- Email: [email protected]
Direct endoscopic jejunosotomy for the administration of levodopa–carbidopa intestinal gel in Parkinson's disease
Parkinsonism and Related Disorders xxx (2014) 1e3
Contents lists available at ScienceDirect
Parkinsonism and Related Disorders journal homepage: www.elsevier.com/locate/parkreldis
Letter to the Editor
Direct endoscopic jejunosotomy for the administration of levodopaecarbidopa intestinal gel in Parkinson’s disease Keywords: Parkinson’s disease Levodopaecarbidopa intestinal gel Direct endoscopic jejunosotomy Percutaneous endoscopic gastrostomy
Levodopaecarbidopa intestinal gel (LCIG) is effective in the treatment of Parkinson’s disease (PD) complicated by severe motor fluctuations and dyskinesias. When compared with an optimised oral medication regimen, LCIG significantly reduces “off” time and increases “on” time, without an increase in troublesome dyskinesias [1]. The commonest serious complications of LCIG infusion are those related to the tubing required to deliver the medication. The conventional tubing system involves an outer percutaneous gastrostomy (PEG) tube through which a fine bore jejunal extension tube (“inner tube”) is inserted and fed down to the jejunum (a so-called PEG-J system). Potential complications of this system include blockage, displacement into the stomach or inadvertent removal of the inner tube by the patient. Inner tube blockage can occur either by solidification of liquid residue within the tube or by knotting of the tube within the gut. Tube dysfunction in these patients causes sudden and complete cessation of medication delivery, potentially triggering a significant deterioration in Parkinsonism. In our initial experience with the PEG-J system for the delivery of LCIG, we found that tube complications were extremely common. This prompted us to trial direct endoscopic jejunostomy (DEJ) in these patients. We describe our experience with these two techniques. Ethical approval for this study was waived by our institution’s IRB. The technique of PEG-J insertion has been previously described [2]. PEG-J procedures were performed by a single endoscopist with the patient under sedation and following antibiotic premedication. Following insertion of a 20 French Frecker gastrostomy tube, a fine bore (9 French) inner tube with a pigtail end was inserted through the Frecker tube and fed down to the jejunum using a guidewire. The DEJ procedure is less well described in the literature so is described in detail below. DEJ procedures were performed under intravenous sedation and with antibiotic premedication. Two endoscopists performed the DEJ, one to do the endoscopic part of the procedure and the second, an assistant, to perform the percutaneous procedure. A paediatric colonoscope was inserted through the upper gut and into the jejunum. A suitable site for the DEJ
was then determined using transillumination. A site was considered suitable if the transilluminating light was clearly seen and if external finger palpation of the site could be clearly seen by the endoscopist. Once a suitable position was found, the assistant punctured the small bowel with a 23G spinal needle. This needle was then captured with a snare by the endoscopist to hold the small bowel in position. The assistant then inserted an insertion trochar alongside the spinal needle under local anaesthetic. Once the trochar was seen endoscopically, the snare was loosened and swapped from the spinal needle to the trochar. A string was then passed through the trochar and captured by the snare. The colonoscope with string was then removed and a 20 French Frecker gastrostomy tube was pulled back into position using a standard “pull technique”. It was then secured externally by means of a bumper. The LCIG pump was connected directly to the tube. Between May 2008 and Aug 2013, 17 patients with PD at our institution have been treated with LCIG via percutaneous enterostomy. In the initial 8 patients we employed the PEG-J system (clinical details and results in Table 1) and in the remaining 9 patients, we have used DEJ (clinical details and results in Table 2). Patients were usually discharged 2e3 days after the procedure and were subsequently reviewed at regular intervals in the outpatient clinic. Complications of the procedure were systematically recorded. At the time of writing, follow up of the PEG-J patients ranged between 2 weeks and 57 months (mean 33 months) while follow up of the direct PEJ patients ranged between 3 months and 25 months (mean 12.7 months; median 12 months). In our experience, DEJ is an equally safe procedure as PEG-J for patients with PD who require