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Choi: Updated evidence for optimal anesthesia following laparoscopic cholecystectomies

Updated evidence for optimal anesthesia following laparoscopic cholecystectomies

Yoon Ji Choi
Received January 9, 2023       Accepted January 17, 2023
The gold standard surgical treatment for symptomatic gallstone disease is laparoscopic cholecystectomy (LC) [1], which is a minimally invasive procedure to remove the gallbladder. Compared to conventional open cholecystectomy, evidence of a significantly shorter hospital stay and faster patient recovery has been shown worldwide with LC [2].
LC is classically performed under general anesthesia (GA) with controlled ventilation using endotracheal intubation, which can help prevent aspiration, dyspnea, and hypercapnia resulting from carbon dioxide pneumoperitoneum [3]. Pneumoperitoneum during laparoscopy, which can cause abdominal and respiratory discomfort, is not well tolerated in patients who are awake during the procedure. The 2018 PROSPECT guidelines on LC recommended that wound/port infiltration be used as the routine regional technique, while the other available techniques were not recommended because of limited trial evidence, the rate of failure, or the potential for complications. However, several recent studies [47] have verified the availability and safety of regional anesthesia (RA), including spinal and epidural anesthesia, for LC. Under RA, patients are awake and oriented at the end of the procedure and are able to ambulate earlier than patients receiving GA. Other advantages include less postoperative pain, nausea, and vomiting and a reduced neuroendocrine stress response compared with GA [47]. In addition, the risk of mortality, venous thromboembolism, myocardial infarction, and several other complications is lower with RA [8]. However, RA, such as spinal anesthesia, may cause abdominal discomfort and shoulder pain [9,10]. Therefore, various studies have assessed the feasibility of using RA for patients undergoing LC [4,7,913].
In this issue of the Korean Journal of Anesthesiology, we would like to introduce a systematic review and network meta-analysis on the effect of single-dose RA for LC conducted by De Cassai et al. [14]. This study showed that most RA techniques are effective in reducing postoperative opioid consumption, pain on the first postoperative day, and postoperative nausea and vomiting (PONV), which is consistent with previously published guidelines. The authors concluded that all the RA techniques assessed in patients undergoing LC in the 46 included studies were superior to placebo in reducing opioid consumption. Among the included techniques, the paravertebral block, which significantly reduced morphine consumption, was the most effective. Postoperative pain was also evaluated at 12 h after surgery in 53 studies and 24 h after surgery in 65 studies. Compared to placebo, the subcostal transversus abdominis plane (TAP) block showed the greatest reduction in postoperative pain at 12 h, and the erector spinae plane (ESP) block showed the greatest reduction in postoperative pain compared to placebo at 24 h. Additionally, PONV was significantly reduced compared to placebo or no intervention in 40 studies evaluating the ESP block; TAP block; intraperitoneal instillation; and wound/port invasion, excluding the rectus sheath block, with the TAP block showing the greatest effect on PONV. Additionally, the need for rescue analgesics after LC was reduced by all interventions in the 28 studies evaluating this outcome, with the quadratus lumborum block being the most effective.
Regrettably, differences in the hospital length of stay was not assessed in this study due to a lack of appropriate performance studies. Nevertheless, the strength of this study was the inclusion of various outcomes besides postoperative pain to evaluate the effect of RA on patients undergoing LC.
Although GA has potential advantages over RA in patients undergoing LC, the challenges of RA will continue to develop, particularly with advances in medical devices and RA techniques, and more diverse results will be expected from ongoing clinical studies.
NOTES

Funding

None.

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

References

1. Bessa SS, Katri KM, Abdel-Salam WN, El-Kayal el-SA, Tawfik TA. Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: a prospective randomized study. J Laparoendosc Adv Surg Tech A 2012; 22: 550-5.
[Article] [PubMed]
2. Keus F, de Jong JA, Gooszen HG, van Laarhoven CJ. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev 2006; (4): CD006231.
[Article]
3. Duncan CB, Riall TS. Evidence-based current surgical practice: calculous gallbladder disease. J Gastrointest Surg 2012; 16: 2011-25.
[Article] [PubMed] [PMC]
4. Tiwari S, Chauhan A, Chaterjee P, Alam MT. Laparoscopic cholecystectomy under spinal anaesthesia: a prospective, randomised study. J Minim Access Surg 2013; 9: 65-71.
[Article] [PubMed] [PMC]
5. Hajong R, Khariong PD, Baruah AJ, Anand M, Khongwar D. Laparoscopic cholecystectomy under epidural anesthesia: a feasibility study. N Am J Med Sci 2014; 6: 566-9.
[Article] [PubMed] [PMC]
6. Das W, Bhattacharya S, Ghosh S, Saha S, Mallik S, Pal S. Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: a randomized prospective trial. Saudi J Anaesth 2015; 9: 184-8.
[Article] [PubMed] [PMC]
7. Hamad MA, El-Khattary OA. Laparoscopic cholecystectomy under spinal anesthesia with nitrous oxide pneumoperitoneum: a feasibility study. Surg Endosc 2003; 17: 1426-8.
[Article] [PubMed]
8. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321: 1493.
[Article] [PubMed] [PMC]
9. Tzovaras G, Fafoulakis F, Pratsas K, Georgopoulou S, Stamatiou G, Hatzitheofilou C. Spinal vs general anesthesia for laparoscopic cholecystectomy: interim analysis of a controlled randomized trial. Arch Surg 2008; 143: 497-501.
[Article] [PubMed]
10. Yuksek YN, Akat AZ, Gozalan U, Daglar G, Pala Y, Canturk M, et al. Laparoscopic cholecystectomy under spinal anesthesia. Am J Surg 2008; 195: 533-6.
[Article] [PubMed]
11. Tzovaras G, Fafoulakis F, Pratsas K, Georgopoulou S, Stamatiou G, Hatzitheofilou C. Laparoscopic cholecystectomy under spinal anesthesia: a pilot study. Surg Endosc 2006; 20: 580-2.
[Article] [PubMed]
12. Sinha R, Gurwara AK, Gupta SC. Laparoscopic cholecystectomy under spinal anesthesia: a study of 3492 patients. J Laparoendosc Adv Surg Tech A 2009; 19: 323-7.
[Article] [PubMed]
13. Kar M, Kar JK, Debnath B. Experience of laparoscopic cholecystectomy under spinal anesthesia with low-pressure pneumoperitoneum--prospective study of 300 cases. Saudi J Gastroenterol 2011; 17: 203-7.
[Article] [PubMed] [PMC]
14. De Cassai A, Sella N, Geraldini F, Tulgar S, Ahiskalioglu A, Dost B. Single shot regional anesthesia for laparoscopic cholecystectomies: a systematic review and network meta - analysis. Korean J Anesthesiol 2023; 76: 34-46.
[Article] [PubMed]

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