Percutaneous Endoscopic Gastrojejunostomy Research Articles

Levodopa-Carbidopa-Entacapone Intestinal Gel in Advanced Parkinson Disease: A Multicenter Real-Life Experience.

For Parkinson disease (PD) patients who have been diagnosed with advanced disease that can no longer be effectively controlled with optimized oral or transdermal medications, a range of device-aided therapies (DAT) are available, comprising either deep brain stimulation or infusion therapies providing continuous dopaminergic stimulation. Levodopa-entacapone-carbidopa intestinal gel (LECIG) infusion is the latest DAT for advanced PD (APD) that was approved in Romania in 2021. What is the experience to date in real-world clinical practice in Romania regarding the efficacy and tolerability of LECIG in APD? A retrospective evaluation of 74 APD patients treated with LECIG at 12 specialized APD centers in Romania. Demographic data and various clinical parameters were recorded, including Mini Mental State Evaluation score or Montreal Cognitive Assessment Test score. Levodopa-equivalent daily dose and the administered doses of levodopa and other PD medications were evaluated at baseline and after starting LECIG treatment. The efficacy of LECIG in reducing daily hours of off time, motor fluctuations, and dyskinesias were assessed. Any percutaneous endoscopic gastrojejunostomy system or device complications after starting LECIG treatment were noted. At baseline, patients were taking oral levodopa for a mean of 5.3 times per day, with a high proportion also taking concomitant add-on therapies (dopamine agonists, 86%, monoamine oxidase type-B inhibitors, 53%; catechol-O-methyltransferase inhibitors, 64%). LECIG treatment significantly reduced daily off time versus baseline from 5.7 h/d to 1.7 hours per day ( P < 0.01). Duration and severity of dyskinesias was also significantly reduced versus baseline, and improvements were observed in Hoehn and Yahr Scale scores. LECIG treatment also allowed a significant reduction in the use of concomitant oral medications. These findings suggest that LECIG treatment is an effective DAT option in APD that can simplify the treatment regimen.

Comparison of two types of extension tubes for people with Parkinson’s disease in advanced treatment with levodopa–entacapone–carbidopa intestinal gel infusions: a prospective, crossover quality study

BackgroundWithin Parkinson’s disease (PD) management, a pivotal juncture often arises when individuals with PD (PwP) necessitate advanced therapies to stabilise symptom fluctuations and reduce off-periods, which are intrinsic to living...

Endoscopic Complications Are More Frequent in Levodopa–Carbidopa Intestinal Gel Treatment via JET-PEG in Parkinson’s Disease Patients Compared to Nutritional PEG in Non-Parkinson’s Disease Patients

Background: To date, no studies comparing complication rates between patients with nutritional percutaneous endoscopic gastrostomy (N-PEG) and Parkinson’s disease (PD) patients with percutaneous endoscopic gastro-jejunostomy (JET-PEG) for treatment administration have been published. Our study aimed to compare complication rates and the number of re-endoscopies between N-PEG and JET-PEG patients. Methods: Individuals requiring N-PEG or JET-PEG insertion between 2014 and 2021 were included in this single-center retrospective observational study. Complications were divided into time-related medical and technical complications. Reasons for post-insertion re-endoscopies and their number were also analyzed. Results: Eighty-seven subjects, 47 (54.02%) in JET-PEG group and 40 (45.98%) in the N-PEG group, were included. Early and technical complications were more frequent in JET-PEG vs. N-PEG subjects (70% vs. 10% [p &lt; 0.001], and 54.5% vs. 5.1% [p &lt; 0.001], respectively). The presence of psychiatric disease was associated with a higher number of early complications (p &lt; 0.002). All three types of complications were significantly more frequent in subjects where a healthcare professional did not handle PEG (p &lt; 0.001). Subjects with JET-PEG required a higher number of re-endoscopies compared to the N-PEG group (57.1% vs. 35%, p = 0.05). Conclusions: Complications are significantly more common in individuals with JET-PEG than those with N-PEG, which can be attributed to higher mobility in PD patients.

