Percutaneous endoscopic gastrostomy versus fluoroscopic gastrostomy in amyotrophic lateral sclerosis (ALS) sufferers with nutritional impairment: A meta-analysis of current studies

[Medical nutrition therapy in amyotrophic lateral sclerosis - Do we act or react? A case report and multidisciplinary review]

Introduction

Background: amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with a progressive course. The current prevalence is between 3 and 6 cases/100,000. Malnutrition is closely related to patient prognosis in ALS. The implications of this conditions have been that we should recommend patient care in a multidisciplinary unit. Case report: the case presented shows the evolution of a patient with ALS. The patient was referred to different clinical departments after neurological evaluation and her nutritional, functional and respiratory status were assessed. There was no nutritional deterioration at diagnosis; however, intake was below energy-protein requirements. The clinical evolution of the patient showed a decrease in muscle mass with preservation of weight and fat mass. "Aggressive" measures to control nutritional status such as gastrostomy were rejected in the initial stages of the disease, but had to be carried out after development of dysphagia and associated malnutrition. This situation of progressive morphofunctional deterioration and the development of disease-related complications made essential the participation of different health services and professionals in its control. Dicussion: the management of ALS in a multidisciplinary manner allows to improve the course of the disease and the quality of life of both the patients and their families. Patient follow-up is based on the adjustment and management of complications. The basis of the relationship with these patients includes maintaining an adequate communication with them and their families, and ensuring joint decision-making about their condition.

Endoscopic vs radiologic gastrostomy for enteral feeding: A systematic review and meta-analysis

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiological gastrostomy (PRG) are minimally invasive techniques commonly used for prolonged enteral nutrition. Despite safe, both techniques may lead to complications, such as bleeding, infection, pain, peritonitis, and tube-related complications. The literature is unclear on which technique is the safest.

AIM

To establish which approach has the lowest complication rate.

METHODS

A database search was performed from inception through November 2022, and comparative studies of PEG and PRG were selected following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All included studies compared the two techniques directly and provided absolute values of the number of complications. Studies with pediatric populations were excluded. The primary outcome of this study was infection and bleeding. Pneumonia, peritonitis, pain, and mechanical complications were secondary outcomes. The risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB2) and we used The Risk of Bias in Nonrandomized Studies (ROBINS-I) to analyze the retrospective studies. We also performed GRADE analysis to assess the quality of evidence. Data on risk differences and 95% confidence intervals were obtained using the Mantel-Haenszel test.

RESULTS

Seventeen studies were included, including two randomized controlled trials and fifteen retrospective cohort studies. The total population was 465218 individuals, with 273493 having undergone PEG and 191725 PRG. The only outcome that showed a significant difference was tube related complications in retrospective studies favoring PEG (95%CI: 0.03 to 0.08; P < 0.00001), although this outcome did not show significant difference in randomized studies (95%CI: -0.07 to 0.04; P = 0.13). There was no difference in the analyses of the following outcomes: infection in retrospective (95%CI: -0.01 to 0.00; P < 0.00001) or randomized (95%CI: -0.06 to 0.04; P = 0.44) studies; bleeding in retrospective (95%CI: -0.00 to 0.00; P < 0.00001) or randomized (95%CI: -0.06 to 0.02; P = 0.43) studies; pneumonia in retrospective (95%CI: -0.04 to 0.00; P = 0.28) or randomized (95%CI: -0.09 to 0.11; P = 0.39) studies; pain in retrospective (95%CI: -0.05 to 0.02; P < 0.00001) studies; peritonitis in retrospective (95%CI: -0.02 to 0.01; P < 0.0001) studies.

CONCLUSION

PEG has lower levels of tube-related complications (such as dislocation, leak, obstruction, or breakdown) when compared to PRG.

Outcomes and Complications of Radiological Gastrostomy vs. Percutaneous Endoscopic Gastrostomy for Enteral Feeding: An Updated Systematic Review and Meta-Analysis

Background

Percutaneous endoscopic gastrostomy (PEG) and percutaneous radiological gastrostomy (PRG) are commonly utilized to establish access to enteral nutrition. However, data comparing the outcomes of PEG vs. PRG are conflicting. Therefore, we aimed to conduct an updated systemic review and meta-analysis comparing PRG and PEG outcomes.

