Percutaneous Gastrojejunostomy Research Articles

Two endoscopic suturing techniques for the prevention of percutaneous gastrojejunostomy tube retrograde migration

Video 1Two suturing techniques for the fixation of percutaneous gastrojejunostomy tubes.

S2313 Esophageal Stricture Recalcitrant to Repeated Dilation in Complex Rheumatological and Bullous Disease

Introduction: Many rheumatological diseases have been well characterized to affect the esophagus. Esophageal involvement in autoimmune bullous disease is rare and almost always occurs with severe cutaneous symptoms. We report a case of severe esophageal strictures recalcitrant to repeated dilatation in a patient with complex rheumatological disease and isolated esophageal bullous disease. Case Description/Methods: A 50-year-old female presented with complete inability to tolerate oral intake for several weeks. Past history included Sjogren's syndrome and esophageal strictures with many previous dilatations. Physical exam findings were relevant for poor skin turgor, dry mucous membranes, and skin hyperpigmentation on her hands and forearms. Laboratory studies showed hypokalemia, hypoalbuminemia, and anemia. The patient was admitted. Her esophagram and esophagogastroduodenoscopy (EGD) showed a proximal esophageal stricture which was dilated using a push style dilator to 14mm. The stricture recurred, requiring repeated dilatation and placement of a percutaneous gastrojejunostomy. Once oral intake was tolerated, she was discharged with outpatient follow-up. Outpatient rheumatological workup showed antibodies to ANA, RNP, SSA, CCP, and Smith indicating mixed connective tissue disease with features of systemic lupus erythematosus, rheumatoid arthritis, and scleroderma. She required multiple dilatations over several months and was started on mycophenolate mofetil with some clinical improvement. The dysphagia recurred 2 months later and EGD showed and esophageal stricture measuring 7mm requiring a neonatal upper gastroscope to facilitate balloon dilatation. Biopsies examined for immunofluorescence showed continuous linear deposition along the basement membrane zone for IgG and C3, consistent with atypical esophageal bullous systemic lupus erythematosus or atypical esophageal bullous pemphigoid. The patient declined systemic steroids. Her mycophenolate mofetil dose was increased and she received weekly dilatations to prevent Koebnerization and allow time for medical therapy effect. After 3 months of treatment, she had symptom improvement (Figure). Discussion: In patients with systemic immune mediated disorders including rheumatological disease, bullous diseases can be considered as a cause of esophageal stricture. Bullous disease with esophageal involvement can be difficult to treat, especially in this patient who declined corticosteroids. A combination approach using both immune suppression and dilatation was effective.Figure 1.: a. Pre- dilatation during repeated dilation treatments. Diameter 8mm. b. Post- dilatation. Diameter 11mm. c. Immunofluorescence showing IgG deposition along the basement membrane.

A68 DISTAL MIGRATION OF A PERCUTANEOUS GASTROJEJUNAL DUODOPA INFUSION TUBE DUE TO BEZOAR FORMATION AT THE JEJUNAL TUBE TIP

