Nutritional support teams increase percutaneous endoscopic gastrostomy uptake in motor neuron disease
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Online Submissions: http://www.wjgnet.com/esps/ World J Gastroenterol 2012 November 28; 18(44): 6461-6467
wjg@wjgnet.com ISSN 1007-9327 (print) ISSN 2219-2840 (online)
doi:10.3748/wjg.v18.i44.6461 © 2012 Baishideng. All rights reserved.
BRIEF ARTICLE
Nutritional support teams increase percutaneous
endoscopic gastrostomy uptake in motor neuron disease
Lin Zhang, Leanne Sanders, Robert JL Fraser
Lin Zhang, Nutrition and Dietetic Department, Flinders Uni- the discussion regarding gastrostomy was recorded as
versity of South Australia, Bedford Park 5042, South Australia, Nutritional Support Team (involved in providing nutrition
Australia input viz Gastroenterologist, Speech Pathologist, Dieti-
Leanne Sanders, Department of Nutrition and Dietetics, Repa- tian) and other (involved in non-nutritional aspects of
triation General Hospital, Daw Park 5041, South Australia, Aus-
patient care). Factors affecting placement and outcomes
tralia
including length of survival, change in weight and QoL
Robert JL Fraser, School of Medicine, Flinders University of
South Australia, Bedford Park 5042, South Australia, Australia were determined.
Author contributions: Fraser RJL and Sanders L designed the
study; Fraser RJL, Sanders L and Zhang L planned the study; RESULTS: Case records were available for all 86 pa-
Zhang L and Sanders L gathered and analyzed the data; Zhang L, tients (49 men, mean age at diagnosis 66.4 years).
Sanders L and Fraser RJL interpreted the data and prepared the Thirty-eight patients had bulbar symptoms and 48 had
manuscript. peripheral disease as their presenting feature. Sixty-six
Correspondence to: Robert JL Fraser, PhD, Professor of patients reported dysphagia. Thirty-one patients had
Medicine, School of Medicine, Flinders University of South Aus- undergone gastrostomy insertion. The major indications
tralia, Bedford Park 5042, South Australia, for PEG placement were dysphagia and weight loss.
Australia. robert.fraser@health.sa.gov.au
Nine patients required immediate full feeding, whereas
Telephone: +61-8-82751765 Fax: +61-8-82751083
Received: February 29, 2012 Revised: May 16, 2012
17 patients initially used the gastrostomy to supplement
Accepted: May 26, 2012 oral intake, 4 for medication administration and 1 for
Published online: November 28, 2012 hydration. Initially the PEG regime met 73% ± 31% of
the estimated total energy requirements, increasing to
87% ± 32% prior to death. There was stabilization of
weight in patients undergoing gastrostomy [BMI at 3
2 2
mo (22.6 ± 2.2 kg/m ) and 6 mo (22.5 ± 2.0 kg/m )
Abstract after PEG placement compared to weight at the time
AIM: To examine factors influencing percutaneous en- 2
of the procedure (22.5 ± 3.0 kg/m )]. However, weight
doscopic gastrostomy (PEG) uptake and outcomes in loss recurred in the terminal stages of the illness. There
motor neuron disease (MND) in a tertiary care centre. was a strong trend for longer survival from diagnosis
among MND in PEG recipients with limb onset presenta-
METHODS: Case notes from all patients with a con- tion compared to similar patients who did not undergo
firmed diagnosis of MND who had attended the clinic at the procedure (P = 0.063). Initial discussions regarding
the Repatriation General Hospital between January 2007 PEG insertion occurred earlier after diagnosis when seen
and January 2011 and who had since died, were au- by nutrition support team (NST) clinicians compared to
dited. Data were extracted for demographics (age and other clinicians. (5.4 ± 7.0 mo vs 11.9 ± 13.4 mo, P =
gender), disease characteristics (date of onset, bulbar 0.028). There was a significant increase in PEG uptake
or peripheral predominance, complications), date and (56% vs 24%, P = 0.011) if PEG discussions were ini-
nature of discussion of gastrostomy insertion, nutritional tiated by the NST staff compared to other clinicians.
status [weight measurements, body mass index (BMI)], There was no change in the ALSFRS-R score in patients
date of gastrostomy insertion and subsequent progress who underwent PEG (pre 34.1 ± 8.6 vs post 34.8 ±
(duration of survival) and quality of life (QoL) [Amyo- 7.4), although in non-PEG recipients there was a non-
trophic Lateral Sclerosis Functional Rating Scale-Revised significant fall in this score (33.7 ± 7.9 vs 31.6 ± 8.8).
