Dysphagia is an expected common complication in amyotrophic lateral sclerosis (ALS), although a subset of patients may die before developing this symptom.^{Reference Kushta, Molfino, Inghilleri, Sabatelli and Rossi Fanelli1} Dysphagia leads to weight loss (a poor prognostic factor), aspiration pneumonia (often fatal) and dehydration. Furthermore, it negatively impacts the quality of life (QoL) of both patients and caregivers.^{Reference Lisiecka, Kelly and Jackson2} As a consequence, gastrostomy has been a long-standing management strategy for ALS. Ideally, it should be performed at the onset of dysphagia, or potentially earlier in patients with pre-existing weight loss or significant respiratory impairment. However, most patients delay their decision until symptoms are more marked, increasing the risks associated with the intervention at a later stage.

Despite its widespread use, there is currently no controlled clinical trial or robust evidence demonstrating that gastrostomy increases either the survival or the QoL for patients with ALS, or their caregivers.^{Reference Castanheira, Swash and De Carvalho3} Conversely, the intervention appears to be safe.^{Reference Castanheira, Swash and De Carvalho3,Reference McDonnell, Schoenfeld, Paganoni and Atassi4} The imprecise evidence regarding the benefits of gastrostomy suggests that patient selection must be rigorous, avoiding a posture of imposing the procedure on all patients.

In this issue, Delaire et al.^{Reference Dallaire, Bachand, Shaul and Lareau-Trudel5} report retrospective data from 54 ALS patients who underwent gastrostomy at their center between 2010 and 2023. The authors aimed to quantify the 30-day mortality rate and report associated complications, while also attempting to identify negative predictors for these outcomes, despite the small sample size. The study reported a 30-day mortality rate of 9.3% and a major complication incidence of 16.7%. These rates were similar between percutaneous endoscopic gastrostomy (PEG) and radiologically inserted gastrostomy (RIG). The limited number of patients and the incomplete or non-timely respiratory evaluation of this cohort prevented the authors from reaching robust conclusions regarding prognostic factors. The results were indeed contradictory: the analysis suggested no association with forced vital capacity values, yet the authors claimed that poor respiratory function remained a significant risk factor.

Despite the methodological limitations acknowledged by the authors, the detailed analysis of complications is a valuable contribution to the literature. Furthermore, the observation of a slight increase in mean weight post-procedure represents a positive outcome. These findings generally align with a recent retrospective study of 100 patients who underwent RIG,^{Reference An, Jang and Hering6} which reported a 30-day mortality rate of 6%, a low complication rate, and an association between poor respiratory function and an increased risk of post-procedural respiratory failure. This new study contributes to growing body of knowledge that is relevant for optimizing ALS patient care.