Percutaneous Endoscopic Transgastric Jejunostomy (PEG-J) Tube Placement for Levodopa-Carbidopa Intrajejunal Gel Therapy in the Interventional Radiology Suite: A Long-term Follow-up

Per-oral image guided gastrojejunostomy insertion for levodopa-carbidopa intestinal gel in Parkinson's disease is safe and may be advantageous

BACKGROUND

Procedural aspects and complications of gastrojejunostomy insertion are important considerations in the use of levodopa-carbidopa intestinal gel therapy (LCIG) and may limit uptake. We describe our experience of using per-oral image guided gastrojejunostomy (PIG-J) which avoids the need for endoscopy and routine sedation in percutaneous endoscopic gastrojejunostomy (PEG-J) and allows more secure tube placement than radiologically inserted gastrojejunostomy techniques.

METHODS

We describe a case series of 32 patients undergoing PIG-J insertion for LCIG therapy in a single centre. Under local anaesthetic, a fluoroscopy-guided gastric puncture allows access for the guidewire which is then used to pull through the gastrostomy tube allowing for secure fixation, followed by placement of the gastrojejunal extension.

RESULTS

Between December 2015 to April 2020, 32/34 patients referred for PIG-J underwent this procedure successfully, 2 cases unsuccessful due to technical considerations. One patient developed delirium following successful implantation. Ten patients (31%) required a replacement tube due to blockage or displacement within the first 12 months of placement, including 2 patients who needed more than one replacement. Minor complications occurred in 10 other patients (31%), including infection (9 patients); a small haematoma not requiring intervention who later developed an infection (1 patient); and peri-stomal acid leakage (1 patient).

CONCLUSION

In summary, PIG-J insertion is safe with a similar complication rate to traditional PEG-J, well tolerated and effective for use in LCIG administration. This may widen access to LCIG for PD patients who may not be suitable or unable to tolerate PEG-J.

Operation of the percutaneous endoscopic gastrostomy-jejunostomy tube without endoscopy in patients with Parkinson's disease on levodopa-carbidopa intestinal gel infusion therapy

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It is important to treat tube-related adverse events without endoscopy.

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All PEG-J tube kinks were resolved using tube manipulation with fluoroscopy.

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Use of an antispasmodic agent before PEG-J may have lowered success rate.

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Most tube-associated adverse events were clarified without endoscopy.

Introduction

Tube-related adverse events (AEs) occur frequently in patients with Parkinson’s disease (PD) receiving levodopa-carbidopa intestinal gel therapy. Endoscopy has become evasive since the beginning of the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to evaluate methods that use the percutaneous endoscopic gastrostomy-jejunostomy (PEG-J) tubes without endoscopy.

Methods

We included 19 patients in this study. The contrast agent was injected into the PEG-J tube to clarify the AEs related to the use of the tube. When the kink of the PEG-J tube was found, it was pulled approximately 5–10 cm. When placing or replacing the PEG-J tube, the percutaneous endoscopic gastrostomy (PEG) tube was pushed into the gastrostomy hole to bring its tip closer to the pylorus before a new PEG-J tube was inserted into it.

Results

The mean patient age was 63.1 ± 9.9 years, while the mean duration of PD was 16.7 ± 6.3 years. Tube-related AEs included PEG-J tube kinks (32 events), connector failures (20 events), and PEG-J tube entanglements without/with bezoars (9 events/5 events). All PEG-J tube kinks were resolved by tube manipulation with a fluoroscopic guide. In 66 of 85 events (77.6%), the PEG-J tube was placed or replaced without endoscopy. We believe that the use of the antispasmodic agent just before PEG-J operation reduced this rate.

Conclusion

Our methods were able to resolve most AEs associated with PEG-J tube use without endoscopy.