PEG-J Tube Research Articles

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.

Mo1195 A Novel Method for Peg-J Tube Insertion Using Single Balloon Enteroscopy and the Wedge Technique

Mo1195 A Novel Method for Peg-J Tube Insertion Using Single Balloon Enteroscopy and the Wedge Technique

OC.02.4: The Role of the Gastroenterologist in Advanced Parkinson’s Disease: Continuous Infusion of Levodopa-Carbidopa by PEG-J Tube

OC.02.4: The Role of the Gastroenterologist in Advanced Parkinson’s Disease: Continuous Infusion of Levodopa-Carbidopa by PEG-J Tube

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

Placement of the Abbvie Peg-J Tube for the Treatment of Parkinson's Disease in the Interventional Radiology Suite

The primary treatment for Parkinson's disease is dopaminergic stimulation. Although levodopa has historically been administered orally, maintaining a predictable plasma concentration of the drug is challenging. As a result, enteral administration of carbidopa/levodopa (Duopa) has emerged as a promising tool in the treatment of the disease. This requires placement of an enteric catheter, two of which have been approved by the Food and Drug Administration for delivery of Duopa. The approved tubes are placed using the “peroral” or “pull” technique, a method traditionally requiring endoscopy. This technical note describes placement of the AbbVie PEG-J tube by means of the peroral route while utilizing only sonographic and fluoroscopic guidance. After placing an orogastric tube and achieving percutaneous access to the stomach under fluoroscopic visualization, a snare catheter is advanced through the percutaneous access into the stomach. The orogastric tube is engaged with the snare and retracted, bringing the attached snare with it to the mouth. The AbbVie PEG tube is attached to the snare, pulled back down the esophagus and into the stomach before being retracted through the percutaneous access to the skin. Finally, the AbbVie J tube is advanced through the gastrostomy tube into the proximal jejunum and attached with the provided connectors. As demonstrated, the AbbVie PEG-J tube can be placed safely and effectively using a percutaneous image-guided technique without the use of an endoscope.

Practical Use of the Levodopa Pump

Patients with advanced Parkinson's disease and motor complications undergoing optimized oral therapy can significantly benefit from continuous intrajejunal levodopa/carbidopa infusion applied by means of a medication pump. However, this requires a correctly positioned PEG-J tube and finely adjusted pump settings. Although this method is a routine procedure in specialist centers, no standard procedure has been defined up to now. For this reason, an expert recommendation regarding the practical application has been developed in order to standardize the procedure and facilitate patient access to this treatment option.

Outpatient titration of carbidopa/levodopa enteral suspension (Duopa)

Carbidopa/levodopa enteral suspension (CLES; Duopa) is a suspension or gel formulation of carbidopa/levodopa that is approved by the USA Food and Drug Administration for the treatment of advanced Parkinson's disease patients with motor fluctuations. CLES is delivered at a constant rate continuously throughout the day into the jejunum through an infusion pump via a PEG-J tube implanted surgically. The efficacy of CLES was established in the USA based on a randomized, double-blind, double-dummy, active controlled, parallel group and 12-week study, in which mean daily OFF time was reduced by 4.0 h, compared to 1.9 h with oral immediate release carbidopa/levodopa. The CLES hardware consists of a cassette containing the drug, a pump to deliver the drug and tubing to connect the PEG-J to the pump. It is critical to understand the appropriate conversion of the carbidopa/levodopa daily dosages to the CLES dosage and how to program the pump and titrate CLES to achieve the most effective dose. We describe one methodology for patient selection, outpatient titration and pump programming.