Evaluation of a single center on the efficacy of percutaneous endoscopic gastro-jejunostomy (PEG/J) in the therapy of Parkinson's disease with levodopa-carbidopa intestinal gel, from the experimental phase to today

BACKGROUND: The aim of this study was to evaluate the results obtained in terms of efficacy, safety, and complication rates, in the treatment of patients with Parkinson’s disease, after the creation of a percutaneous endoscopic gastro-jejunostomy (PEG-J), with levodopa/carbidopa intestinal gel.METHODS: We report the experience of our center, from the experimental phase performed from 2009 to 2011 until today, using the “pull-string Ponsky-Gauderer type gastrostomy” technique.RESULTS: Since the experimental phase we have observed immediate relief of symptoms in all patients. We had no intraoperative complications, while at a distance, in the experimental phase, we had a case of pressure injuries at the gastric level and a case of severe inflammation of the stoma. In the following years we detected four cases of ostomy inflammation and only one case of bumper incarceration syndrome.CONCLUSIONS: Regarding the technique, PEG/J proved to be safe both in the short and long term, with a very low complication rate: the effectiveness of levodopa gel therapy, in our opinion, is important, both for the rapidity of the response to symptoms and on patient compliance.

Adverse effects of levodopa/carbidopa intrajejunal gel treatment: A single-center long-term follow-up study.

Levodopa/carbidopa intrajejunal gel (LCIG) is an effective therapeutic strategy to overcome levodopa-induced motor complications in advanced Parkinson's disease (PD). However, it requires invasive percutaneous endoscopic gastrojejunostomy (PEG-J) and may be associated with serious adverse effects (AE). In this study, we aimed to evaluate long-term AEs related to LCIG treatment in a large homogenous cohort of advanced PD patients. One hundred three consecutive PD patients were regularly monitored for LCIG-related, PEG-J-related, and device-related AEs up to 14 years. Incidence of AEs was studied in time applying a time-to-event analysis and Cox proportional hazard model with age, disease duration, gender, and recurrent AE as covariates. Health-related quality of life (HRQoL) was estimated at each visit and compared to HRQoL before the LCIG treatment. Among 296 AEs noted, 48.8% were LCIG-related, 32.4% PEG-J-related, and 19.6% device-related. While most of the studied AEs steadily accumulated throughout the follow-up period, 24.3% of the patients (95% CI 10.1%-36.3%) experienced PEG-J-related AE already within the first days after the PEG-J insertion. Cox model revealed that older patients had higher probability of psychosis, PEG-J- and device-related AEs (p < .05, p < .05, and p=.02) and suggested increased recurrence risk in those with early PEG-J and device-related AEs. Despite relatively high incidence of AEs, HRQoL significantly increased in the follow-up period (p < .0001). AEs related to LCIG treatment are common. Therefore, careful patient selection and monitoring throughout the treatment is recommended, especially in those with early side effects. Nevertheless, LCIG significantly improves HRQoL in advanced PD patients on a long term.

Successful Treatment of Superior Mesenteric Artery Syndrome With Percutaneous Endoscopic Gastrojejunostomy in a Sarcopenic Patient With Cirrhosis.

Successful Treatment of Superior Mesenteric Artery Syndrome With Percutaneous Endoscopic Gastrojejunostomy in a Sarcopenic Patient With Cirrhosis.

Difficult to treat esophageal perforation after endoscopic balloon dilation for stenosis due to endoscopic submucosal dissection followed by chemoradiotherapy: A case report.

Introduction and importanceThere is no clear consensus on a specific treatment for esophageal perforation. The surgical approach is deemed necessary for local severe infection and pleural contamination requiring debridement.Presentations of caseWe have reported herein the case of a patient with esophageal perforation with severe mediastinal and thoracic abscess after endoscopic balloon dilation for stenosis due to endoscopic submucosal dissection and chemoradiotherapy. A surgical approach with primary closure was performed, but not found effective; while conservative treatment with mediastinal drainage via posterior neck and recovery of nutritional status was found to be effective. For the recovery of nutritional status, enteral nutrition was assessed using a polymeric formula through a percutaneous endoscopic gastrojejunostomy tube.DiscussionEsophageal perforation is a life-threatening condition. Iatrogenic injuries are the frequent cause of esophageal perforation. For esophageal perforation, not only surgical interventions but also conservative treatments including various endoscopic approaches have been performed. If the inflammation is not localized, surgical intervention is often needed; however, if the patient's general condition is stable, conservative treatment with drainage, antibiotics, and nutritional management may be considered, even in cases of esophageal perforation.ConclusionsEsophageal perforation with a large perforation site with widespread inflammation can be improved with proper thoracic and mediastinal drainage and adequate nutrition support if the patient's condition is mild.

