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

David J Morrell; Marvin H Chau; Joshua S Winder; Edward S Stredny; Vamsi V Alli; Elizabeth H Sinz; Sprague W Hazard; Zachary Simmons; Eric M Pauli

doi:10.1007/s00464-023-09896-w

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

Surg Endosc. 2023 Jun;37(6):4338-4344. doi: 10.1007/s00464-023-09896-w. Epub 2023 Feb 3.

Authors

David J Morrell¹, Marvin H Chau², Joshua S Winder³, Edward S Stredny⁴, Vamsi V Alli³, Elizabeth H Sinz⁴, Sprague W Hazard⁴, Zachary Simmons⁵, Eric M Pauli³

Affiliations

¹ Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA. dmorrell@pennstatehealth.psu.edu.
² Penn State College of Medicine, Hershey, PA, USA.
³ Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
⁴ Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.
⁵ Department of Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.

PMID: 36735049
DOI: 10.1007/s00464-023-09896-w

Abstract

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.

Keywords: Amyotrophic lateral sclerosis; Percutaneous endoscopic gastrostomy; Rectus sheath block; Transversus abdominis plane block.

MeSH terms

Aged
Amyotrophic Lateral Sclerosis* / complications
Amyotrophic Lateral Sclerosis* / surgery
Anesthesia*
Female
Gastrostomy / methods
Humans
Male
Retrospective Studies
Weight Loss