Jejunal Extension Research Articles

Problems related to levodopa-carbidopa intestinal gel treatment in advanced Parkinson's disease.

BackgroundContinuous levodopa‐carbidopa intestinal gel (LCIG) diminishes daily “off” time and dyskinesia in patients with advanced Parkinson′s disease (PD). Complications are common with percutaneous endoscopic gastrostomy with a jejunal extension tube (PEG‐J).Aim of the StudyTo report the clinical outcome of LCIG in patients with advanced PD in the years 2006–2014 at Helsinki University Hospital.Patients and MethodsLevodopa‐carbidopa intestinal gel treatment started following PEG‐J placement in patients with advanced PD after successful in‐hospital LCIG trial with a nasojejunal tube. Demographics, PEG‐J procedures, discontinuation of LCIG, complications and mortality were retrospectively analyzed.Results [mean (SD)]Sixty patients with advanced PD [age 68(7) years; duration of PD: 11(4) years] had LCIG treatment for 26(23) months. The majority of patients with advanced PD were satisfied with the LCIG treatment. For 51 patients (85%), the pump was on for 16 hr a day, and for nine patients (15%) it was on for 24 hr a day. After 6 months, the levodopa‐equivalent daily dose (LEDD) had increased by 30% compared to pre‐LCIG LEDD. Sixty patients underwent a total of 156 PEG‐J procedures, and 48 patients (80%) had a total of 143 complications. Forty‐six patients (77%) had 119 PEG‐J or peristomal complications, and 22 patients (37%) had a total of 25 other complications. The most common complications were accidental removal of the J‐tube in 23 patients (38%) and ≥5% weight loss in 18 patients (30%). Fifteen patients discontinued the LCIG after 21 (21) months. At the end of the follow‐up period of 33(27) months, 38 patients were still on LCIG and nine (15%) had died.ConclusionMost patients were satisfied with LCIG treatment. A few patients lost weight whereas the majority had complications with PEG‐J. When LCIG treatment is carried out, neurological and endoscopic units must be prepared for multiple endoscopic procedures.

P.066 Intrajejunal levodopa infusion (ILI) for Parkinson’s Disease (PD): a Canadian experience

Background: ILI has been in use in Canada since 2011 to treat advanced PD. We review the benefits and complications of ILI for PD in a tertiary movement disorders center in Canada. Methods: Detailed chart review of patients treated with ILI at including motor UPDRS scores, ILI pump and PEG-J tube complications. Patients and caregivers were interviewed at regular clinic follow up about their experience with ILI. Results: 13 patients received ILI [10M, 3F; mean age 65.6 yrs, range (51.8-79.5); PD duration 14.2 yrs, range (9.1-22.0); mean follow-up 1.8 yrs, range (0.2-4.8)]. Patients reported improvement in motor function, decreased dyskinesias and ‘OFF times’ [mean motor UPDRS: pre-ILI 37.1, 1-6months post-ILI 27.5]. Common complications included dislodgement, knotting or blockage of the jejunal tube extension requiring endoscopic re- insertion (29 incidents in 6 patients over 5 yrs). Four patients discontinued Duodopa treatment, for reasons of declining cognition, inability to care for the pump, and/or minimal benefit. Conclusions: ILI is useful for the treatment of advanced PD, in patients that can care for the pump apparatus.

850 A Novel Through the Snare Technique for Percutaneous Endoscopic Gastro-Jejunostomy Tube Placement

Percutaneous endoscopic gastro-jejunostomy (PEG-J) tube placement is an increasingly in demand procedure, but due to technical difficulty and its time consuming nature, is often referred to surgeons and interventional radiologists. The most common procedural complications include loop formation within the stomach which causes retraction of either the guidewire or jejunal extension tubing out of the small bowel as well as displacement of the jejunal extension tubing out of the small bowel during withdrawal of the endoscope. Here we present a through the snare technique for PEG-J placement which decreases procedure length and is easier to perform than the traditional methods. A 52-year-old male presents with his first episode of alcohol induced pancreatitis complicated by symptoms of gastric outlet obstruction. A 24 Fr PEG tube was placed in the traditional fashion. The upper endoscopy revealed a luminal stenosis in the second portion of the duodenum secondary to acute inflammation from acute pancreatitis. Next, a snare was placed through the PEG tube and opened. The endoscope is advanced through the snare and a guidewire is placed into the small bowel. The endoscope is then exchanged and the wire left in place. As the endoscope is withdrawn, through the snare, the snare is closed and the wire brought out through the PEG tube. The end of the wire not within the small bowel is then pulled back in order to straighten the guidewire. The jejunal extension tube is then advanced over the guidewire. The patient tolerated the procedure well. The procedure duration was 18 minutes. The PEG portion was immediately used for decompression and the patient was discharged after his jejunal feeds were advanced to a goal rate. This novel method for PEG-J placement is technically simple and virtually eliminates looping of the guidewire. Furthermore, it obviates the need for the use of a second endoscope as well as fluoroscopy, which may not be readily available at all centers.

