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

Amyotrophic lateral sclerosis is a rapidly progressive disease of unkn own etiology resulting in tetraparalysis, dysarthria, dysphagia, and u ltimately death from respiratory insufficiency. In the course of the d isease, recurrent episodes of aspiration, pneumonia, dehydration, and malnutrition may necessitate nasoenteral tube placement, an inconvenie nt and unattractive arrangement in patients with dribbling and impaire d swallowing. A percutaneous endoscopic gastrostomy seemed a better, t hough potentially hazardous, alternative in view of the often severely restricted pulmonary function of these patients. Therefore, we prospe ctively investigated the use of percutaneous endoscopic gastrostomy in 68 consecutive patients with amyotrophic lateral sclerosis. Minimum r equired 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 o r less. The methodology of insertion was adapted to facilitate the ear ly 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 pat ients (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 m ore difficult, the success rate was 89% (49/55); it was 96% (49/51) wh en 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. Pe ristomal redness was present in 6 cases, and 5 patients required analg esics for wound pain. Median survival (122 days) in gastrostomy-eligib le patients was not different from median survival in the group that d id not receive a gastrostomy (92.5 days), but in the latter group, tub e-related complaints (3 out of 6 patients) and repeated episodes of ch oking on foods and drinks interfered with quality of life. Provided th e gastrostomy placement technique minimizes air insufflation, facilita tes 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.