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      Spinal/epidural block as an alternative to general anesthesia for laparoscopic appendectomy: a prospective randomized clinical study

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          Abstract

          Introduction

          Laparoscopic appendectomy (LA) has been generally performed under general anesthesia. Laparoscopic appendectomy is rarely performed under regional anesthesia because of pneumoperitoneum-related problems.

          Aim

          To compare spinal/epidural anesthesia (SEA) and general anesthesia (GA) during LA with respect to perioperative and postoperative adverse events and postoperative pain.

          Material and methods

          Fifty patients, aged 18–65, who underwent LA, were randomly allocated to two groups: the GA (n = 25) and SEA (n = 25) groups. Perioperative and postoperative adverse events, postoperative pain level, and patient satisfaction were compared between the groups.

          Results

          None of the patients needed conversion to an open procedure or conversion from SEA to GA. In the SEA group we encountered shoulder pain in 6 (24%) patients, abdominal discomfort/pain in 4 (16%) patients, anxiety in 4 (16%) patients, and hypotension in 2 (8%) patients intraoperatively. Also, post-spinal headache was observed in 5 (20%) patients in the SEA group. Postoperative right shoulder pain was significantly higher in the GA group compared to the SEA group (32% vs. 8%; p = 0.037). In the SEA group the incidence of urinary retention and in the GA group the incidence of postoperative nausea and vomiting (PONV) were higher, but these differences were not statistically significant. The postoperative surgical pain level was significantly lower in the SEA group (p < 0.001).

          Conclusions

          Spinal/epidural anesthesia is effective and safe in ASA I healthy patients undergoing LA. Less postoperative pain, PONV and shoulder pain are the advantages of SEA compared to GA.

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          Most cited references 32

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          Circulatory and Respiratory Complications of Carbon Dioxide Insufflation

           C.N. Gutt,  T Oniu,  A Mehrabi (2004)
          Background: Although providing excellent outcome results, laparoscopy also induces particular pathophysiological changes in response to pneumoperitoneum. Knowledge of the pathophysiology of a CO 2 pneumoperitoneum can help minimize complications while profiting from the benefits of laparoscopic surgery without concerns about its safety. Methods: A review of articles on the pathophysiological changes and complications of carbon dioxide pneumoperitoneum as well as prevention and treatment of these complications was performed using the Medline database. Results: The main pathophysiological changes during CO 2 pneumoperitoneum refer to the cardiovascular system and are mainly correlated with the amount of intra-abdominal pressure in combination with the patient’s position on the operating table. These changes are well tolerated even in older and more debilitated patients, and except for a slight increase in the incidence of cardiac arrhythmias, no other significant cardiovascular complications occur. Although there are important pulmonary pathophysiological changes, hypercarbia, hypoxemia and barotraumas, they would develop rarely since effective ventilation monitoring and techniques are applied. The alteration in splanchnic perfusion is proportional with the increase in intra-abdominal pressure and duration of pneumoperitoneum. Conclusion: A moderate-to-low intra-abdominal pressure (<12 mm Hg) can help limit the extent of the pathophysiological changes since consecutive organ dysfunctions are minimal, transient and do not influence the outcome.
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            Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals.