The use of enteral access for continuous delivery of levodopa-carbidopa in patients with advanced Parkinson's disease.

Continuous delivery to the jejunum of levodopa-carbidopa is a promising therapy in patients with advanced Parkinson's disease, as it reduces motor fluctuation. Percutaneous endoscopic gastrostomy and jejunal tube (PEG-J) placement is a suitable option for this. However, studies focused in PEG-J management are lacking. We report our experience regarding this technique, including technical success, adverse events and outcomes, in patients with advanced Parkinson's disease. Twenty-seven advanced Parkinson's disease patients (17 men, median age: 64 years, median disease duration: 11 years) were included in a retrospective study from June 2007 to April 2015. The median follow-up period was 48 months (1-96). No adverse events were noted during and after nasojejunal tube insertion (to assess treatment efficacy). After a good therapeutic response, a PEG-J was placed successfully in all patients. The PEG tube was inserted according to Ponsky's method. The jejunal extension was inserted during the same procedure in all patients. Twelve patients (44%) experienced severe adverse events related to the PEG-J insertion, which occurred after a median follow-up of 15.5 months. Endoscopy was the main treatment modality. Patients who experienced severe adverse events had a higher comorbidity score (p = 0.011) but were not older (p = 0.941) than patients who did not. While all patients responded well to levodopa-carbidopa regarding neurological outcomes, gastro-intestinal severe adverse events were frequent and related to comorbidities. Endoscopic treatment is the cornerstone for management of PEG-J related events. In conclusion, clinicians and endoscopists, as well as patients, should be fully informed of procedure-related adverse events and patients should be followed in centres experienced in their management.

Short article: Buried bumper syndrome in children: incidence and risk factors.

Buried bumper syndrome (BBS) is a serious complication in gastrostomy-dependent children. Many need surgical correction. On account of comorbidities, this becomes a high-risk procedure. Our aim was to review the incidence of BBS in children and to identify the risk factors. Retrospective review of patients' records over 10 years, 2006-2015, was carried out. Types of tubes, operative interventions, comorbidities and records were noted. Two-tailed Fisher's exact test was used for statistical analysis. A total of 535 patients were reviewed. Overall, 475 had only percutaneous endoscopic gastrostomy (PEG) and 60 had a jejunal extension with percutaneous endoscopic gastrostomy (PEG-J). Twenty-nine patients (PEG-J - 16/26; PEG - 13/26) had a total of 31 BBS episodes. The overall incidence of BBS in our study was 5.4%. The age at presentation ranged from 1 to 18 years (median 8.6 years). All had significant comorbidities (neurodevelopmental 26/29, cardiorespiratory 14/29, genetic 16/29). Overall, 27/29 had two or more comorbidities. The mean time to development of BBS was 1025±634 days. BBS was found in the second or the subsequent tube in four patients with PEGs (P<0.0004) and in 10 PEG-Js (P<0.0001). Twenty-five patients needed laparotomy. There were no postoperative deaths. In BBS, the two significant risk factors identified were a having PEG-J and two or more previous gastrostomy insertions. Vigilance in documentation and prolonged follow-up to provide regular education to carers can reduce the incidence of this preventable complication.

