PEG-J Tube Research Articles

Jejunal levodopa infüzyonu alan Parkinson hastalarında PEG-J tüpünün kısa ve uzun dönem güvenilirliği ve devamlılığı

Aims: To investigate PEG-J related adverse events and tube durability in patients with Parkinson’s disease who underwent PEG-J procedure for jejunal drug infusion. 
 Methods: PEG-J implanted patients, who were planned jejunal levodopa infusion, were included in the study. The demographic characteristics of the patients, tube durability, tube replacement, reason for tube replacement, number of procedures, and adverse events related to procedures were retrospectively analyzed. 
 Results: Thirty-four patients with a mean age of 65.7±9.8 years included in the study. The mean total PEG-J follow-up period of the patients was 33.6±21.1 months. Functions of PEG-J tubes were preserved in 82.5% at 6 months, 78.4% at 12 months, and 65.2% at 18 months. Twenty-one (% 61,8) patients required at least one PEG-J replacement. Of the PEG-J replacements, 90.4% were due to device-related advers events. A total of 29 procedure or stoma related adverse events occurred in 21 (61.8%) patients, and a total of 28 PEG-J tube related adverse events occurred in 19 (55.9%) patients. A total of 6 (17.5%) early procedure-related adverse events (acute abdomen and peritonitis, prolonged bleeding, stoma leakage, stoma infection) were observed, all occurring in the first 7 days. Twenty-three (67.6%) stoma-related late adverse events (stoma leakage, stoma infection, abscess) were detected. Two patients who developed peritonitis were successfully treated with conservative treatments.
 Conclusion: PEG-J used for drug application is a safe method and can be used for a long time without the need for frequent replacement. Most of advers events can be managed with conservative treatments.

Levodopa-Carbidopa Intestinal Gel for Parkinson's Disease over 11 years: One Center's "Real-World" Experience.

Levodopa-carbidopa intestinal gel (LCIG) therapy has been shown to be a safe and effective treatment for advanced Parkinson's disease (PD). Limited data are available regarding long-term benefits and complications in Canada. Objective of the study was to review long-term experience and clinical outcomes in PD patients with LCIG therapy over 11 years in a multidisciplinary University clinic setting. Chart review was done on PD patients with LCIG from 2011 to 2022. Data collected: dosing, UPDRS-III motor scores, OFF times, hours with dyskinesias, MoCA, complications, discontinuation reasons, and nursing time requirements. Thirty-three patients received LCIG therapy with a mean follow-up of 3.25±2.09 years. UPDRS-III scores showed reduction of 15% from baseline (mean 35.9) up to 4 years (mean 30.4). Daily OFF time improved from baseline (mean 7.1 ± 3.13 hours) up to 5 years (mean 3.3 ± 2.31 hours; -53.5%; p < 0.048), and dyskinesias remained stable. Nursing time averaged 22 hours per patient per year after PEG-J insertion and titration. Most common complications were PEG-J tube dislodgement and stoma site infection (0-3zero to three events/patient/year). Serious side effects were seen in four (12%) patients resulting in hospitalization and/or death. Nine patients (27.2%) discontinued the treatment due to lack of improved efficacy over oral therapy or development of dementia and 10 (30%) died of causes unrelated to LCIG infusion. Patients on LCIG showed improved motor function over 5-year follow-up. Serious complications were uncommon. Dedicated nursing time is required by LCIG-trained nurses in a multidisciplinary setting for optimum management.

Intrajejunal Levodopa Infusion for Parkinson’s Disease over 11 years: A Canadian Experience (P13-11.014)