S2695 Successful Treatment of Superior Mesenteric Artery Syndrome in a Cirrhotic Patient with Percutaneous Endoscopic Gastrojejunostomy

S2695 Successful Treatment of Superior Mesenteric Artery Syndrome in a Cirrhotic Patient with Percutaneous Endoscopic Gastrojejunostomy

Neskorý vznik tenzného pneumoperitonea cez brušnú stenu po zavedení PEG-J

A 71-year-old woman with Parkinson’s disease underwent elective percutaneous endoscopic gastrojejunostomy due to levodopa-carbidopa intestinal gel treatment. Less than one week after the procedure, the patient developed abdominal distension. X-ray and computed tomography revealed massive pneumoperitoneum. An external binder was dislocated above the abdominal wall. After replacing the binder and fixating it onto the skin, imaging showed no regression of free air. Drainage was performed using a Redon drain, and a gush of free air and ascites leaked out of the abdominal wall. Ventilatory air leakage beside the gastric tube caused permanent massive pneumoperitoneum. After the removal of the PEG tube, the patient fully recovered. In this article, we present a late complication of pneumoperitoneum with air leakage from the abdominal wall stoma. This complication is rarer than air leakage from the visceral wall stoma.

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

Procedural aspects and complications of gastrojejunostomy insertion are important considerations in the use of levodopa-carbidopa intestinal gel therapy (LCIG) and may limit uptake. We describe our experience of using per-oral image guided gastrojejunostomy (PIG-J) which avoids the need for endoscopy and routine sedation in percutaneous endoscopic gastrojejunostomy (PEG-J) and allows more secure tube placement than radiologically inserted gastrojejunostomy techniques. We describe a case series of 32 patients undergoing PIG-J insertion for LCIG therapy in a single centre. Under local anaesthetic, a fluoroscopy-guided gastric puncture allows access for the guidewire which is then used to pull through the gastrostomy tube allowing for secure fixation, followed by placement of the gastrojejunal extension. Between December 2015 to April 2020, 32/34 patients referred for PIG-J underwent this procedure successfully, 2 cases unsuccessful due to technical considerations. One patient developed delirium following successful implantation. Ten patients (31%) required a replacement tube due to blockage or displacement within the first 12 months of placement, including 2 patients who needed more than one replacement. Minor complications occurred in 10 other patients (31%), including infection (9 patients); a small haematoma not requiring intervention who later developed an infection (1 patient); and peri-stomal acid leakage (1 patient). In summary, PIG-J insertion is safe with a similar complication rate to traditional PEG-J, well tolerated and effective for use in LCIG administration. This may widen access to LCIG for PD patients who may not be suitable or unable to tolerate PEG-J.

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

BackgroundLevodopa–carbidopa intestinal gel (LCIG) treatment, a unique drug delivery system for patients with advanced Parkinson’s disease (PD), is covered by health insurance in Japan since September 2016. Various LCIG procedure/device-associated adverse events (AEs) have been reported; however, reports on their treatment have been limited. This is the first multicenter study to clarify the frequency and timing of device-related AEs.MethodsBetween September 2016 and December 2018, 104 patients introduced to the LCIG treatment for advanced PD in 11 hospitals were included. The patients’ characteristics, AEs incidence, AEs time, and tube exchange time were investigated.ResultsThe median follow-up period was 21.5 months. Minor AE cases were 29.4%, whereas major AE cases were 43.1%. Majority of major AEs (n = 55, 94.8%) were managed with endoscopic treatment, such as tube exchange. Few severe AEs required surgical treatment (n =3, 5.2%). The mean (range) exposure to percutaneous endoscopic gastrojejunostomy (PEG-J) was 14.7 (0–33) months. One year after the LCIG treatment introduction, 55 patients (54.0%) retained the original PEG-J tube. The mean PEG-J tube exchange time was 10.8 ± 7.0 months in all patients, 11.6 ± 4.7 and 10.5 ± 7.7 months in patients with scheduled exchange and who underwent exchange due to AEs, respectively.ConclusionsSome device-related AEs occurred during the LCIG treatment; however, only few were serious, most of which could be treated with simple procedures or tube replacement with endoscopy. Therefore, the LCIG treatment is feasible and safe and is a unique treatment option for PD, requiring endoscopists’ understanding and cooperation.