(ALSFRS-R)]. In addition, the type of clinician initiating Four patients died within one month of the procedure,
WJG|www.wjgnet.com 6461 November 28, 2012|Volume 18|Issue 44|Zhang L et al . PEG outcomes in MND
4 developed bacterial site infection requiring antibiotics crease the use of PEG including nutrition education and
and 1 required endoscopic therapy for gastric bleeding. early discussion of alternative feeding routes[10,11]. It has
Less serious complications attributed to the procedure also been suggested that involvement of multidisciplinary
included persistent gastrostomy site discomfort, poor teams may have a role and potentially improve the length
appetite, altered bowel function and bloating. of survival [11-13].
The aim of the current study was to examine the fac-
CONCLUSION: Initial discussion with NST clinicians
tors associated with the uptake and the outcomes of PEG
increases PEG uptake in MND. Gastrostomy stabilizes
placement in patients with MND being managed in a ter-
patient weight but weight loss recurs with advancing
tiary referral centre.
disease.
© 2012 Baishideng. All rights reserved. MATERIALS AND METHODS
Key words: Motor neuron disease; Multidisciplinary ma A retrospective case note audit was conducted at the Re
nagement; Nutrition support team; Percutaneous endo- patriation General Hospital (RGH), a 270-bed university
scopic gastrostomy; Survival affiliated teaching metropolitan hospital. The study was
approved by the Southern Adelaide Clinical Human
Peer reviewer: Andrew Ukleja, MD, Assistant Professor, De- Research Ethics Committee. To preserve patient anonymity,
partment of Gastroenterology, Cleveland Clinic Florida, 2950 a unique study ID was assigned to each patient, and personal
Cleveland Clinic Blvd., Weston, FL 33331, United States details were kept separate from the research data.
Patients were included in this study if they had at
Zhang L, Sanders L, Fraser RJL. Nutritional support teams in-
tended RGH for management of MND, and had died
crease percutaneous endoscopic gastrostomy uptake in motor
neuron disease. World J Gastroenterol 2012; 18(44): 6461-6467
between January 2007 and January 2011. All diagnoses
Available from: URL: http://www.wjgnet.com/1007-9327/full/ of MND were confirmed by one or two neurologists
v18/i44/6461.htm DOI: http://dx.doi.org/10.3748/wjg.v18. based on El Escorial criteria after appropriate clinical
i44.6461 examinations and investigations. Patient characteristics
including gender, age, dates of MND onset and diagno-
sis, presentation features of MND, and complications
(the presence of respiratory insufficiency, dysphagia and
INTRODUCTION dementia) were recorded.
The type of MND was classified as either bulbar
In patients with motor neuron disease (MND), the man- or limb disease according to symptoms at presentation.
agement of dysphagia either at diagnosis or developing Patients with both bulbar and limb symptoms were classified
during disease progression remains a major clinical is- as having bulbar disease.
sue[1-3]. Provision of adequate nutrition is important in To assess nutrition status, weights at four times were
these patients as malnutrition and dehydration can in- determined: usual (prior to diagnosis of MND), at diagnosis,
crease the rate of disease progression and adversely upset at assessment (when the dietetic service was involved), and
quality of life (QoL)[1]. Although percutaneous endoscopic at death. In patients undergoing gastrostomy, the weight at
gastrostomy (PEG) insertion is an important strategy in PEG insertion, and 3 and 6 mo post-procedure were also
optimizing nutritional management, the effect of this in- recorded. Body mass index (BMI) and percentage weight
tervention on survival remains controversial with studies loss (PWL) were also calculated over time.
