Asparagus and jejunal-through-PEG: an unhappy encounter in intrajejunal levodopa infusion therapy

OUP accepted manuscript

We report a case of small bowel occlusion due to the formation of a bezoar around a knot at the distal end a gastro-jejunal catheter used for continuous levodopa/carbidopa intestinal gel (LCIG) in a patient with advanced Parkinson’s disease. The patient presented with a history of abdominal pain and vomiting starting 24 h before admission and frequent failure of his LCIG device for the past week. Small bowel occlusion along with a knot formation on the distal catheter was confirmed by contrast enhanced CT scan. After failure of endoscopic extraction, the patient was taken to theater. The presence of a knot and a bezoar was confirmed and extraction proceeded via transverse enterotomy without the need for bowel resection. Despite inhalation pneumonia and prolonged ileus, the patient recovered fully. LCIG treatment was reinstated a month later through new gastro-jejunal catheter. This case highlights a severe and surprising complication of LCIG treatment.

Phytobezoar Associated with Levodopa-carbidopa Intestinal Gel Infusion in Patients with Parkinson's Disease: A Case Report and Literature Review

Continuous intrajejunal infusion of levodopa-carbidopa intestinal gel (LCIG) is an established device-aided therapy for advanced Parkinson's disease (PD). Phytobezoar associated with LCIG is a rare device-related complication and presents with exacerbations of gastrointestinal and PD symptoms. We herein report the case of a phytobezoar that was formed at a knot on the pigtail-shaped J-tube and developed only in association with postprandial abdominal pain, similar to a feeling of a tube being pulled in without an exacerbation of PD symptoms. Such abdominal pain may be a warning sign of phytobezoar in LCIG-treated patients. Despite device-related complications, high-pressure alarms are not always present, and PD symptoms are not always exacerbated.

The impact of tube replacement timing during LCIG therapy on PEG-J associated adverse events: a retrospective multicenter observational study

Background

Levodopa–carbidopa intestinal gel (LCIG) treatment, a unique drug delivery system for patients with advanced Parkinson’s disease (PD), is covered by health insurance in Japan since September 2016. Various LCIG procedure/device-associated adverse events (AEs) have been reported; however, reports on their treatment have been limited. This is the first multicenter study to clarify the frequency and timing of device-related AEs.

Methods

Between September 2016 and December 2018, 104 patients introduced to the LCIG treatment for advanced PD in 11 hospitals were included. The patients’ characteristics, AEs incidence, AEs time, and tube exchange time were investigated.

Results

The median follow-up period was 21.5 months. Minor AE cases were 29.4%, whereas major AE cases were 43.1%. Majority of major AEs (n = 55, 94.8%) were managed with endoscopic treatment, such as tube exchange. Few severe AEs required surgical treatment (n =3, 5.2%). The mean (range) exposure to percutaneous endoscopic gastrojejunostomy (PEG-J) was 14.7 (0–33) months. One year after the LCIG treatment introduction, 55 patients (54.0%) retained the original PEG-J tube. The mean PEG-J tube exchange time was 10.8 ± 7.0 months in all patients, 11.6 ± 4.7 and 10.5 ± 7.7 months in patients with scheduled exchange and who underwent exchange due to AEs, respectively.

Conclusions

Some device-related AEs occurred during the LCIG treatment; however, only few were serious, most of which could be treated with simple procedures or tube replacement with endoscopy. Therefore, the LCIG treatment is feasible and safe and is a unique treatment option for PD, requiring endoscopists’ understanding and cooperation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02269-7.

Migration of a Percutaneous Endoscopic Gastrojejunostomy Tube into the Colon with Small Intestinal Telescoping

Continuous duodenal levodopa/carbidopa intestinal gel delivery by a gastrostomy infusion system improves control of Parkinson's disease. The overall complication rates of percutaneous endoscopic gastrojejunostomy were reported to be 41% and 59% for immediate and delayed adverse events, respectively. A 72-year-old woman underwent percutaneous endoscopic gastrojejunostomy using the delivery system noted above. Abdominal pain and vomiting occurred 3 months later. Esophagogastroduodenoscopy showed a longitudinal ulcer extending from the lower gastric body to the ileum end, with small intestinal telescoping. Colonoscopy showed a large bezoar of food residue that was attached around the tip of the tube, reaching the ascending colon, which may have acted as an anchor. Thus, the gastric antrum and small intestine were shortened with telescoping. This complication was resolved by crushing the bezoar with forceps during colonoscopy and can be prevented by consuming a fiber-free diet and periodic exchanges of the tube using esophagogastroduodenoscopy.