treatment with LCIG, and is associated with fewer serious delayed complications, such as tube removal or blockage. Of our initial 8 patients who underwent PEG-J, 6 experienced at least 1 episode of either inadvertent removal or blockage of the inner tube and 3 of these had multiple such complications. One patient in the PEG-J group (patient 2) had a total of 12 episodes of inadvertent tube removal or blockage within 54 months. Of the 9 patients who have undergone DEJ, there have been no episodes of inadvertent tube removal or blockage. To our knowledge, the present study is the first comparison of the experience using PEG-J versus DEJ in PD patients receiving LCIG. Fan et al. [2] reported a lower incidence of tube malfunction using DEJ, compared with PEG-J, in patients receiving enteral nutrition. Shike et al. [3] reported an incidence of tube malfunction of only 3% in cancer patients receiving DEJ, whereas Wolfsen et al. [4] reported tube malfunction in 53% of 75 patients having PEG-J for enteral feeding. A particular issue with the PEG-J system is the fine bore inner tube, which has several disadvantages in PD patients being treated
http://dx.doi.org/10.1016/j.parkreldis.2014.03.015 1353-8020/Ó 2014 Published by Elsevier Ltd.
Please cite this article in press as: Kimber TE, Schoeman M, Direct endoscopic jejunosotomy for the administration of levodopaecarbidopa intestinal gel in Parkinson’s disease, Parkinsonism and Related Disorders (2014), http://dx.doi.org/10.1016/j.parkreldis.2014.03.015
2
Letter to the Editor / Parkinsonism and Related Disorders xxx (2014) 1e3
Table 1 Clinical details and tube-related complications in patients who received PEG-J devices. Patient
Age at time of PEG-J (years)
Duration of PD at time of PEG-J (years)
Time since PEG-J (months)
Complications within first week post-insertion
Delayed complications
1
74
13
Nil
Nil (however patient abandoned LCIG 2 weeks post PEG-J insertion)
2
55
10
Discontinued LCIG 2 weeks post PEG-J Deceased 57 months post original PEG-J due to gut infarction
Nil
3
65
12
42
Nil
4
38
6
31
5
59
11
Gastric perforation and peritonitis, required laparotomy to repair Nil
In the first 54 months post PEG-J insertion patient experienced 6 episodes of inner tube removal, 6 episodes of inner tube blockage and 1 episode of gastric outlet obstruction due to inner tube migration into stomach. DEJ inserted 54 months post initial PEG-J, no further problems until death 3 months later from bowel infarction Stoma infection 1 month post-PEG-J. Entire PEG-J system required replacement on 4 occasions over next 30 months (3 blockages, 1 migration of entire inner tune into duodenum). After final blockage, PEG-J replaced with DEJ. No further problems Inner tube blockage 4 months post PEG-J insertion
6
69
14
7 8
71 66
23 8
Discontinued LCIG after 30 months to have DBS 45
51 Discontinued LCIG after 12 months
Acute abdomen day 1 post PEG-J, laparotomy performed. No findings of concern but PEG replaced with Foley catheter. PEG-J procedure repeated 6 weeks later; hospitalacquired pneumonia Nil Stoma infection 2 weeks post-PEG-J
with LCIG. The inner tube is much more likely to become knotted or inadvertently removed than the wide bore gastrostomy tube. Inadvertent inner tube removal is a particular risk in patients with severe dyskinesias or those who “pund” (ie. repetitively manipulate the tubing system). Secondly, the inner tube can migrate back into the stomach, in which location the pharmacodynamics of the LCIG are compromised because of the loss of continuous enteral absorption. Removal or blockage of the inner tube necessitate a return to the endoscopy suite for tube replacement, thereby exposing patients to
Nil
Inner tube blockage 12 months post PEG-J; severe weight loss; severe gastroesophageal reflux with esophageal stricture requiring dilatation
Entire PEG-J system replaced on 4 occasions over next 4 years due to blockages Replacement PEG-J 3 months later for leakage/stoma infection; inner tube blockage 4 months post-replacement PEG-J; ongoing stoma discomfort led to discontinuation of LCIG 12 months original PEG-J
the risks of hospitalisation and general anaesthesia, as well as substantially increasing the financial burden of this already expensive therapy. In other respects, complications of the two procedures appear to be comparable. Gastric perforation complicated by peritonitis occurred in 1 patient in each group. Delayed complications in the DEJ group have been limited to stoma leakage and/or cellulitis, which have necessitated revision of the DEJ in 2 of 9 cases. In comparison, cellulitis was the indication for tube revision in 1 of the 8 PEG-J cases.