reporting both benefit[2] and lack of effectiveness[3,4]. The To assess the role of different clinical groups in PEG
reasons for these discrepancies are unclear and may relate, management in MND, the type of clinician initiating the
in part, to the timing of PEG insertion in different patient discussion of PEG, dates of initial PEG discussion and
subgroups[4,5]. Weight gain or weight maintenance has PEG insertion, and reasons for accepting or declining
been reported as another positive outcome of PEG, but the procedure, together with the rationale for PEG were
the duration of the effect is also uncertain[2,6]. Although recorded. Clinicians with expertise in PEG insertion and
a number of indications, including weight loss and chok- management (dietitian, gastroenterologist or speech pa-
ing have been proposed for PEG insertion in MND[6-8], thologist) were considered as a nutritional support team
published data indicate that the procedure is performed (NST). Other clinicians involved in MND management
in less than 50% of patients, who fulfill these criteria[1]. In were recorded individually (e.g., palliative care physicians,
part, this may reflect delays in PEG insertion until there neurologists, specialist nurses, sleep registered nurses, rheu-
is a major clinical deterioration in swallowing[7], although matologists and general physicians) and grouped as other.
limited data show subclinical abnormalities in pharyngeal To evaluate the effect of PEG placement on QoL, the
function often occur earlier[9]. Thus, it is possible that results from the Amyotrophic Lateral Sclerosis Functional
some patients who might benefit from supplemental nu- Rating Scale-Revised (ALSFRS-R) [14] were obtained
trition may not receive this at the appropriate time[7]. from the Palliative Care MND clinic at the RGH. Scores
A number of strategies have been proposed to in- were extracted from the records at the closest time prior
WJG|www.wjgnet.com 6462 November 28, 2012|Volume 18|Issue 44|Zhang L et al . PEG outcomes in MND
All patients audited n = 86
Table 1 Summary of patient demographic and disease charac-
teristics characteristics of subjects (mean ± SD) or n (%)
Yes No
Dysphagia
n = 66 n = 20
Males 49 (57)
Type of MND
Yes No No Bulbar as predominant symptom 38 (44)
PEG
n = 31 n = 35 n = 20 Limb as predominant symptom 48 (56)
Age at symptom onset (yr) 65.0 ± 13.7
B L B L L Age at diagnosis (yr) 66.4 ± 13.0
Bulber (B)/Limb (L) Survival after PEG placement (mo) 11.3 ± 10.1
n = 20 n = 11 n = 18 n = 17 n = 20
Living arrangements
Alone 13 (15)
Figure 1 Patient numbers according to dysphagia, percutaneous endo- With spouse 50 (58)
scopic gastrostomy insertion and type of motor neuron disease. PEG: With other family member 10 (12)
Percutaneous endoscopic gastrostomy. Care facility 7 (8)
Not recorded 6 (7)
Complications during illness
to (≤ 1 to 5 mo) (Q1) and after (≤ 1 to 5 mo) (Q2) Dysphagia 66 (77)
PEG insertion in these patients. For non-PEG patients, Respiratory insufficiency 47 (55)
ALSFRS-R assessments at “correlated” time points Q1’ Dementia 5 (6)
Symptom onset to PEG placement (mo) 20.3 ± 8.0
and Q2’, corresponding to the mean interval before and Diagnosis to PEG placement (mo) 10.8 ± 8.3
after PEG insertion were used for comparison.
The outcomes in terms of formula delivery and level MND: Motor neuron disease; PEG: Percutaneous endoscopic gastros-
of nutrition support as well as any complications of PEG tomy.
placement were also recorded.
Extracted data were entered into a spreadsheet and
analysed using Predictive Analytics Software Statistics procedure between the groups.
Version 18.0.3 for Windows (PASW, formerly SPSS, The major reason for having a PEG inserted was dys-
SPSS Inc., 2010, Chicago, IL, United States). Patient phagia (n = 26), with severe weight loss (n = 4) and pro-
phylaxis (n = 1) also recorded. The reasons for PEG inser-
characteristics were recorded as mean ± SD and counts
tion not proceeding after discussion (n = 38) were patient
(percentages). Categorical data were compared by χ 2 tests.
