Laparoscopically assisted percutaneous endoscopic gastrostomy performed for remnant stomach in patient with amyotrophic lateral sclerosis: a case report.

BACKGROUND: Although percutaneous endoscopic gastrostomy (PEG) offers better access to the gastrointestinal system, in patients with previous abdominal surgery, PEG can be unsuccessful. Laparoscopically assisted percutaneous endoscopic gastrostomy (LAPEG) is indicated for such patients. However, patients with amyotrophic lateral sclerosis (ALS) may be more susceptible to anesthesia-related complications than other patients, requiring the indications for LAPEG, along with perioperative management, to be considered carefully. CASE PRESENTATION: A 70-year-old, male patient with ALS was referred to our hospital for a gastrostomy for progressive dysphagia. He had undergone an open distal gastrectomy for gastric ulcer perforation in his twenties. Upper gastrointestinal endoscopy denied the transillumination sign and focal finger invagination. Because the risk of respiratory complications caused by general anesthesia was not considered serious, the decision was made to perform a LAPEG. Under careful, intraoperative airway management and neuromuscular monitoring, adhesiolysis was performed to increase mobility of the remnant stomach. A gastrostomy tube was inserted through the abdominal wall and into the remnant stomach under laparoscopic and endoscopic guidance. The patient was discharged in stable condition on postoperative day 3 without any respiratory complications. CONCLUSIONS: LAPEG was able to be performed in a patient with ALS with a previous gastrectomy. A perioperative team comprised of neurologists, endoscopists, surgeons, anesthesiologists, and nurses who are fully conversant with ALS must be assembled to deal with potentially complex medical issues related to the procedure and anesthetic and perioperative management.

[Two Separate Instances of Anesthetic Management in a Patient Initially Diagnosed with Stiff-person Syndrome].

In this case report, we describe separate instances of general anesthetic management administered to a patient during treatment for two unrelated conditions. The patient, a 57-year-old woman who had been experiencing walking difficulties for about four years, fell down because of muscle rigidity and spasms and fractured her humerus. She was subsequently diagnosed with stiff-person syndrome. The fracture was treated conservatively, but three weeks later the alignment of the humerus became worse and the patient was scheduled to undergo an open reduction and internal fixation under general anesthesia (GA). Anesthesia was induced using propofol and fentanyl, and rocuronium was given for the tracheal intubation. The operation was completed successfully while anesthesia was maintained using sevoflurane and remifentanil without incident Four months later, the patient developed paraneoplastic syndrome stemming from breast cancer, and underwent a resection of the cancer under GA. The patient received propofol for the laryngeal mask insertion, and sevoflurane and pentazocine for maintenance of anesthesia. She was discharged from the hospital without any respiratory or airway problems. We used sevoflurane for maintenance of anesthesia on both occasions, and rocuronium for the first tracheal intubation. The patient's hemodynamics were stable during the operation. No prolonged effect of the muscle relaxant or any autonomic reactions were observed. The patient was fully conscious and in good respiratory condition after both surgeries, and was extubated in the operating room. There were no perioperative complications.