Table 2 Clinical details and tube-related complications in patients who received DEJ devices. Time since DEJ (months)
Complications within first week post-insertion
Delayed complications
6
25
Nil
76 70 67
15 7 18
20 18 14
Nil Nil Nil
5
60
9
12
6 7
74 71
6 12
8 8
Perforation of stomach by DEJ tube: required laparotomy and repair of stomach; DEJ tube was preserved Nil Pain delayed discharge to 4th post-DEJ day
13 months post DEJ: leakage from stoma, new DEJ inserted through existing tract. Nil Nil 10 months post DEJ: excess granulation tissue around stoma led to DEJ replacement Nil
8
72
15
6
Nil
9
64
19
3
Nil
Patient
Age at time of DEJ (years)
1
75
2 3 4
Duration of PD at time of DEJ (years)
Nil Mild DEJ site infections requiring oral antibiotics 1 mild DEJ site infection requiring oral antibiotics 1 mild DEJ site infection requiring oral antibiotics
Please cite this article in press as: Kimber TE, Schoeman M, Direct endoscopic jejunosotomy for the administration of levodopaecarbidopa intestinal gel in Parkinson’s disease, Parkinsonism and Related Disorders (2014), http://dx.doi.org/10.1016/j.parkreldis.2014.03.015
Letter to the Editor / Parkinsonism and Related Disorders xxx (2014) 1e3
3
In summary, DEJ is a feasible alternative to PEG-J for the administration of LCIG in patients with PD and may have fewer tuberelated complications.
Thomas E. Kimber* Neurology Unit, Royal Adelaide Hospital and Department of Medicine, Adelaide University, North Terrace, Adelaide, SA 5000, Australia
References
Mark Schoeman Gastrointestinal Endoscopic Services, Royal Adelaide Hospital and Department of Medicine, Adelaide University, North Terrace, Adelaide, SA 5000, Australia E-mail address: [email protected].
[1] Olanow CW, Kieburtz K, Odin P, Espay AJ, Standaert DG, Fernandez HH, et al. Continuous intrajejunal infusion of levodopa-carbidopa intestinal gel for patients with advanced Parkinson’s disease: a randomised, controlled, double-blind, double-dummy study. Lancet Neurol 2014;13:141e9. [2] Fan AC, Baron TH, Rumalla A, Harewood GC. Comparison of direct percutaneous endoscopic jejunosotomy and PEG with jejunal extension. Gastrointest Endosc 2002;56:890e4. [3] Shike M, Latkany L, Gerdes H, Bloch AS. Direct percutaneous endoscopic jejunostomies for enteral feeding. Gastrointest Endosc 1996;44:536e40. [4] Wolfsen HC, Kozarek RA, Ball TJ, Patterson DJ, Botoman VA. Tube dysfunction following percutaneous endoscopic gastrostomyand jejunostomy. Gastrointest Endosc 1991;36:261e3.
* Corresponding author. E-mail address: [email protected] (T.E. Kimber).