<h3>Objective:</h3> To analyze long-term experience in the clinical management of Parkinson’s disease (PD) patients with intrajejunal levodopa infusion (ILI) therapy over 11 years. <h3>Background:</h3> ILI therapy is a safe and effective drug delivery method for advanced Parkinson’s disease with proven short-term efficacy and safety profile. Limited data is available regarding long-term benefits and complications. ILI is done at the University of Alberta Hospital in a multidisciplinary clinic including neurology, gastroenterology, psychiatry, PT, OT, and specialized nursing. <h3>Design/Methods:</h3> Retrospective chart review was done for patients with PD who underwent ILI from 2011 to 2022. Data collected included dosing, UPDRS-III motor scores, OFF times, hours with dyskinesias, MoCA scores, complications, discontinuation reasons, and nursing time requirements. <h3>Results:</h3> Thirty-three patients received ILI therapy with a mean follow up of <i>3.25 ± 2.09</i> years. Over 11 years, <i>6 (18.1%)</i> patients discontinued treatment due to side effects or lack of efficacy, <i>2 (6.06%)</i> transitioned to DBS therapy, and <i>11 (33.3%)</i> died of causes unrelated to ILI infusion. One patient died from haematemesis related to a coiled PEG-J tube. UPDRS-III score showed relative reduction by <i>16.3%</i> from baseline (<i>mean 33</i>) maintained for 4 years <i>(mean 28)</i>. Mean daily OFF time improved from baseline (mean <i>7.1± 3.13 hours</i>) up to 5 years (mean <i>3.3± 2.31 hours</i>; −<i>73.07%; p - 0.048</i>). Dyskinesias remained stable. Nursing time averaged 22 hours per patient per year after PEG-J insertion and titration. Most common complications were PEG-J tube dislodgement and pump malfunction in <i>18 (54.5%</i>) patients over the study period. <h3>Conclusions:</h3> Patients on ILI had improved motor scores, reduced OFF-times, and stable dyskinesias over 5-year follow-up. Most common complication was PEG-J dislodgement; serious complications were uncommon. Nursing time requirements necessitate ILI trained nurses. <b>Disclosure:</b> Dr. VEKHANDE has nothing to disclose. Dr. Hamed has nothing to disclose. Ms. Tremain has nothing to disclose. Mrs. Mah has nothing to disclose. Dr. Shetty has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Abbvie. Dr. Suchowersky has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for Syneos/Alexion. The institution of Dr. Suchowersky has received research support from Roche. The institution of Dr. Suchowersky has received research support from Wave LifeSciences. The institution of Dr. Suchowersky has received research support from CHDI. Dr. Suchowersky has received publishing royalties from a publication relating to health care. Dr. Suchowersky has received publishing royalties from a publication relating to health care.

S2788 A Rare Case of Duodenal Crohn’s Disease Presenting as Megaduodenum

Introduction: Crohn’s disease of the duodenum is exceedingly rare and accounts for less than 2% of Crohn’s disease cases, disease confined to the duodenum is an even rarer entity.[1] Megaduodenum is typically seen in infants and its presence in adults is the subject of a few case reports. We present an unusual presentation of an adult patient with Crohn’s disease presenting as megaduodenum. Case Description/Methods: A 20-year-old male with a history of gastroparesis presented with mild epigastric pain, intractable nausea, vomiting, and 60 pounds of weight loss over the last six months. The patient had severe food intolerance to the point where he required total parenteral nutrition. CT scan showed distention of the stomach with tapering of the proximal duodenum, followed by subsequent marked diffuse distention of the remaining duodenum with subsequent narrowing at the duodenojejunal junction. (a). An esophagoduodenoscopy (EGD) was performed that showed distended duodenum, a proximal duodenal stricture, and another stricture at the duodenojejunal junction with inflamed mucosa and severe stenosis which could not be traversed. (b,c). Biopsies showed duodenitis consistent with Crohn’s disease. A PEG-J tube was placed for enteral feeding which the patient did not tolerate and ultimately required resection of the distended duodenum. Discussion: Megaduodenum is usually congenital and is a rare entity in adults. In this case, duodenal distention was likely acquired and unfortunately required resection due to the severity of symptoms. In our opinion, the patient likely had skipped lesions in the duodenum with significant dilatation of the inflamed area. There was no colorectal involvement confirmed by a colonoscopy. Post-operative biopsies also confirmed Crohn’s disease in the duodenum.Figure 1.: (a): Megaduodenum on CT scan Figure (b): Duodenal distention on EGD Figure (c): Duodenal stricture on EGD.

Endoscopic ultrasound-guided gastrojejunostomy with lumen-apposing metal stent in a boy with neurological impairment requiring jejunal feeding.

Video 1EUS-guided, LAMS-assisted gastrojejunostomy for re-routing a PEGJ tube in neurologically impaired children.

Direct endoscopic placement of percutaneous endoscopic gastrostomies with jejunal extension tubes (PEG-J) using ultra-thin endoscopes - long-term outcomes from a U.S. tertiary referral center.

Several techniques for PEG-J tube placement have been described, commonly requiring fluoroscopic guidance and/or fixation of the jejunostomy tube (J-tube) into the small intestine. We describe a modified technique for placing jejunostomy tubes under direct visualization through a PEG with the use of ultra-thin endoscopes and steel guidewire. A retrospective study at a single tertiary academic center evaluating patients who underwent PEG-J placement between 2010 and 2020. All PEG tubes were placed with a pull-through technique. The Olympus GIF-N180 endoscope was advanced through the PEG to the jejunum and a Savary-Gilliard guidewire was used for placement of the J-tube extension. Fifty-eight patients underwent PEG-J placement (median age 61years; women 52%). Surgically altered gastric anatomy was observed in 11 patients (19%). Median procedure time was 44min for new PEG-J tube placement (range 26-103) and 20min for placement of a J-tube extension through an existing PEG tube (range 9-86) or gastrostomy tract. Technical success rate was in 100%. Sixty-two repeat procedures were performed for J-tube exchange in 27 patients (46%, range 1-9 per patient), of which 51 procedures (82%) were done using the same technique. The most common indication for tube replacement was tube dysfunction (63%, n = 39). The median procedure time for tube exchange was 20min (range 2-62). No major adverse events were encountered. PEG-J tubes can be placed effectively, rapidly, and safely using an ultra-thin caliber endoscope and a stiff steel wire through the PEG tube or mature gastrostomy site, precluding the need for fluoroscopy or oral access. J-tubes can be easily replaced utilizing the same technique.

