all patients).
The authors concluded that their results supported placement of gastrostomy tubes with radiographic methods in ALS patients because of an improved success rate and decreased aspiration with RIG.
The authors address most of the limitations of this study in the discussion section of the paper. Foremost, this was an observational study with the change in route of gastrostomy placement over time. Documentation inadequacies led to the exclusion of a number of patients, and can be a source of missed data, even in patients that were included. Practices change, and increased experience with gastrostomy placement in ALS patients, feeding protocols and bowel management over time may have led to an overall improvement in care unrelated to the type of gastrostomy. Sample size was also limited, and certainly there were too few patients with “Pull” versus “Push” RIG placement to make comparisons. It is difficult to draw a strong take-home message regarding aspiration, when so few patients had aspiration. Additionally, there did not appear to be objective criteria for diagnosis of aspiration pneumonia, nor disclosure of, or control over who made the diagnosis.
Our GI physician noted that our practices for PEG placement with ALS have evolved over time, and we now know to elevate the head-of-bed in those with aspiration risk, and our PEG placement is done with supervision from an anesthesiologist. It was also noted by the group that this retrospective study was done by the radiology department.
As usual, some of the benefit of diving into the details of these studies is found outside of the abstract conclusions. Our team is involved in the UVAHS ALS Clinic and we provide recommendations and follow up to patients with ALS, including those that receive G-tubes. It was interesting to note that 44% of the patients in this cohort chose not to proceed with gastrostomy placement. While we definitely see some patients that do better than average post-PEG placement, the average survival after G-tube of less than 10 months in this study is a bit unsettling, and is perhaps a sign that feeding tube placement, for a variety of reasons, is still often delayed until late in the disease process.
Our Take Home Message (s)
1. Radiologically placed gastrostomy may reduce the risk of aspiration pneumonia after G-tube placement, at the cost of increased short-term pain and increased length of hospital stay.
2. There is a need for further research to investigate procedures that optimize both endoscopic and radiologic gastrostomy placements in patients with potential for respiratory compromise.
Other News on the UVAHS GI Nutrition Website: (www.ginutrition.virginia.edu):
Upcoming Webinars 2015:
–On hold for now
Check out What’s New:
–“Nutrition Support Blog”
Latest Practical Gastroenterology article:
–DiBaise J, Parrish CR. Part V: Short Bowel Syndrome in Adults – Part 5: Trophic Agents in the Treatment of Short Bowel Syndrome. Practical Gastroenterology 2015;XXXVIII(5):56.
Joe Krenitsky MS, RD
Carol Rees Parrish MS, RD
PS – Please feel free to forward on to friends and colleagues.