19 February 2014
Please cite this article in press as: Kimber TE, Schoeman M, Direct endoscopic jejunosotomy for the administration of levodopaecarbidopa intestinal gel in Parkinson’s disease, Parkinsonism and Related Disorders (2014), http://dx.doi.org/10.1016/j.parkreldis.2014.03.015
Contents lists available at ScienceDirect
Parkinsonism and Related Disorders journal homepage: www.elsevier.com/locate/parkreldis
Letter to the Editor
Direct endoscopic jejunosotomy for the administration of levodopaecarbidopa intestinal gel in Parkinson’s disease Keywords: Parkinson’s disease Levodopaecarbidopa intestinal gel Direct endoscopic jejunosotomy Percutaneous endoscopic gastrostomy
Levodopaecarbidopa intestinal gel (LCIG) is effective in the treatment of Parkinson’s disease (PD) complicated by severe motor fluctuations and dyskinesias. When compared with an optimised oral medication regimen, LCIG significantly reduces “off” time and increases “on” time, without an increase in troublesome dyskinesias [1]. The commonest serious complications of LCIG infusion are those related to the tubing required to deliver the medication. The conventional tubing system involves an outer percutaneous gastrostomy (PEG) tube through which a fine bore jejunal extension tube (“inner tube”) is inserted and fed down to the jejunum (a so-called PEG-J system). Potential complications of this system include blockage, displacement into the stomach or inadvertent removal of the inner tube by the patient. Inner tube blockage can occur either by solidification of liquid residue within the tube or by knotting of the tube within the gut. Tube dysfunction in these patients causes sudden and complete cessation of medication delivery, potentially triggering a significant deterioration in Parkinsonism. In our initial experience with the PEG-J system for the delivery of LCIG, we found that tube complications were extremely common. This prompted us to trial direct endoscopic jejunostomy (DEJ) in these patients. We describe our experience with these two techniques. Ethical approval for this study was waived by our institution’s IRB. The technique of PEG-J insertion has been previously described [2]. PEG-J procedures were performed by a single endoscopist with the patient under sedation and following antibiotic premedication. Following insertion of a 20 French Frecker gastrostomy tube, a fine bore (9 French) inner tube with a pigtail end was inserted through the Frecker tube and fed down to the jejunum using a guidewire. The DEJ procedure is less well described in the literature so is described in detail below. DEJ procedures were performed under intravenous sedation and with antibiotic premedication. Two endoscopists performed the DEJ, one to do the endoscopic part of the procedure and the second, an assistant, to perform the percutaneous procedure. A paediatric colonoscope was inserted through the upper gut and into the jejunum. A suitable site for the DEJ
was then determined using transillumination. A site was considered suitable if the transilluminating light was clearly seen and if external finger palpation of the site could be clearly seen by the endoscopist. Once a suitable position was found, the assistant punctured the small bowel with a 23G spinal needle. This needle was then captured with a snare by the endoscopist to hold the small bowel in position. The assistant then inserted an insertion trochar alongside the spinal needle under local anaesthetic. Once the trochar was seen endoscopically, the snare was loosened and swapped from the spinal needle to the trochar. A string was then passed through the trochar and captured by the snare. The colonoscope with string was then removed and a 20 French Frecker gastrostomy tube was pulled back into position using a standard “pull technique”. It was then secured externally by means of a bumper. The LCIG pump was connected directly to the tube. Between May 2008 and Aug 2013, 17 patients with PD at our institution have been treated with LCIG via percutaneous enterostomy. In the initial 8 patients we employed the PEG-J system (clinical details and results in Table 1) and in the remaining 9 patients, we have used DEJ (clinical details and results in Table 2). Patients were usually discharged 2e3 days after the procedure and were subsequently reviewed at regular intervals in the outpatient clinic. Complications of the procedure were systematically recorded. At the time of writing, follow up of the PEG-J patients ranged between 2 weeks and 57 months (mean 33 months) while follow up of the direct PEJ patients ranged between 3 months and 25 months (mean 12.7 months; median 12 months). In our experience, DEJ is an equally safe procedure as PEG-J for patients with PD who require treatment with LCIG, and is associated with fewer serious delayed complications, such as tube removal or blockage. Of our initial 8 patients who underwent PEG-J, 6 experienced at least 1 episode of either inadvertent removal or blockage of the inner tube and 3 of these had multiple such complications. One patient in the PEG-J group (patient 2) had a total of 12 episodes of inadvertent tube removal or blockage within 54 months. Of the 9 patients who have undergone DEJ, there have been no episodes of inadvertent tube removal or blockage. To our knowledge, the present study is the first comparison of the experience using PEG-J versus DEJ in PD patients receiving LCIG. Fan et al. [2] reported a lower incidence of tube malfunction using DEJ, compared with PEG-J, in patients receiving enteral nutrition. Shike et al. [3] reported an incidence of tube malfunction of only 3% in cancer patients receiving DEJ, whereas Wolfsen et al. [4] reported tube malfunction in 53% of 75 patients having PEG-J for enteral feeding. A particular issue with the PEG-J system is the fine bore inner tube, which has several disadvantages in PD patients being treated
http://dx.doi.org/10.1016/j.parkreldis.2014.03.015 1353-8020/Ó 2014 Published by Elsevier Ltd.