Methods

Medline, Embase, and Cochrane library databases were searched until February 24, 2023. Primary outcomes included 30-day mortality, tube leakage, tube dislodgement, perforation, and peritonitis. Secondary outcomes included bleeding, infectious complications, and aspiration pneumonia. All analyses were conducted using Comprehensive Meta-Analysis Software.

Results

The initial search revealed 872 studies. Of these, 43 of these studies met our inclusion criteria and were included in the final meta-analysis. Of 471,208 total patients, 194,399 received PRG and 276,809 received PEG. PRG was associated with higher odds of 30-day mortality when compared to PEG (odds ratio (OR): 1.205, 95% confidence interval (CI): 1.015 - 1.430, I² = 55%). In addition, tube leakage and tube dislodgement were higher in the PRG group than in PEG (OR: 2.231, 95% CI: 1.184 - 4.2 and OR: 2.602, 95% CI: 1.911 - 3.541, respectively). Perforation, peritonitis, bleeding, and infectious complications were higher with PRG than PEG.

Conclusion

PEG is associated with lower 30-day mortality, tube leakage, and tube dislodgement rates than PRG.

Percutaneous endoscopic gastrostomy in amyotrophic lateral sclerosis: outcomes of a dedicated anesthesia and surgery protocol

BACKGROUND

Patients requiring percutaneous endoscopic gastrostomy (PEG) for amyotrophic lateral sclerosis (ALS) related dysphagia represent a clinical challenge. Diminished pulmonary function and aspiration risks can lead to anesthesia-related complications, and gastric displacement from hemidiaphragm elevation may preclude safe gastric access. This study reports the efficacy and outcomes of a dedicated anesthesia/surgery management protocol for ALS patients undergoing PEG.

METHODS

In 2013, a PEG placement protocol for ALS patients was developed emphasizing efficient pre-operative evaluation, rapidly metabolized anesthetic agents, and minimization of opioid use. Outcomes were analyzed retrospectively. Preoperative weight loss, pulmonary function tests, total analgesia, procedural time, and 90-day morbidity and mortality were recorded.

RESULTS

From 2013-2019, 67 ALS patients (mean age 65.3 years, 52.2% female) received a PEG under the protocol. Mean percentage weight loss 6 months before PEG was 9.3 ± 5.1% with 38.8% of patients meeting criteria for severe malnutrition. Mean anesthesia time (propofol induction to anesthesia emergence) was 34.5 ± 10.8 min and mean operative time (endoscope insertion to dressing placement) was 16.4 ± 8.2 min. Regional anesthesia with liposomal bupivacaine was performed in 76.1%. All attempts at PEG placement were successful. With a mean follow-up of 6.1 ± 6.8 months, all PEGs were functional and there were no surgical site complications. Thirty-day readmission rate was 7.0% and 90-day mortality was 22.4% (46.7% occurring within 30 days). Mean time from surgery to death was 8.8 ± 7.8 months.

CONCLUSIONS

Protocols for optimizing PEG may help overcome challenges present in the ALS patient population. Despite patient comorbidities, protocol implementation and dedicated team members resulted in a high procedural success rate and low complication rate. Further study is warranted to optimize the timing of PEG placement in relation to ALS disease progression and determine the utility of regional anesthesia during PEG placement.

Percutaneous Radiology Gastrostomy (PRG)-Associated Complications at a Tertiary Hospital over the Last 25 Years

OBJECTIVES

We aimed to describe and compare the complications associated with different percutaneous radiologic gastrostomy (PRG) techniques.

METHODS

A retrospective and prospective observational study was conducted. Patients who underwent a PRG between 1995-2020 were included.

TECHNIQUES

A pigtail catheter was used until 2003, a balloon catheter without pexy was used between 2003-2009 and a balloon catheter with gastropexy was used between 2015-2021. For the comparison of proportions, X² tests or Fisher's test were used when necessary. Univariate analysis was performed to study the risk factors for PRG-associated complications.

RESULTS

n = 330 (pigtail = 114, balloon-type without pexy = 28, balloon-type with pexy = 188). The most frequent indication was head and neck cancer. The number of patients with complications was 44 (38.5%), 11 (39.2%) and 54 (28,7%), respectively. There were seven (25%) cases of peritonitis in the balloon-type without-pexy group and 1 (0.5%) in the balloon-type with-pexy group, the latter being the only patient who died in the total number of patients (0.3%). Two (1%) patients of the balloon-type with-pexy group presented with gastrocolic fistula. The rest of the complications were minor.

