Why do you need an intestinal port for the administration of Duopa?
Medications taken by mouth have to go through the stomach before they are absorbed in the small intestine (specifically in the jejunum). The problem is the time that it takes for the medication to leave the stomach is fairly variable. Many patients have a slow stomach and therefore we cannot be sure the medication was actually absorbed. The intestinal port (also called a PEG-J or GJ-Tube) is simply a ~ 15-inch tube that has been placed through the skin into the stomach extending into the small intestine. It delivers the Duopa medication directly into the jejunum (small intestine) where the absorption is fairly predictable.
What are the risks?
GJ-Tube placement is a relatively safe and low risk procedure. The two main complications seen are bleeding and infection at the insertion site.
How is a Duopa GJ-Tube placed?
Your procedure will be done at El Camino Hospital where you will be set up with an IV to allow access for moderate, also known as “twilight” sedation. You will then be taken to the procedure room where you will have a team of two nurses, a radiology technician and your interventional radiologist. You will be connected to heart, blood pressure and oxygen monitors during the entire procedure. IV medication will be administered to make you comfortable (moderate sedation). A tube will be inserted through your nose (nasogastric tube) and maneuvered to your stomach with fluoroscopic guidance. Through this tube, the stomach is filled with a small amount of air to better visualize the stomach anatomy. A site on the skin is cleaned and sterilized and local anesthetic is injected in this area to numb the site. Small buttons called “T-fasteners” are then placed on the skin and into the stomach. These help bring the stomach wall close to the abdominal wall. At this point, the stomach is affixed to the anterior abdominal wall (gastropexy).
Between the T-fasteners a needle is inserted into the stomach, and air is aspirated to confirm placement. A guidewire is passed through the needle, the needle is removed, and a GJ-Tube is placed over the guidewire and advanced into the stomach. A dye is injected to confirm correct tube placement, and an external bolster is placed on the tubing to keep it securely in place at the skin. A retention balloon at the end of the GJ-Tube inside the stomach is inflated with fluid, which prevents the GJ-Tube from being pulled out. A guidewire is then inserted through the jejunostomy port on the GJ-Tube and using fluoroscopic guidance, maneuver the jejunostomy extension into the small intestines. Nasogastric tube tube is then removed. Actual procedure time is about 30 minutes, but expect to be at the hospital for about 4-6 hours total time.
What to expect after the intestinal port procedure?
You may experience discomfort and tenderness in the stomach area or discharge around the tube. You may use over the counter medication such as Acetaminophen (Tylenol) or Ibuprofen (Advil /Motrin) for minor discomfort unless you are restricted from taking these medications. If you feel that Tylenol or Advil are not enough for pain control, please contact the Interventional Radiology Clinic at 650-404-8445. We can send pain medication to your pharmacy for the first few days if it is necessary. Most patients will get sedation during the procedure. It is a twilight mild sedation. That means you will be awake during the procedure, but hopefully will be comfortable and most of the time won’t be able to remember. If you received sedation, you should not drive, consume alcohol, operate heavy machinery or make any important decisions for the remainder of the day.
When can I shower after the procedure?
You can shower the day after the procedure. It is ok if the tube site gets wet, as long as you dry it with a towel after the shower. If you have a dressing around the tube and it gets wet. Please change it as soon as possible.
What can I eat after the procedure?
Immediately after the procedure, the stomach takes a day or so to recover. Therefore if you try to eat normally you can have pain or nausea. Try to stay on a mild liquid diet on the day of the procedure in small quantities. You can slowly advance your diet towards a normal diet the day after the procedure.
When can I resume my normal activities?
You may resume your regular activities (including driving) after 24 hours unless you have been restricted for another reason. No exercising, lifting have objects or strenuous activity for the next 3 days.
How does the tube stay in place?
There is an inflated balloon at the tip of the GJ-tube that is filled with water. It is much larger than the tract through which the tube enters the stomach. That balloon prevents the tube from falling out. Meanwhile, there is a flange on the GJ-Tube. It is on the outside, and you can see it close to the skin. This flange is meant to be advanced toward the skin and it maintains some traction on the balloon (inside of you) so that there won’t be any leakage of fluid from the stomach along the tube tract. It also prevents the balloon from sliding from the stomach into the intestine where it can cause obstruction. The GJ-tube should be gently retracted while the flange is retracted so that the tube is snug.
How do I care for the tube site?
It is ok to get wet during the shower and it is helpful to clean the site with soap and water. After the shower, it is important to keep the site dry. In the days after the procedure, we recommend changing the dressing daily. After a few days, if the site stays clear without discharge it is often better to keep the site exposed without a dressing. It does not increase the risk of infection. Do not use ointments as they may cause the tube to slip. Check the skin daily for signs of infection and irritation. If it gets red and painful it could require oral antibiotics.
Flushing: you should flush the tube daily. You can fill a syringe with tap or drinking water. Connect the syringe to the tube and flush with firm and steady pressure. Do not force the syringe if flushing the tube is difficult.
What about those little buttons near the G-tube entry site?
Those buttons (2-4 of them) are temporary and were placed as part of the procedure. They will fall off on their own in 1-2 weeks. Throw them away! Do not try to replace them and definitely do not go to the ER or try to schedule an appointment if they fall off. They are supposed to fall off!
What should I watch for?
You may be sore after the procedure, but this should not get worse and should subside within a few days. The pain should be fairly localized around the tube site. If the pain gets diffuse throughout the abdomen you should call your interventional radiologist immediately. Another common occurrence is a small amount of discharge around the tube.
These are the things you should watch for:
Increased abdominal pain or abdominal distention
Redness or increased tenderness at the G-Tube insertion site
Fluid or pus leaking around the catheter insertion site
If you have any of the above you should contact our team (650-404-8445) or you can send us a message through My Health Online (MHO).
Can I take a bath and swim with the tube in place?
Yes. you can take a bath or swim in a private pool after 4 weeks from the initial placement. At that time the skin around the tube will be healed.
Can I stop the Duopa pump?
You can stop the pump for 2 hours without needing to take the carbidopa/levodopa pills because the effect can last that long. If you need to stop for more than 2 hours during the day, please contact your neurologist and take your oral medications as prescribed.
What if I have questions about using my G-Tube catheter?
Although we do not manage the medications, you should contact us for any issues with the tube. You can call the Interventional Radiology Clinic (650-404-8445) M-F from 8 am till 5 pm if you have questions. An appointment will be made to review the use of the GJ-Tube and give you any additional information. We are sure you will have more questions that can be answered at the time of the follow-up appointment. You can always send us a message on MyHealth Online and it will be answered within 24 hours.
If the tube becomes clogged, it may need to be changed. There is no need to go to the emergency room. Contact us during the normal business hours and usually, we can schedule to have it fixed within 24 hours.