Abstract Background Continuous intestinal infusion of levodopa/carbidopa intestinal gel (LCIG) for the treatment of advanced Parkinson’s Disease (PD) leads to less variability in plasma drug levels and improved symptom control. Percutaneous Gastrojejunostomy (PEG-J) tube placement has a high placement success rate; however, delayed tube malfunctions occur in approximately 58% of cases within two years. A rare complication is bezoar formation at the jejunal tube tip. Aims To present a case of bezoar formation at the jejunal tip of a PEG-J tube that caused distal migration of the tube with gastroduodenal ulceration and required surgical extraction. Methods Full chart review was conducted including clinical notes, laboratory results, radiographic imaging, endoscopy reports, and surgical reports. A relevant literature review was conducted. Results A 57-year-old male with severe PD underwent endoscopic guided PEG-J tube insertion for continuous infusion of LCIG; intestinal administration was effective for symptom control. Two years later, he noted that the gastric tube had retracted approximately 15 cm into the stoma without external manipulation of the apparatus. Attempts to externally pull the tube back into position were unsuccessful. The patient underwent Gastroscopy (EGD) with fluoroscopy. Contrast was used to confirm placement of the jejunal tip within the jejunum, but also showed migration of the gastric tip into the duodenum. A gastroscope was used to reposition the gastric tube in the stomach; the jejunal tube was visualized to be under traction. The bumper on the apparatus was re-positioned and external tape was used to further secure the apparatus and prevent migration. A month later the tube had migrated again; repeat EGD showed the jejunal tube to be under traction with some resultant ulceration of the pyloric channel and duodenal bulb where the tube had been pressing against the mucosa. The jejunal tube could not be pulled back and appeared to be fixed distally. A CT scan was obtained to assess for complications and a coiled tip was seen in the proximal jejunum. Surgical extraction of the malfunctioning tube was required. At laparotomy, the coiled tip of the feeding tube was successfully removed via enterotomy. The tube tip had coiled around itself and was encased with food materials, creating a large bezoar that was being pulled distally by peristalsis. The patient subsequently underwent insertion of a new GJ tube for ongoing administration of LCIG and has been doing well since. Conclusions Bezoar formation at the jejunal tip of LCIG PEG-J tubes is a rare complication and can lead to distal migration and traction related gastroduodenal ulceration. Surgical removal may be required. Funding Agencies None

Percutaneous Gastrojejunostomy Tube Insertion in Patients with Surgical Gastrojejunal Anastomoses: Analysis of Success Rates and Durability

Patients with a gastrojejunal anastomosis pose challenging anatomy for percutaneous gastrojejunostomy (GJ)-tube placement. A retrospective review of 24 patients (mean age 67.8 years, 13 males) with GJ anastomoses who underwent attempted GJ tube placement revealed infeasible placement in 6 patients (25%) due to an inadequate window for puncture. When a gastric puncture was achieved, GJ tube insertion was technically successful in 83% (15/18) of attempts, resulting in an overall technical success rate of 63% (15/24). The most common tube-related complication was the migration of the jejunal limb into the stomach, which occurred in 40% (6/15) of successful cases. No major procedure related complications were encountered.

Percutaneous gastrojejunostomy tubes: Identification of predictors of retrograde jejunal limb migration into the stomach

PurposeTo identify whether technically modifiable factors during gastrojejunostomy (GJ) tube insertion are predictive of retrograde jejunal limb migration into the stomach. Materials and methodsRetrospective review of our procedural database over a 5-year period revealed 988 successful primary GJ tube insertions. Medical records and imaging were reviewed for cases of retrograde jejunal limb migration. Primary analysis was performed on 74 patients with retrograde tip migration within 3 months after placement (37 males, mean age = 57). Comparison was performed on 67 control patients (34 males, mean age = 51) who had radiologically confirmed GJ tube stability for at least 6 months. Procedural fluoroscopic images were analyzed for multiple GJ tube configuration parameters. The stomach was designated into antrum, body, and fundus. Predictors of retrograde tip migration were analyzed with univariate and multivariate logistic regression analysis. ResultsA total of 110 patients (11.1%) had retrograde jejunal limb migration, with 74 (7.5%) occurring within 3 months of placement. On multivariate analysis, the factors associated with a significantly lower risk of tip malposition included gastric puncture site in the antrum (OR: 0.27, 95% CI: 0.13–0.56, p < 0.001) and GJ tract angle less than 30 degrees away from the pylorus (OR: 0.35, 95% CI: 0.16–0.76, p = 0.008). No patient in either cohort had a major complication within 30 days of procedure. ConclusionTo minimize the risk of retrograde tip migration, GJ tubes should be inserted into the gastric antrum with an entry tract oriented as directly towards the pylorus as possible.