Levodopa-carbidopa enteral suspension in advanced Parkinson’s disease: clinical evidence and experience

The duration of action of oral levodopa becomes shorter as Parkinson's disease (PD) progresses. Patients with advanced PD may develop potentially disabling motor fluctuations and abnormal involuntary movement (dyskinesia), which cannot be managed with optimized oral or transdermal PD medications. The progressively worsening symptoms can have a substantial impact on the patient quality of life (QoL). Levodopa-carbidopa intestinal gel (LCIG) is delivered continuously via a percutaneous endoscopic gastrostomy with a jejunal extension (PEG-J). LCIG is licensed for the treatment of levodopa-responsive advanced PD in individuals experiencing severe motor fluctuations and dyskinesia when available combinations of antiparkinsonian medications have not given satisfactory results. Initial evidence for the efficacy and tolerability of LCIG came from a number of small-scale studies, but recently, three prospective studies have provided higher quality evidence. A 12-week double-blind comparison of LCIG with standard levodopa therapy, a 52-week open-label study extension of the double-blind study, and a 54-week open-label safety study, demonstrated significant improvements in 'off' time and 'on' time without troublesome dyskinesia, and QoL measures that were maintained in the longer term. There are also observations that LCIG may be effective treatment for nonmotor symptoms (NMS) although the evidence is limited. There is a need for further research on the efficacy of LCIG in reducing NMS, dyskinesia and improving QoL. This review surveys the clinical evidence for the effectiveness and tolerability of LCIG in the management of advanced PD and highlights some practical considerations to help optimize treatment.

Short- and long-term outcomes from percutaneous endoscopic gastrostomy with jejunal extension.

There is a paucity of data regarding the safety and efficacy of percutaneous endoscopic gastrostomy with jejunal extension (PEG-J). We evaluated adverse events related to PEG-J and determined the clinical impact of PEG-J in those with chronic pancreatitis (CP). This cohort study included all patients who underwent PEG-J placement in a tertiary-care academic medical center between 2010 and 2012. Main outcome measurements were (1) short- and long-term complications related to PEG-J and (2) changes in weight and hospitalizations during the 12-month period before and after PEG-J in the CP subgroup. Of 102 patients undergoing PEG-J placement, the overall technical success rate was 97%. During a median follow-up period of 22months (1-46months, n=90), at least one tube malfunction occurred in 52/90 (58%; 177 episodes) after a median of 53days (3-350days), requiring a median of two tube replacements. Short-term (<30days) tube malfunction occurred in 28/90 (31%) and delayed in 24/90 (27%); these included dislodgement (29%), clogging (26%) and kinking (14%). In the CP subgroup (n=58), mean body weight (kg) (70 vs. 71, p=0.06) and body mass index (kg/m2, 26 vs. 27, p=0.05) increased post-PEG-J. Mean number of hospitalizations (5 vs. 2, p<0.0001) and inpatient days per 12 months (22 vs. 12, p=0.005) decreased. While we observed no major complications related to PEG-J, half of patients had at least one episode of tube malfunction. In the CP subgroup, jejunal feeding via PEG-J significantly reduced the number of hospitalizations and inpatients days, while improving nutritional parameters.

Novel Lumen-Apposing Metal Stent for Treatment of a Benign Gastric Stricture after Caustic Injury

A 69 year old female developed extensive mucosal injury (Zargar Grade 2b) of her esophagus and stomach caused by accidental ingestion of a caustic alkali substance. Eight days after injury, EGD showed esophageal fibrosis with a stricture in the mid-esophagus, diffuse erythema of the stomach and a large ulcer encompassing a large portion of the antrum. The patient underwent a percutaneous endoscopic gastrostomy (PEG) with a 16 French PEG tube confirmed to be 5 cm away from the ulcer. Two weeks after PEG tube placement, the patient reported persistent sialorrhea. Endoscopy revealed worsening of the esophageal stricture and via fluoroscopy, the total length was determined to be 10 cm, with a diameter of 3 mm in the narrowest segment. The patient underwent multiple through-the-scope (TTS) guidewire-assisted endoscopic balloon dilations (EBD) of this esophageal stricture. She then began to have intractable nausea and vomiting after each bolus of tube feeds, and serial measurements of gastric residual volume (GRV) were increasingly elevated. Repeat endoscopy showed a tight prepyloric stricture secondary to the healing antral ulcer, and the PEG tube was replaced with a 16 French PEG tube with jejunal extension (PEG-J). Eleven days after placement, due to retrograde migration of the J-tube, the PEG-J tube was removed. The decision was made to place a novel lumen-apposing self-expandable metal stent (LAMS). A guidewire was inserted into the stomach through the existing gastrostomy tract and was advanced beyond the prepyloric stricture. A 10 mm x 10 mm LAMS (AXIOSTM Stent, Boston Scientific, Marlborough, Massachusetts, USA) was advanced over the guidewire and positioned across the prepyloric stricture with endoscopic and fluoroscopic guidance. This was followed by placement of a 16 French PEG tube into the stomach via the existing gastrostomy tract. During the 12 weeks after stent placement, the area remained patent with no evidence of migration or erosion, and the patient has been able to tolerate tube feedings well with appropriate weight gain. The use of LAMS for treatment of benign strictures can serve as a safe alternative treatment to EBD. Furthermore, the risk of migration, which has been associated with use of traditional fully-covered self-expandable metal stents is potentially lower with LAMS.Figure 1Figure 2

Gastric per-oral endoscopic myotomy for refractory gastroparesis: results from the first multicenter study on endoscopic pyloromyotomy (with video).