Enteral Delivery of Posaconazole or Izavuconazole in Patients with Inability to Swallow Tablets Can Achieve Therapeutic Drug Levels: A Single Center Pilot Study

<h3>Purpose</h3> One of the most common challenges facing the transplant population are invasive fungal infections including aspergillosis, mucormycosis, and those due to endemic fungi. Fungal prophylaxis is becoming standard of practice to limit development of invasive fungal infections. Isavuconazole and posaconazole are commonly used antifungal medications as both prophylaxis and treatment. These drugs are approved for oral and intravenous (IV) administration however, use via alternative enteric routes have not been well studied. <h3>Methods</h3> A retrospective chart review was conducted of transplant patients receiving triazole therapy for prophylaxis or treatment over a seven month period. Patients with an inability to swallow oral medications switched during their course of care from IV therapy to non-oral enteric administration of isavuconazole or posaconazole via nasogastric, orogastric, percutaneous endoscopic gastrostomy (PEG), or percutaneous endoscopic gastrojejunostomy (PEG-J) tubes were included in the study. <h3>Results</h3> We identified 17 patients administered isavuconazole or posaconazole via non-oral enteric routes (Table 1). The indication for therapy was primarily for prophylaxis after single or double lung transplantation. The majority (83%) of cases were therapeutic at the time of their first drug level assessment, with a mean level of 2.47 +/- 0.71 for isavuconazole and 0.84 +/- 1.03 for posaconazole. All patients not therapeutic at initial assessment had doses increased and subsequently achieved therapeutic levels. <h3>Conclusion</h3> Our case series shows isavuconazole and posaconazole can be administered via non-oral enteric routes with therapeutic drug monitoring to achieve acceptable serum drug concentrations and avoid prolonged IV therapy in a transplant population. Given the increasing complexity and age of transplant recipients, continued studies are needed to address alternative antifungal dosing regimens.

Comprehensive assessment of levodopa-carbidopa intestinal gel for Turkish advanced Parkinson’s disease patients

Background/aimLevodopa-carbidopa intestinal gel (LCIG) is an effective treatment modality in the management of advanced Parkinson’s disease (PD) despite frequent adverse events and different rates of dropouts. Efficacy and safety data regarding Turkish patients on LCIG are limited. This study aims to report in detail the efficacy and adverse effect profile of LCIG among advanced PD patients from a Turkish center for movement disorders.Materials and methodsTwenty-two patients (50% male) who started receiving LCIG between December 2014 and March 2020 were recruited. The efficacy of LCIG was assessed with the Unified Parkinson’s Disease Rating Scale (UPDRS III), Clinical Global İmprovement (CGI) scale, and Quality of Life scale (PDQ8). Improvements in gait disorders and nonmotor features were also questioned. Adverse events (AE) were collated into 3 topics: related to percutaneous endoscopic gastrojejunostomy (PEG-J), device-related, and LCIG infusion-related. Results Mean age and pre-LCIG disease duration were 66.7 (8.8) and 13.3 (8.0) years respectively. UPDRS III scores and H-Y scale assessments significantly improved. Better quality of life scores, clinical global improvements, and improvements in dysarthria, dysphagia, and gait were observed. None of our patients dropped out or died during a mean 17.5-month (12.3) period. Overall 20 (90.9%) patients experienced at least one AE. Twelve patients had PEG-J–related complications; three had acute abdomen. Eight (36.4%) patients had device-associated problems. Half of the patients required at least one additional endoscopic procedure and 7 had a device replaced. Mean body weight decreased from 69.5 to 62.5 kg and seven patients had newly onset PNP at a follow-up electromyography. Dyskinesia related to LCIG infusion was observed in 5 (22.7%) patients. There was no significant increase in hallucination among patients. ConclusionLCIG is an efficient treatment modality in the management of Turkish patients with advanced Parkinson’s disease. Although most of the patients had at least one AE, none of them dropped out. Patient selection, patient compliance, and collaborative management are important steps affecting the success of modality.

Gastrointestinal: Recurrent colic and the percutaneous endoscopic gastrojejunostomy.

