# Laparoscopic Cholecystectomy for a Patient after Percutaneous Endoscopic Gastrostomy due to Myotonic Dystrophy: A Case Report and Literature Review

## TL;DR

A patient with myotonic dystrophy and a PEG tube successfully underwent laparoscopic cholecystectomy with careful planning and specialized perioperative care.

## Contribution

This case report provides surgical and anesthetic strategies for laparoscopic cholecystectomy in patients with myotonic dystrophy and PEG tubes.

## Key findings

- Laparoscopic cholecystectomy was safely performed in a patient with myotonic dystrophy and a PEG tube.
- Computed tomography confirmed the PEG location to avoid injury during surgery.
- Specialized anesthetic and postoperative care minimized complications.

## Abstract

Percutaneous endoscopic gastrostomy (PEG) is commonly performed for enteral nutrition in patients with various diseases. However, there are few reports on abdominal surgeries for patients after PEG, and the tips for these procedures have not been established. Specifically, in laparoscopic surgeries of the upper abdomen, a gastrostomy can interfere with the surgical field. In addition, perioperative management of concomitant diseases that require PEG placement, including neuromuscular disorders, is required.

A 64-year-old man with a PEG due to malnutrition from myotonic dystrophy was diagnosed with acute cholangitis and choledocholithiasis. After lithotomy during endoscopic retrograde cholangiopancreatography, the patient was scheduled for laparoscopic cholecystectomy for the cholelithiasis. Although the patient had myotonic dystrophy and limited respiratory function, his general condition was deemed acceptable for surgery. Given the potential risk of gastrostomy injury and the need to ensure sufficient working space, the location of the gastrostomy tube was preoperatively confirmed via a computed tomography scan, and precautions were taken to prevent injuries caused by port insertion, forceps manipulation, and pneumoperitoneum during the procedure. Ultimately, the gastrostomy did not interfere with manipulation around the gallbladder, and the surgery was completed without any complications. To manage myotonic dystrophy, general intravenous anesthesia with propofol was administered, with minimal use of muscle relaxants during surgery. Postoperatively, the patient was managed with high nasal flow to reduce respiratory workload, epidural anesthesia to prevent respiratory depression due to pain, and early initiation of aggressive physical therapy. The patient was discharged on postoperative day 4 without complications.

Using appropriate surgical strategies, laparoscopic cholecystectomy may be safely performed for patients with myotonic dystrophy after PEG.