Direct endoscopic jejunosotomy for the administration of levodopa-carbidopa intestinal gel in Parkinson's disease

[Real-time 3D reconstruction CT-jejunography guided direct percutaneous endoscopic jejunostomy for levodopa-carbidopa intestinal gel treatment in a patient with prior gastrojejunostomy]

A 68-year-old woman with Parkinson's disease, who had previously undergone Roux-en-Y gastrojejunostomy for early gastric cancer, complained of wearing-off and troublesome dyskinesia that had progressed over 7-years. After the introduction of levodopa-carbidopa intestinal gel therapy (LCIG) by nasojejunal tube, she had a good clinical response. Percutaneous endoscopic gastrostomy with a jejunal extension tube was difficult in this case, due to lack of gastrostomy site and fibrous postoperative adhesion. We introduced LCIG by direct percutaneous endoscopic jejunostomy (D-PEJ) which offers a less invasive procedure to operative tube placement. The factors affecting the success of D-PEJ could interfere with transillumination, abdominal thickness and the location of other organs. We determined the optimum site of catheter insertion with the assistance of real-time 3D reconstruction CT-jejunography. She was discharged home on postoperative day 14 without any procedure-related complications. Real-time 3D reconstructive CT-jejunography guided D-PEJ is a useful method for a patient who benefit from LCIG with prior gastrojejunostomy.

[Levodopa-carbidopa intestinal gel treatment introduced by surgical gastrostomy in a patient of Parkinson's disease after Billroth II gastrojejunostomy]

A 68-year-old man, who had received Billroth II gastrojejunostomy because of duodenal ulcer at the age of 20, was diagnosed to have Parkinson's disease at age 57 years. The drug therapy has been effective in the first 10 years, however, recently he was suffering from troublesome dyskinesia and wearing-off in spite of diligent drug adjustments. Although the indication of levodopa-carbidopa intestinal gel (LCIG) treatment was good, percutaneous endoscopic gastrostomy was difficult because of abdominal adhesion. Therefore, we introduced LCIG by surgical gastrostomy. After LCIG therapy, wearing-off and dyskinesia disappeared. This is the first case of Parkinson's disease patient with LCIG therapy by surgical gastrostomy in Japan.

Levodopa-carbidopa intestinal gel: 'dismantling the road blocks of a journey'

Levodopa-carbidopa intestinal gel offers superior treatment to standard oral therapy in selective patients with advanced Parkinson disease. The costs involved in instituting and maintaining this treatment are high but largely mitigated with the quality of life years the treatment offers. Key to this is ensuring a high retention rate once the treatment is instituted. We outline factors and considerations from our experience and viewpoints at each stage of the process to address in this 'journey' patients undertake that can help maximise retention rates and benefits.