            The benefit of laparoscopic (LA) versus open (OA) appendectomy, particularly for complicated appendicitis, remains unclear. Our objectives were to assess 30-day outcomes after LA versus OA for acute appendicitis and complicated appendicitis, determine the incidence of specific outcomes after appendectomy, and examine factors influencing the utilization and duration of the operative approach with multi-institutional clinical data. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2005-2008), patients were identified who underwent emergency appendectomy for acute appendicitis at 222 participating hospitals. Regression models, which included propensity score adjustment to minimize the influence of treatment selection bias, were constructed. Models assessed the association between surgical approach (LA vs OA) and risk-adjusted overall morbidity, surgical site infection (SSI), serious morbidity, and serious morbidity/mortality, as well as individual complications in patients with acute appendicitis and complicated appendicitis. The relationships between operative approach, operative duration, and extended duration of stay with hospital academic affiliation were also examined. Of 32,683 patients, 24,969 (76.4%) underwent LA and 7,714 (23.6%) underwent OA. Patients who underwent OA were significantly older with more comorbidities compared with those who underwent LA. Patients treated with LA were less likely to experience an overall morbidity (4.5% vs 8.8%; odds ratio [OR], 0.60; 95% confidence interval [CI], 0.54-0.68) or a SSI (3.3% vs 6.7%; OR, 0.57; 95% CI, 0.50-0.65) but not a serious morbidity (2.6% vs 4.2%; OR, 0.86; 95% CI, 0.74-1.01) or a serious morbidity/mortality (2.6% vs 4.3%; OR, 0.87; 95% CI, 0.74-1.01) compared with those who underwent OA. All patients treated with LA were significantly less likely to develop individual infectious complications except for organ space SSI. Among patients with complicated appendicitis, organ space SSI was significantly more common after laparoscopic appendectomy (6.3% vs 4.8%; OR, 1.35; 95% CI, 1.05-1.73). For all patients with acute appendicitis, those treated at academic-affiliated versus community hospitals were equally likely to undergo LA versus OA (77.0% vs 77.3%; P = .58). Operative duration at academic centers was significantly longer for both LA and OA (LA, 47 vs 38 minutes [P < .0001]; OA, 49 vs 44 minutes [P < .0001]). Median duration of stay after LA was 1 day at both academic-affiliated and community hospitals. Within ACS NSQIP hospitals, LA is associated with lower overall morbidity in selected patients. However, patients with complicated appendicitis may have a greater risk of organ space SSI after LA. Academic affiliation does not seem to influence the operative approach. However, LA is associated with similar durations of stay but slightly greater operative times than OA at academic versus community hospitals. Copyright © 2010 Mosby, Inc. All rights reserved.
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              Laparoscopic versus open appendectomy in patients with suspected appendicitis: a systematic review of meta-analyses of randomised controlled trials

              Background Several systematic reviews (SRs) of randomised controlled trials (RCTs) comparing laparoscopic versus open appendectomy have been published, but there has been no overview of SRs of these two interventions. This overview (review of review) aims to summarise the results of such SRs in order to provide the most up to date evidence, and to highlight discordant results. Methods Medline, Embase, Cinahl, the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects were searched for SRs published up to August 2014. Study selection and quality assessment using the AMSTAR tool were carried out independently by two reviewers. We used standardised forms to extract data that were analysed descriptively. Results Nine SRs met the inclusion criteria. All were of moderate to high quality. The number of randomized controlled trials (RCTs) they included ranged from eight to 67. The duration of surgery pooled by eight reviews was 7.6 to 18.3 minutes shorter using the open approach. Pain scores on the first postoperative day were lower after laparoscopic appendectomy in two out of three reviews. The risk of abdominal abscesses was higher for laparoscopic surgery in half of six meta-analyses. The occurrence of wound infections pooled by all reviews was lower after laparoscopic appendectomy. One review showed no difference in mortality. The laparoscopic approach shortened hospital stay from 0.16 to 1.13 days in seven out of eight meta-analyses, though the strength of the evidence was affected by strong heterogeneity. Conclusion Laparoscopic and open appendectomy are both safe and effective procedures for the treatment of acute appendicitis. This overview shows discordant results with respect to the magnitude of the effect but not to the direction of the effect. The evidence from this overview may prove useful for the development of clinical guidelines and protocols. Electronic supplementary material The online version of this article (doi:10.1186/s12876-015-0277-3) contains supplementary material, which is available to authorized users.
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                Author and article information

                Journal
                Wideochir Inne Tech Maloinwazyjne
                Wideochir Inne Tech Maloinwazyjne
                WIITM
                Videosurgery and other Miniinvasive Techniques
                Termedia Publishing House
                1895-4588
                2299-0054
                16 January 2018
                June 2018
                : 13
                : 2
                : 148-156
                Affiliations
                [1 ]Department of Anesthesiology, Lutfiye Nuri Burat State Hospital, Istanbul, Turkey
                [2 ]Department of General Surgery, Lutfiye Nuri Burat State Hospital, Istanbul, Turkey
                [3 ]Department of Anesthesiology, Haseki Training and Research Hospital, Istanbul, Turkey
                [4 ]Department of General Surgery, Cerrahpasa Medicine Faculty, Istanbul, Turkey
                [5 ]Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
                Author notes
                Address for correspondence Turgut Donmez MD, Department of General Surgery, Lutfiye Nuri Burat State Hospital, 50.yıl Mh.A blok 2106 sok., Sultangazi, 34300 Istanbul, Turkey. phone: +90 5347400967. e-mail: surgeont73@ 123456hotmail.com
                Article
                31465
                10.5114/wiitm.2018.72684
                6041592
                Copyright: © 2018 Fundacja Videochirurgii

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.

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