LAUSR

Most patients with Parkinson’s disease (PD) experience a wearing-off phenomenon in advanced stages of the disease requiring frequent oral administrations of levodopa. In addition, more than 80% of patients with PD develop dysphagia, which is associated with insufficient medication intake, malnutrition, and aspiration pneumonia during disease progression. Percutaneous endoscopic gastrostomy (PEG) may be considered in patients who experience dysphagia to ensure intake of sufficient medication and prevent aspiration pneumonia because levodopa is often effective in improving the swallowing function in PD. However, anatomical deformities of the stomach or postural deformities such as severe camptocormia and scoliosis may hinder safe PEG placement. Herein, we present the case of a 71-year-old woman with PD who exhibited the wearing-off phenomenon and was being treated with oral levodopa/carbidopa and entacapone every 3 hours in addition to a rotigotine transdermal patch. She had a Hoehn and Yahr stage of 5 in the off state, and the progression of motor symptoms resulted in difficulty swallowing, thereby affecting her regular oral administration of levodopa, mainly in the off state. Although PEG was considered to ensure sufficient levodopa intake and to improve the swallowing function, a thoracoabdominal computed tomography scan revealed a large sliding hiatal hernia located posterior to the heart, suggesting that safe PEG placement would be impossible (Fig. 1A,B). We proposed percutaneous transesophageal gastro-tubing (PTEG), which was performed safely, by approaching the left side of the neck (Fig. 1C). Subsequently, the patient was able to regularly take the levodopa preparation via the PTEG tube, thereby resulting in a decreased off time. The patient also displayed mild improvement of dysphagia and increased oral food intake. Measurement of plasma levodopa concentrations confirmed satisfactory levodopa absorption (Fig. 1D). PTEG, a minimally invasive technique, was developed in Japan for enteral nutrition and drainage in cases where PEG was considered logistically difficult. The tube is placed into the stomach via the cervical esophagus at the left neck under ultrasonic guidance. Although the procedures of PTEG are less invasive than those of PEG, PTEG remains unknown to most surgeons and gastroenterologists outside of Japan. PEG is commonly used for long-term tube feeding to address dysphagia in patients with advanced PD who experience swallowing problems as the disease progresses. However, PEG is not suitable in some cases, such as gastrectomy, severe ascites, advanced gastric cancer, and interposing organs between the anterior gastric wall and abdominal wall. Moreover, a large hiatal hernia can lead to unsuccessful PEG tube placement. Specifically, our patient could not undergo PEG because the large sliding hiatal hernia hindered the identification of a safe puncture site. Therefore, PTEG was performed successfully without any specific issues and resulted in regular administration of levodopa with satisfactory levodopa pharmacokinetics and amelioration of motor symptoms. Levodopa can lead to improvements in motor and nonmotor symptoms, including dysphagia, when administered at a sufficient dose. This study suggests that PTEG should be considered as an alternative procedure of levodopa administration in patients with advanced PD when PEG is not feasible for reasons such as anatomical abnormalities.■