Feeding Tube Surgery for Advanced ALS May Be Safer with Modified Approach and Risk Analysis

Surgery to insert a feeding tube directly into the stomach of late-stage amyotrophic lateral sclerosis (ALS) patients can be made safer by adapting procedures now in place for high-risk patients, identified with the help of a tool for stratifying patients according to risk.

The study, ”A risk stratifying tool to facilitate safe late-stage percutaneous endoscopic gastrostomy in ALS,” was published in the journal Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration.

When swallowing difficulties prevent ALS patients from getting adequate nutrition, physicians often turn to a procedure that inserts a tube into the stomach through an opening in the abdomen. But the surgery, called percutaneous endoscopic gastrostomy (PEG) insertion, has been criticized as unsafe for patients with substantial difficulties breathing.

For this reason, both the American Academy of Neurology and European Federation of Neurological Societies changed their recommendations, which now state that PEG insertion should only be performed when a patient’s forced vital capacity (FVC) is greater than 50 percent predicted.

Researchers at the University of Oxford evaluated outcomes among patients who underwent the procedure between 2011 and 2015, comparing results between those with better and worse FVC, and among those with various risk classifications.

One-third of the 107 patients evaluated had a FVC of less than 50 percent predicted before the PEG procedure. Researchers started stratifying patient in 2013, and 58 were stratified according to risk. Two-thirds of this group were considered high-risk patients.

The procedure for higher risk patients was modified to be performed only by the most experienced surgeons, and to use lower doses of sedatives. Patients were tilted at an angle, instead of lying in a horizontal position, to put less pressure on the diaphragm. They also had the possibility of receiving non-invasive ventilation, and oxygen supplementation was used restrictively.

Since lower doses of sedatives were used, all patients undergoing the modified procedure received counseling on the possibility that they would be partially aware during the procedure.

Two patients in the highest risk group, amounting to 9%, died within a month of the surgery, while no early deaths occurred in the low-risk group. At six months, 28 patients had died — 38% in the group with low lung capacity, and 19% in the group with better breathing function.

Sixteen deaths were reported in those who underwent stratification, six in the high-risk group (24%), seven in the medium-risk group (35%), and three among those at low risk (15%). None of the deaths were linked to the surgical procedure.

“Our experience of employing a modified semi-recumbent procedure performed by a team experienced in PEG insertion in patients with respiratory involvement, associated with reduced sedation and with the option of nasal NIV, suggests that PEG can be safely carried out in those ALS patients stratified as higher risk for respiratory complications,” the researchers wrote. “We conclude that FVC ≤50% should not preclude successful PEG.”