preference (n = 17), death before PEG placement [n = 9,
Continuous data between groups and within groups were
(4 discussed with NST, 5 with other)] and lack of medical
compared by independent-sample T tests and paired-
fitness for procedure (n = 1). In 11 patients no reason for
samples T tests, respectively. P ≤ 0.05 was considered refusal was recorded. In patients who died before the PEG
statistically significant in all analyses. could be undertaken, 4 instances were due to advanced dis-
ease and respiratory failure preventing the safe performance
RESULTS of the procedure. Two of these were initially discussed with
NST and 2 with other clinicians. Of the other 5 patients
Case records were available for all 86 patients with MND (2 NST, 3 other) the patients initially agreed to the gastros-
who attended the hospital and met the selection crite- tomy but then failed to proceed with the procedure.
ria. Demographic and disease characteristics are shown Regardless of the presentation (i.e., bulbar or limb),
in Table 1. The breakdown of the number of patients there was a trend towards longer survival in MND pa-
according to the type of MND, presence of dysphagia tients with dysphagia after PEG insertion (21.6 ± 15.6
and PEG insertion are shown in Figure 1. mo), compared to patients who had dysphagia, but did
In total, 31 subjects underwent PEG placement us- not undergo the procedure (16.8 ± 11.0 mo, P = 0.089).
ing a pull technique with either a 20 Fr (n = 28) or an 18 This increased length of survival reflected the effect in
Fr device. All of these patients had dysphagia. Patients patients with limb onset MND who developed dysphagia
with bulbar presentation (20/38, 53%), were more likely (PEG: 26.4 ± 20.4 mo vs non-PEG: 14.4 ± 10.8 mo, P =
to have PEG inserted than those presenting with limb 0.063) (Figure 2) as in bulbar MND patients there was no
symptoms (11/48, 23%, P = 0.004). difference in survival with or without PEG (19.2 ± 12.0
PEG placement was discussed with 75.6% (65/86) mo vs 18.0 ± 10.8 mo, P = 0.656).
patients, 92.1%, with bulbar (35/38) and 62.5% with limb PEG insertion was accompanied by stabilization of
onset (30/48). The NST initiated these discussions in 36 patient weight 3 and 6 mo after placement. In contrast, pa-
patients and other clinicians in 29 patients. There was a tients who did not undergo PEG placement had ongoing
significant increase in the percentage of patients undergo- weight loss. However, further weight loss occurred in all pa-
ing PEG when the initial discussions were held with the tients as MND progressed (Table 3). Thus, the mean BMI
NST (56% vs 24%, P < 0.02, Table 2). In addition, these for PEG patients decreased significantly from usual weight
patients had longer time from symptom onset to diagno- to diagnosis (P = 0.003), diagnosis to assessment for PEG
sis, and a shorter time from diagnosis to PEG. There was (P = 0.001) and from this assessment to death (P = 0.023).
no difference in the time from the initial discussion to the There was a trend for PEG to be offered to patients who
WJG|www.wjgnet.com 6463 November 28, 2012|Volume 18|Issue 44|Zhang L et al . PEG outcomes in MND
Table 2 Relationship between the uptake of percutaneous endoscopic gastrostomy and clinician initiating discussion
Nutritional support team Other clinicians P value
Initial PEG discussions, n 36 29
Patients undergoing PEG insertion after initial discussion, n 20 (56%, 20/36) 7 (24%, 7/29) 0.011
MND symptom onset to MND diagnosis, mo 12.8 (± 7.5), n = 26 8.4 (± 3.9), n = 17 0.017
MND diagnosis to initial PEG discussion, mo 5.4 (± 7.0), n = 20 11.9 (± 13.4), n = 6 0.028
Initial PEG discussion to placement, mo 3.5 (± 3.3), n = 20 4.4 (± 3.2), n = 6 0.572
PEG placement to death, mo 12.9 (± 11.1), n = 20 8.8 (± 10.1), n = 6 0.422
MND symptom onset to death, mo 30.0 (± 13.2), n = 26 31.2 (± 13.2), n = 17 0.740
MND diagnosis to death, mo 18.0 (± 15.6), n = 36 21.6 (± 15.6), n = 27 0.393
MND: Motor neuron disease; PEG: Percutaneous endoscopic gastrostomy.