CONCLUSIONS

The most frequent complications associated with the administration of enteral nutrition through PRG were minor and the implementation of the balloon-type technique with pexy has led to a decrease in them.

Percutaneous endoscopic gastrostomy using the introducer method with ultra-slim endoscopy in amyotrophic lateral sclerosis patients with respiratory compromise: A safe technique

BACKGROUND AND AIM

Percutaneous endoscopic gastrostomy (PEG) placement is recommended in patients with amyotrophic lateral sclerosis (ALS), but the procedure is considered high risk. In this study, we aimed to compare the outcome of ALS patients with and without PEG. The success of the procedure and complications of PEG insertion were also explored.

METHODS

Patients with ALS who met the criteria for enteral feeding support were consecutively recruited. Patients who consented had PEG insertion using the modified technique of introducer method with transoral ultra-slim endoscopy.

RESULTS

A total of 64 patients were recruited, of which 36 (56%) patients consented to PEG. The median age of all patients was 65 years and 59% were male. There was no difference in demographic and clinical characteristics between patients who agreed to a PEG and those who did not. The mortality rate at 6 and 12 months was lower in the PEG cohort compared with non-PEG, but this was not statistically significant (6 months: 28.6% vs 32.2%, P = 0.561; 12 months: 38.9% vs 50.0%, P = 0.374). Amongst the PEG cohort, 61% were stratified high risk and 31% moderate risk. Thirty-one percent of them required long-term home noninvasive ventilation. All patients (100%) underwent successful PEG insertion at single attempt using the modified approach. The complications reported over a period of 6 months were infected PEG site (17%), dislodged gastrostomy tube (14%), and minor bleeding (8%).

CONCLUSION

In ALS patients with moderate to high risk of PEG insertion, the introducer technique utilizing ultra-slim endoscopy guidance was well tolerated and safe.

Percutaneous endoscopic gastrostomy and jejunostomy: Indications and techniques

Nutritional support is essential in patients who have a limited capability to maintain their body weight. Therefore, oral feeding is the main approach for such patients. When physiological nutrition is not possible, positioning of a nasogastric, nasojejunal tube, or other percutaneous devices may be feasible alternatives. Creating a percutaneous endoscopic gastrostomy (PEG) is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk. Many diseases require nutritional support by PEG, with neurological, oncological, and catabolic diseases being the most common. PEG can be performed endoscopically by various techniques, radiologically or surgically, with different outcomes and related adverse events (AEs). Moreover, some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent. These conditions highlight many ethical problems that become difficult to manage as treatment progresses. The aim of this manuscript is to review all current endoscopic techniques for percutaneous access, their indications, postprocedural follow-up, and AEs.

Gastrostomy tubes: Fundamentals, periprocedural considerations, and best practices

Gastrostomy tube placement is a procedure that achieves enteral access for nutrition, decompression, and medication administration. Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events (AEs). Appropriate indications, contraindications, ethical considerations, and comorbidities of patients referred for gastrostomy placement should be weighed and balanced. Additionally, endoscopist should consider either a transoral or transabdominal approach is appropriate, and radiologic or surgical gastrostomy tube placement is needed. However, medical history, physical examination, and imaging prior to the procedure should be considered to tailor the appropriate approach and reduce the risk of AEs.

Comparative Safety of Endoscopic vs Radiological Gastrostomy Tube Placement: Outcomes From a Large, Nationwide Veterans Affairs Database

INTRODUCTION

A gastrostomy is generally performed in patients who are unable to maintain volitional intake of food. We compared outcomes of percutaneous endoscopic gastrostomy (PEG) and interventional radiologist-guided gastrostomy (IRG) using an integrated nationwide database.

METHODS

Using the VA Informatics and Computing Infrastructure database, patients who underwent PEG or IRG from 2011 through 2021 were selected using Current Procedural Terminology and International Classification of Diseases codes. The primary outcome was the comparative incidence of adverse events between PEG and IRG. Secondary outcomes included all-cause mortality. Comorbidities were identified using International Classification of Diseases codes, and adjusted odds ratio (OR) for adverse events were calculated using multivariate logistic regression analysis.