A 71-year-old lady presented with long-standing colicky epigastric pain and vomiting on a background of advanced Parkinson's disease, treated by third-line medical therapy with duodopa administered by a percutaneous endoscopic gastrojejunostomy (PEG-J) tube. The PEG-J tube provided a steady and constant bioavailability of the drug by overcoming the slow and erratic gastric emptying commonly observed in patients with Parkinson's disease. On examination, the patient was afebrile and hemodynamically stable. She had a soft abdomen with focal epigastric tenderness without peritonism. Her biochemical investigations were unremarkable. Computed tomography scan demonstrated a long segment of thickened small bowel along the PEG-J tubing, with duplicated layers of bowel forming concentric rings consistent with a jejuno-jejunal intussusception (Fig. 1). She underwent a laparotomy demonstrating collapsed proximal loops of jejunum telescoping into distally dilated loops, with a palpable intraluminal mass. Following reduction of the intussusception, a longitudinal enterotomy was performed to deliver a phytobezoar formed over a PEG-J tube knot (Fig. 2). The PEG-J was otherwise well positioned, and no underlying anatomical abnormality was identified. Intussusception is classified according to site of origin: entero-enteric, ileocolic, or colocolic. The vast majority are entero-enteric with jejuno-jejunal intussusceptions being extremely uncommon. Intussusception in adults is almost always due to intraluminal tumors, and rarely are bezoars or PEG-J tubes cited as underlying causes. Unlike children, symptoms in adults are nonspecific, and therefore, abdominal computed tomography is the preferred imaging modality to obtain a diagnosis. Surgery remains the cornerstone of management for adults given the high incidence of intraluminal pathology. Phytobezoars can develop because of a variety of medical pathologies including gastrointestinal motility disorders. Most likely due to her underlying Parkinson's disease, and the rare complication of PEG-J tube knotting, this patient developed a bezoar acting as a lead point causing recurrent intussusception. This case represents an exceedingly rare presentation of a jejunal intussusception secondary to a bezoar forming over a knot in the PEG-J tubing. These images highlight this interesting case, demonstrating the importance of intussusception as a differential diagnosis in patients with nonspecific abdominal complaints, especially those predisposed to gastrointestinal dysmotility, to avoid delays in diagnosis.

LCIG in treatment of non-motor symptoms in advanced Parkinson's disease: Review of literature.

BackgroundFor managing nonmotor symptoms (NMS) in advanced Parkinson's disease (PD), levodopa–carbidopa intestinal gel (LCIG) infusion is of interest as it shows lesser plasma fluctuations of both drugs as compared to oral levodopa–carbidopa (LC).ObjectivesTo highlight LCIG effect in NMS among advanced PD patients and appraise the currently available literature.MethodsPubMed screening (till 2020) of 184 articles was done, of which 51 were selected. Among them, 23 original articles relevant to the research question were included, of which 6 were then excluded after careful reading of full articles. The 17 relevant studies of the review provide Grade C level of evidence of efficacy.ResultsLCIG is beneficial in improving or relieving various NMS especially (mood, cognition/memory, sleep, gastrointestinal symptoms, urinary symptoms, and quality of life questionnaires) in patients with advanced PD. Amelioration of motor functions or direct relations may lead to improvement in NMS PD patients using LCIG. Adverse events noted in patients treated with LCIG include pneumoperitoneum, abdominal pain, stoma infection, reversible peripheral neuropathy, local tube problems, impulse control disorder, and weight loss. Serious adverse events were mostly found to be unrelated to LCIG.ConclusionsLCIG provides an uninterrupted intestinal levodopa infusion by percutaneous endoscopic gastrojejunostomy (PEG‐J). It effectively decreases plasma fluctuations of levodopa and reduces motor instability and NMS burden in advanced PD. However, adequate dose modification and individualization of therapy are essential for optimal effect.

Effects of proactive and rescue enteral tube feedings on weight change in children undergoing treatment for high-grade CNS tumors.