S2216 A Knot in My Stomach: A Rare Cause of a Malfunctioning PEG-J Tube

Introduction: Gastrostomy and jejunostomy tubes are placed to provide long term nutrition. Tube malfunctioning is not uncommon and usually due to coiling, occlusion, and malpositioning. We report a rare case of percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) tube malfunction due to a knot formation. Case Description/Methods: A 45 year old female with history of traumatic brain injury with resultant tracheostomy and PEG-J tube, presented from a nursing home for PEG-J tube malfunction. The PEG-J tube was noted to be torn externally with an inability to administer feeds or medications. An abdominal CT scan revealed a percutaneous G-J tube with the balloon inflated within the gastric body, a portion of the tube coiled within the duodenum, but the distal end in the proximal jejunum. Bedside removal of the tube was unsuccessful due to significant resistance. She then underwent upper endoscopy which revealed an intact gastrostomy with the internal balloon properly inflated in the gastric body. The jejunal extension was found to have a knot in the tube in the gastric portion with the remainder of the tube extending into the duodenum. The distal end of the PEG-J was grasped with a snare, cut externally, and the knotted portion was withdrawn with the scope. A replacement PEG was then placed via the gastrostomy. The patient was subsequently discharged without further complication. Discussion: Enteral feeding tubes provide nutrition in patients who are unable to tolerate oral diet. This can be achieved with feeds administered into the stomach, or into the small bowel via gastrostomy with a longer tube, or via direct access into the small bowel. Jejunal feeding is preferred in patients with gastric bypass, gastroparesis, gastric outlet obstruction or refractory peptic ulcer disease. Complications of PEG-J tubes include coiling, kinking, malpositioning, and occlusion. There are six previously reported cases of knotted PEG-J tubes causing tube malfunction. A proposed mechanism is that the longer tube inserted distally into the GI tract is prone to coiling during peristalsis, which can lead to knot formation. Knotting of a PEG-J tube is a rare complication that may not be apparent on imaging as in this patient. It is important to consider this complication when deciding on the method of enteral feeding. It should also be considered in the differential diagnosis in a case of a malfunctioning PEG-J tube, especially if the tube cannot be removed bedside due to increased resistance to removal.Figure 1.: Knotted PEG-J.

Adverse Event Fatalities Related to GI Endoscopy.

Death after endoscopy is rare, under-reported, and has variable causes. This study aimed to evaluate the incidence and causes of fatal endoscopic adverse events (AEs) across two academic medical centers and to identify patient-, procedure-, and sedation-related risk factors. This is a retrospective cohort study of fatal adverse events causally related to endoscopy at Denver Health Medical Center and the University of Colorado Hospital from 2011 to 2020. Fatal AEs were retrieved from the physician-reported database. Electronic medical records were then reviewed to determine medical history, procedure details, subsequent treatments, and time and cause of death. From January 2011 to January 2020, 146,010 GI endoscopy procedures were performed. Median patient age was 70 [51-78] and 57% were male. Thirty-one deaths were identified, 28 of which were attributed to endoscopy, yielding a procedure-related fatality rate of 0.018%. Procedures included 11 EGDs, one colonoscopy, two flexible sigmoidoscopies, six ERCPs, seven upper EUS, and one PEG-J tube placement. Specific causes of death included aspiration in four patients (14%); cardiac arrest or myocardial infarction in seven patients (25%); perforation in nine patients (32%); bleeding in four patients (14%); cholangitis or sepsis without perforation in three patients (11%); and acute pancreatitis in one patient (3.6%). Fatal endoscopic AEs were rare but tended to occur in older patients with major comorbidities. Most deaths occurred from aspiration pneumonia, cardiac arrest, or perforation-related sepsis within 1week of the procedure.

PEG J tube placement with optimization of J tube insertion.