Table 3 Comparison of weight assessments for patients with 1.0
Whether patient had
motor neuron disease undergoing percutaneous endoscopic PEG inserted or not
Probability of freedom from event
gastrostomy 0.8
Yes
Time points n 1
Body mass index (mean ± SD) kg/m
2 No
0.6
Usual 20 26.6 ± 4.3
Diagnosis 23 25.3 ± 4.0
Assessment 25 23.8 ± 3.6 0.4
PEG insertion 25 22.5 ± 3.0
3 mo post-PEG 16 22.6 ± 2.2
0.2
6 mo post-PEG 13 22.5 ± 2.0
Death 16 21.2 ± 2.2
Percentage of weight loss (mean ± SD) 0.0
Usual to diagnosis 22 5.8 ± 7.5
0.00 20.00 40.00 60.00 80.00 100.00
Diagnosis to assessment 26 5.9 ± 7.0
Time from MND diagnosis to death (mo)
Assessment to PEG insertion 28 5.9 ± 5.9
PEG insertion to 3 mo after 18 -0.1 ± 6.02
3 to 6 mo post-PEG 13 1.4 ± 5.1 Figure 2 Kaplan-Meier plots of survival probabilities after percutaneous
6 mo post-PEG to death 12 2.4 ± 4.9 endoscopic gastrostomy placement among patients with limb onset mo-
tor neuron disease who developed dysphagia. MND: Motor neuron disease;
1 PEG: Percutaneous endoscopic gastrostomy.
Some data unavailable due to patients being unable to be weighed. Usual-
pre-MND diagnosis; Diagnosis-at diagnosis of MND; Assessment-when
dietetic service was involved pre-PEG insertion; 2Percentage of weight
recorded in 19 patients after PEG insertion. These in-
gain. MND: Motor neuron disease; PEG: Percutaneous endoscopic gastros-
tomy.
cluded pain at the site of the gastrostomy at follow up (n
= 9), poor appetite (n = 4), bacterial site infection requir-
ing antibiotics (n = 4), death within 30 d (n = 4, respira-
had greater weight loss from diagnosis to assessment (PWL tory failure), nausea (n = 3), constipation (n = 2), diarrhea
of PEG patients: 5.9% ± 7.0% vs PWL of non-PEG pa- (n = 2), vomiting (n = 2), bloating (n = 1) and gastric
tients with dysphagia: 2.3% ± 6.5%, P = 0.076). hemorrhage (n = 1).
Initially, 17 patients used PEG to supplement oral
intake; nine required immediate full feeding; four
used PEG for medication administration and one for DISCUSSION
hydration. Eight patients were nil by mouth. Initially the The new findings from this study are that initial discus-
feeding regime met 73% ± 31% of the estimated total sions of PEG insertion by a NST significantly increases
energy requirements and this increased to 87% ± 32% the uptake of PEG by patients with MND, compared to
prior to death. when discussions were initiated by other clinicians. There
Fifty-nine patients (68.6%) had at least one assess- was also a trend for increased survival for patients with
ment with the ALSFRS-R performed during their illness. limb onset disease who had a PEG, but not for patients
There was no change in the ALSFRS-R score in patients with bulbar onset disease. Consistent with previous stud-
who underwent PEG (34.1 ± 8.6, n = 19 at Q1 and 34.8 ies, PEG placement initially arrested weight loss, although
± 7.4, n = 17 at Q2). Interestingly, in patients who did with disease progression patients again lost weight prior
not undergo PEG placement, there was a non-significant to death. Data on the QoL were incomplete but no de-
fall in the ALSFRS-R score from 33.7 ± 7.9 (n = 31) at crease was seen in the ratings in patients undergoing
Q1’ to 31.6 ± 8.8 (n = 18) at Q2’. There was no signifi- PEG placement.
cant difference between Q1 and Q1’ (P = 0.886), or Q2 Previous reports suggest that the uptake of PEG is
and Q2’ (P = 0.252). approximately 20%[1], although up to 80% of MND pa-
Possible adverse effects related to the procedure were tients developed dysphagia at some point in their illness.
