Stavroula Georgopoulou

Laparoscopic cholecystectomy under spinal anesthesia : A pilot study

BackgroundRegional anesthesia has not been used as the sole anesthetic procedure other than in the scenario of a patient at high risk to undergo laparoscopic cholecystectomy with CO2 pneumoperitoneum under general anesthesia.MethodsFifteen ASA grade I or II patients underwent laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum under spinal anesthesia. Intraoperative parameters, postoperative pain and recovery in general, as well as patient satisfaction at follow-up were prospectively recorded in a pilot study to assess the feasibility and safety of the procedure.ResultsAll operations were completed laparoscopically and conversion from spinal to general anesthesia was not required in any of the cases. Median pain score 4 h postoperatively was 1.5 (range, 0–5), at 8 h it was 1 (range, 0–6), and at 24 h it was 1 (range, 0–4). All patients were discharged after 24 h. Follow-up 2 weeks postoperatively showed all but one patient to be satisfied and strongly recommending the anesthetic procedure.ConclusionLaparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum can be successfully and safely performed under spinal anesthesia. Furthermore, it seems that spinal anesthesia is associated with minimal postoperative pain and at least an equally good recovery as with general anesthesia.

Spinal vs General Anesthesia for Laparoscopic Cholecystectomy: Interim Analysis of a Controlled Randomized Trial

OBJECTIVE To compare spinal anesthesia with the gold standard general anesthesia for elective laparoscopic cholecystectomy in healthy patients. DESIGN Controlled randomized trial. SETTING University hospital. PATIENTS One hundred patients with symptomatic gallstone disease and American Society of Anesthesiologists status I or II were randomized to have laparoscopic cholecystectomy under spinal (n = 50) or general (n = 50) anesthesia. METHODS Intraoperative parameters, postoperative pain, complications, recovery, and patient satisfaction at follow-up were compared between the 2 groups. RESULTS All the procedures were completed by the allocated method of anesthesia, as there were no conversions from spinal to general anesthesia. Pain was significantly less at 4 hours (P < .001), 8 hours (P < .001), 12 hours (P < .001), and 24 hours (P = .02) after the procedure for the spinal anesthesia group compared with those who received general anesthesia. There was no difference between the 2 groups regarding complications, hospital stay, recovery, or degree of satisfaction at follow-up. CONCLUSIONS Spinal anesthesia is adequate and safe for laparoscopic cholecystectomy in otherwise healthy patients and offers better postoperative pain control than general anesthesia without limiting recovery.

Intra-operative intravenous fluid restriction reduces perioperative red blood cell transfusion in elective cardiac surgery, especially in transfusion-prone patients: a prospective, randomized controlled trial

BackgroundCardiac surgery is a major consumer of blood products, and hemodilution increases transfusion requirements during cardiac surgery under CPB. As intraoperative parenteral fluids contribute to hemodilution, we evaluated the hypothesis that intraoperative fluid restriction reduces packed red-cell (PRC) use, especially in transfusion-prone adults undergoing elective cardiac surgery.Methods192 patients were randomly assigned to restrictive (group A, 100 pts), or liberal (group B, 92 pts) intraoperative intravenous fluid administration. All operations were conducted by the same team (same surgeon and perfusionist). After anesthesia induction, intravenous fluids were turned off in Group A (fluid restriction) patients, who only received fluids if directed by protocol. In contrast, intravenous fluid administration was unrestricted in group B. Transfusion decisions were made by the attending anesthesiologist, based on identical transfusion guidelines for both groups.Results137 of 192 patients received 289 PRC units in total. Age, sex, weight, height, BMI, BSA, LVEF, CPB duration and surgery duration did not differ between groups. Fluid balance was less positive in Group A. Fewer group A patients (62/100) required transfusion compared to group B (75/92, p < 0.04). Group A patients received fewer PRC units (113) compared to group B (176; p < 0.0001). Intraoperatively, the number of transfused units and transfused patients was lower in group A (31 u in 19 pts vs. 111 u in 62 pts; p < 0.001). Transfusions in ICU did not differ significantly between groups. Transfused patients had higher age, lower weight, height, BSA and preoperative hematocrit, but no difference in BMI or discharge hematocrit. Group B (p < 0.005) and female gender (p < 0.001) were associated with higher transfusion probability. Logistic regression identified group and preoperative hematocrit as significant predictors of transfusion.ConclusionsOur data suggest that fluid restriction reduces intraoperative PRC transfusions without significantly increasing postoperative transfusions in cardiac surgery; this effect is more pronounced in transfusion-prone patients.Trial registrationNCT00600704, at the United States National Institutes of Health.

Monitoring of brain oxygen saturation (INVOS) in a protocol to direct blood transfusions during cardiac surgery: a prospective randomized clinical trial

