The yin and yang of gastrostomy in the management of ALS

Though we do not yet have a cure for amyotrophic lateral sclerosis (ALS), we can provide treatment, and the host of medical and other interventions provided by ALS specialists and multidisciplinary care teams increases survival and substantially improves quality of life for patients and their families. Dysphagia is one of the most consequential symptoms in ALS, and ultimately affects the majority of patients. It causes dehydration, weight loss, choking, and chronic aspiration, which substantially increase the risk of potentially fatal aspiration pneumonia. Weight loss alone worsens progression and survival in ALS,¹ presumably because caloric deficit due to dysphagia promotes muscle catabolism, adding to underlying muscle loss from motor neuron death, thereby accelerating weakness and decline. In attempts to circumvent this cascade, enteral tube feeding has been used in the management of ALS for many years, principally via percutaneous endoscopic gastrostomy (PEG).² However, gastrostomy tube placement can be hazardous in advanced cases, as impaired respiratory function may increase the risk of respiratory arrest during sedation, as well as ventilator dependence postoperatively. Consequently, gastrostomy tubes are typically only recommended for those patients having forced vital capacity (FVC) >50% of the predicted normal value.^3,4