S2361 Endoscopic Ultrasound-Guided Gastrojejunostomy for the Treatment of Benign Gastric Outlet Obstruction

INTRODUCTION: We present a case of a successful endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) for the treatment of benign gastric outlet obstruction (GOO). CASE DESCRIPTION/METHODS: A 37 year-old obese (BMI 80) female with history of an open cholecystectomy presented with nausea and vomiting. Imaging demonstrated a GOO with an obstructive lesion seen at the site of her prior cholecystectomy. An EUS with fine-needle aspiration demonstrated chronic inflammatory changes without evidence of malignancy, and she was discharged with a percutaneous gastrojejunostomy (PEG-J) tube. The patient required frequent PEG-J revisions complicated by the location of the PEG insertion coupled with a deformed pylorus. In order to overcome the anatomy, an ultra-slim bronchoscope was instead used to serve as a rigid steering catheter to advance the wire into the distal small bowel. Unfortunately, despite a longer J-tube, she returned shortly after with a dislodged PEG-J tube, and EUS-GJ was performed given the extensive attempts of revisions. The upper endoscope was advanced under fluoroscopic guidance, and contrast was injected defining the stricture. Water with methylene blue was infused to distend the small bowel. The upper endoscope was exchanged for a linear echoendoscope after which a 19-gauge needle was used to puncture the small bowel from stomach, and methylene blue was aspirated confirming location. An electrocautery-enhanced lumen apposing metal stent (LAMS) was deployed resulting in successful creation of a gastrojejunostomy. The lumen of the LAMS was then dilated with a balloon dilator under fluoroscopic guidance. The stent was then secured in place with the OverStitch device. The patient’s PEG-J was removed and her gastrocutaneous fistula closed using an over the scope clip. The patient tolerated a regular diet without any complications and was discharged. DISCUSSION: Our case highlights the use of bronchoscope to navigate deformed sites that would otherwise be difficult with a flexible angiocatheter. Secondly, it highlights the emergence of EUS-GJ as an innovative alternative to surgical gastrojejunostomy and enteral stenting in benign or malignant GOO. Studies suggests EUS-GJ to be superior to the conventional therapy as it is less invasive and provides lower GOO recurrence and reintervention rates. The EUS-GJ in our patient was technically successful and allowed for resumption of an oral diet, and it signifies EUS-GJ is an effective and potentially safe alternative to conventional treatments of GOO.Figure 1.: Fluoscopic images of navigating through the site of gastric outlet obstruction.Figure 2.: Needle puncture of jejunum under echosonography.Figure 3.: Post-LAMS deployment in gastric body.

S0927 Endoscopic Ultrasound-Guided Gastrojejunostomy With a Lumen Apposing Metal Stent for Benign Diseases: An Emergent Concept

INTRODUCTION: Gastric outlet obstruction (GOO) with benign causes can be managed with percutaneous gastrojejunostomy or surgical gastrojejunal bypass, however, many patients requiring invasive intervention are high-risk surgical candidates. Endoscopic-ultrasound guided gastrojejunal bypass (EUSGJ) has emerged as a minimally invasive alternative. The procedure involves the creation of a fistula between the stomach and jejunum using EUS and placement of a lumen-apposing metal stent (LAMS) across the fistula tract. Our aim in this case series was to identify the technical and clinical success rates of EUSGJ in benign cases of GOO. METHODS: Patients who underwent EUSGJ for benign GOO over six years were included. Technical success was defined as creation of a successful gastrojejunal fistulous tract. Clinical success was defined as the ability to tolerate a diet post-procedure. RESULTS: Seventeen patients were included in the study (male: 58.8%, n = 10, mean age 57.9 y). The indication for most (82.3%) cases was groove pancreatitis. Technical success was achieved in 17 (100%) patients. Clinical success was achieved in 17 (100%) patients. Six (35.3%) patients required bridging stent placement, with 2 procedures (11.8%) converted to a natural orifice transluminal endoscopic surgery (NOTES) technique. Seventeen (100%) patients tolerated an oral diet post procedure, with majority (47.1%) tolerating a soft diet. Median procedure time was 43 minutes (range 22–189 minutes). Median hospital stay duration was 3 days (range 1–9 days). No cases encountered immediate, short-term, or long-term adverse events. CONCLUSION: EUSGJ is an emerging procedure with comparable efficacy and safety to the current gold standard therapies. Our case series demonstrated a 100% technical and clinical success rate with no post-procedural complications, a clinically relevant finding as all patients successfully avoided surgical intervention. Endoscopic-ultrasound guided gastrojejunal bypass should hold a place as a new minimally invasive option for patients with benign luminal gastrointestinal obstruction.Table 1.: Clinical Characteristics

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.

