Radiologically Inserted Gastrostomy Tube Placement Guided by the Assessment and Primary Palliative Care Provided by an Amyotrophic Lateral Sclerosis Multidisciplinary Clinic: A Single-Arm Retrospective Clinical Study.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with a median survival of about 3 years. An ALS multidisciplinary team can provide primary palliative care and improve outcomes and quality of life for patients. Feeding tube insertion may be considered for patients with significant weight loss, or respiratory insufficiency. While radiologically inserted gastrostomy (RIG) tube placement may be an option, further studies are required to determine its best timing and appropriateness. This study's objectives were to evaluate the feasibility and outcomes of RIG tube placement in ALS patients over a 90-day follow-up period through the assessment and primary palliative care provided by the multidisciplinary team. This retrospective study reviewed the placement of 16 or 18 French RIG-tube without intubation or endoscopy for 36 ALS patients at a single center between April 2019 and December 2021. Measures included ALS Functional Rating Scale-Revised (ALSFRS-R) scores to determine the ALS stage. Demographic, clinical, procedural, and follow-up data were reviewed. Results showed that the RIG tube placement had a low rate of minor adverse events (11%) and no major procedure-related adverse events. The mean ALSFRS-R score at the time of procedure in subjects who died within 90 days was lower than of those alive beyond 90 days (P = .04). This study found that RIG-tube placement is a safe and effective way to manage dysphagia in ALS patients and highlights the importance of educating members of the multidisciplinary clinic in palliative care principles to determine the appropriateness of RIG tube placement.

Impact of anticoagulation and antiplatelet therapy on dialysis catheter fibrin sheath formation.

PURPOSE Fibrin sheaths are a significant cause of dialysis catheter dysfunction. This study aimed to determine the role of anticoagulation, antiplatelet medications, and other factors in delaying fibrin sheath formation. METHODS An institutional review board-approved retrospective review of all patients treated for tunneled dialysis catheter fibrin sheaths from January 2014 to January 2020 was undertaken. All catheters were symmetric tipped, 14.5 F in diameter, and placed via the internal jugular vein. Seventy patients with venographically confirmed fibrin sheaths that developed after de novo catheter placement were identified. Recurrent fibrin sheaths were excluded. The impact of anticoagulation and antiplatelet therapy, as well as statin therapy, catheter side (right or left), hematocrit, platelet count, prothrombin time (PT), and international normalized ratio (INR), on the time to fibrin sheath formation was determined. RESULTS Patients on anticoagulation had a longer median catheter implantation time of 109.2 days (interquartile range (IQR): 29.3-178.5 days) compared to 80.7 days (IQR: 28.0-168.6 days) among patients not on anticoagulation. Catheter dwell time among patients taking antiplatelet therapy was 86.0 days (IQR: 31.5-160.7 days) versus 74.4 days (IQR: 27.5-202.4 days) for patients not on antiplatelet medication. Patients taking statins versus those not taking statins had median catheter dwell times of 97.5 days (IQR: 27.5-138.5 days) and 62.4 days (IQR: 29.9-259.6 days), respectively. Time to fibrin sheath formation was not significantly associated with hematocrit (P =.16), platelet count (0.12), PT (P =.51), or INR (P =.74). CONCLUSION Anticoagulation has no significant benefit in delaying sheath formation in patients with tunneled dialysis catheters. Hematologic and coagulation parameters at the time of catheter placement were also not associated with catheter dwell time.

Safety and effectiveness of radiologic and endoscopic percutaneous gastrostomy placement: A randomized study.

BACKGROUND: Gastrostomy tubes placed radiologically, endoscopically or surgically facilitate long-term home enteral nutrition (HEN). Patient-specific clinical factors may affect placement techniques, confounding direct comparisons between radiologically inserted gastrostomy (RIG) and percutaneous endoscopic gastrostomy (PEG) outcomes. This study sought to evaluate the differences in clinical outcomes in patients undergoing gastrostomy tube placement by interventional radiologists or gastroenterologists. METHODS: A single-center prospective trial randomizing patients initiating HEN to RIG or PEG was conducted between March 2018 and June 2021. Patients were followed until the time of gastrostomy removal or until 9 months after tube placement. Tracked complications included peritonitis, abscess, bleeding, bowel perforation, and tube occlusion, malposition, or damage. Periprocedural pain rating and quality of life (QoL) surveys were collected. RESULTS: Forty-two patients were randomized to RIG or PEG. Twenty patients underwent RIG (mean age, 63.0 ± 11.7 years; 85% male; 95% with head and neck cancer) and 22 patients underwent PEG (mean age, 66.3 ± 10.9 years; 81.8% male; 90.9% with head and neck cancer). RIG and PEG groups had 4.18 ± 5.49 and 2.80 ± 5.82 complications per 1000 HEN days, respectively (P = 0.357). The most frequent complications were tube malposition and abscess formation for the RIG and PEG groups, respectively. No major complications occurred in either group. There was no difference in the average of pain ratings in all pain inventory components across both groups. Both groups reported improvement in overall QoL after gastrostomy tube placement (P = 0.532). CONCLUSION: RIG is noninferior to PEG regarding complication rates, pain, and QoL when compared in a prospective randomized fashion.