WJG|www.wjgnet.com 6464 November 28, 2012|Volume 18|Issue 44|Zhang L et al . PEG outcomes in MND
The reasons for this are unclear, but may reflect lack of or limb onset patients; however, the control group in this
enthusiasm by both patient and clinicians about a proce- study contained patients who did not require PEG place-
dure whose value remains uncertain. Also, patients may ment and therefore might have had better nutrition status
lack sufficient information about the procedure and its initially.
implications. Additionally in some patients, respiratory Maintaining a patient’s weight is a possible advan-
dysfunction may present a contraindication to gastrosto- tage of PEG in nutrition management in MND, but the
my by preventing safe performance of the procedure[9]. duration of this effect is unclear. In the present study,
The current report extends previous data showing the patients’ weight stabilized for six months after PEG
that involvement of multidisciplinary teams in the care placement, but with disease progression, patients again
of patients with MND enhances the uptake of interven- lost weight. Weight gain at three months post-PEG
tions, including gastrostomy[10,12,15,16]. In this study, pos- has been previously described[5,6], but only one report[2]
sible PEG placement was discussed with the majority of has described ongoing weight gain over 12 mo post-
patients regardless of the presence of dysphagia or the gastrostomy. In that study, the patients’ baseline BMI
type of presentation of MND. However, the initiation prior to PEG insertion was lower (19.7 kg/m2) than in
of discussion by clinicians with a background in nutri- the present study (22.5 kg/m2) and this may explain the
tion significantly increased the patients’ uptake of PEG discrepancy.
insertion. It is possible that clinicians familiar with MND The benefits of PEG in prolonging survival and main-
are more aware of the importance of nutrition adequacy taining weight did not reach statistical significance in this
in MND management and clinicians who are closely study, and may have reflected a bias in patient selection,
involved in management of PEG insertions are able to since patients who underwent PEG placement had more
better allay patients’ concerns. Furthermore, the NST severe weight loss. Several studies have concluded that
raised the topic significantly earlier than other clinicians lower PWL prior to PEG placement is associated with
after diagnosis, which potentially allowed more time for longer survival[5]. This suggests that early recognition of
the patients to adjust to the concept and undergo PEG weight loss may be important to optimize timing of the
insertion before their overall condition deteriorated. procedure[7]. Consequently PWL has been recommended
The time from PEG discussion to PEG insertion was as the best indicator of malnutrition and for the referral
similar between these two clinician groups suggesting for PEG, rather than BMI[5,12,16]. In the United Kingdom,
that patients were not simply referred to the NST when using ≥ 10% PWL from baseline has been preferred as
nutrition was inadequate. Overall survival of patients an indicator for PEG insertion instead of BMI in MND
undergoing PEG placement was similar irrespective of patients[17]. An Irish review suggested that PEG was war-
their referring clinician, suggesting that there was no ranted when 5%-10% of weight loss was observed in
difference in the patients with whom the procedure was MND patients[18], and Chiò et al[5] found that patients with
discussed to explain the difference in uptake. PWL ≥ 10% fared worse after PEG placement. Thus,
The effect of PEG feeding on survival in patients the optimal timing remains uncertain[1,9]. In the current
with MND has been controversial. It is possible that dif- study, an additional interesting finding was that, consistent
ferences in reported outcomes may reflect the different with other reports[18], patients experienced rapid weight
subtypes of MND undergoing the procedure as well as loss prior to death even with PEG nutrition. The reasons
the timing of the procedure[2-6,9]. In the current study, for this are unclear. Although overall PEG feeding did not
there was a strong trend for prolonged survival after achieve 100% of the feeding goals (reflecting the desire to
PEG, but only in those patients with limb onset disease. provide supplemental feeding/hydration in some patients,
The reasons for this are unclear. An early study[2] suggest- and voluntary restriction in others in the terminal phase
ed that PEG prolonged survival significantly in MND of their illness) overall nutrition intake appeared adequate.
patients with bulbar symptoms, including those in whom It is possible that loss of muscle mass with disease pro-
dysphagia developed at any stage. However, in this study gression[19] and increased energy requirement due to re-
the symptoms at presentation (i.e., bulbar or limb) were spiratory insufficiency[18] may be important contributory
not defined[2]. Another case control study[5] found no factors.
