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

Enteral nutrition is necessary in patients for whom oral nutrition is insufficient or impossible. Nasogastric tube insertion can be readily performed and is useful in the short term as a form of enteral feeding but can have lower feeding efficacy as well as the risk of potential complications, such as irritation, ulceration, bleeding, esophageal reflux, and aspiration pneumonia. Patients sometimes also report discomfort with this procedure [9]. In cases where long-term enteral nutrition is required, placement of a gastrostomy tube may be considered. PEG was introduced by Gauderer et al. as an alternative to the laparotomy gastrostomy [10]. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system than other surgical methods [9]. The procedure is easy to perform, less invasive, and has been widely used with good outcomes [11]. However, it is contraindicated for patient with severe ascites, peritonitis, serious coagulation disorder or gastrointestinal obstruction [9, 12]. Although the gastrostomy tube can be inserted in patients with previous abdominal surgery involving the stomach after confirming a safe tract with no interposed organs, PEG insertion is difficult to perform [9, 13]. An endoscopic or radiologic gastrostomy may be considered as an alternative, although these methods are sometimes technically demanding and require specialized equipment and experienced personnel [14].

If an endoscopic or radiologic gastrostomy is not possible, LAPEG should be considered as a minimally invasive alternative to the open gastrostomy. LAPEG, which was described for the first time by Raaf et al. [15], eliminates the risk of blind injury to the viscera and allows the optimal site for gastrostomy placement in both the stomach and abdominal wall to be determined. LAPEG also enables the stomach to be pulled into a normal position and other organs overlying the stomach to be avoided under direct observation via laparoscopy. Barkmeire reported a higher success rate for laparoscopically assisted techniques (100%) than for conventional PEG (84%), although the procedural and postprocedural complication rates were similar [16]. Some studies have reported successful LAPEG in patients with previous abdominal surgery of any kind [3, 6]. However, LAPEG can be highly invasive in cases where adhesiolysis of the remnant stomach is difficult or poses a high risk of bleeding or damage to other organs or the operative time is significantly prolonged. In such cases, a laparoscopically assisted jejunostomy, open gastrostomy or open jejunostomy should be considered as an alternative. In the present case, LAPEG was planned, because the patient opted for a gastrostomy rather than nasogastric tube insertion or a jejunostomy, because tube and nutritional management was easier with a gastrostomy than with other methods. The adhesion of the remnant stomach and other organs was not severe, allowing adhesiolysis to be performed easily and the LAPEG to be performed less invasively.

In patients with ALS, perioperative management for preventing respiratory complications is extremely important, because critical, postoperative, respiratory complications can lead to decreased quality of life. In preoperative management, the results of serial pulmonary function tests and ALSFRS-R assessment during the preoperative period should aim to evaluate the functional status of these patients and determine whether they may require postoperative mechanical ventilation [17]. To minimize the risk of respiratory complications in patients with ALS, the current guidelines recommend that the patients undergo PEG before their VC decreases to 50% of the normal value [18]. For intraoperative management, careful monitoring and appropriate drug selection are necessary, especially in surgery requiring general anesthesia and muscle relaxants. In patients with ALS, an abnormal response to a muscle relaxant can lead to respiratory depression, and depolarizing neuromuscular blocking agents (succinylcholine) have the potential to induce hyperkalemia [17]. In the present case, surgery was performed under general anesthesia using a low-dose, non-depolarizing neuromuscular blocking agent (rocuronium) and epidural anesthesia with careful airway management and intraoperative neuromuscular monitoring. In postoperative management, aggressive physiotherapy is recommended to restore pulmonary function. Although the present patient was an exception, mechanical ventilation should be performed in patients with respiratory muscle weakness. Noninvasive ventilation (NIV) reduces respiratory fatigue, promoting CO2 washout and better oxygenation. Some studies have reported that NIV is effective in ALS patients after elective surgery under general anesthesia as means of safely preventing postoperative respiratory failure [19, 20].

There are no previous studies describing the details of LAPEG in patients with ALS, and the safety of laparoscopic surgery in these patients is still unclear. Diaphragmatic pacing, used to stimulate the diaphragm to prevent atrophy and prolong life by preventing pulmonary complications, and laparoscopic diaphragmatic pacing have sometimes been performed in patients with ALS. A multicentric study of these methods demonstrated that laparoscopic diaphragm surgery can be performed safely in patients with ALS [21]. It is possible that laparoscopic surgery, including LAPEG, can also be performed safely in patients with ALS.

留言 (0)

沒有登入
gif