[Analysis of PEG-J associated complications in 14 adult patients treated with levodopa-carbidopa intestinal gel]

We analyzed 14 patients in our hospital, who underwent levodopa-carbidopa intestinal gel (LCIG) treatment through a percutaneous endoscopic gastrojejunostomy (PEG-J). The PEG-J related complications were observed in 10 patients (71.4%). Detailed complications are as followings: J-tube related complications such as kinking (3 cases, 21.4%), pump malfunctions (3 cases, 21.4%), skin troubles in the gastrostoma (7 cases, 50.0%), duodenal perforation, peritonitis, and ulcers (2 cases, 14.3%). These results indicated that the sufficient care for PEG-J associated complications are important in LCIG treatment.

Fistulization of J-PEG Jejunal Tube into the Colon in a Patient Treated with Duodopa® Infusion: A Case Report

The continuous delivery of a levodopa/carbidopa gel suspension (Duodopa®) into the small bowel through a jejunal tube inserted via percutaneous endoscopic gastrostomy represents a new treatment method in advanced Parkinson disease. Some severe device-related complications have been described in the last few years. Some of them are associated with phytobezoar formation at the pigtail of the catheter. We present the case of a Parkinson disease patient treated with the Duodopa infusion system complicated by jejunal tube fistulization into the colon. We suggest a possible treatment strategy for this complication, which has not been described in the literature to date.

Intrajejunal levodopa infusion therapy for Parkinson's disease: practical and pragmatic tips for successful maintenance of therapy

INTRODUCTION

Intrajejunal levodopa infusion (IJLI) therapy is one of the most influential therapies in moderate to late stage Parkinson's disease with documented effects on motor and nonmotor symptoms and quality of life. The process of initiation and maintenance of therapy however, remains a challenge particularly in the long term. Areas covered: The authors reviewed 'evidence base' for pathways and advice given to patients pre and post IJLI initiation. The authors found lack of patient, carer and clinician led 'real life' advisory documents which need to be given to patients on IJLI. Expert commentary: Experience from centers engaged in IJLI therapy as well as feedback from carers and patients on IJLI suggest wide variability of practical advice given to patients. This is important as such tips could avoid termination of treatment or serious adverse events in some cases. In this review the authors provide a collection of pragmatic and practical tips for patients initiated on IJLI, both related to the short and long term and which we believe is a key unmet need. The paper is illustrated with two case reports.

Duodopa® treatment for advanced Parkinson's disease: a review of efficacy and safety

Enterally administered levodopa/carbidopa gel (Duodopa®) is used for the treatment of advanced Parkinson's disease (PD) in patients with motor fluctuations and dyskinesias. This review summarizes the current efficacy and safety data on this drug. Clinically important differences (CID) have been used to assess whether statistical improvements in symptoms translate into meaningful improvements for the patients. A PubMed search in February 2012 found 23 papers with efficacy data and 33 with safety data. Of 11 studies reporting Unified Parkinson's Disease Rating Scale (UPDRS) III scores, 10 found improvements that met the CID of 10.8 points. Of 7 studies reporting UPDRS IV scores, 5 found improvements meeting the CID of 2.3 points. Quality of life (QoL) was assessed in 6 studies using the 8- or 39-question version of the Parkinson's disease Questionnaire, and all reported improvements meeting the CID (10 points). Due to the nature of the data, it is not possible to give exact numbers for the frequency of adverse events. However, the findings seem to be in line with a previous report stating the majority of adverse events were related to the infusion system or surgical procedure rather than the drug. In conclusion, the large majority of studies have reported that Duodopa® is clinically effective in relieving the symptoms of advanced PD and improving QoL in comparison with conventional therapy. High-quality randomized trials with larger patient numbers will yield greater insights into the efficacy and safety of this treatment.