Peritonitis after percutaneous endoscopic gastrojejunostomy
for levodopa–carbidopa intestinal gel treatment despite
concomitant use of gastropexy
and Masahisa Katsuno
Gastrointestinal Surgery, Nagoya University Graduate School of Medicine, and
Brain and Mind
Research Center, Nagoya University, Nagoya, Japan
gastropexy, levodopa–carbidopa intestinal gel,
Parkinson’s disease, percutaneous
endoscopic gastrojejunostomy, peritonitis.
Accepted for publication 15 January 2018.
Showa-ku, Nagoya 466-8550, Japan.
A 58-year-old man with Parkinson’s disease experienced peritonitis after percuta-
neous endoscopic gastrojejunostomy (PEG-J) for levodopa–carbidopa intestinal gel
treatment despite concomitant use of gastropexy. Although gastropexy reduces
complications including peritonitis, clinicians should consider structural character-
istics of PEG-J devices and patients’ anatomical differences. We recommend that
suture threads are removed 2–4 weeks after PEG-J and that the PEG-J tube length
outside the body is routinely recorded to assess tube dislocation.
Levodopa–carbidopa intestinal gel (LCIG) treatment
improves motor ﬂuctuations and quality of life in patients
with Parkinson’s disease (PD).
One of the most serious
adverse effects associated with LCIG treatment is peritonitis
(incidence rate, approximately 3%).
Peritonitis is life-
threatening and requires immediate antibiotics with/without
surgical treatment. However, little information is available
on peritonitis after percutaneous endoscopic gastrojejunos-
tomy (PEG-J) for LCIG.
PEG-J devices (AbbVie, North Chicago, IL) are placed
using the standard pull method. However, the pull method
reportedly has a higher incidence of postoperative peritonitis
than the push method with gastropexy.
devices comprise two parallel needles and a suture-holding
loop to percutaneously and tightly suture the stomach to the
In many Japanese institutions, gastropexy
is performed before PEG-J placement to lower the risk of
complication, including peritonitis.
Herein, we report a patient who developed peritonitis
after PEG-J despite concomitant use of gastropexy.
A 45-year-old man developed right-hand tremor and was
diagnosed as PD. At 58 years, he spent around a half day in
the off-state and experienced troublesome peak-dose and
diphasic dyskinesia. Uniﬁed Parkinson’s Disease Rating
Scale (UPDRS) III was 10 in the on-state and 24 in the off-
state. UPDRS IV was 8. Additionally, he had nonmotor
symptoms such as akathisia and shortness of breath in the
off-state. He had freezing of gait during the best on-period.
Regarding activity of daily living, he decided to undergo
We determined the position of the air-ﬁlled stomach and
adjacent organs using endoscopy and abdominal X-rays.
Stomach indentation determined the optimal puncture site
by external palpation. Furthermore, the stomach was
anchored to the abdominal wall using the gastropexy device
(Create Medic, Kanagawa, Japan). We placed a PEG tube
using a standard pull technique at the center of the gas-
tropexy site. Finally, a PEG-J tube was advanced into the
jejunum (Fig. 1a–c). Three doses of 1.0 g intravenous cefa-
zolin were given for 3 days. He had an uncomplicated peri-
We removed suture threads of gastropexy on postopera-
tive day 7 and discharged him on day 8. On day 9, he pre-
sented with a chief complaint of abdominal pain. Computed
tomography scans revealed stomach detachment from the
abdominal wall, the PEG-J tube running through the peri-
toneal cavity, free air, and inﬂammatory changes in the fatty
tissue (Fig. 1d). Accordingly, surgeons recommended surgi-
A vertical midline incision was made in the upper abdo-
men, and the abdominal cavity was cleaned with saline
because of cloudy ascites and fatty tissue around the PEG-J
tube (Fig. 1e). The PEG-J tube outside the body was pulled
Neurology and Clinical Neuroscience 6 (2018) 64–66
ª 2018 Japanese Society of Neurology and John Wiley & Sons Australia, Ltd