RESULTS

A total of 23,566 (70.7 ± 10.2 years) patients underwent PEG and 9,715 (69.6 ± 9.7 years) underwent IRG. Selected frequent indications for PEG vs IRG were as follows: stroke, 6.8% vs 5.3%, P < 0.01; aspiration pneumonia, 10.9% vs 6.8%, P < 0.001; feeding difficulties, 9.8% vs 6.3%, P < 0.01; and upper aerodigestive tract malignancies 58.8% vs 79.8%, P < 0.01. Across all subtypes of malignancies of the head and neck and foregut, the proportion of patients undergoing IRG was greater than those undergoing PEG (P < 0.001). The all-cause 30-day mortality and overall incidence of adverse events were significantly lower for PEG compared with those for IRG (PEG vs IRG): all-cause 30-day mortality, 9.35% vs 10.3% (OR 0.80; 95% confidence interval [CI] 0.74-0.87; P < 0.01); perforation of the colon, 0.12% vs 0.24% (OR 0.50; 95% CI 0.29-0.86; P = 0.04); peritonitis, 1.9% vs 2.7% (OR 0.68; 95% CI 0.58-0.79; P < 0.01); and hemorrhage 1.6% vs 1% (OR 1.47; 95% CI 1.18-1.83; P < 0.01).

DISCUSSION

In a large nationwide database of more than 33,000 gastrostomy procedures, PEG was associated with a lower incidence of adverse outcomes and the 30-day mortality than IRG.

Epidemiology and survival trends of motor neurone disease in Northern Ireland from 2015 to 2019

BACKGROUND AND PURPOSE

This study evaluates the incidence, prevalence and survival trends of motor neurone disease (MND) in Northern Ireland from 2015 to 2019.

METHODS

A capture-recapture analysis was performed using five independent data sources. Incidence and prevalence rates were standardized to the European Standard Population. Survival outcomes were analysed using Kaplan-Meier curves and Cox regression analysis.

RESULTS

Amongst 254 total cases of MND, capture-recapture analysis estimated three missing cases (case ascertainment 98.8%). Age standardized incidence of captured cases was 3.12 per 100,000 (2.73, 3.50) and standardized prevalence ranged from 9.45 to 6.49 per 100,000 from 2015 to 2019. Standardized incidence and prevalence rates in 2006 were 1.4 and 3.3 per 100,000 respectively. Of identified cases, 133 (52.4%) were male; 94.5% had amyotrophic lateral sclerosis; median age of onset was 67 years; median time to diagnosis was 12 months (95% confidence interval 11.2, 12.8); survival from diagnosis was 12 months (95% confidence interval 10.6, 15.4); 25 (9.8%) reported a family history of MND or frontotemporal dementia; and a known MND-associated genetic mutation was identified in 7.9% of total cases, of which the most common was C9orf72 (5.7% of all patients). Factors associated with improved survival were younger age at onset, longer time to diagnosis, attendance at regional MND clinic, and initial neurology presentation as outpatient (all p < 0.001).

CONCLUSION

The incidence and prevalence of MND in Northern Ireland has increased over the last 10 years, in line with increasing rates reported from other European countries. Improved survival was associated with younger age at onset, longer time to diagnosis, attendance at a regional MND clinic and outpatient presentation to a Neurology Department.

Current practices and barriers in gastrostomy indication in amyotrophic lateral sclerosis: a survey of ALS care teams in The Netherlands

OBJECTIVE

To describe current practices and barriers and support needs in gastrostomy indication and decision-making amongst rehabilitation physicians of ALS care teams in the Netherlands. Methods: Cross-sectional online survey of rehabilitation physicians of ALS care teams in the Netherlands. Survey items covered current practices in timing of indication (i.e. indicators and criteria), goals, initiating discussion about gastrostomy, and criteria for preferred method of placement; and barriers and support needs in indication and decision-making. Descriptive analysis was used for quantitative responses, thematic, and content analysis for qualitative data. Results: Twenty-nine physicians (41%) of 27 ALS care teams (71%) responded. Timing of indication: physicians agreed on important indicators but not cutoff values/criteria. Goals: optimizing nutritional status (100%), ensuring safe food-intake (72%), and reducing effort of meals (59%). Initiating discussion about gastrostomy: 52% introduces the topic early after diagnosis, 48% at indication. Criteria for method of placement included physician preference (69%), availability of service (21%), lower complication risk (17%), contraindication (59%), and patient preference (24%). Reported barriers (69% of respondents) were: patient readiness (52%), timing of indication (31%), and organizational barriers (18%). Support needs (62%): evidence-based timing of indication (35%) and tailored patient education (31%). Conclusions: There is practice variation in the timing of first introduction of gastrostomy and preferred method of placement, but agreement on goals and indicators . More evidence on optimal timing of gastrostomy placement is needed. However, until then early and regular discussion of the topic of gastrostomy and better patient information may promote patient readiness and support patient choice.