Please cite this article in press as: Kimber TE, Schoeman M, Direct endoscopic jejunosotomy for the administration of levodopaecarbidopa intestinal gel in Parkinson’s disease, Parkinsonism and Related Disorders (2014), http://dx.doi.org/10.1016/j.parkreldis.2014.03.015
2
Letter to the Editor / Parkinsonism and Related Disorders xxx (2014) 1e3
Table 1 Clinical details and tube-related complications in patients who received PEG-J devices. Patient
Age at time of PEG-J (years)
Duration of PD at time of PEG-J (years)
Time since PEG-J (months)
Complications within first week post-insertion
Delayed complications
1
74
13
Nil
Nil (however patient abandoned LCIG 2 weeks post PEG-J insertion)
2
55
10
Discontinued LCIG 2 weeks post PEG-J Deceased 57 months post original PEG-J due to gut infarction
Nil
3
65
12
42
Nil
4
38
6
31
5
59
11
Gastric perforation and peritonitis, required laparotomy to repair Nil
In the first 54 months post PEG-J insertion patient experienced 6 episodes of inner tube removal, 6 episodes of inner tube blockage and 1 episode of gastric outlet obstruction due to inner tube migration into stomach. DEJ inserted 54 months post initial PEG-J, no further problems until death 3 months later from bowel infarction Stoma infection 1 month post-PEG-J. Entire PEG-J system required replacement on 4 occasions over next 30 months (3 blockages, 1 migration of entire inner tune into duodenum). After final blockage, PEG-J replaced with DEJ. No further problems Inner tube blockage 4 months post PEG-J insertion
6
69
14
7 8
71 66
23 8
Discontinued LCIG after 30 months to have DBS 45
51 Discontinued LCIG after 12 months
Acute abdomen day 1 post PEG-J, laparotomy performed. No findings of concern but PEG replaced with Foley catheter. PEG-J procedure repeated 6 weeks later; hospitalacquired pneumonia Nil Stoma infection 2 weeks post-PEG-J
with LCIG. The inner tube is much more likely to become knotted or inadvertently removed than the wide bore gastrostomy tube. Inadvertent inner tube removal is a particular risk in patients with severe dyskinesias or those who “pund” (ie. repetitively manipulate the tubing system). Secondly, the inner tube can migrate back into the stomach, in which location the pharmacodynamics of the LCIG are compromised because of the loss of continuous enteral absorption. Removal or blockage of the inner tube necessitate a return to the endoscopy suite for tube replacement, thereby exposing patients to
Nil
Inner tube blockage 12 months post PEG-J; severe weight loss; severe gastroesophageal reflux with esophageal stricture requiring dilatation
Entire PEG-J system replaced on 4 occasions over next 4 years due to blockages Replacement PEG-J 3 months later for leakage/stoma infection; inner tube blockage 4 months post-replacement PEG-J; ongoing stoma discomfort led to discontinuation of LCIG 12 months original PEG-J
the risks of hospitalisation and general anaesthesia, as well as substantially increasing the financial burden of this already expensive therapy. In other respects, complications of the two procedures appear to be comparable. Gastric perforation complicated by peritonitis occurred in 1 patient in each group. Delayed complications in the DEJ group have been limited to stoma leakage and/or cellulitis, which have necessitated revision of the DEJ in 2 of 9 cases. In comparison, cellulitis was the indication for tube revision in 1 of the 8 PEG-J cases.