We present a case series of 5 patients who underwent placement of a PEG tube followed by a J extension tube (PEG-J). PEG-J placement is usually performed as a 2-step procedure and is used for a variety of conditions such as gastroparesis. First, the PEG tube is placed using endoscopic transillumination, followed by tube placement with the pull method, and trimming of the PEG tube to approximately 20 cm. This is followed by insertion of the J extension tube through the PEG tube; the J extension tube is grasped by an endoscope and guided through the pylorus to a position distal to the ligament of Treitz. Two common problems related to the length of the PEG tube portion can occur when placing the J tube. A short PEG tube may not allow advancement of the J tube distal enough because of looping. On the other hand, a PEG tube that is too long can prevent adequate J tube insertion. Although the adverse events of PEG tubes are well documented, we did not find any published literature addressing problems with the placement of J tube extensions, although it is a frequently occurring problem in our clinical practice. Therefore, we have tried to address this problem. We present our technique for PEG-J tube placement, which allows optimal PEG tube length independent of the depth of J tube insertion. After PEG tube placement with the pull method, only the introducer is cut, and the entire length of the silicon PEG tube is left in situ. The tip of the J tube is lubricated and inserted into the PEG tube. In parallel, the J tube is grasped, in our cases with an endoclip, and gently maneuvered into the duodenum and eventually into the jejunum while the J tube is threaded into the PEG tube, matching the pull force from the J tube insertion by the endoscope. We use a pediatric colonoscope to achieve deep jejunal intubation; however, either the adult colonoscope or enteroscope are adequate alternative endoscopes. Once the J tube seal reaches the silicon portion of the PEG tube and further introduction is needed, a 5- to 10-cm portion of the silicon is cut using the sharp tip of the scissors provided with the PEG tube kit (Fig. 1). These steps of “peel and advance” are repeated until the J tube is advanced to the desired location and clipped to the jejunum mucosa. This technique allows optimal J tube placement without gastric looping or a too-short jejunal J tube insertion (Fig. 2). We followed all patients over 4 weeks. No PEG-J tube replacement adverse events were noted. Two patients had abdominal imaging at 4 weeks documenting optimal J tube placement without J tube loops or short J tubes resulting in proximal migration of the J tube (Video 1, available online at www.giejournal.org). All authors disclosed no financial relationships. https://www.videogie.org/cms/asset/9bec0238-72be-450f-8dbd-3862997703e4/mmc1.mp4Loading ... Download .mp4 (104.88 MB) Help with .mp4 files Video 1PEG-J tube placement with optimization of J tube insertion.

S2371 Endoscopic Vacuum Therapy (EVT) for the Successful Treatment of Duodenal Fistula

INTRODUCTION: Perforation is a devastating complication. The solution has always been surgical. At the Minneapolis, we have encountered a case of complicated duodenal ulcer which failed both surgical and radiology interventions. The EVT finally achieved the closure. CASE DESCRIPTION/METHODS: A 65 y/o veteran presented with persistent vomiting and weight loss. Initial CT revealed a large stomach and a duodenal wall thickening. EGD showed a large amount of bezoar, reflux esophagitis, and ulcerated duodenal stricture that only 6mm endoscope could pass. A 15 mm Axio stent was placed in the stricture. The patient’s symptoms improved and the stent was removed after 3 weeks. Two weeks later, the symptoms recurred. NPO and TPN were initiated. Repeat EGD revealed a pin point pylorus that could not be traversed. Liquid contrast was injected. A duodenal fistula between the duodenal bulb and sub-hepatic space was identified. A surgical procedure was then performed consisting of pylorus exclusion, gastro-jejunostomy (GJ), and sub-hepatic drain, Continuous bilious material via the sub-hepatic drain continued. The patient was unable to tolerate any oral intake. A PEG-J tube then was inserted by the Interventional radiology. Afterwards, the patient’s abdominal pain and drainage increased. Another EGD was performed. This time, a wide-open GJ was seen. The tube was found to pass through the suture line of the “excluded pylorus”. There were 2 additional disruptions at suture line. The PEG-J tube was repositioned into the GJ. The 3 open disruptions at the suture lines were cauterized using argon plasma and then closed using two 8mm and one 12mm Ovasco clips. Within a week, the percutaneous drain from the fistula decreased by 80%. But abdominal pain continued. A fifth EGD was performed to initiate EVT. A new PEG-J tube was inserted through the GJ into the duodenum loop. The distal tip loop string of the tube was secured onto the duodenal wall using 3 small endo-clips. High vacuum suction was applied to the J-port. Within a few days, all drainage from the fistula had ceased. A sixth EGD showed that 1 of the 3 Ovasco clips had fallen off so that standard 9mm endoscope could pass. The duodenal bulb was narrowed. The fistula resolved. The PEG-J was removed. DISCUSSION: EVT is a very effective treatment for perforation and fistula. The fundamental basis is to evacuate gastric, bile, and pancreatic secretions near the internal wound. This therapy should be considered as first-line rather than last resort.

