David J Morrell, MD1, Marvin H Chau, BS2, Vamsi V Alli, MD1, Elizabeth H Sinz, MD1, Sprague W Hazard, MD1, Zachary Simmons, MD1, Eric M Pauli, MD1. 1Penn State Health Milton S. Hershey Medical Center, 2The Pennsylvania State University College of Medicine
Introduction: 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 protocol for ALS patients was developed by an ALS neurologist, two neuro- anesthesiologists, and one surgical-endoscopist. The protocol emphasized efficient pre-operative evaluation, rapidly metabolized anesthetic agents, reduced procedural times, and minimization of opioid use. Outcomes were analyzed following implementation of the protocol through retrospective review of the medical record. Preoperative weight loss, pulmonary function tests, total analgesia, procedural time, and 90-day morbidity and mortality were recorded.
Results: From 2013-2018, 39 ALS patients (mean age 64.7 years, 56.4% female, mean BMI 25.1 kg/m2, 82% outpatient) received a PEG under the protocol. PEGs were performed by one surgical-endoscopist using a standard Ponsky/pull method and safe-tract technique with anesthesia administered by one of two dedicated neuro-anesthesiologists. Mean percentage weight loss 6 months before PEG was 9.6% with 41% of patients meeting criteria for severe malnutrition. Mean forced expiratory volume was 55.4% predicted and mean forced vital capacity was 55.1% predicted. Mean anesthesia time (propofol induction to anesthesia emergence) was 32.2 minutes and mean operative time (endoscope insertion to dressing placement) was 14.8 minutes. Transversus abdominis plane block with liposomal bupivacaine was performed in 46.2%. There were no anesthetic or operative complications and all attempts at PEG placement were successful. Mean perioperative opioid requirement was 4.58 morphine milligram equivalents (MME). With a mean follow-up of 6.3 months, all PEGs were functional and there were no surgical site complications. One patient was re-evaluated within 30 days for loosening of a painful PEG bumper. Thirty-day readmission rate was 5.1% (1 acute respiratory failure, 1 benign postoperative pneumoperitoneum) and 90-day mortality was 19.4% (all unrelated to PEG). Mean time from surgery to death was 9.3 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, low complication rate, and low MME requirement. 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.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95047
Program Number: P437
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster