The use of enteral access for continuous delivery of levodopa-carbidopa in patients with advanced Parkinson's disease

Abstract

Background: Continuous delivery to the jejunum of levodopa-carbidopa is a promising therapy in patients with advanced Parkinson's disease, as it reduces motor fluctuation. Percutaneous endoscopic gastrostomy and jejunal tube (PEG-J) placement is a suitable option for this. However, studies focused in PEG-J management are lacking.

Objectives: We report our experience regarding this technique, including technical success, adverse events and outcomes, in patients with advanced Parkinson's disease.

Methods: Twenty-seven advanced Parkinson's disease patients (17 men, median age: 64 years, median disease duration: 11 years) were included in a retrospective study from June 2007 to April 2015. The median follow-up period was 48 months (1-96).

Results: No adverse events were noted during and after nasojejunal tube insertion (to assess treatment efficacy). After a good therapeutic response, a PEG-J was placed successfully in all patients. The PEG tube was inserted according to Ponsky's method. The jejunal extension was inserted during the same procedure in all patients. Twelve patients (44%) experienced severe adverse events related to the PEG-J insertion, which occurred after a median follow-up of 15.5 months. Endoscopy was the main treatment modality. Patients who experienced severe adverse events had a higher comorbidity score (p = 0.011) but were not older (p = 0.941) than patients who did not.

Conclusions: While all patients responded well to levodopa-carbidopa regarding neurological outcomes, gastro-intestinal severe adverse events were frequent and related to comorbidities. Endoscopic treatment is the cornerstone for management of PEG-J related events. In conclusion, clinicians and endoscopists, as well as patients, should be fully informed of procedure-related adverse events and patients should be followed in centres experienced in their management.

Keywords: PEG; PEG-J; Parkinson’s disease; adverse events; duodopa; levodopa; percutaneous endoscopic gastrostomy and jejunal tube.

Figure 1.

Flowchart of study population. N: number of patients; FU: follow-up; PEG-J: percutaneous endoscopic gastrostomy and jejunal tube

Figure 2.

Stomach (a) and duodenum (b) in a patient with a trans-pyloric duodenal linear ulcer, due to traction of the jejunal tube, who presented with abdominal pain nine months after percutaneous endoscopic gastrostomy and jejunal tube (PEG-J) insertion. This patient required PEG-J definitive removal.

Figure 3.

Computed tomography showing extra-intestinal air bubbles (arrows), following percutaneous endoscopic gastrostomy and jejunal tube replacement (intestinal perforation). The patient presented abdominal pain and was put on antibiotics and outcome was uneventful.

Figure 4.

Coronal multiplanar CT reconstruction showing (a) internal bumper migration into the duodenum and (b, c) multiple jejunal fistulas caused by migration of the jejunal extension. This severe adverse event occurred 14 months after percutaneous endoscopic gastrostomy and jejunal tube (PEG-J) placement. The patient presented to the emergency room with abdominal pain, nausea and vomiting. The patient required surgical treatment with intestinal resection and re-anastomosis; follow-up was favourable but PEG-J had to be definitely removed.