Gastric per-oral endoscopic myotomy (G-POEM) recently has been reported as minimally invasive therapy for gastroparesis. The aims of this study were to report on the first multicenter experience with G-POEM and to assess the efficacy and safety of this novel procedure for patients with gastroparesis with symptoms refractory to medical therapy. All patients with gastroparesis who underwent endoscopic pyloromyotomy (G-POEM) at 5 medical centers were included. Procedures were performed following the same principles as esophageal POEM. Clinical response was defined as improvement in gastroparetic symptoms with absence of recurrent hospitalization. Adverse events were graded according to the American Society for Gastrointestinal Endoscopy lexicon. A total of 30 patients with refractory gastroparesis (11 diabetic, 12 postsurgical, 7 idiopathic) underwent G-POEM. Previous therapies included Botox injection in 12, transpyloric stenting in 3, and PEG with jejunal extension (PEGJ) in 1. Nausea/vomiting were the predominant symptoms in 25 patients. Weight loss was present in 27patients with an average of 10% loss of body weight. G-POEM was completed successfully in all 30 (100%) patients with a mean procedure time of 72 minutes (range, 35-223 min). The mean myotomy length was 2.6 ± 2.3cm. The mean length of hospital stay was 3.3 days (range, 1-12 days). Two adverse events occurred in 2 (6.7%) patients, including 1 capnoperitoneum and 1 prepyloric ulcer, rated as mild and severe, respectively. Clinical response was observed in 26 (86%) patients during a median follow-up of 5.5 months. Four patients (2 diabetic, 1 postsurgical, 1 idiopathic cause) did not respond to G-POEM. Repeat gastric emptying scan was obtained in 17patients, normalized in 8 (47%), and improved in 6 (35%) patients. G-POEM is a technically feasible procedure. This small non-randomized study suggests the effectiveness of G-POEM for the treatment of patients with gastroparesis refractory to medical therapy. It concomitantly results in normalization of GES in a significant proportion of treated patients.

The PEG-Pedi-PEG technique: a novel method for percutaneous endoscopic gastrojejunostomy tubeplacement(with video).

When PEG tube feeding is complicated by anatomic obstruction, dysmotility, or aspiration, a need arises for feeding beyond the pylorus. The currently available percutaneous gastrojejunostomy (PEG-J) kits have issues with the jejunal extension portion migrating back into the stomach. The aim of this study was to evaluate the feasibility and safety of a novel technique that creates PEG-J tubes by combining an adult percutaneous gastrostomy (PEG) tube with a pediatric PEG tube, the PEG-Pedi-PEG procedure. This was a retrospective study at a single tertiary care center. The main outcome measures were success of placement, rate of retrograde tube migration, early (<24 h after procedure was performed) and late (>24 h after procedure was performed) adverse events. Seventeen patients underwent PEG-Pedi-PEG procedures during the study period. Technical success was achieved in all patients (100%). The retrograde migration rate of the jejunal extension tube was 0%. Early adverse events included peristomal pain in 1 patient. Late adverse events included inadvertent tube removal (3 patients), diarrhea (1 patient), prolonged ileus/gastroparesis (1 patient), and tube occlusion (1 patient). Mean follow-up was 290 days. The PEG-Pedi-PEG procedure is a novel endoscopic technique to facilitate post-pyloric feeding because the pediatric PEG bumper may act like a sail in the small bowel, with peristalsis pushing the bumper distally and thus decreasing the possibility of migration back into the stomach. This study demonstrated excellent technical success, no retrograde migration, and a low rate of adverse events.