Predictors of Response for "Off" Time Improvement With Levodopa-Carbidopa Intestinal Gel Treatment: An Analysis of the GLORIA Registry.

Background: Levodopa-carbidopa intestinal gel (LCIG) is a long-term therapy for motor fluctuations in patients with advanced Parkinson's disease (PD). The aim of this analysis was to identify the baseline characteristics that predict “Off” time reduction in advanced PD patients treated with LCIG under routine clinical care in the GLORIA registry.Methods: Patients were followed under routine care for 24 months (M) with delivery of LCIG via percutaneous gastrojejunostomy. Analysis of covariance (ANCOVA) and logistic regression were performed to identify baseline characteristics that predict “Off” time reduction.Results: Compared to baseline, 86% (n/N = 131/152; mean ± SD baseline “Off” time: 3.4 ± 2.2 h) of M24 completers had ≥ 1 h reduction in “Off” time and 64% (n/N = 97/152; mean ± SD baseline “Off” time: 7.6 ± 2.9 h) had ≥ 3 h “Off” time reduction at M24. Most baseline characteristics were similar across responder subgroups; however, patients with ≥ 3 h “Off” time improvement had more “Off” time and less time with dyskinesia at baseline compared to patients with <3 h “Off” time reduction. Despite having less improvement in absolute “Off” h at M24, patients with <3 h “Off” time reduction experienced a 33% median reduction in “Off” time and a 44% median reduction in dyskinesia duration at M24, which was similar to the dyskinesia improvement observed among patients with ≥ 3 h “Off” time improvement (50% median reduction). Baseline “Off” time was both the best predictor of and the only significant factor associated with “Off” time improvement (P <0.0001).Conclusions: LCIG treatment led to clinically meaningful improvements in “Off” time in 86% of advanced PD patients and those with greater “Off” time are likely to experience the largest absolute reduction in hours “Off.”

Temporary percutaneous radiologic gastrojejunostomy with single gastropexy.

Although the effectiveness of percutaneous radiologic gastrojejunostomy (PRGJ) has been reported, a detailed description of the indications and clinical effectiveness of temporary PRGJ is still limited. To evaluate the clinical effectiveness and technical feasibility of temporary PRGJ using the modified Chiba-needle technique with single gastropexy. Temporary PRGJ using the modified Chiba-needle technique with single gastropexy was performed in 27 consecutive patients (19 men, 8 women; mean age = 61 years; age range = 32-77 years) for esophageal perforation (n = 18) or postoperative gastroparesis (n = 9). Outcomes analyzed included the technical and clinical success, procedure-related complications, and the tube indwelling period. Technical and clinical success was achieved in all 27 patients. All the tubes were electively removed 19-364 days (mean indwelling period = 104 days) after confirmation of the possibility of oral intake. Asymptomatic pneumoperitoneum occurred in 2/27 (7.4%) patients as minor complications and was resolved spontaneously by the time of the one-week follow-up. There were no major complications. During the follow-up period, a total of 11 tube changes were performed in seven patients for an elective tube change within a six-month interval (n = 5) or because of tube occlusion (n = 6). Temporary PRGJ using the modified Chiba-needle technique with a single gastropexy was clinically effective and technically feasible in patients with esophageal perforation or gastroparesis. It can provide adequate enteral nutrition during its temporary placement.