Reduction of Sniff Nasal Inspiratory Pressure (SNIP) as an Early Indicator of the Need of Enteral Nutrition in Patients with Amyotrophic Lateral Sclerosis

Percutaneous endoscopic gastrostomy (PEG) is the standard procedure for feeding severely dysphagic patients with amyotrophic lateral sclerosis (ALS). It is associated with prolonged survival and improvement in quality of life. Nasal inspiratory pressure during a sniff (SNIP) is a respiratory test used extensively in ALS for the assessment of inspiratory muscle strength. In this study, we aimed to investigate the role of SNIP at baseline to predict PEG placement in ALS. Data from a clinical incident cohort of 179 ALS cases attending the multidisciplinary ALS unit of the University of Bari between April 2006 and December 2012 were retrospectively analysed. At baseline, patients underwent detailed neurological, nutritional and respiratory assessments, including measurements of SNIP and forced vital capacity (FVC). Patients were therefore followed up approximately every three to six months until they were able to attend the centre. The censoring date for the survival analysis was 15 April 2014, with PEG placement as the main outcome. Cox proportional hazard regression models were used to examine the association between SNIP and PEG placement, adjusted for possible confounders. During the follow-up period, 75 participants (42%) received PEG implant. PEG placement was more frequent (57% vs. 31%; p = 0.001) and earlier (after 11.6 ± 14.0 months from the first visit, vs. 23.3 ± 15.5 months; p < 0.0001) in the group of patients with baseline SNIP ≤ 40 cm H₂O. Baseline SNIP was a predictor of PEG placement even after correction for multiple potential confounders (HR 0.98; 95% CI: 0.96–0.99; p = 0.02). To conclude, the present study showed that SNIP at baseline is an early indicator of disease progression and therefore of the need for enteral nutrition in ALS.

Percutaneous gastrostomy in amyotrophic lateral sclerosis: a review

Amyotrophic lateral sclerosis (ALS) causes dysphagia and consequent poor nutrition. Sometimes enteral feeding is offered. Percutaneous endoscopic gastrostomy (PEG) is currently the technique of choice for enteral nutrition of these patients. This systematic review addresses the role of PEG and other enteral feeding techniques in maintaining ALS patients' survival and quality of life and in identifying prognostic factors for survival, in order to optimize their usefulness. We also evaluated the mortality of enteral feeding in the first 30 days after each procedure and its complications. Studies were retrieved from Pubmed, Google Scholar, and Cochrane databases, using the relevant keywords, and by hand search. The inclusion criteria were prospective and retrospective designs of studies of people with clinically diagnosed ALS in whom gastrostomy or nasogastric enteral feeding were used in management, published in English. Studies with sample sizes <40, or which focused on a specific gastrostomy technique utilizing less than 30 subjects were excluded in order to avoid small sample bias. We conclude that PEG is safe and probably prolongs survival in non-malnourished ALS patients. However, older age at onset, marked loss of weight or reduced body mass index from symptomatic onset, and marked respiratory dysfunction negatively influence the outcome after PEG insertion. The currently available evidence does not meaningfully address the impact of PEG on quality of life in ALS. The literature about other enteral feeding techniques is insufficient for reliable conclusions. The optimum time for PEG insertion and preferences for specific gastrostomy techniques also require more investigation.

Safety of endoscopic gastrostomy tube placement compared with radiologic or surgical gastrostomy: nationwide inpatient assessment

BACKGROUND AND AIMS

A gastrostomy tube is often required for inpatients requiring long-term nutritional access. We compared the safety and outcomes of 3 techniques for performing a gastrostomy: percutaneous endoscopic gastrostomy (PEG), fluoroscopy-guided gastrostomy by an interventional radiologist (IR-gastrostomy), and open gastrostomy performed by a surgeon (surgical gastrostomy).