Carbidopa levodopa enteral suspension

Introduction: The search for consistent, effective treatments in Parkinson’s disease (PD) is ongoing. The importance of continuous dopaminergic stimulation (CDS) is understood to underlie best medical therapy for PD by providing closer replication of physiological patterns of dopamine release in healthy brains.Areas covered: An overview of interventions to improve motor fluctuations in PD is presented. Significant improvements in off-time are achieved by providing continuous therapy using targeted deep brain stimulation (DBS), subcutaneous apomorphine infusion and carbidopa/levodopa enteral suspension (Duopa). Duopa is a newly approved treatment in the US for advanced PD that delivers levodopa pumped to the intestinal tract through a percutaneous gastrostomy with jejunum tube extension (PEG-J tube). Trials with carbidopa/levodopa enteral suspension show improvement in motor fluctuations, reduction in plasma levodopa variation and improvement in overall “on” time compared with oral immediate release formulation of carbidopa/levodopa.Expert opinion: The degree of improvement in number of off hours per day on carbidopa/levodopa enteral suspension infusion rivals that seen with DBS and apomorphine infusion and makes this new treatment a valuable option in advanced fluctuating PD patients, especially those who are neither candidates for DBS or who do not have access to apomorphine infusion therapy or who have failed either or both therapies.

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.

Mo1403 Gastrojejunal Tube Feeding: a Potential New Treatment for Sphincter of Oddi Dysfunction Type III (SODPPP) Patients With Severe Post-Prandial Pain

Mo1403 Gastrojejunal Tube Feeding: a Potential New Treatment for Sphincter of Oddi Dysfunction Type III (SODPPP) Patients With Severe Post-Prandial Pain Tae Joo Jeon*, Byung Kyu Park, Laith H. Jamil, Simon K. Lo Cedars-Sinai Medical Center, Los Angeles, CA; Division of Gastroenterology, Inje University Sanggye Paik Hospital, Seoul, Korea (the Republic of); Division of Gastroenterology, National Health Insurance Service Ilsan Hospital, Goyang-si, Korea (the Republic of) Background: ERCP and Sphincterotomy had been widely used to evaluate and treat the Sphincter of Oddi dysfunction (SOD) type III condition until their benefit was disputed by the recent EPISOD study. Unfortunately, there is no proposed alternative to manometry-directed sphincterotomy at the present moment. Aim: To determine if gastrojejunal tube (PEGJ) feeding may have therapeutic benefits for SODPPP patients. Method: All SODPPP patients without sustained improvement after bi-ductal sphincterotomies were offered percutaneous endoscopic gastrostomy-jejunostomy tube (PEGJ) feeding. SOD III was defined by pancreatic or biliary type pain without a dilated duct or abnormal pancreatic or liver tests. PEGJ was placed in the usual fashion and inserted into the proximal antrum. PEGJ’s tip location in the proximal jejunum was confirmed with fluoroscopy. Strict NPO was kept within the first 4-6 weeks. PEGJ feeding was maintained as long as these patients needed feeding to provide nutrition or pain relief. Results: Nine highly symptomatic SODPPP patients underwent PEGJ tube insertion for feeding. All were female. Median age was 41 years old (25-53). Median duration of SOD symptoms was 27 months (22-96). All but one patient had elevated pancreatic or biliary sphincter pressure. Only one patient did not have a prior cholecystectomy. Eight patients had sphincterotomy and experienced pain improvement for a short duration (median; 8 weeks) before recurrence of symptoms. The mean duration of tube feeding was 5.08 months (S.E 1.83). Seven patients reported dramatic pain improvement. Six had less number of hospitalizations or ER visits after PEGJ feeding. Five patients were satisfied with the procedure and could return to normal daily activities while on tube feeding. Only 1 patient was not satisfied because of the lack of effectiveness. The demand of analgesics was decreased in 5 patients. Complications included prolonged tube insertion site pain-2, pinkish drainage-1, and nausea-1. Persistent insertion site pain was the reason for tube removal on day 7 in on patient. There were 4 tube malfunctions (J-tube dislodgement-2, tube coiling-1, broken tube-1). PEGJ had since been removed in 5 patients (no benefit-1, dramatic clinical improvement-1, husband’s disagreement-1, unsightly catheter-1, insertion site pain1). Interestingly, those 2 patients who had tube removal due to personal issues eventually requested PEGJ re-insertion. Conclusion: PEGJ feeding may have therapeutic benefits for the subset of highly symptomatic SOD III patients with postprandial pain exacerbations. It may represent a breakthrough in the management of these patients and should be confirmed by a larger, prospective clinical study.

Randomized Study of Radiologic vs Endoscopic Placement of Gastrojejunostomies in Patients at Risk of Aspiration Pneumonia.

