ALSに対する経管栄養のコクランレビュー

ALS：筋萎縮性側索硬化症に対する経管栄養のコクランレビューを紹介します。今年アップデイトされました。

Katzberg HD, Benatar M. Enteral tube feeding for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD004030.

ただ、2009年9月までの系統的レビューでもランダム化比較試験は1つもありませんでした。そのため、ALS患者に対する経管栄養の有用性は明確にはなっていません。ただ、現状のベストのエビデンスとしては、一部のALS患者に対しては生命予後を改善する可能性があります。栄養改善のエビデンスも不十分ですが、やや有効の可能性があります。

質の高いエビデンスは現状ではありませんが、ALS患者の筋萎縮の原因が、原疾患だけでなく低栄養・飢餓を合併している可能性があります。その場合には特に、栄養改善が重要となると私は考えます。また、栄養状態良好のALS患者には、積極的な栄養介入は不要かもしれませんが、嚥下評価は必要だと思います。

Abstract
BACKGROUND: Enteral feeding (tube feeding) is offered to many people with amyotrophic lateral sclerosis/motor neuron disease experiencing difficulty swallowing (dysphagia) and maintaining adequate nutritional intake leading to weight loss.

OBJECTIVES: To examine the efficacy of percutaneous endoscopic gastrostomy placement or other tube feeding placement on: (1) survival;(2) nutritional status; (3) quality of life;(4) minor and major complications of percutaneous endoscopic gastrostomy.

SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (24 November 2009), MEDLINE (from January 1966 to September 2009), and EMBASE (from January 1980 to September 2009) for all papers on enteral tube feeding in amyotrophic lateral sclerosis/motor neuron disease. The results were screened to identify randomised controlled trials and to identify non-randomized studies that might be worthy of review and discussion. We checked references in published articles and enlisted personal communications to identify any additional references.

SELECTION CRITERIA: A priori selection criteria included randomised and quasi-randomized controlled trials evaluating the efficacy of percutaneous endoscopic gastrostomy or other feeding tube placement. Since no such trials were discovered, all prospective and retrospective controlled studies were reviewed in the 'Background' or 'Discussion' sections of the review.

DATA COLLECTION AND ANALYSIS: We independently assessed study design and extracted data. We considered the following outcomes: (1) survival rate in months (of primary interest), (2) nutritional status measured by weight change, change in body mass index, or other quantitative index of nutritional status, (3) self-perceived quality of life and (4) safety of the procedure as indicated by minor and major complications of surgical or radiological guided PEG tube insertion.

MAIN RESULTS: We found no randomised controlled trials comparing the efficacy of enteral tube feeding with those people who continued to eat orally, without enteral feeding. We summarized the results of retrospective and prospective studies in the 'Discussion' section.

AUTHORS' CONCLUSIONS: There are no randomised controlled trials to indicate whether enteral tube feeding is beneficial compared to continuation of oral feeding for any of the outcome measures. The 'best' evidence to date suggests a survival advantage for some people with amyotrophic lateral sclerosis/motor neuron disease, but these conclusions are tentative. Evidence for improved nutrition is also incomplete but tentatively favorable. Quality of life has been addressed in studies and needs more attention. Based on a number of recent non-randomized studies comparing surgical and radiographic approaches to feeding tube insertion these two procedures for PEG tube insertion appear to be equivalent.