Abstract No. 594 Percutaneous gastrojejunostomy tubes: identification of predictors of retrograde tip migration into the stomach

Abstract No. 594 Percutaneous gastrojejunostomy tubes: identification of predictors of retrograde tip migration into the stomach

4:03 PM Abstract No. 225 Primary percutaneous pull-type gastrojejunostomy tube placement: a 5-year experience

To evaluate outcomes of primary percutaneous pull-type gastrojejunostomy placement and make comparison with conventional balloon-retained devices. Over a 5-year period, from January 2014 to December 2018, a total of 68 adult patients underwent primary placement of a percutaneous gastrojejunostomy (GJ) tube. A push-type (balloon-retained) GJ was placed in 57, and a pull-type (mushroom retained) device with immediate jejunal tube extension was placed in 11. Records were reviewed for procedure indication, technical success, fluoroscopy time, immediate- and short-term complications, as well as jejunal tip migration. Indications for primary GJ placement were aspiration or risk of (n = 36), feed intolerance (n = 15), gastroparesis or gastric outlet obstruction (n = 12), and the simultaneous need for venting gastrostomy and jejunal feeding (n = 5). Technical success was noted in all 68 patients. Average fluoroscopy time did not differ between push-type (12.5 min ± 8.0) and pull-type (12.2 min ± 3.1) techniques (P = 0.89). Retrograde migration of the jejunal tip into the stomach was identified in six patients (11%) for a total of eight instances in the push-type group, compared to three patients (27%) for a total of 14 instances in the pull-type group, though this was not statistically significant (P = 0.13). Major complications were identified in four push-type patients (all hemodynamically significant bleeding events), and none of the pull-type patients. Primary placement of balloon-retained gastrojejunostomy and mushroom-retained gastrostomy with immediate jejunal extension have high technical success rates, similar average procedural time and incidence of jejunal tip migration.

Percutaneous Gastrojejunostomy Catheter Placement Using a Slow-Leak Balloon through the Reconstructed Gastric Tube after Esophagectomy.

Twelve patients who had undergone esophageal reconstruction because of cancer and in whom conventional percutaneous radiologic or endoscopic gastrostomy was considered difficult are reported. These patients underwent placement of a percutaneous gastrojejunostomy catheter through the reconstructed gastric tube using a slow-leak balloon that had been developed for percutaneous transesophageal gastrotubing. Retrospective evaluation showed successful outcomes without severe complications in all patients. Eight (66.6%) were able to resume oral intake, which allowed gastrojejunostomy catheter withdrawal in 3 (25%). This technique is feasible with acceptable clinical outcomes for patients who have undergone gastric tube reconstruction after esophagectomy.

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.

Effects of percutaneous gastrojejunostomy on nutritional intake and prognosis in severe brain injury patients

Objective To evaluate the effects on nutritional intakes and clinical outcomes of severe brain injury patients receiving percutaneous gastrojejunostomy (PEG-J) feedings. Methods The severe brain injury patients treated in ICU of Changshu No.1 Hospital from Jan 2013 to Dec 2016 were enrolled in the study. Patients were randomized into: control group, patients received nasoduodenal feedings and treatment group, patients received PEG-J feedings. The feeding speed was adjusted according to the amount of gastric residual or reflux vomiting. The daily dose of enteral nutrition in the first week, endocrine function, immune function, nutritional states and clinical outcomes were recorded. Results Totally 87 patients were enrolled in this study, 45 patients in the control group and 42 patients in the treatment group. The daily dose of enteral nutrition of the treatment group were significantly more than the control group from the fourth to the seventh days (P= 0.001, <0.01, 0.024), the CD4+T-lymphocyte percentage and CD4+/CD8+ ratio were significantly higher in the treatment group on day 7 (P=0.03, 0.01), levels of thyroidstimulating hormone, free triiodothyronine and free thyroxine of the treatment group were higher (P=0.036, 0.013, 0.025), and the level of hormonal was lower in the treatment group (P=0.004). The levels of albumin, prealbumin and insulin dosage were not significantly different between the two groups, neither did mortality, rates of organ failures. But the treatment group has a higher Barthel index scores (P=0.049), shorter length of mechanical ventilation and stay ICU (P=0.044, 0.048), and the lower incidence of vomiting and ventilator associated pneumonia (P=0.013, 0.037). Conclusions PEG-J could increase energy intake, improve immunity and endocrine function, promote the recovery of life ability, reduce the incidence of VAP, shorten mechanical ventilation time and ICU stay in severe brain injury patients. Key words: Percutaneous gastrostomy-jejunostomy; Severe brain injury; Enteral nutrition; Clinical outcomes