PTU-103 How Best to Deliver Enteral Access for Post-Pyloric Home Enteral Tube Feeding? A 2-Year Review

Introduction Home enteral tube feeding (HETF) has grown in the past 2 decades and there is now also a growing demand for post-pyloric HETF (PP-HETF) for selected cases. 1,2 The optimum route for delivering this is not established, with several options available including surgical jejunostomy (SJ), direct percutaneous endoscopic jejunostomy (DPEJ), and PEG with jejunal extension (PEG-J). We have reviewed our experience to help identify comparative outcomes. Methods Choice of feeding device was clinician-led according to indication, surgical and endoscopic risk. A 2 year review was done from Jan 2014 onwards. Patients were included if they were (1) already undergoing PP-HETF as of January 2014 or (2) had an interventional procedure to start PP-HETF at any time thereafter during the study period. Cases were identified from the community dietetic and electronic endoscopy databases. Case files were reviewed to identify outcome measures which were categorised as: Success of planned procedures; longevity of feeding device, premature removal (removal because of sepsis, migration, blockage or accidental), procedural complications or mortality Results 26 patients were identified (M:F 14:12, median age 55, range 22–83). Indications for PP-HETF were learning difficulties with Gastro-oesophgeal(GO) reflux (8), neurodegenerative or cerebrovascular disease with GO reflux (5), upper GI cancers(9) & others (4). Feeding interventions done successfully prior to or during the study period were SJ (10), DPEJ (14), PEG-J (14).Procedural success rates during study period were; SJ; 10/10 (100%), DPEJ;7/11 (64%), PEG-J; 12/13 (92%).Longevity of feeding devices at review census point (in months, median & range) was: SJ, 11 (3–23); DPEJ,18 (3–48); PEG-J, 6 (0.25–23). Tube premature removal rates (and reasons) were: SJ; 3/10 (30%; all fell out), DPEJ; 3/14(21%; 1 accidental, 2 infected), PEG-J; 6/14 (43%; 4 accidental, 2 blocked). There were no procedural complications recorded but one patient (DPEJ) died Conclusion In this case series which includes similar numbers of the common PP-HETF options, SJ had the highest, and DPEJ the lowest, procedure success rate.DPEJ had the highest longevity. Choice of feeding device for PP-HETF will depend on co-morbidity and surgical/ endoscopic risk but when DPEJ can be placed this may be the preferred option for long-term feeding. References 1 Ojo O. Managing patients on enteral feeding tubes in the community. Br J Community Nurs 2010; 15 :S6–S13. 2 Ojo O. The challenges of home enteral tube feeding: a global perspective. Nutrients 2015; 7 (4):2524–2538. doi:10.3390/nu7042524. Disclosure of Interest None Declared

Use of enteral access for continuous delivery of levodopa-carbidopa in patients with advanced Parkinson's disease

Introduction and aim Continuous delivery to the jejunum of levodopa-carbidopa is a promising therapy in patients with advanced Parkinson's disease, as it reduces motor fluctuation. Percutaneous endoscopic gastrostomy and jejunal tube placement is a suitable option for this. However, studies focused in percutaneous endoscopic gastrostomy and jejunal tube management are lacking. We report our experience regarding this technique, including technical success, adverse events and outcomes, in patients with advanced Parkinson's disease. Material and methods Twenty-seven advanced patients with Parkinson's disease (17 men, median age: 64 years, median disease duration: 11 years) were included in a retrospective study from June 2007 to April 2015. The median follow- up period was 48 months [1–96 months]. Results No adverse event was noted during and after nasojejunal tube insertion (to assess treatment efficacy). After a good therapeutic response, a percutaneous endoscopic gastrostomy and jejunal tube was placed successfully in all patients. The percutaneous endoscopic gastrostomy tube was inserted according to the Ponsky's method. The jejunal extension was inserted during the same procedure in all patients. Twelve patients (44%) experienced severe adverse events related to the percutaneous endoscopic gastrostomy and jejunal tube insertion, which occurred after a median follow-up of 15.5 months. Endoscopy was the main treatment modality. Patients who experienced severe adverse events had higher comorbidity score ( P = 0.011) but were not older ( P = 0.941) than patients who did not. Conclusions While all patients responded well to levodopa-carbidopa regarding neurological outcomes, severe adverse events were frequent and related with comorbidities. Endoscopic treatment is the cornerstone for management of percutaneous endoscopic gastrostomy and jejunal tube-related events. In conclusion, clinicians, endoscopists, as well as patients, should be fully informed of procedure-related adverse events and patients should be followed in centres experienced in their management.

Are PEGJs a Risk Factor for the Buried Bumper Syndrome?