METHODS

Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent a gastrostomy from 2016 to 2017. They were identified using the International Classification of Diseases, 10th Revision, Procedure Coding System. The selected patients were divided into 3 cohorts: PEG (0DH64UZ), IR-gastrostomy (0DH63UZ), and open surgical gastrostomy (0DH60UZ). Adjusted odds ratios for adverse events associated with each technique were calculated using multivariable logistic regression analysis.

RESULTS

Of the 184,068 patients meeting the selection criteria, the route of gastrostomy tube placement was as follows: PEG, 16,384 (53.7 ± 29.0 years); IR-gastrostomy, 154,007 (67.2 ± 17.5 years); and surgical gastrostomy, 13,677 (57.9 ± 24.3 years). Compared with PEG, the odds for colon perforation using IR-gastrostomy and surgical gastrostomy, respectively, were 1.90 (95% confidence interval [CI], 1.26-2.86; P = .002) and 6.65 (95% CI, 4.38-10.12; P < .001), for infection of the gastrostomy 1.28 (95% CI, 1.07-1.53; P = .006) and 1.61 (95% CI, 1.29-2.01; P < .001), for hemorrhage requiring blood transfusion 1.84 (95% CI, 1.26-2.68; P = .002) and 1.09 (95% CI, .64-1.86; P = .746), for nonelective 30-day readmission 1.07 (95% CI, 1.03-1.12; P = .0023) and 1.13 (95% CI, 1.06-1.2; P = .0002), and for inpatient mortality 1.09 (95% CI, 1.02-1.17; P = .0114) and 1.55 (95% CI, 1.42-1.69; P < .0001).

CONCLUSIONS

Placement of a gastrostomy tube (PEG) endoscopically is associated with a significantly lower risk of inpatient adverse events, mortality, and readmission rates compared with IR-gastrostomy and open surgical gastrostomy.

Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.

ALS: Management Problems

Amyotrophic lateral sclerosis (ALS) is a fatal disease with no cure; however, symptomatic management has an impact on quality of life and survival. Symptom management is best performed in a multidisciplinary care setting, where patients are evaluated by multiple health care professionals. Respiratory failure is a significant cause of morbidity and mortality in patients with ALS. Early initiation of noninvasive ventilation can prolong survival, and adequate use of airway clearance techniques can prevent respiratory infections. Preventing and treating weight loss caused by dysphagia may slow down disease progression, and expert management of spasticity from upper motor neuron dysfunction enhances patient well-being.

Functional and Endoscopic Indicators for Percutaneous Endoscopic Gastrostomy (PEG) in Amyotrophic Lateral Sclerosis Patients

(1) Background: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative condition, whose bulbar involvement compromises language, swallowing, and airway protection. When oral nutrition is no longer adequate, percutaneous endoscopic gastroscopy (PEG) may be indicated. However, as exact timing is still debatable, we tried to find it. (2) Methods: A prospective cohort study was performed using fiber-optic endoscopic evaluation of swallowing (FEES), functional evaluation scales (ALS Functional Rating Scale-Revised (ALSFRS-R) and bulbar sub-score (ALSFRS-R-B)), lung function tests (like Forced Vital Capacity (FVC), Cough Peak Flow (CPF)) and anthropometric data. (3) Results: Twenty-three patients were enrolled (mean 65.4 ± 9.1 years, 60.9% males), 12 with spinal-onset. During the study period, 58 FEES were performed (1–4/patients). Even before formal PEG indication, suggestions were given to correct the alterations found. PEG was placed in 12 patients, on average 21.8 months after diagnosis (FVC = 69.9% ± 26.7%, ALSFRS-R-B = 7.7 ± 3.7, ALSFRS-R = 28.9 ± 12.3), and being 91.7% under ventilatory support. ALSFRS-R-B, CPF, FVC, and ALSFRS-R showed significant discriminant ability for PEG placement. Sensitivity and specificity were, respectively, ALSFRS-R-B ≤ 8 (100/90.9), CPF ≤ 205 (83.3), FVC ≤ 74 (83.3/74.2), and ALSFRS-R < 29 (83.3/65.1). (4) Conclusions: FEES provide additional information beyond formal PEG indication. ALSFRS-R-B score ≤ 8 was found as a best functional and noninvasive indicator for PEG placement in ALS patients.