P3234 - Predictors of Percutaneous Endoscopic Gastrostomy Placement in Patients with Progressive Neuromuscular Dysphagia

Tuesday, October 24, 2023

10:30 AM – 4:00 PM PT

Location: Exhibit Hall

Has Audio

Presenting Author(s)

R. Christopher Chase, MD

Mayo School of Graduate Medical Education
Jacksonville, FL

R. Christopher Chase, MD¹, Pedro Cortes, MD¹, Christopher J.. Lamb, MD², Dawn Francis, MD², Kenneth DeVault, MD², Maoyin Pang, MD, PhD²
¹Mayo School of Graduate Medical Education, Jacksonville, FL; ²Mayo Clinic Florida, Jacksonville, FL

Introduction: In the progression of dysphagia secondary to neurologic disorders (ND), a percutaneous gastrostomy tube (PEG) is commonly employed to achieve long-term nutritional goals safely. We aimed to characterize predictors for PEG tube placement in patients evaluated for dysphagia secondary to progressive ND.

Methods: Patients with dysphagia related to ND were identified retrospectively across four tertiary academic centers from December 2010 – December 2021. The primary endpoint was placement of gastrostomy. We performed multivariable logistic regression for the primary outcome and Cox proportional hazards regression for the primary endpoint to identify predictors. The severity of the patient’s underlying clinical condition was gauged by the Charlson Comorbidity Index, the Clinical Fragility Scale (CFS), American Association of Anesthesiology (ASA) classification, and clinical features.

Results: A total of 273 patients were included (median age 63.9, male 42.6%). The most common disorders were multiple sclerosis (27.1%), myasthenia gravis (22.3%) and amyotrophic lateral sclerosis (ALS, 15.4%). A gastrostomy was recommended in 38 patients (13.9%) at the initial consultation. At follow-up, a total of 51 patients had a gastrostomy (median time: 48 days, interquartile range: 7-181). Characteristics that predicted recommendation of PEG were: diagnosis of ALS (HR 10.39, 95% CI: 5.34-20.19, P< 0.0001), CFS per point (HR 1.49, 95% CI: 1.23-1.81, P< 0.0001), ASA Classification per point (HR 2.23, 95% CI: 1.28-3.89, P=0.0046), under evaluation for ND including electromyography (HR 2.06, CI 95%: 1.10-3.82), and dysphagia to both liquids and solids (HR 2.57, CI 95%: 1.44-4.57, P=0.0014). Figure 1. Increased BMI was protective (HR 0.92, CI 95%: 0.87-0.98, P=0.0212). Table 1.

Discussion: In this cohort of patients with neurologic disease, the diagnosis of ALS was the greatest identified risk factor for PEG placement. Other than this diagnosis, the presence of solid and liquid dysphagia was the main clinical finding which predicted PEG placement. We found that both the ASA score and CFS were highly predictive of the need for PEG placement. We suggest that when considered in conjunction with the predictive clinical feature of dysphagia to both solids and liquids, these scores may help clinicians anticipate PEG when applied to neurologic disorders as a whole.

Figure: Figure 1, A: Kaplan-Meier Curve, Incidence of Gastrostomy Placement by Diagnosis of ALS. P<0.001. Figure 1, B: Kaplan-Meier Curve, Cumulative Incidence of Gastrostomy Placement by Type of Dysphagia, P<0.001.

	Univariable		Multivariable*
	HR (95% CI)	P Value	HR (95% CI)	P Value
Age at Evaluation, per 1 year	1.04 (1.01-1.06)	0.0049	1.02 (0.99-1.04)	0.2755*
Male	2.60 (1.46-4.62)	0.0011	1.30 (0.70-2.42)	0.4078
White Race	0.71 (0.28-1.78)	0.4604	1.32 (0.51-3.42)	0.5726
Body Mass Index, per 1 kg/m²	0.92 (0.87-0.96)	0.0060	0.92 (0.87-0.98)	0.0092
Mayo Arizona	3.62 (2.08-6.29)	< 0.0001	1.16 (0.60-2.23)	0.6619
Amyotrophic Lateral Sclerosis	17.7 (9.60-32.60)	< 0.0001	10.39 (5.34-20.19)	< 0.0001*
Myasthenia Gravis	0.20 (0.06-0.65)	0.0074	0.63 (0.18-2.16)	0.4624
Hereditary Neuropathy	0.11 (0.02-0.80)	0.0296	0.27 (0.04-2.01)	0.2002
Multiple Sclerosis	0.16 (0.05-0.48)	0.0015	0.45 (0.13-1.56)	0.2089
Clinical Frailty Scale, per 1 point	1.92 (1.61-2.30)	< 0.0001	1.49 (1.23-1.81)	< 0.0001*
ASA Classification, per 1 point	3.76 (2.32-6.10)	< 0.0001	2.23 (1.28-3.89)	0.0046
Charlson Comorbidity Index, per 1 point	1.03 (0.92-1.17)	0.5903	0.99 (0.80-1.22)	0.9088
Arm Weakness Present	4.22 (2.31-7.70)	< 0.0001	0.94 (0.43-2.04)	0.8782
Leg Weakness Present	2.62 (1.50-4.57)	0.0007	1.23 (0.67-2.27)	0.5076
EMG Performed	3.01 (1.68-5.37)	0.0002	2.06 (1.10-3.82)	0.0229
Aspiration Pneumonia	2.05 (1.12-3.76)	0.0198	0.95 (0.51-1.78)	0.8673
Speech Swallow Evaluation	2.13 (1.21-3.75)	0.0085	0.91 (0.49-1.68)	0.7519
Portable Ventilator	12.75 (6.46-25.13)	< 0.0001	1.66 (0.79-3.47)	0.1775
Pulmonary Function Tests Performed	2.32 (1.32-4.08)	0.0036	0.74 (0.39-1.40)	0.3525
Diabetes Mellitus	0.36 (0.13-1.00)	0.0502	0.50 (0.17-1.42)	0.1926
Time with Neuromuscular Disorder, per 365 days	0.95 (0.91-0.99)	0.0190	0.99 (0.94-1.04)	0.7021
Type of Dysphagia
Solids Only	1.00 (reference)	NA	1.00 (reference)	NA
Liquids Only	2.82 (0.66-12.15)	0.1634	2.73 (0.64-11.63)	0.1735
Both	3.97 (2.23-7.07)	< 0.0001	2.57 (1.44-4.57)	0.0014*
Referred by Neurology	3.19 (1.71-5.97)	0.0003	0.83 (0.40-1.71)	0.6172
Evaluated by esophagologist	0.58 (0.28-1.19)	0.1361	1.13 (0.52-2.48)	0.7608

Disclosures:

R. Christopher Chase indicated no relevant financial relationships.

Pedro Cortes indicated no relevant financial relationships.

Christopher Lamb indicated no relevant financial relationships.

Dawn Francis indicated no relevant financial relationships.

Kenneth DeVault indicated no relevant financial relationships.

Maoyin Pang indicated no relevant financial relationships.

R. Christopher Chase, MD¹, Pedro Cortes, MD¹, Christopher J.. Lamb, MD², Dawn Francis, MD², Kenneth DeVault, MD², Maoyin Pang, MD, PhD². P3234 - Predictors of Percutaneous Endoscopic Gastrostomy Placement in Patients with Progressive Neuromuscular Dysphagia, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.