Objective: In patients at risk of aspiration pneumonia due to gastroesophageal reflux who require gastrojejunostomy feeding tubes, the tubes are placed either radiologically (RIGJ) or endoscopically (PEGJ). There is little published evidence of the superiority of one technique over the other. Methods: Patients referred for long-term jejunal feeding were randomly allocated to have a 14F RIGJ or 15F with 9F jejunal extension PEGJ inserted. A technetium-99m (99mTc) colloid study was done to determine the presence of gastroesophageal reflux and jejunogastric reflux after feeding tube placement. We recorded enteral feed and tube-related complications, in addition to tube-related morbidity and mortality to 90 days following placement. Results: Baseline characteristics were similar between groups, with gastroesophageal reflux demonstrated in 52%. Following enteral tube placement, gastroesophageal reflux was not observed by 99mTc studies or any difference in clinical outcome to 90 days after placement. No jejunal tubes were displaced in any of the 31 RIGJ tubes, while 9 tubes were displaced in the 34 PEGJ patients (P = .008). Reversible jejunal tube blockages occurred: 19 RIGJ (5 patients) and 61 PEGJ (11 patients) (P = .003, χ2 = 9.1). Conclusion: There was little difference between the 2 tubes for clinical outcomes. RIGJ tubes were less prone than PEGJ tubes to reversible blockage and displacement. It is likely that the better outcome for RIGJ tubes relates to their larger tube diameter and stiffness.

Emerging Role of Endoscopically Placed Feeding Tubes in Pregnant Women with Poor Oral Nutrition Leading to Successful Fetal and Maternal Outcomes: Presidential Poster

Purpose: Studies have shown that poor nutrition during pregnancy can adversely affect maternal and fetal outcomes. We successfully managed three pregnant women with declining nutrition by inserting feeding tubes endoscopically. Patient 1 was a 37-year-old G8P4A4L4 woman at 27 weeks of gestation who was admitted for a pontine hemorrhage. The patient was started on NG tube feeds. No neurologic improvement was seen in 2 weeks and a PEG tube was inserted endoscopically. Fetal condition was stable on initial serial evaluations. However, at 31 weeks of gestation, a cesarean-section was performed for a non-reassuring fetal heart rate and a pre-term infant was delivered with improving Apgar scores (Table 1). Patient 2 was a 25-year-old G2P0A0L1 woman at 18 weeks of gestation who presented with vomiting secondary to hyperemesis gravidarum refractory to anti-emetic therapy. Given her weight loss of 20 lbs and persistent symptoms, a PEG-J tube was inserted at 19 weeks gestation (Table 1). She tolerated the tube feeds well and her symptoms improved with anti-emetic therapy. At 25 weeks of gestation the patient redeveloped persistent vomiting. EGD revealed a displaced PEG-J tube in the stomach which was repositioned into jejunum without any complications. A cesarean section was performed at 37 weeks of gestation due to preeclampsia. The patient delivered a 1,990 gram healthy infant. Patient 3 was a 30-yearold G1P0A0L0 woman at 27 weeks of gestation who also presented with refractory hyperemesis gravidarum for the last 24 weeks. She had lost 10 lbs from her pre-pregnancy weight (Table 1). A PEG-J tube was inserted at 28 weeks of gestation. She had a vaginal delivery at 37 weeks with a term infant weighing 2,400 grams. The feeding tube was removed in the latter two patients within 2 days after delivery with good tolerance of oral diet. This is the first series of three cases of endoscopically placed feeding tubes to maintain nutrition in pregnant women with poor oral nutrition. Ultrasound guidance was used to insert the tubes as the gravid uterus causes changes in the anatomy of the stomach. Continuous fetal monitoring was done to ensure fetal well being during the procedure. Endoscopically placed gastrostomy and jejunostomy tubes in such cases have been reported as 1-2 patient case reports previously in the literature (n=12), with good maternal and fetal outcomes and a low feeding tube related complication rate. Total parentral nutrition may not be a suitable option in these cases due to high risk of complications with TPN in pregnancy. Endoscopically inserted feeding tubes at an experienced facility may be a better alternative to TPN in pregnant women with poor oral nutrition for improved maternal and fetal outcomes.Table: Table. Indications for percutaneous feeding tube insertion with related pre-pregnancy variables and post-pregnancy outcomes

PWE-194 Randomised study of RIGJ vs PEGJ in Patients at Risk of Aspiration Pneumonia

IntroductionIn patients at risk of aspiration pneumonia due to gastro-oesophageal reflux who require gastrojejunostomy feeding tubes, the tubes are placed either radiologically (RIGJ) or endoscopicaly (PEGJ). There is little published...