S2034 An Uncommon Cause of Chest Pain: Acute Esophageal Necrosis

INTRODUCTION: Acute esophageal necrosis (AEN) is a rare but important cause of hematemesis, melena, dysphagia, and chest pain typically seen in patients with vascular disease in which esophageal necrosis circumferentially embodies the esophagus with GEJ (gastroesophageal junction) sparing. We present the case of chest pain and hematemesis secondary to AEN. CASE DESCRIPTION/METHODS: A 70-year-old male with ESRD, DM, prior CVA on Eliquis, with altered mental status, hypotension, neck, back, and chest pain. In the ED, he was hypotensive 67/51mmHg, and had coffee ground emesis. Hemoglobin decreased from 9.9 to 7.1g/dL requiring blood transfusions, PPI drip, and ICU admission. Upper endoscopy demonstrated diffuse, severe mucosal necrosis with black necrotic tissue in the middle and lower thirds of the esophagus (Figure 1, 2), but with normal tissue and sparing of the GEJ (Figure 3). A percutaneous gastrojejunostomy tube was placed. The patient had clinical improvement, but expired after a prolonged hospital course. DISCUSSION: Acute Esophageal Necrosis is a rare endoscopic finding defined by diffuse, circumferential black mucosa that spares the GEJ. More common in older males, and associated with heart failure, atherosclerosis, diabetes, renal failure, and cancer, its etiology remains uncertain though may be from severe underlying chronic disease, progressive vascular insufficiency, reduced mucosal barriers, and gastric regurgitation. Due to less blood, this pathology starts in the distal third of the esophagus, progressing proximally. The GEJ is spared due to increased vasculature. Though a rare cause of chest pain, it is important to consider AEN due to its significant complications of perforation and stricture and high mortality rate. Currently, there are no guidelines for management, though esophageal rest, intravenous fluids, and improved nutrition via PEG-J tube or parenteral nutrition are generally sought after. Though rare, AEN should be considered in patients with severe chest pain due to its significant complications and a high mortality rate, and further studies are needed to aid in management to improve patient outcomes.Figure 1.: Diffuse, severe necrotic tissue encircling the esophagus.Figure 2.: Necrotic tissue circumferentially encompassing the esophagus.Figure 3.: Necrotic tissue of the distal esophagus with abrupt transition point with sparing of the GE junction.

S0559 Dislodgement and Perforation in Endoscopic Percutaneous Enteral Tube Placement: Jejunal Extension Risk and Chemotherapy Administration Outcomes

INTRODUCTION: Gastrointestinal perforation is a significant risk in almost all endoscopic procedures. Tube dislodgement is unique to percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) placement. We assessed associated risks of PEG and PEG-J tube PD in all patients (pts) as well as those with malignancy who received chemotherapy. METHODS: 509 pts identified by diagnostic codes for initial attempt at PEG or PEG-J tube placement from 2012-2017 were retrospectively reviewed. 29 pts were excluded from analysis due to aborted procedures and lack of outcome data. Figure 1 PD related complications were defined as radiographical, endoscopic, or surgically confirmed perforation or frank tube migration requiring medical or procedural intervention within 6 months from procedure date. As only 3 perforations occurred with 2 having concurrent tube dislodgements, PD was considered as a composite outcome in analysis. Initial chemo, demographic characteristics, maneuver type, tube size, antiplatelet or anticoagulant use (AAU), malignancy status, baseline proton pump inhibitor (PPI) and histamine receptor 2 antagonist (H2RA) use, body mass index (BMI), diabetes status, and albumin levels were collected Table 1. Univariate and multivariate models were used to assess association of risk factors with PD outcome of interest. RESULTS: Of the 480 pts in the study, 22 (4.6%) developed tube dislodgement with 3 (0.6%) suffering perforation. Median time to PD was 22 days (IQR 7–52). 73 (15%) specifically underwent PEG-J placement. Over half the study population (56%) had malignancy and 167 (33%) received chemotherapy. 1 of 3 perforations occurred at time of procedure and 1 of 3 perforations involved PEG-J placement. Age ≥ 70, tube size (≤20 Fr vs > 20 Fr), baseline malignancy, PPI/H2RA use, AAU, albumin < 3, and BMI < 18 or >30 did not increase risk of PD on univariate analysis Table 2. Chemotherapy within 30 days prior to 15 days after the procedure did not increase odds of PD on univariate (0.642, CI 0.14–2.81, P < 0.55) or multivariate analysis (OR 0.789, CI 0.17–3.56, P < 0.75) while PEG-J procedures increased risk of PD in both (OR 3.94, CI 1.64–9.49 P < 0.0022 and OR 3.81, CI 1.55–9.33 P < 0.0034, respectively) Table 2. CONCLUSION: PD incidence in percutaneous endoscopic enteral tube placement is not influenced by chemotherapy administration even when given in the periprocedural period. PD remains higher in PEG-J procedures and is primarily related to jejunal extension malfunction.Figure 1.: Flowchart of study exclusion.Table 1.: Characteristics of patients undergoing initial percutaneous endoscopic enteral tube placement (2012–2017)Table 2.: Univariate and multivariate associations with perforation or dislodgement following endoscopic percutaneous enteral tube placement

