Mushroom-cage gastrostomy tube placement in patients with amyotrophic lateral sclerosis: a 5-year experience in 104 patients in a single institution

Abstract

To review our experience of placement of a mushroom-cage gastrostomy tube (Entristar, Tyco Healthcare, Mansfield, MA), using radiological guidance, in patients with amyotrophic lateral sclerosis (ALS). All procedures were performed under local anaesthesia without sedation. Complications were recorded as peri-procedural, early (<24 h), late (>24 h), major or minor. Deaths were recorded as related to the underlying ALS or secondary to radiological-inserted gastrostomy (RIG) placement. Replacement RIG tube rate was recorded. Over a 5-year period RIG tubes were placed in 104 patients with ALS (male n = 52, female n = 52), with a median age of 62 years (range 34-86 years). All procedures were technically successful. Of the RIG procedures, 21/104 (20.2%) were performed with respiratory support. The 30-day mortality rate was 7/104 (6.7%); no patient died as a result of the procedure. There were 23/104 (22.1%) complications overall; 20/104 (19.2%) were minor and 3/104 (2.9%) major, requiring surgery (n = 2) and radiological-guided abscess drainage (n = 1). A median interval between replacement RIG procedures in 20/104 (19.2%) patients was 141.5 days (range 43-537 days). A mushroom-cage RIG tube may be safely and effectively inserted in a 'one-step' radiological procedure and may replace endoscopic-inserted gastrostomy tubes in the nutritional management of ALS.

Nutrition Management of Amyotrophic Lateral Sclerosis

“…The need for invasive mechanical ventilation by tracheostomy is an inevitable need to sustain pulmonary function 35 , 36 . ALS patients often choose invasive or NIV to treat declining respiratory function 3 , 9 , 37 . The most significant negative prognostic factor is a lower percentage of predicted FVC at diagnosis 3 , 38 .…”

“…Optimizing the timing of placement of a feeding tube is imperative 10 . Diaphragmatic weakness causes a “high‐riding” stomach, in which the stomach lies under the ribs, which can increase the difficulty of PEG placement 37 . Nasogastric tube feedings are indicated only for short‐term nutrition support due to the high risk of aspiration and because of their uncomfortable and embarrassing nature 48 .…”

Paravertebral block for radiologically inserted gastrostomy tube placement in amyotrophic lateral sclerosis

“…We believe the 30‐ and 90‐day mortality rates in our series are unrelated to the procedure and reflect the terminal nature of progressive ALS. Compared with other case series of RIG placement, where 30‐day mortality ranged from 4% to 9%, 10,18,19,26 our observed 2% mortality is low, possibly due to the short nature of the RIG procedure and minimal duration of procedural stay. All gastrostomies were placed in patients meeting King's stage IV criteria 27 …”

Endocavitary contrast enhanced ultrasound (CEUS): a novel problem solving technique

“…Even when anchored with a catheter balloon or a “mushroom cage” [27], these tubes can become dislodged in daily activity leading to leakage and infection. Ultrasound contrast agents administered via the tube can confirm correct placement, exclude extravasation and allow assessment of the regional bowel for peristaltic abnormality or wall thickening (Fig.…”