Children with high-grade CNS cancers frequently experience malnutrition during treatment. We assessed the effects of proactive enteral tube (ET) placement/enteral tube feedings (ETF) on weight in infants/children with high-grade CNS tumors treated with aggressive chemotherapy. We conducted a retrospective study of patients age 0 to 19 years treated for new high-grade CNS tumors between 2002 and 2017 at a tertiary pediatric hospital system. Patients underwent placement of proactive ET (≤ 31 days postdiagnosis; n = 45), rescue ET (> 31 days, due to weight loss; n = 9), or no ET (n = 18). Most received surgically placed ET (98%), with percutaneous endoscopic gastrojejunostomy or gastrojejunostomy tubes favored to allow jejunal feeding. The majority of patients with ET used ETF (91%). Using mixed-effects regression models, we examined differences in mean weights between ET/ETF groups across the first year of treatment. We also evaluated observed weight changes. All infants (n = 22, median age, 1.5 years) had proactive ET placed and 21 of 22 used proactive ETF. Infants showed an initial increase in mean percentage weight change that eventually leveled off, for an estimated increase of 10.4% over the year. For the pediatric cohort (n = 50, median, 8.1 years), those receiving proactive ETF experienced weight increases (+9.9%), those with rescue ETF experienced an initial decline and eventually rebounded for no net change (0.0%), and those with no ETF demonstrated an initial decline that persisted (-11.9%; P interaction < .001). Analysis of observed weights revealed nearly identical patterns. Proactive ETF was effective at maintaining weight and/or facilitating weight gain over the first year of treatment and was acceptable to patients/families.

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

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

Levodopa/carbidopa intestinal gel in treatment of non-motor symptoms in advanced Parkinson's disease

To identify the advantages of LCIG in the treatment of NMS among APD patients and appraise the currently available literature to identify the gaps in the available evidence. background:Levodopa is the most commonly used drug for the treatment of motor symptoms of Parkinson's Disease (PD). For managing non-motor symptoms (NMS) in advanced Parkinson's disease (APD), levodopa-carbidopa intestinal gel (LCIG) infusion is preferred over oral levodopa-carbidopa because it bypasses the gastrointestinal tract and overcomes fluctuation and variation in the plasma drug levels. Levodopa is the most commonly used drug for the treatment of motor symptoms of Parkinson's Disease (PD). For managing non-motor symptoms (NMS) in advanced Parkinson's disease (APD), levodopa-carbidopa intestinal gel (LCIG) infusion is preferred over oral levodopa-carbidopa because it bypasses the gastrointestinal tract and overcomes fluctuation and variation in the plasma drug levels. LCIG has been found to be beneficial in improving or relieving various NMS. (central nervous system symptoms, cardiovascular system symptoms, gastrointestinal tract symptoms, systemic symptoms, urinary symptoms, reproductive system symptoms) in patients with APD. LCIG provides an uninterrupted intestinal levodopa infusion by percutaneous endoscopic gastrojejunostomy (PEG-J). It effectively decreases fluctuations in plasma concentrations of levodopa, reduces NMS burden and motor fluctuations in APD, however; adequate dose modification and individualization of therapy are essential for optimal effect.

Current Practices for Outpatient Initiation of Levodopa-Carbidopa Intestinal Gel for Management of Advanced Parkinson’s Disease in the United States

In 2015, the US Food and Drug Administration approved levodopa-carbidopa intestinal gel (LCIG; also known as carbidopa-levodopa enteral suspension in the US) for the treatment of motor fluctuations in patients with advanced Parkinson’s disease. LCIG provides a continuous infusion of levodopa and carbidopa by means of a portable pump and percutaneous endoscopic gastrojejunostomy tube. The delivery system has a two-fold pharmacokinetic advantage over orally administered carbidopa/levodopa. First, levodopa is delivered in a continuous rather than intermittent, pulsatile fashion. Second, delivery to levodopa’s site of absorption in the jejunum bypasses the stomach, thereby avoiding issues with erratic gastric emptying. In blinded prospective clinical trials and observational studies, LCIG has been shown to significantly decrease “off” time, increase “on” time without troublesome dyskinesia, and reduce dyskinesia. Consistent with procedures in previous studies, LCIG initiation and titration in the pivotal US clinical trial were performed in the inpatient setting and followed a standardized protocol. In clinical practice, however, initiation and titration of LCIG have a great degree of flexibility and, in the US, almost always take place in the outpatient setting. Nonetheless, there remains a significant amount of clinician uncertainty regarding titration in outpatient clinical practice. This review aims to shed light on and provide guidance as to the current methods of titration in the outpatient setting, as informed by the medical literature and the authors’ experiences.FundingAbbVie, Inc.Plain Language SummaryPlain language summary available for this article.

Percutaneous endoscopic gastrojejunostomy for treating superior mesenteric artery syndrome

Percutaneous endoscopic gastrojejunostomy for treating superior mesenteric artery syndrome