Table 2 Clinical details and tube-related complications in patients who received DEJ devices. Time since DEJ (months)
Complications within first week post-insertion
Delayed complications
6
25
Nil
76 70 67
15 7 18
20 18 14
Nil Nil Nil
5
60
9
12
6 7
74 71
6 12
8 8
Perforation of stomach by DEJ tube: required laparotomy and repair of stomach; DEJ tube was preserved Nil Pain delayed discharge to 4th post-DEJ day
13 months post DEJ: leakage from stoma, new DEJ inserted through existing tract. Nil Nil 10 months post DEJ: excess granulation tissue around stoma led to DEJ replacement Nil
8
72
15
6
Nil
9
64
19
3
Nil
Patient
Age at time of DEJ (years)
1
75
2 3 4
Duration of PD at time of DEJ (years)
Nil Mild DEJ site infections requiring oral antibiotics 1 mild DEJ site infection requiring oral antibiotics 1 mild DEJ site infection requiring oral antibiotics
Please cite this article in press as: Kimber TE, Schoeman M, Direct endoscopic jejunosotomy for the administration of levodopaecarbidopa intestinal gel in Parkinson’s disease, Parkinsonism and Related Disorders (2014), http://dx.doi.org/10.1016/j.parkreldis.2014.03.015
Letter to the Editor / Parkinsonism and Related Disorders xxx (2014) 1e3
3
In summary, DEJ is a feasible alternative to PEG-J for the administration of LCIG in patients with PD and may have fewer tuberelated complications.
Thomas E. Kimber* Neurology Unit, Royal Adelaide Hospital and Department of Medicine, Adelaide University, North Terrace, Adelaide, SA 5000, Australia
References
Mark Schoeman Gastrointestinal Endoscopic Services, Royal Adelaide Hospital and Department of Medicine, Adelaide University, North Terrace, Adelaide, SA 5000, Australia E-mail address: [email protected].
[1] Olanow CW, Kieburtz K, Odin P, Espay AJ, Standaert DG, Fernandez HH, et al. Continuous intrajejunal infusion of levodopa-carbidopa intestinal gel for patients with advanced Parkinson’s disease: a randomised, controlled, double-blind, double-dummy study. Lancet Neurol 2014;13:141e9. [2] Fan AC, Baron TH, Rumalla A, Harewood GC. Comparison of direct percutaneous endoscopic jejunosotomy and PEG with jejunal extension. Gastrointest Endosc 2002;56:890e4. [3] Shike M, Latkany L, Gerdes H, Bloch AS. Direct percutaneous endoscopic jejunostomies for enteral feeding. Gastrointest Endosc 1996;44:536e40. [4] Wolfsen HC, Kozarek RA, Ball TJ, Patterson DJ, Botoman VA. Tube dysfunction following percutaneous endoscopic gastrostomyand jejunostomy. Gastrointest Endosc 1991;36:261e3.
* Corresponding author. E-mail address: [email protected] (T.E. Kimber).
19 February 2014
Please cite this article in press as: Kimber TE, Schoeman M, Direct endoscopic jejunosotomy for the administration of levodopaecarbidopa intestinal gel in Parkinson’s disease, Parkinsonism and Related Disorders (2014), http://dx.doi.org/10.1016/j.parkreldis.2014.03.015