Placement of the AbbVie PEG-J tube for the treatment of Parkinson's disease in the interventional radiology suite

Effectiveness and safety of an atropine/midazolam and target controlled infusion propofol-based moderate sedation protocol during percutaneous endoscopic transgastric jejunostomy procedures in Parkinson's disease: a real-life retrospective observational study

Patients with Parkinson's disease (PD), often elderly with various comorbidities, may require a continuous intestinal infusion of carbidopa/levodopa gel by the placement of a percutaneous endoscopic gastrostomy (PEG) with a jejunal tube (PEG-J) to improve their motor outcome and quality of life. However, it is unclear what is the best procedural sedation protocol for PEG-J procedures. Fifty patients with PD and indication for PEG-J procedure (implantation, replacement, removal) underwent, from 2017 to 2022, a sedation protocol characterized by premedication with atropine (0.01 mg/Kg i.v.), midazolam (0.015-0.03 mg/Kg i.v.) and induction with bolus propofol (0.5-1 mg/Kg i.v.) as well as, finally, sedation with continuous infusion propofol (2-5 mg/Kg/h i.v.) by Target Controlled Infusion (TCI) technique. Ninety-eight per cent of patients experienced no intraprocedural or peri-procedural adverse events. All the procedures were technically successful. A good discharge time was recorded. The vital parameters recorded during the procedure did not vary significantly. A PEG-J procedure conducted within 30 min showed a significant advantage over end-tidal carbon dioxide (EtCO2). Indeed, the latter showed some predictive behavior (OR: 1.318, 95% CI 1.075-1.615, p = 0.008). In the real world, this sedation protocol showed a good safety and effectiveness profile, even with reduced doses of midazolam and a TCI propofol technique in moderate sedation.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

Operation of the percutaneous endoscopic gastrostomy-jejunostomy tube without endoscopy in patients with Parkinson's disease on levodopa-carbidopa intestinal gel infusion therapy

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It is important to treat tube-related adverse events without endoscopy.

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All PEG-J tube kinks were resolved using tube manipulation with fluoroscopy.

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Use of an antispasmodic agent before PEG-J may have lowered success rate.

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Most tube-associated adverse events were clarified without endoscopy.

Introduction

Tube-related adverse events (AEs) occur frequently in patients with Parkinson’s disease (PD) receiving levodopa-carbidopa intestinal gel therapy. Endoscopy has become evasive since the beginning of the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to evaluate methods that use the percutaneous endoscopic gastrostomy-jejunostomy (PEG-J) tubes without endoscopy.

Methods

We included 19 patients in this study. The contrast agent was injected into the PEG-J tube to clarify the AEs related to the use of the tube. When the kink of the PEG-J tube was found, it was pulled approximately 5–10 cm. When placing or replacing the PEG-J tube, the percutaneous endoscopic gastrostomy (PEG) tube was pushed into the gastrostomy hole to bring its tip closer to the pylorus before a new PEG-J tube was inserted into it.

Results

The mean patient age was 63.1 ± 9.9 years, while the mean duration of PD was 16.7 ± 6.3 years. Tube-related AEs included PEG-J tube kinks (32 events), connector failures (20 events), and PEG-J tube entanglements without/with bezoars (9 events/5 events). All PEG-J tube kinks were resolved by tube manipulation with a fluoroscopic guide. In 66 of 85 events (77.6%), the PEG-J tube was placed or replaced without endoscopy. We believe that the use of the antispasmodic agent just before PEG-J operation reduced this rate.

Conclusion

Our methods were able to resolve most AEs associated with PEG-J tube use without endoscopy.

Metoclopramide Reduces Fluoroscopy and Procedure Time during Gastrojejunostomy Tube Placement: A Placebo-Controlled Trial

PURPOSE

To determine whether a single 10-mg intravenous dose of the promotility agent metoclopramide reduces the fluoroscopy time, radiation dose, and procedure time required for gastrojejunostomy (GJ) tube placement.

METHODS

This prospective, randomized, double-blind, placebo-controlled trial enrolled consecutive patients who underwent primary GJ tube placement at a single institution from April 10, 2018, to October 3, 2019. Exclusion criteria included age less than 18 years, inability to obtain consent, metoclopramide allergy or contraindication, and altered pyloric anatomy. Average fluoroscopy times, radiation doses, and procedure times were compared using t-tests. The full study protocol can be found at www.clinicaltrials.gov (NCT03331965).

RESULTS

Of 110 participants randomized 1:1, 45 received metoclopramide and 51 received placebo and underwent GJ tube placement (38 females and 58 males; mean age, 55 ± 18 years). Demographics of the metoclopramide and placebo groups were similar. The fluoroscopy time required to advance a guide wire through the pylorus averaged 1.6 minutes (range, 0.3-10.1 minutes) in the metoclopramide group versus 4.1 minutes (range, 0.2-27.3 minutes) in the placebo group (P = .002). Total procedure fluoroscopy time averaged 5.8 minutes (range, 1.5-16.2 minutes) for the metoclopramide group versus 8.8 minutes (range, 2.8-29.7 minutes) for the placebo group (P = .002). Air kerma averaged 91 mGy (range, 13-354 mGy) for the metoclopramide group versus 130 mGy (range, 24-525 mGy) for the placebo group (P = .04). Total procedure time averaged 16.4 minutes (range, 8-51 minutes) for the metoclopramide group versus 19.9 minutes (range, 6-53 minutes) for the placebo group (P = .04). There were no drug-related adverse events and no significant differences in procedure-related complications.

CONCLUSIONS

A single dose of metoclopramide reduced fluoroscopy time by 34%, radiation dose by 30%, and procedure time by 17% during GJ tube placement.

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.

Percutaneous Endoscopic Transgastric Jejunostomy (PEG-J) Tube Placement for Levodopa-Carbidopa Intrajejunal Gel Therapy in the Interventional Radiology Suite: A Long-term Follow-up

Background

Percutaneous endoscopic gastrojejunostomy (PEG) and radiologically inserted gastrojejunostomy (RIG) are both safe and effective techniques for gastrojejunal tube placement. The authors compared these 2 procedures in patients with advanced Parkinson's disease (PD) who required the continuous intrajejunal delivery of a levodopa/carbidopa gel suspension (LCIG).

Methods

Outcomes were retrospectively collated from 30 PEG and 12 RIG procedures performed at 2 centers in patients with advanced PD for the delivery of LCIG.

Results

Baseline clinical characteristics, incidence of early severe adverse events, late major complications, dropout, and the mean time-lapse of tube replacements were comparable in the PEG and RIG groups.

Conclusion

The current results suggest that, in patients with PD, the RIG technique is as safe and effective as the endoscopic procedure, and it can be considered a valid option for patients who require LCIG when the endoscopic procedure is not available or unfeasible.