OC-077 Jejunal tube feeding experience in paediatric nutrition support

IntroductionThere is an emerging group of children in whom poor and worsening upper GI dysmotility limits feed toleration and impacts growth; we wished to evaluate the role of jejunal tube...

Roux-en-Y: the route to successful long-term jejunal feeding

Background and aimIncreasing numbers of children with marked upper Gastrointestinal (GI) dysmotility require home enteral tube feeding (HETF). We reviewed the need and outcome of medium/long-term jejunal feeding for problematic...

Endoscopic placement of jejunal feeding tubes by using the Resolution clip: report of 2 cases

The utility of jejunal feeding in critically ill patients is well accepted.1-4 There are multiple techniques for placing jejunal feeding tubes, including surgical jejunostomy, direct percutaneous enterojejunostomy, passing a jejunal extension through a PEG (PEG-J), and nasojejunal (NJ) placement. Inadvertent withdrawal of the tube during scope removal and other complications during the placement of a jejunal feeding tube can lead to a frustrating experience for the endoscopist. We describe our experience with a technique that may ease the endoscopic placement of either NJ or PEG-J tubes.

Randomized Prospective Comparison of Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Feeding Tube Placement Versus Percutaneous Endoscopic Gastrostomy Feeding Tube Placement with Jejunal Extension (PEG-J), for Enteral Feeding

Randomized Prospective Comparison of Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Feeding Tube Placement Versus Percutaneous Endoscopic Gastrostomy Feeding Tube Placement with Jejunal Extension (PEG-J), for Enteral Feeding Mark Delegge, Greg Buck, John Fang, James Disario, Glen Lehman, Gregory Ginsberg, Steve Mcclave PEG-J and DPEJ are accepted procedures for enteral feeding into the jejunum. The prospective comparison of DPEJ to PEG-J methods of percutaneous, endoscopic, jejunal access has not been previously examined. This study aimed to compare the clinician re-intervention rates related to complications of DPEJ versus PEG-J placement with regard to retrograde jejunal (J)-tube migration and J-tube failure within three to six months. The primary endpoint was re-intervention rate within three to six months related to J-tube migration and J-tube failure. Re-intervention rate was defined as the percentage of subjects with successful J-tube placement requiring any intervention at a hospital/clinic by the investigator and/or medical Staff, related to tube repositioning, tube repair, tube trade-out, or tube removal. Clinical assessment, physical exam, procedure data, device performance, patient satisfaction, and adverse events were tracked at baseline and at 1, 2, 3, 4, 5, and 6 months post placement. Eligible patients were randomized to receive either a DPEJ or a PEG-J tube. A total of 40 patients were treated. Nineteen (19) patients were treated with DPEJ, 20 patients with PEG-J, and 1 patient with both devices. The demographics of both groups were comparable. The primary reasons for receiving jejunal feeding included gastroparesis (8, 20.5%), chronic pancreatitis (23, 59%), and increased risk of reflux and aspiration (8, 20.5%). Sixteen (16) (84.2%) patients in the DPEJ group had a successful device placement as compared to 18 (90%) patients in the PEG-J group (p Z 0.59). The device was retained in place for 57.5 days for the DPEJ group and 51.5 days for the PEG-J group (p Z 0.77). Reintervention rate difference between the two groups was statistically significant with 31% of the DPEJ patients receiving a re-intervention and 75% of PEG-J patients (p Z .007). Both groups were satisfied with the feeding tube. A total of 31 patients experienced an adverse event, with 14 (73.7%) patients in the DPEJ group and 17 (85%) in the PEG-J group (p Z 0.38). Eight (8) events were serious and device related (1 DPEJ, 7 PEG-J). None were unanticipated. One patient in the PEG-J group experienced pneumonia.Re-intervention rates and serious device related events were statistically significantly lower in the DPEJ group than in the PEG-J group. No serious complications were unanticipated.