significant survival benefit of the use of PEG, but PEG A further potential benefit from PEG insertion in
was associated with prolonged survival in their whole MND patients has been the potential to improve QoL[6],
study cohort and among those with bulbar onset; the but this has not been systematically assessed[1,2,3,17]. In
reasons for this discrepancy are unclear but may reflect the current study, ALSFRS-R scores were maintained
an older patient profile in the current study. Forbes et after the gastrostomy PEG. However, interpretation of
al[3] found no survival difference, and in their study limb the data is limited, in part because of difficulties in ob-
onset patients fared worse than bulbar onset patients, taining comparable data between PEG and non-PEG
although the survival in this study was shorter than in the patients. In addition, the comparison of QoL is likely
present study. Strong et al[4] found that gastrojejunostomy to be affected by the severity of dysphagia before PEG
was associated with shorter survival in either bulbar onset placement which in itself contributes to the probability
WJG|www.wjgnet.com 6465 November 28, 2012|Volume 18|Issue 44|Zhang L et al . PEG outcomes in MND
of the procedure[8]. Also, adverse effects associated with REFERENCES
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Patients who received counseling from a Nutrition Support Professional were date: the care of the patient with amyotrophic lateral sclero-
more likely to undergo the procedure. Interestingly the patients with peripheral sis: multidisciplinary care, symptom management, and cog-
onset of disease had a trend to longer survival consistent with the concept that nitive/behavioral impairment (an evidence-based review):
muscle mass is preserved by adequate nutrition. report of the Quality Standards Subcommittee of the Ameri-
can Academy of Neurology. Neurology 2009; 73: 1227-1233
Applications 12 Rio A, Cawadias E. Nutritional advice and treatment by dieti-
The findings support the use of multidisciplinary teams in this disease and also
tians to patients with amyotrophic lateral sclerosis/motor neu-
provide a possible rationale for the findings of better survival in units where this rone disease: a survey of current practice in England, Wales,
is undertaken. Northern Ireland and Canada. J Hum Nutr Diet 2007; 20: 3-13
Terminology 13 Chiò A, Bottacchi E, Buffa C, Mutani R, Mora G. Positive
MND is a progressive neurological condition of unknown aetiology character- effects of tertiary centres for amyotrophic lateral sclerosis
ized by relentless progression to respiratory failure. on outcome and use of hospital facilities. J Neurol Neurosurg
Peer review Psychiatry 2006; 77: 948-950
Well written manuscript (retrospective study) regarding PEG tube utilization 14 Cedarbaum JM, Stambler N, Malta E, Fuller C, Hilt D,
in patients with MND. It provides some new inside to early PEG placement in Thurmond B, Nakanishi A. The ALSFRS-R: a revised ALS
patients with malnutrition and MND. functional rating scale that incorporates assessments of
WJG|www.wjgnet.com 6466 November 28, 2012|Volume 18|Issue 44|Zhang L et al . PEG outcomes in MND
respiratory function. BDNF ALS Study Group (Phase III). J 17 Leigh PN, Abrahams S, Al-Chalabi A, Ampong MA, Gold-
Neurol Sci 1999; 169: 13-21 stein LH, Johnson J, Lyall R, Moxham J, Mustfa N, Rio A,
15 Traynor BJ, Alexander M, Corr B, Frost E, Hardiman O. Ef- Shaw C, Willey E. The management of motor neurone dis-
fect of a multidisciplinary amyotrophic lateral sclerosis (ALS) ease. J Neurol Neurosurg Psychiatry 2003; 74 Suppl 4: iv32-iv47
clinic on ALS survival: a population based study, 1996-2000. 18 Hardiman O. Symptomatic treatment of respiratory and
J Neurol Neurosurg Psychiatry 2003; 74: 1258-1261 nutritional failure in amyotrophic lateral sclerosis. J Neurol
16 Rio A, Ellis C, Shaw C, Willey E, Ampong MA, Wijesekera 2000; 247: 245-251
L, Rittman T, Nigel Leigh P, Sidhu PS, Al-Chalabi A. Nu- 19 The Motor Neurone Disease Australia Publication Review
tritional factors associated with survival following enteral Committee. Motor neurone disease aspects of care: for the
tube feeding in patients with motor neurone disease. J Hum primary health care team. 3rd ed. Gladesville NSW: MND
Nutr Diet 2010; 23: 408-415 Australia, 2011
S- Editor Gou SX L- Editor Webster JR E- Editor Lu YJ
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