A144 A MULTIDISCIPLINARY TEAM APPROACH REDUCES PEG SITE COMPLICATIONS

Abstract Background Education provided to patients and their family on how to care for the percutaneous enteroscopic gastrotomy (PEG) tube is limited and varies widely. This can result in site and tube complications, patient discomfort and increased health care utilization. In addition, a lack of practitioner expertise and variability in practice can affect timely treatment of PEG site complications. Continuous Levodopa/Carbidopa Intestinal Gel (LCIG) has become a standard of treatment option for patients with advanced Parkinson Disease. This medication is delivered by a jejunal tube through a PEG tube (PEG-J). Previous studies in this population reported up to 40% of adverse events related to the PEG site. At Toronto Western Hospital, we developed a multidisciplinary team (MDT), involving a gastroenterologist, a clinical nurse specialist (CNS) with expertise in wound and stoma care and the movement disorder clinical nurse to care for the PEG-J in this patient population. Aims To evaluate the effectiveness of our MDT in reducing PEG site complications and health care utilization. Methods Consecutive PEG-J patients (n=33) assessed by the MDT between October 2018 and September 2019 were provided standard education on the routine care and maintenance of PEG site complications. The CNS uses a systematic approach to prevent, assess and treat PEG site complications. Before and after the MDT approach, patients were seen the day after the PEG insertion (POD 1), 2 weeks after (titration) and then ad hoc determined by incidence of mild, moderate and severe complications. Post implementation of a MDT approach, patients are seen POD 1, at titration and every 3–6 months during routine visits to the Movement Disorder Clinic. Table 1 outlines classification and suggested treatment based on severity for mild, moderate and severe PEG site complications. Results The systematic MDT approach completely eliminated all unscheduled, urgent contact to the health care providers by patients who have been assessed and provided education by the MDT (n=33), including new PEG-J (n=7) and previously inserted PEG-J (n=26). 28.5% of new PEG-J patients had moderate or severe site complication rate, 71.5% had mild or no complications. In the group of patients with previously inserted PEG-J tubes, 58% had moderate or severe site complications, 42% had mild or no complications. Conclusions An interprofessional MDT systematic approach drastically reduces PEG site complications and urgent health care utilization. Patients who receive standardized education pre- and post-insertion have a lower incidence of moderate or severe classification of PEG site complications and unscheduled clinic visits. Funding Agencies None

A156 LOW COMPLICATION RATE IN THE OUTPATIENT INTRAJEJUNAL LEVODOPA/CARBIDOPA INTESTINAL GEL CLINICAL PROGRAM

Abstract Background Levodopa/carbidopa intestinal gel (LCIG) is a formulation that is delivered continuously through a percutaneous endoscopy gastro-jejunal tube (PEG-J) for the treatment of patients with advanced Parkinson’s disease (PD). LCIG significantly reduces periods of increased motor symptoms without troublesome dyskinesia. Adverse events related to this treatment have been attributed to PEG-J insertion and the device used for LCIG delivery, rather than to the LCIG preparation itself. To date, the data evaluating long-term efficacy and safety of PEG-J insertion for LCIG administration in the outpatient setting is limited. Aims The aim of this study is to describe short and long-term adverse events (AEs) associated with outpatient PEG-J tube insertion for LCIG administration at our centre. Methods A retrospective chart review was performed of all PD patients who underwent PEG-J insertion for LCIG therapy at Toronto Western Hospital from March 2011 to October 2019. All AEs associated with PEG-J insertion were collected including procedure and tube related complications, hospital admissions, emergency room (ER) visits and deaths. Data was analyzed using descriptive statistics. Results A total of 58 patients were identified and included in the final analysis. 37 (64%) male, with a mean age of 74 years +/-6.17. The mean duration of PD diagnosis prior to PEG-J insertion was 16.5 years +/-2.0. Mean time from PEG-J insertion to data collection was 37.5 months +/- 19.3. 30 (51%) patients had post-procedural abdominal pain or site pain. This pain improved with over the counter analgesics. 9 (16%) had possible site infection; 6 received oral antibiotics and 3 had the tube replaced. 19 (33%) developed granulation tissue, with only 2 patients requiring tube exchange. 32 (55%) had their tube removed or exchanged secondary to PEG-J malfunction. No ER visits related to the PEG-J were recorded. During the data collection period, 12 (21%) patients died for reasons unrelated to PEG-J insertion. There were no reported serious adverse events (SAEs), including post-procedure perforation, bleeding, fistula formation, development of intra-abdominal collections or buried bumper syndrome. Conclusions This study demonstrates the absence of serious AEs associated with outpatient PEG-J insertion for LCIG administration in patients with advanced PD. The most common short-term AE was post-procedural pain. The most common long-term AE was related to PEG-J malfunction requiring replacement. This study supports that the current method of outpatient PEG-J insertion for the administration of LCIG is safe in patients with advanced PD. Funding Agencies None

888 Percutaneous Gastrojejunostomy Tubing Utilization and Safety With Levodopa-Carbidopa Intestinal Gel in Advanced Parkinson’s Disease Patients: Interim Results of the Long-Term DUOGLOBE "Real-World" Observational Study