Safety of Levodopa-Carbidopa Intestinal Gel in Advanced Parkinsonʼs Disease Patients: Interim Results of a U.S. Subset in the DUOGLOBE Observational Study

Introduction: Levodopa-carbidopa intestinal gel (LCIG) (also known in the US as carbidopa-levodopa enteral suspension [CLES]) is a long-term treatment option for advanced Parkinson's disease (PD) patients and administered via percutaneous gastrojejunostomy (PEG-J) and an external pump. Objective of this interim analysis in a US patient subset in the DUOGLOBE observational study was to investigate routine clinical practice of PEG-J insertion, component replacements of the device and associated safety/tolerability.2834_A Figure 1. Percentage of patients with number of component replacements based on type of proceduralist performing the PEG-J insertion occurring in the first 6 months of treatment.2834_B Figure 2. Summary of treatment-emergent Serious Adverse Events occurring in the first 6 months of treatment in a US patient subsetMethods: DUOGLOBE is an ongoing observational multi-country study with a 3 year follow-up. This interim analysis included patients recruited at 19 US sites who had at least the PEG-J insertion procedure performed. The safety profile of these patients was investigated regarding the type of proceduralist performing the PEG-J insertion, type of tubing used, frequency of tube replacements and Serious Adverse Events (SAEs) reported. This interim analysis was not powered for comparison between groups due to limited number of patients. Results: Twenty-seven US patients were included in the interim analysis. 16 (59%) had PEG-J insertion performed by a gastroenterologist (GI) with 13 (81%) completing the first 6 months of the study. 11 subjects (41%) had an interventional radiologist (IR) perform the procedure with 8 (73%) completing the first 6 months of the study. Out of the entire US subset, 81.5% of patients had no tube replacements during the first 6 months with overall similar percentages of subjects with 0/1/2/3 tube replacements between the two types of proceduralists (GI: 0-75%, 1-25%, 2-0%, 3-0%; IR: 0-90.9%, 1-0%, 2-9.1%, 3-0%) during the first 6 months of the study (figure 1). Of the 5 tube replacements, 4 were performed by a GI using AbbVie proprietary tubing and 1 was performed by an IR using non-AbbVie tubing. The incidence of treatment-emergent SAEs is summarized in Table 1. Conclusion: In this interim analysis of the US subset of a multi-country observational study with CLES, limited by small patient numbers, GIs more frequently performed PEG-J insertion than IRs with similar percentage of subjects completing the first 6 months of the study. Frequency of tube replacements and AEs leading to drug withdrawn were similar between GIs and IRs.

Nursing experience of a patient who developed incisional infection and embedding syndrome after percutaneous endoscopy gastrojejunostomy

Objective To explore the nursing essentials of complicated incision infection and embedding syndrome after percutaneous endoscopy gastrojejunostomy(PEGJ). Methods Comprehensive treatment and care including improved nursing methods, negative pressure suction, the dressing strengthening, and enteral nutrition. Results The swelling of the incision gradually subsided. On the 18th day, there was slight redness around the tube, no exudate, no fever, and the incision healed well. On the 20th day, family members were taught with routine maintenance method of the PEG/J tube, and the patient was discharged from hospital with the tube home for continue treatment. Conclusion Comprehensive nursing methods according to cause analysis can improve the curative effect of complications after PEGJ implantation. Key words: Infection; Nursing care; Embedding syndrome

Direct Percutaneous Endoscopic Jejunostomy for the Management of Gastroparesis in Pregnancy

Providing meaningful nutrition in cases of refractory hyperemesis during pregnancy can be challenging; although intragastric enteral nutrition is the most common approach, it is contraindicated in certain cases and carries the risk of increased nausea and vomiting. A 36-year-old primigravid woman with a history of gastroparesis presented at 16 weeks of gestation with nausea and vomiting. With no improvement with conventional approaches and signs of malnutrition, a direct percutaneous endoscopic jejunostomy was placed. Her nutritional status improved, and the pregnancy ended in the delivery of a healthy neonate. Direct percutaneous endoscopic jejunostomy in pregnancy is an option in patients in whom intragastric feeding is contraindicated and may offer a more secure approach than percutaneous gastrojejunostomy.