AimPercutaneous endoscopic gastrostomies (PEGs) with or without a jejunal extension (PEGJs) are a well-accepted method of enteral feeding. They are associated with a number of complications, including the buried bumper syndrome (BBS). We aimed to identify risk factors for BBS, our current management strategies, and optimal timing for surgical treatment. MethodsHospital coding and a database compiled by our specialist nutrition nurse were used to identify all cases of buried bumpers from January 2012 to December 2014 as well as all PEG/PEGJ devices inserted during this time. A retrospective case note review was performed for each patient with BBS to identify risk factors, management strategies, and outcomes. ResultsTwo hundred twelve PEGs and 22 PEGJs were inserted. Nine patients were identified with BBS. Patients with PEGJ tubes were significantly more likely to develop BBS (7/22, 32%) than those with PEG tubes (2/212, 0.9%) P<0.01. There was one death in the study group because of abdominal sepsis associated with an intraperitoneal PEG bumper 33days after BBS was diagnosed and before removal was attempted. All other patients underwent laparotomy to remove the bumper. Mean hospital stay was 22days postoperatively. ConclusionsBuried bumper syndrome is a serious condition which warrants urgent intervention. We have demonstrated a higher than expected rate of BBS associated with PEGJ tubes. We hypothesize that this may be related to the jejunal extensions leading to difficulty in the usual maintenance regimen that all carers are taught after PEG/PEGJ insertion.

Fluoroscopy-guided jejunal extension tube placement through existing gastrostomy tubes: analysis of 391 procedures.

We aimed to evaluate the safety and efficacy of fluoroscopically placed jejunal extension tubes (J-arm) in patients with existing gastrostomy tubes. We conducted a retrospective review of 391 J-arm placements performed in 174 patients. Indications for jejunal nutrition were aspiration risk (35%), pancreatitis (17%), gastroparesis (13%), gastric outlet obstruction (12%), and other (23%). Technical success, complications, malfunctions, and patency were assessed. Percutaneous gastrostomy (PEG) tube location, J-arm course, and fluoroscopy time were correlated with success/failure. Failure was defined as inability to exit the stomach. Procedure-related complications were defined as adverse events related to tube placement occurring within seven days. Tube malfunctions and aspiration events were recorded and assessed. Technical success was achieved in 91.9% (95% CI, 86.7%-95.2%) of new tubes versus 94.2% (95% CI, 86.7%-95.2%) of replacements (P = 0.373). Periprocedural complications occurred in three patients (0.8%). Malfunctions occurred in 197 patients (50%). Median tube patency was 103 days (95% CI, 71-134 days). No association was found between successful J-arm placement and gastric PEG tube position (P = 0.677), indication for jejunal nutrition (P = 0.349), J-arm trajectory in the stomach and incidence of malfunction (P = 0.365), risk of tube migration and PEG tube position (P = 0.173), or J-arm length (P = 0.987). A fluoroscopy time of 21.3 min was identified as a threshold for failure. Malfunctions occurred more often in tubes replaced after 90 days than in tubes replaced before 90 days (P < 0.001). A total of 42 aspiration events occurred (OR 6.4, P < 0.001, compared with nonmalfunctioning tubes). Fluoroscopy-guided J-arm placement is safe for patients requiring jejunal nutrition. Tubes indwelling for longer than 90 days have higher rates of malfunction and aspiration.

Short- and Long-Term Safety of PEG-J Used for Continuous Infusion of Levodopa-Carbidopa Intestinal Gel