INTRODUCTION: Levodopa-carbidopa intestinal gel (LCIG, carbidopa-levodopa enteral suspension [CLES] in the US) administered via percutaneous gastrojejunostomy (PEG), a jejunal (J) extension tube and an external pump is a long-term treatment option for patients with advanced Parkinson’s disease (aPD). Limited data exists on PEG-J component utilization and replacements during LCIG treatment in a ‘real-world’ setting. This interim analysis investigated the routine clinical practice of PEG-J insertion and component replacements of the device and associated safety. METHODS: DUOGLOBE is an ongoing multinational observational study with 3-year follow-up. This interim analysis included patients who had the PEG-J insertion procedure from 55 global sites. The type of tubing used, frequency of and reasons for tube replacements, and Serious Adverse Events (SAEs) were assessed. This analysis was not powered for statistical comparisons. RESULTS: This interim dataset had 188 patients with PEG-J tube placement (mean duration of PEG-J exposure: 515.8 days); 178 patients with PEG-J tubing manufacturer data were included in this analysis. At initial PEG-J tube placement, 83% (n = 148) of patients received AbbVie-proprietary tubing and 17% (n = 30) received non-AbbVie tubing. Most patients 79% (n = 141) did not require a PEG-J replacement. Patients needing any PEG-J replacement was similar between AbbVie and non-AbbVie tubing (22% and 17%); 5% of patients (n/N = 7/148) with AbbVie tubing required 2 PEG-J replacements (n/N = 0/30 for non-AbbVie tubing). In the first 12 months, Kaplan-Meier estimates demonstrated that 84% of patients did not require a tube replacement with AbbVie tubing (non-AbbVie tubing, 89%). The most common reasons for the first PEG-J replacement for AbbVie tubing was a routine, preplanned procedure (6%), PEG-J dislocation (4%), occlusion and leaking (each 2%), and other (5%); for non-AbbVie tubing PEG-J dislocation (10%) was the only reported reason. Overall, 38% of patients experienced an SAE who had AbbVie tubing (n = 56) and 47% for non-AbbVie tubing (n = 14). Gastrointestinal (GI)-related SAEs were reported in patients [n(%)] with AbbVie tubing [8(5%)] and non-AbbVie tubing [6(20%)]; 1 (1%) and 2 (7%) patients discontinued due to a GI-related AE, respectively. CONCLUSION: This interim analysis of patients in a multinational observational study with LCIG demonstrated that most patients did not require PEG-J tube replacements in a real-world setting and safety was similar to the known safety profile of LCIG.

2648 A Case of Amebiasis in a Patient With Familial Hypertriglyceridemia Complicated by Recurrent Pancreatitis

INTRODUCTION: Amebiasis disproportionately affects people in developing countries because poor sanitation conditions increase the risk for pathogen acquisition. In the United States, individuals who travel to endemic areas and men who have sex with men are two groups at higher risk of exposure. The following case highlights the importance of exposure history and avoiding anchoring bias. The patient’s constellation of symptoms could be explained by his history of chronic pancreatitis and pancreatic insufficiency, but upon further investigation he was also found have an infective enteritis. CASE DESCRIPTION/METHODS: A 44-year-old man with a past medical history significant for type 2 diabetes mellitus, idiopathic small fiber neuropathy, and familial hypertriglyceridemia complicated by recurrent pancreatitis was admitted for recurrent symptoms of nausea, vomiting, non-bloody diarrhea, and abdominal pain. Within the previous year, the patient had a PEG-J tube placement for nutritional support in the setting of severe pancreatitis complicated by acute fluid collections. On arrival to the emergency department, he was tachycardic and labs revealed a leukocytosis of 18 × 103 µL, lipase of 510 U/L, and normal LFTs. The CT scan showed a stable pancreatic pseudocyst and no suggestion of acute pancreatitis. Imaging did reveal mild thickening and dilated loops of small bowel consistent with enteritis in the left mid and left lower abdomen. Stool pathogen panel sent during previous admission had returned positive for Entamoeba histolytica (E. histolytica). The patient endorsed drinking well water from his backyard and using it to flush his PEG-J tube. DISCUSSION: The majority of amebiasis cases are asymptomatic, however 10% are associated with significant morbidity and mortality. E. histolytica is one of four species of intestinal amebae and the one related most to symptomatic disease. Malnutrition, which was present in our patient, is a risk factor for severe disease. Studies have shown that interaction between the host’s intestinal flora and E. histolytica may influence pathogenic behavior. Our patient's treatment regimen consisted of metronidazole, which is active against the trophozoite stage, and paromomycin, which eliminates intraluminal cysts. His source of exposure was likely the well water which was uncovered through a detailed exposure history.