Image-guided placement of percutaneous de novo low-profile gastrojejunostomy tubes in the pediatric population: a study of feasibility and efficacy.

De novo low-profile gastrojejunostomy tubes in pediatric patients offer less external catheter bulk and decreased propensity for dislodgement as children become more mobile. While small cohort studies have evaluated de novo placement of coaxial, adjustable-length, percutaneous gastrojejunostomy (GJ) tubes in children, placement of de novo low-profile GJ tubes in pediatric patients has not been analyzed. This study evaluates technical feasibility, safety and clinical efficacy of percutaneous, retrograde placement of de novo low-profile GJ tubes in infants and children. Following institutional review board approval, all de novo low-profile GJ tube placements in patients were retrospectively reviewed between May 2014 and May 2017. Technical parameters of fluoroscopy time, tube size, T-fasteners and complications were recorded. Clinical data, including age, indication, weight gain and complications, were analyzed. Thirty-four de novo low-profile GJ tubes were placed in 34 patients (median age: 9.4months, range: 2months-11.8years; median pre-procedural weight: 7.5kg, range: 2.9-31.6kg). Twenty-one 14-Fr and 13 16-Fr GJ tubes were placed with technical success rate of 100%. Average weight gain 3months' post procedure was 1.1kg (range: 0.3-4.8kg) and average weight percentile for age increase was 9.6% (range: -48.9% to 53.5%). One major complication occurred following balloon inflation within the tract causing pain requiring urgent replacement of the GJ tube. Minor complications occurred in 11 patients (32%): accidental dislodgement (n=9), skin irritation (n=4), tube dysfunction (n=2), leakage (n=2) and tube migration into the esophagus (n=1). Percutaneous, antegrade, image-guided placement of de novo low-profile GJ tubes is technically feasible, safe and clinically efficacious in appropriately selected pediatric patients.

Thirty-day complication rate of percutaneous gastrojejunostomy and gastrostomy tube insertion using a single-puncture, dual-anchor technique

PurposeOur objective was to assess 30-day mortality and complication rates associated with percutaneous enteral feeding tube insertion using a single-puncture, dual-suture anchor gastropexy and peel-away sheath technique. We explored differences in complications based on indication and gastrostomy versus gastrojejunostomy tube. MethodsA retrospective review was conducted of adult patients undergoing fluoroscopically guided gastrojejunostomy (GJ) and gastrostomy (G) tube insertions between July 2011 and 2014 by five interventional radiologists at a single tertiary care centre. A single-puncture dual-anchor gastropexy technique with a peel-away sheath was used for all patients. Complications within 30 day post-procedure were classified based on the Society of Interventional Radiology Standards of Practice for Gastrointestinal Access. Procedure-related mortality and complication rates, as well as indication-specific complication rates, were compared between GJ and G groups. Results559 consecutive patients underwent G (86) or GJ (473) tube insertion. Primary technical success was 100%. Nine major (1.6%) and 60 minor (10.7%) complications occurred for an overall complication rate of 12.3%. The 30-day complication rate was significantly higher for GJ compared to G tube insertion (13.5% v. 5.8%, p = .049). There was a trend toward a higher 30-day minor complication rate for the GJ group (11.8% v. 4.7%, p = .057), but no significant difference between groups with respect to major complications (1.7% v. 1.2%, p = 1.0). Four procedure-related deaths occurred resulting in an overall procedure-related mortality of 0.7%. No significant difference in the procedure-related mortality was found between GJ and G groups (0.6% v. 1.2%, p = .49). ConclusionThe 30-day major complication and procedure-related mortality rates from G and GJ tube insertion are low when using a single-puncture, dual-anchor gastropexy technique. GJ tube insertion is associated with a higher overall complication rate, likely due to more minor complications, but may avoid long-term adverse events.