When it has been decided that the patient will continue
Duodopa treatment, a tube is inserted into the stomach (PEG)
with the help of a gastroscope. An 'inner tube' is put through
the tube (PEG) and pushed through the pylorus into the small
This chapter describes actions to take before operation,
the tube system, how to dress the stoma, and the daily care
of the tube wound.
Before PEG surgery
Follow hospital routines during insertion of
PEG. Example: fasting, premedication, Venflon.
Send the PEG and inner tube with the patient to the endoscopy
Due to the nature of the patients disease, it is
important that no longer than 2 hours elapse after the patient
takes their PD medication as the muscles become rigid, making
surgery significantly more difficult and increasing the
risk of complications. If there are delays, the patient
will need to continue with oral rescue medication until
surgery is possible.
The PEG tube is inserted as usual and the inner tube is
fed down into the small intestine with the help of the gastroscope.
Post-operative care and maintenance of the PEG
The dressed wound should be inspected to make sure that
there is no bleeding or leakage. If there is, the dressing
should be replaced.
Mild tension should be applied to the PEG some time after
the operation to prevent the PEG from moving around in the
wound, and to prevent leakage that may cause peritonitis.
Check the tension as follows:
Dressing the wound
Pull the PEG until you feel a mild resistance. If
the tension is too tight there is a risk of tissue damage.
Move the outer stop plate 2 mm clear of the skin
and lock it.
Daily dressing of the tube wound is necessary for the
first three weeks after surgery.
One or two weeks after the operation, the stop plate may
be fixed 2 cm from the skin when the wound has healed. The
tube orifice should be cleaned with soap and water during
showers/baths. Make sure the skin is dried afterwards.
Measures in case of complications
|The tube wound is inflamed.
||Rub on water-repellent barrier cream.
|The tube wound is infected.
||Use NaCl (normal saline 0.9%) and cotton wool/gauze
swab to clean it, once or twice daily.
In complicated cases, a bacteria culture may be
taken. Treat with antibiotics if there is no improvement.
The tube system consists of a PEG and an inner tube fixed
to the outer connections and leading through the PEG into
the stomach and into the small intestine.
The connections are attached to the PEG and inner tube.
- Undo the white cap of the PEG tube.
- Remove the RED cap from the cassette tubing.
- Connect the cassette tubing to the PEG. Do this by holding the PEG tube with one
hand securely whilst gently rotating clockwise the cassette tube onto the PEG
with the other hand. DO NOT twist the PEG tube, as this may dislodge the tubing
internally. Do all the twisting with the cassette tubing not the PEG tubing
- Hold the PEG tube with one hand securely whilst gently rotating the cassette tube
anti-clockwise. Then remove the cassette tube from the PEG with the other hand.
Placement of the intestinal tube
During the PEG operation it is recommended that the surgeon
places the inner tube in the small bowel with the help of
Note: It may be difficult to pull back the gastroscope
without also removing the tube. If this happens the most
important thing is to place the tip of the tube well past
Optimal tube position
Optimal tube position is when:
No loop is present in the stomach.
The tip of the tube is well down the duodenum. It
is recommended to place the tip in the distal part of
the duodenum near the Treitz ligament to reduce the
risk of dislocation to the stomach.
Experience has shown that the tip can also be placed
just beyond the ligament of Treitz, in the proximal
jejunum, so that the tube will stay in place correctly.
Available knowledge indicates that the absorption of
levodopa does not differ at any site in the upper small
intestine, including duodenum and the upper part of
The inner tube should be cut off when the tip of the tube
is in upper part of the small intestine and with the smallest
amount possible in the stomach.
The outer tube should be kept as long as is required to
give maximum comfort to the patient.
The connections must always be firmly tightened, or the
inner tube may lose its position in the small bowel or move
back into the stomach.
Starting permanent treatment
On the day of operation, EXTRA DOSE is used to fill the
Do not use the morning dose as this function has a time
lock of 20 hours.
Connect the medicine cassette to the PEG tube.
Filling the PEG tube
- Press the ON/OFF button, keep pressed for 3 seconds.
The pump runs the programme and displays the set values.
This takes approx. 30 seconds and STOPPED will be displayed.
Press the NEXT button several times until 'Extra
dose X.X ml' is displayed (3 ml to fill the tube + any
- Change the dosage using the arrow buttons until the
desired dose is reached.
Confirm the change of dosage by pressing the ENTER/CLEAR
Press the STOP/START button and keep pressed until (---- ---- ----) disappears. The pump runs through
the set values again. This takes approx. 15 seconds.
Press the EXTRA DOSE button.
- Reset the pump to the normal extra dosage according
to steps 1-4.
During the test treatment period and after insertion
of the PEG, a Duodopa Support Nurse will be on hand to offer
advice and guidance on operating the pump and adjusting
After PEG operation, the Morning dose is increased by
3 ml due to flushing of tube.
- Take the Duodopa cassette out of the fridge at
least 20 minutes before starting the pump.
- Attach the cassette to the pump:
Remove stopper from the pump tube.
Remove the RED cap
from the cassette tubing.
- Fit the hooks of the cassette onto the pivot
pins at the pump's base.
- Place the pump on a level surface.
- Steady the cassette and put a coin in the slot
of the lock knob.
- Lock the cassette by pushing the coin or the
Duodopa key and turning it 90 degrees counter-clockwise
until it stops.
5. Connect the cassette tubing to the PEG. Do this by holding the PEG tube with
one hand securely whilst gently rotating clockwise the cassette tube onto the
PEG with the other hand. DO NOT twist the PEG tube, as this may dislodge the
tubing internally. Do all the twisting with the cassette tubing not the PEG
6. Turn the pump on:
Press and hold down the [ON/OFF] button for 3 seconds.
Press and hold down the [STOP/START] button for 3
7. Give the Morning Dose:
Press the [MORNING DOSE] button. The set morning dose
is shown in the display. Press the button again and
the pump will administer the morning dose.
8. Continuous Dose:
The pump will automatically deliver the continuous
dose after the morning dose has been administered.
9. Extra Dose:
(This is to be used if you find you need an extra dose. It should only be required
up to 4 times a day. If you find that you require this more often, you
should contact your Nurse or Duodopa Support Nurse as you may need your
continuous dose increased. The extra dose can only be given again once an hour
Secure the pump safely, e.g. in a bag or with a harness.
Guide to Daily Routine
here to view and download a guide to the use of Duodopa
following PEG surgery.
Click here to view and download the Post-PEG diary.
Stoma dressing instructions
Daily care of the stoma
The stoma should be cleaned with soap and water during
showers/baths. Make sure the skin is dried afterwards.
If the stoma gets inflamed you can rub on a water-repellent
ointment. If it gets infected it should be cleaned thoroughly with salt solution
(normal saline 0.9%) and cotton wool/gauze swab, once or twice daily. You can also
ask to try antiseptic ointment.
In complicated cases, a bacterial culture may be taken
in case antibiotics will be necessary.
- Wash hands thoroughly with soap and water.
- Clean the external plate as advised by your Healthcare
- Open the fixation catch (see Fig 1).
- Detach tube from groove in fixation plate (see
- Move plate away from skin (see Fig 3).
- Clean tube and stoma area and the underside of
the plate and dry. Push 2-3cm of the tube into the stomach and
gently pull back the tube to feel resistance.
- Place the fixation plate back to its original
position (approx 1cm away from the skin). Re-insert tube
in the groove (see Fig 4) and close the fixation catch (see Fig
- Your fixation plate should not be too tight or
too loose. If you feel that it is, your Healthcare
Professional will be able to advise you.