A235 Removal of and Revision after Horizontal Mesh Gastroplasty for Dysphagia and Obstruction

A 67-year-old woman underwent two prior bariatric operations, the latter in 1982 believed to be a horizontal mesh band gastroplasty. She had chronic history of nausea, vomiting and esophagitis, and was transferred acutely to our tertiary referral bariatric center with worsening symptoms of gastric obstruction. Endoscopy showed an hourglass stomach with a waist-like stricture in the mid-stomach. This stricture was dilated to 18 mm, but her symptoms did not improve and an upper GI study showed significant esophageal and proximal gastric dilation with a persistent mid-body narrowing. A PEG-J tube was placed to allow for proximal gastric decompression with the distal “jejunal” tip placed in the distal stomach to allow for nutrition optimization.

Novel Modified Seldinger Technique for Gastrojejunal Feeding Tube Placement

Background:Temporary or long-term nutritional support through gastrojejunal (GJ) feeding tubes is a safe and common means of enteral feeding in adults and children. It is indicated in patients with severe gastroesophageal reflux disease, gastric outlet obstruction, or severe gastric dysfunction or gastroparesis. Several techniques for GJ feeding tube placement have been reported. The most technically challenging part of GJ tube placement is the advancement and optimal positioning of the jejunal extension into the proximal jejunum.Methods:A novel modified Seldinger technique was used for endoscopic placement of a percutaneous low-profile GJ tube (14 French). After gastric access was established, a dilator was advanced under endoscopic vision into the pylorus. Under fluoroscopy, a guidewire was threaded through the dilator into the duodenum. The dilator was then removed, and the GJ tube advanced over the guidewire.Results:A total of 12 patients including 9 pediatric and 3 adult underwent the procedure with no complications. The main indication was gastroparesis with oral intolerance of food. The median operative time was 41.5 minutes. All patients tolerated jejunal tube feeding after surgery.Conclusion:The modified Seldinger technique for percutaneous endoscopic GJ tube placement is a safe and efficient procedure in both children and adults. Further studies are necessary to prove its reproducibility in other centers and to compare it to other methods of PEGJ tube placement.

Long-term PEG-J Tube for Treatment Delivery in Patients With Advanced Parkinsonʼs Disease

Introduction: Duodopa® is a modern treatment for advanced stages of Parkinson's disease (PD) administrated via PEG-J by means of a tube connected to an external pump. Duodopa® is delivered continuously in small quanta preventing large plasma level fluctuations and thus suppressing disabling motor complications related to oral treatment in advanced stages of PD. Methods: We retrospectively analyzed records from 51 PD patients (23 males; mean age 66 (SD) 8 years) treated in the Movement Disorders Center in Prague with Duodopa® PEG-J. Time on PEG-J, weight, Duodopa® dose and adverse effects were analyzed. Results: The mean time on PEG-J was 3.7 (IQR 0.6 - 3.2) years. Adverse effects occurred in 36 (71%) patients commonly manifested by inflammation around the PEG-J stoma (17 pts). Other common side effects were technical problems with the pump (13 pts), excessive tissue granulation (7 pts) or tube dislocation (6 pts). The overall mortality was 24%, with no relationship to PEG-J complications. Out of the surviving patients, treatment was stopped in 11 (23%) due to lack of efficacy and in 4 (8%) due to intolerable side effects related to the PEG-J. In addition, there was an interaction between the change of the Duodopa® dose, change in body weight and PEG-J duration (p=0.023) (Figure 1).FigureConclusion: Despite the relatively high frequency of side effects during Duodopa® treatment, the PEG-J was well tolerated in the majority of PD patients during a relatively long follow-up. Surprisingly, the Duodopa daily consumption co-varied with body weight in different ways according to various durations of the treatment.

Insertion of percutaneous endoscopic gastrostomy tubes with jejunal extensions using the "wedge" technique: a novel method to prevent retrograde tube migration into the stomach.

Background and study aim In percutaneous endoscopic gastrostomy (PEG) with jejunal extension (PEGJ) procedures, retrograde migration of the jejunal extension tube into the stomach during endoscope withdrawal is a frustrating problem. We describe the novel "wedge" technique for inserting the jejunal extension tube, utilizing single-balloon enteroscopy to anchor it in place. Patients and methods Prospective 1-year study of consecutive patients undergoing PEGJ insertion at a single tertiary care center. The primary outcome was number of pyloric intubations required to place the jejunal extension tube. Secondary outcomes included success rate, time, and complications related to jejunal extension tube insertion. Results 17 patients underwent the procedure. The jejunal extension tube was inserted at the first attempt in 15 patients (88.2 %) and 2 required another pyloric intubation. Abdominal X-ray showed that all PEGJ tubes were successfully seated in the proximal jejunum. The mean (SD) time required for jejunal extension insertion was 16.9 (8.6) minutes. Two adverse events occurred due to PEG insertion although none were related to the jejunal extension insertion itself. Conclusions: The "wedge" technique is an effective and easy method for inserting a jejunal extension tube after PEG insertion.