Objective: We describe a case series of 12 patients requiring administration of levodopa-carbidopa intestinal gel (LCIG) who had their tube placed by  per-oral image guided gastrojejunostomy (PIG-J) rather than the traditional percutaneous endoscopic gastrojejunostomy (PEG-J).

Background: In contrast to an approach requiring endoscopy, gastrojejunostomy can be inserted under fluoroscopic guidance. Developed primarily for inserting feeding tubes, the tubes are placed directly through the gastrostomy and use either a balloon or pig-tail end to secure their placement. However, this has a higher risk of being dislodged than the tubes fixed with an internal phalange. A variation on this technique is the per-oral image guided gastrojejunostomy (PIG-J), which allows the insertion of the tube with the more secure fixation device.

Method: The movement disorder centre in Southmead hospital serves as a tertiary referral centre for the South-West of the UK, offering device therapies for PwP for patients with significant motor fluctuations, despite optimal oral medical therapy. In line with current UK practice and NICE guidelines, LCIG would be considered where apomorphine and deep brain stimulation were unsuitable, taking into account patient preferences. The stomach is inflated with a nano-gastric tube, local anaesthetic used to infiltrate the stoma site followed by a needle puncture (under fluoroscopic guidance) and then a guide-wire. The guide-wire is used to pull through the administration tube and the jejunal extension is then placed under fluoroscopic guidance.

Results: We will present the case series of 12 patients with PIG-J insertion, including response to treatments and adverse events.

Conclusion: Per-oral image guided gastrojejunostomy insertion for levodopa-carbidopa intestinal gel is safe and well tolerated in this small cohort of patients with advanced Parkinson’s. The size of this cohort precludes any firm conclusions being drawn as to the potential advantages of this technique. However, based on this preliminary data, we propose that this promising technique warrants further investigation as it has the potential to reduce procedure related complications and may also allow access to LCIG therapy for patients in which PEG-J is unsuitable or not tolerated.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/per-oral-image-guided-gastrojejunostomy-insertion-for-levodopa-carbidopa-intestinal-gel-in-parkinsons-disease-is-safe-and-may-be-advantageous/