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Follow-up and survival after gastrostomy indication in patients with amyotrophic lateral sclerosis

Abstract : Rationale: In Amyotrophic lateral sclerosis (ALS), gastrostomy is indicated when the weight loss is over 10%, in case of repeated aspirations and if the meal time duration is over 45 min. The benefit of gastrostomy on survival in ALS is unclear and its placement is probably too late. The main works on the subject studied survival from diagnosis but not from indication of gastrostomy. The aims of our work were in ALS patients with indication of gastrostomy and who accepted or refused gastrostomy to study from the indication of gastrostomy to the last assessment or death i) the evolution of nutritional and neurological status and ii) the survival. Methods: ALS patients included started follow-up in the referral ALS centre in 2006 and were all dead at 31 december 2017. They had assessment of their neurological (onset form, ALS functional rating scale revised [ALSFRS-R]), nutritional (weight, weight loss, body mass index and body composition by bioelectrical impedancemetry analysis) and respiratory status (forced vital capacity, non-invasive ventilation [NIV]). Statistical analysis was done by using Mann-Whitney test, Chi2 tests, Kaplan-Meier with Log-rank and Cox model for multivariate survival analysis. Results were expressed as median (interquartile range). Results: One hundred and fifty-five patients with indication of gastrostomy were included, 68.4% had accepted the gastrostomy placement. The median delay diagnosis-gastrostomy indication and gastrostomy indication-last assessment were 5.1 months (2.3 – 12.5) and 8.7 months (4.2 – 12.3), respectively. Patient who accepted gastrostomy were less often male (42.5% vs. 63.3%, p= 0.016) and had more often bulbar onset (57.6% vs. 26.5%, p=0.0003). Nutritional status and body composition at indication and at last assessment were not significantly different in patients with or without gastrostomy. At last assessment, in patient with gastrostomy ALSFRS-R was lower (14.0 points [10.8 – 22.0] vs. 20.5 points [12.8 – 26.3], p=0.01). Since gastrostomy indication median survival was higher in patient who accepted gastrostomy (10.3 months [6.7 – 17.5] vs 7.9 month [4.2 – 10.5], p=0.01). Gastrostomy was negatively associated with the risk of death in univariate analysis (HR: 0.64, p=0.01), but not in multivariate analysis. In multivariate analysis, weight loss (-1%/month) and ALSFRS-R slope (-1point/month) during follow-up were positively associated with the risk of death (aHR: 1.62; p=0.0002 and aHR: 2.37; p<0.0001, respectively). An increased delay between gastrostomy indication and VNI placement (+1month) was negatively associated with the risk of death (aHR: 0.95; p=0.0003). Conclusion: In ALS patients with indication of gastrostomy and who accepted gastrostomy, survival seems higher. However, independently of the gastrostomy placement the factors positively associated with the risk of death were a more important alteration of nutrition status (weight loss) and of functional status (ALSFRS-R slope) between indication of gastrostomy and last assessment. It also seems important to consider the placement of NIV after indication of the gastrostomy and not the reverse. In this disease whose functional impairment and death are inevitable, nutritional support adapted to the patient's disorders and wishes remains essential.
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Contributeur : Elisabeth Grelier Connectez-vous pour contacter le contributeur
Soumis le : lundi 1 mars 2021 - 16:33:25
Dernière modification le : samedi 26 mars 2022 - 04:24:58




Philippe Fayemendy, Marion Vergonjeanne, Géraldine Lautrette, N. Calmel, Huguette Sourisseau, et al.. Follow-up and survival after gastrostomy indication in patients with amyotrophic lateral sclerosis. 42ème Congrès Virtuelle ESPEN (European Society for Clinical Nutrition and Metabolism), Sep 2020, Lyon, France. 40, pp.537, 2020, ⟨10.1016/j.clnesp.2020.09.393⟩. ⟨hal-03155234⟩



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