Introduction: Irregular drug plasma levels due to impaired gastric emptying may contribute to motor complications observed in patients with Parkinson's disease (PD) treated with oral medication. One treatment for PD uses percutaneous endoscopic gastrostomy with jejunal extension tube (PEGJ) to continuously deliver levodopa-carbidopa intestinal gel (LCIG, known in the US as carbidopa-levodopa enteral suspension [CLES]) directly to the jejunum for 16 hours, thereby bypassing the stomach and avoiding fluctuating drug plasma levels. We assessed short- and long-term safety of the PEG-J procedure and device used to deliver LCIG in mobile patients with PD from our most recent clinical trial data cut. Methods: All patients received a 15 French Freka PEG tube and a 9 French Freka jejunal extension tube, placed during the same endoscopy. The ideal jejunal tube tip position was distal to the ligament of Treitz. PEG-J procedure- and device-related treatment-emergent adverse events (AEs) reported during 4 phase 3 LCIG studies (including an ongoing open-label extension study into which all others filtered) were integrated and evaluated. AEs and serious AEs (SAEs) in patients treated with LCIG were included in this analysis at the March 2014 data cut-off date. Results: A total of 395 patients were included in this analysis. The median (range) exposure to PEG-J was 986 (1-1972) days; 165 patients were exposed for ≥1095 days, 130 patients were exposed for ≥1260 days, and 70 patients were exposed for ≥1460 days. The incidence of SAEs was highest in the first week and declined rapidly thereafter (Figure 1). Over the long-term, procedure/device-associated AEs occurred in 387 (94%) patients and SAEs occurred in 68 (17%) patients (Table 1), although single events may have been coded to >1 preferred term. Procedure/device-associated AEs led to discontinuation in 19 (4.8%) patients; those that led to discontinuation in >1 patient included complication of device insertion (10 patients; 2.5%), abdominal pain (4 patients, 1.0%), abdominal discomfort (2 patients, 0.5%), and peritonitis (2 patients, 0.5%).Figure 1Table 1: Overall Procedure/Device-associated Adverse EventsConclusion: The overall safety profile of LCIG via PEG-J is comparable to published data in immobile patients (Itkin M et al, Gastroenterology, 2011;141:742-65). Incidence of SAEs declined after the first week post-procedure. The low discontinuation rate of LCIG treatment via PEG-J demonstrates that this treatment can be maintained for long-term use in this mobile patient population with advanced PD.

TRAQUEOESOPHAGEAL FISTULA PATIENTS FED THROUGH PERCUTANEOUS ENDOSCOPIC GASTROSTOMY/GASTROJEJUNOSTOMY: NUTRITIONAL STATUS AND CLINICAL OUTCOME.

tracheoesophageal fistula (TEF) may result from cancer or mechanical ventilation. Endoscopic Gastrostomy or Gastrojejunostomy (PEG/PEG-J) is used for nutritional support. in TEF-patients, evaluating nutritional status when PEG is performed, safety of PEG/PEG-J and clinical outcome. from the files of PEG/PEG-J feed TEF-patients we collected: clinical data, Body Mass Index, albumin, transferrin and cholesterol when gastrostomy was performed, and clinical outcome globally and according with the TEF cause: Group 1: complication of mechanical ventilation, Group 2: cancer. twelve patients, 18-91 years (median: 53), 11 PEG, one PEG-J: six complications of ventilation (neurological diseases), 6 cancers. Mean period from TEF diagnosis until gastrostomy: 2 months in Group 1, 10 months in Group 2. In the day of the gastrostomy, patients presented with malnutrition parameters, most strikingly in the cancer group. Group 1: died a single patient, 3 closed the TEF, resuming oral intake, 2 are still PEG-feed. All cancer patients died (7 months after gastrostomy). One needed a jejunal extension to create a PEG-J. No more complications. PEG/PEG-J was safe in TEF-patients, but cancer patients underwent gastrostomy too late. In TEF-patients, PEG/PEG-J should be considered in a regular basis, earlier in the disease evolution, before established malnutrition.

Ultra-thin caliber endoscopes in daily practice: uses for therapeutic application and beyond on the basis of review of 1028 procedures.

Background and study aims: Ultra-thin caliber endoscopes (UTCEs) are versatile and applicable in various conditions. However, only limited data exist on the actual daily clinical use of UTCEs. The aim of our study was to determine indications for UTCEs in a large patient cohort. In turn, our 2 main objectives were (1) to evaluate patient comfort and safety and (2) to determine benefits and potential advantages associated with the use of UTCEs in this same cohort. Patients and methods: We performed a retrospective analysis of our prospective database of 1028 procedures with UTCEs in 457 patients. All procedures were carried out in the Department of Gastroenterology and Hepatology, VU University Medical Center, in Amsterdam, the Netherlands, between May 2008 and May 2014. In these procedures, either the Fujinon (Tokyo, Japan) EG-530N UTCE or the Olympus (Tokyo, Japan) GIF N-180 UTCE was used. Results: Mean (standard deviation [SD]) age of patients was 64 (20) years, and most (60 %) of the patients were men. Most (61 %) of the underlying diseases, requiring endoscopic procedures, were found in the esophagus. Of the procedures performed, 91 % were successful, and 82 % were therapeutic. In comparison with regular endoscopes, the most important advantage of the UTCE was the ability to pass a stenosis (37 %), followed by nasogastric feeding tube placement (13 %). Newer and more innovative uses of the UTCE were percutaneous endoscopic gastrostomy (PEG)-jejunal extension placement with endoscope introduction through existing PEG tract, retrograde esophageal introduction through existing PEG tract, inspection of colonic neovagina stenosis, and direct inspection of the common bile duct. Conclusions: In everyday clinical practice, the UTCE has specific advantages over conventional endoscopes because of its small caliber. The 3 main advantages are (1) introduction of high-grade strictures; (2) introduction of fistulas, including PEG fistula; and (3) increased patient comfort. The endoscopist should appreciate these advantages and consider use of the UTCE accordingly.