BackgroundBlood transfusions are common in cardiac surgery, but have been associated with increased morbidity and long-term mortality. Efforts to reduce blood product use during cardiac surgery include fluid restriction to minimize hemodilution, and protocols to guide transfusion decisions. INVOS is a modality that monitors brain tissue oxygen saturation, and could be useful in guiding decisions to transfuse. However, the role of INVOS (brain tissue oxygen saturation) as part of an algorithm to direct blood transfusions during cardiac surgery has not been evaluated. This study was conducted to investigate the value of INVOS as part of a protocol for blood transfusions during cardiac surgery.MethodsProspective, randomized, blinded clinical trial, on 150 (75 per group) elective cardiac surgery patients. The study was approved by the Institution Ethics committee and all patients gave written informed consent. Data were initially analyzed based on “intention to treat”, but subsequently were also analyzed “per protocol”.ResultsWhen protocol was strictly followed (“per protocol analysis”), compared to the control group, significantly fewer patients monitored with INVOS received any blood transfusions (46 of 70 patients in INVOS group vs. 55 of 67 patients in the control group, p = 0.029). Similarly, patients monitored with INVOS received significantly fewer units of red blood cell transfusions intraoperatively (0.20 ± 0.50 vs. 0.52 ± 0.88, p = 0.008) and overall during hospital stay (1.31 ± 1.20 vs. 1.82 ± 1.46, p = 0.024). When data from all patients (including patient with protocol violation) were analyzed together (“intention to treat analysis”), the observed reduction of blood transfusions in the INVOS group was still significant (51 of 75 patients transfused in the INVOS group vs. 63 of 75 patients transfused in the control group, p = 0.021), but the overall number of units transfused per patient did not differ significantly between the groups (1.55 ± 1.97 vs. 1.84 ± 1.41, p = 0.288).ConclusionsOur data suggest that INVOS could be a useful tool as part of an algorithm to guide decisions for blood transfusion in cardiac surgery. Additional data from rigorous, well designed studies are needed to further evaluate the role of INVOS in guiding blood transfusions in cardiac surgery, and circumvent the limitations of this study.Trial registrationClinicalTrials.gov: NCT00879463

Laparoscopic transabdominal preperitoneal repair of inguinal hernia under spinal anesthesia: a pilot study

BACKGROUND The laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is an evolving technique associated with the well-known advantages of a minimally invasive approach. However, general anesthesia is routinely required for the procedure. Based on our previous experience in regional anesthesia for laparoscopic procedures, we designed a pilot study to assess the feasibility and safety of performing laparoscopic TAPP repair under spinal anesthesia. METHODS Forty-five American Society of Anesthesiologists I or II patients with a total of 50 inguinal hernias underwent TAPP repair under spinal anesthesia, using a low-pressure CO(2) pneumoperitoneum. Five patients had bilateral hernias, and 4 patients had recurrent hernias. Thirty hernias were indirect and the remaining direct. Intraoperative incidents, postoperative pain complications, and recovery in general as well as patient satisfaction at the follow-up examination were prospectively recorded. RESULTS There was 1 conversion from spinal to general anesthesia and 2 conversions from laparoscopic to the open procedure at a median operative time of 50 minutes (range 30-130). Ten patients complained of shoulder pain during the procedure, and 6 patients suffered hypotension intraoperatively. The median pain score (visual analog scale) was 1 (0-5) at 4 hours after the completion of the procedure, 1.5 (0-6) at 8 hours, and 1.5 (0-5) at 24 hours, and the median hospital stay was 1 day (range 1-2). Sixteen patients had urinary retention requiring instant catheterization. At a median follow-up of 20 months (range 10 months-28 months), no recurrence was detected. CONCLUSIONS TAPP repair is feasible and safe under spinal anesthesia. However, it seems to be associated with a high incidence of urinary retention. Further studies are required to validate this technique.

Laparoscopic ventral hernia repair under spinal anesthesia: a feasibility study

BACKGROUND Regional anesthesia has not been used as the sole anesthetic procedure in laparoscopic ventral hernia repair due to the fear of potential adverse effects of the pneumoperitoneum. However, there are recent reports on the feasibility of performing laparoscopic procedures, such as cholecystectomy, in fit patients, under spinal anesthesia alone. The current study aimed to detect the feasibility of performing laparoscopic ventral hernia repair under spinal anesthesia. METHODS Twenty-five American Society of Anesthesiologists (ASA) I or II patients underwent laparoscopic ventral hernia repair with low-pressure CO2 pneumoperitoneum under spinal anesthesia. In 9 cases the hernia was umbilical/para-umbilical, in 5 cases epigastric, and in 11 cases incisional. Intraoperative incidents, complications, postoperative pain, and recovery in general, as well as patient satisfaction at follow-up examination, were prospectively recorded. RESULTS All operations were completed laparoscopically and conversion from spinal to general anesthesia was not required in any of the cases. Median pain score at 4 hours postoperatively was .5 (range 0-5), at 8 hours 1.5 (range 0-6), and at 24 hours 1.5 (range 0-4). Most patients were discharged 24 hours after the operation; the median hospital stay was 1 day (range 1-3 days). At 2-weeks follow-up, no late complications were detected and all patients reported being satisfied with the anesthetic procedure. CONCLUSION Laparoscopic ventral hernia repair with low-pressure CO2 pneumoperitoneum can be successfully and safely performed under spinal anesthesia. Furthermore, it seems that spinal anesthesia is associated with minimal postoperative pain and smooth recovery.

Laparoscopic ventral hernia repair in obese patients under spinal anesthesia

PURPOSE The aim of the present study was to evaluate the feasibility and efficacy of laparoscopic ventral hernia repair under spinal anesthesia in obese patients (BMI > 30 kg/m(2)). METHODS From January 2007 to February 2010, 23 obese patients had their elective laparoscopic ventral hernia repair under spinal anesthesia. We looked primarily for intra-operative incidences as well as immediate postoperative complications. Long term results and especially recurrences were also to be evaluated. RESULTS Median operative time was 55 min (range 20-100). Intraoperatively, six patients (26%) complained of shoulder pain, three patients (13%) developed bradycardia and two (8.7%) hypotension. Postoperatively, nausea and/or vomiting were recorded in four patients (17.4%), four patients (17.4%) experienced urinary retention and one patient developed wound infection. Median pain score at 4th, 8th and 24th postoperative hour was 0.5 (0-5), 1.5 (0-6), and 1.5 (0-5) respectively. The median length of hospital stay was one day (1-2). At a median follow up of 39 months, one patient was diagnosed with a recurrence. CONCLUSION Spinal anesthesia for LVHR in obese patients (BMI > 30 kg/m(2)) proved an efficient and safe alternative to general anesthesia in the given patient sample.