Best practice in placement of percutaneous endoscopic gastrostomy with jejunal extension tube for continuous infusion of levodopa carbidopa intestinal gel in the treatment of selected patients with Parkinson’s disease in the Nordic region

Objective. Continuous infusion of levodopa carbidopa intestinal gel (LCIG) is associated with a significant improvement in the symptoms and quality of life of selected patients with advanced Parkinson’s disease. Percutaneous endoscopic gastrostomy with jejunal extension (PEG/J) was first described in 1998 and has become the most common and standard technique for fixing the tubing in place for LCIG infusion. Material and methods. A workshop was held in Stockholm, Sweden, to discuss the PEG/J placement for the delivery of LCIG in Parkinson’s disease patients with the primary goal of providing guidance on best practice for the Nordic countries. Results. Suggested procedures for preparation of patients for PEG/J placement, aftercare, troubleshooting and redo-procedures for use in the Nordic region are described and discussed. Conclusions. LCIG treatment administered through PEG/J-tubes gives a significant increase in quality of life for selected patients with advanced Parkinson’s disease. Although minor complications are common, serious complications are infrequent, and the tube insertion procedures have a good safety record. Further development of delivery systems and evaluation of approaches designed to reduce the demand for redo endoscopy are required.

PP12.4 – 2816: Status dystonicus: Is it a gut feeling?

Objective Status dystonicus (SD) is a life-threatening movement disorder. We report nine severely disabled children with SD and gut motility problems managed by the paediatric neurology and gastroenterology teams at the Sheffield Children's Hospital U.K. Methods Retrospective case notes review of nine children admitted with SD at our tertiary paediatric centre looking at underlying neurological diagnoses, age of onset of dystonia, concomitant anti-dystonia medication, intrathecal baclofen pump with rate of daily infusion, anti-reflux medication, gastroenterological investigations, use of enteral feeding (oral, gastrostomy and jejunal feeds) and parental nutrition (PN). Results Nine children, mean age 8.43 years (range 5 months to 15.2 years) presented with SD. Pain, pallor, sweating and spasms were precipitated by enteral feeding. All had multiple, independently observed time points where stopping feeds resulted in resolution of symptoms and recommencement of enteral feeds even at 5 ml per hour lead to the return of dystonic spasms and pain. All showed no evidence of reflux disease on pH impedance studies and gastroscopy and did not show peptic oesophagitis on oesophageal biopsies. All nine had jejunal feeding tubes (jejunal extensions to the PEG) with confirmed tip position in the first loop of the jejunum or close to the duodenojejunal flexure by fluoroscopic placement. Barium studies and plain films ruled out intestinal obstruction or sub-acute obstruction. Five of nine patients with severe feed induced pain and dystonia were treated with PN (3 long term and 2 short term). There was objective evidence of substantial pain resolution in all five. Conclusion Children with SD can be at risk of enteral feed induced abdominal pain and small bowel (foregut) dysmotility with some needing PN. The severity of the neurological condition seems to correlate with the severity of gastrointestinal problems raising the need for an ethical frame work and greater understanding of neuro-gastroenterological relationship.

901 A Novel Technique for Salvaging a Dislodged Lumen Apposing Metal Stent During Creation of an Endoscopic Gastrojejunostomy

Fully-covered lumen apposing metal stents (LAMS) are being used for an increasing number of clinical indications. A recent application is to create an endoscopic bypass for patients with luminal obstruction who are not surgical candidates. Stent dislodgement during deployment is a dreaded complication. We present a case of a 90-year-old man with a history of groove pancreatitis with gastric outlet obstruction who was receiving nutrition via a percutanous gastrostomy with jejunal extension (PEG-J). Due to his age, he was not offered surgery and an endoscopic gastrojejunal bypass was performed.