Prospective comparison of ambulatory with inpatient laparoscopic cholecystectomy: outcome, patient preference and satisfaction

This prospective study compares inpatient with ambulatory laparoscopic cholecystectomy with respect to outcome, patient preference and satisfaction. In total, 51 inpatients and 42 ambulatory cases were included. Mean operating and total anaesthesia times were significantly shorter for ambulatory patients (P = 0.010 and <0.001, respectively). Post-operative pain scores at 24 h were significantly lower for ambulatory patients (P = 0.005) but there was no difference after 48 h. Morbidity included three conversions (one ambulatory and two inpatients), one laparotomy for post-operative bleeding and one percutaneous drainage of a haematoma. There was no significant difference in return to home or work activity between the two groups. Measures of patient satisfaction relating to the admission procedure, amount of information received and hospital environment were significantly higher for ambulatory patients (P < 0.001, <0.001 and <0.001, respectively). The majority of patients (66%) expressed a preference for an ambulatory procedure. In addition to the demonstrated clinical benefits, ambulatory laparoscopic cholecystectomy is preferred by the majority of patients and is associated with significantly higher levels of overall satisfaction.     

Selective spinal anaesthesia in ambulatory surgery

Background and objectives: selective spinal anaesthesia (SSA) is preferable in day hospital surgery. The present investigation aims to confirm the usefulness and safety of this technique. Methods: 250 patients (ASA I–II, mean age 42 ± 3 years) scheduled for day-hospital surgery were enrolled in our study. The puncture was performed with the patients in a lateral position, the ill side down; for proctological surgery the puncture was performed in a sitting position. A 27G Whitacre needle was always used and 1% hyperbaric bupivacaine was administered in 30 s or more, preceded by a single dose of fentanyl (20 μg) injected very slowly. The position was maintained for 10 min. Hemodynamic parameters (SBP, DBP, HR) and pulsoximetry were recorded before anaesthesia (T₀), 5 min after subarachnoid injection (T₁) and then every 15 min (T_n) up to the completion of the surgical procedure. In the last 100 patients enrolled in our study haemodynamic data (CI, EF, SVRI, MAP,HR) were recorded by using a non invasive bioimpedenzometric method, before anaesthesia (T_a), after 15 min (T_b), 60 min (T_c) and 240 min (T_d). The postoperative course was evaluated from the end of surgery on, with regard to analgesic consumption and residual analgesic degree. The incidence of adverse effects was evaluated. Results: the level and degree of anaesthesia was excellent in 183 and good in 67 patients. SBP, DBP, HR and pulsoximetry showed an excellent stability during the study. Haemodynamic stability was confirmed by data obtained with bioimpedenzometry that showed significant variations in CI (P < 0.001), SVN (P < 0.0001) at T_b and T_c as to basal five values. Postoperative analgesia was excellent and the incidence of side effects very low. Conclusions: we believe that the method is suitable for day-hospital surgery because it is easy to execute and provides an excellent degree of surgical anaesthesia, cardiovascular stability, postoperative analgesia and patient safety.     

Is intercostal block for pain management in thoracic surgery more successful than epidural anaesthesia?

Objective: Currently epidural anesthesia is the gold standard for postoperative pain management in thoracic surgery. In a prospective randomised study, the effect of an intercostal nerve block applied at the end of the operation was compared to that of epidural anesthesia. Methods: Thirty patients undergoing thoracotomy were randomised to each group. Patients with resection of the parietal pleura, rib resection and rethoracotomy were excluded from the study. Both groups received non-steroidal anti-inflammatory drugs every 8 h as a baseline analgesic medication and were allowed to ask for supplemental subcutaneous opiate injection, limited to four injections per day. The patients in the epidural catheter group (group I) were provided with a motor pump allowing continuous infusion of bupivacain 0.125% and 2 mg fentanyl/ml at a dosage of 6–10 ml per hour, dependent on the pain level over a period of 5 days. The patients of the second group (group II) received an intercostal nerve block at the end of the operation reaching from the third to the ninth intercostal space with 20 ml 0.5% bubivacaine. Pain was evaluated with a pain score ranging from 1 (no pain) to 10 (worst pain) twice daily in relaxed position and during physical activity like coughing. On the fifth postoperative day, the patients were asked specific questions concerning the subjective pain experience. Costs of both treatments were calculated. Mean pain values and costs of both groups were compared by t-tests for independent samples. A P value of less than 0.05 was considered significant. Results: Eighteen male and 12 female patients, aged between 35 and 71 years (mean 59) were included in the study. Nineteen patients had lobectomy, five bilobectomy, two decortication and three wedge resection. There were 22 right sided and eight left sided procedures. In group I, the mean pain score on the operation day was 3.95 in relaxed position and 6.33 during physical activity like coughing. The mean pain score during the following 4 days was 2.19 in relaxed position and 4.28 with activity. Three patients required additional subcutaneous opiate injection. In group II, the mean score on the operation day was 2.0 in relaxed position and 3.5 during activity. The mean pain score during the next 4 days was 2.84 in relaxed position and 5.65 with activity. Twelve patients received subcutaneous opiates. In both groups, no complications were observed. Costs: The costs for treatment of one patient was €105 in group I and €33 in group II. Patients' satisfaction was equal in both groups, there were no differences in terms of outcome and recovery. Conclusion: Pain management by intercostal block was superior during the first 24 h after surgery whereas on the second day after surgery pain control was significantly better achieved by the epidural catheter in relaxed position. A combination of both forms of anaesthesia seems to be an ideal pain management in patients undergoing thoracic surgery.     

Comparison of perioperative spirometric data following spinal or general anaesthesia in normal-weight and overweight gynaecological patients

BACKGROUND: There is limited data comparing the impact of spinal anaesthesia (SA) and general anaesthesia (GA) on perioperative lung function. Here we assessed the differences of these two anaesthetic techniques on perioperative lung volumes in normal-weight (BMI < 25) and overweight (BMI 25-30) patients using spirometry. METHODS: We prospectively studied 84 consenting patients having operations in the vaginal region receiving either GA (n = 41) or SA (n = 43). Both groups (GA and SA) were further divided into two subgroups each (normal-weight vs. overweight). We measured vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), midexpiratory (MEF25-75) and peak expiratory flow rates (PEFR) at the preoperative assessment (baseline), after premedication, after effective SA, and 20 min, 1 h, 2 h and 3 h after the operation (last measurement after patient mobilization). RESULTS: Premedication was associated with a small but significant decrease in lung volumes in direct correlation with BMI (-5%). Spinal anaesthesia resulted in a significant reduction in lung volumes in overweight as opposed to normal-weight patients. Postoperatively, lung volumes were significantly more reduced following GA than SA as indicated by differences in mean VC (SD) of -12 (6)% vs. -6 (5)% 20 min after the end of the operation in the normal-weight and -18 (5)% vs. -10 (5)% in the overweight patients. There was a significant impact of BMI on postoperative respiratory function, which was significantly more important in the GA group than in the SA group, and recovery of lung volumes was more rapid in the normal-weight patients than in the overweight patients, particularly in the SA group. CONCLUSION: In gynaecological patients undergoing vaginal surgery, the impact of anaesthesia on postoperative lung function as assessed by spirometry was significantly less after SA than GA, particularly in overweight patients.     

Recovery time and patient satisfaction in ambulatory knee arthroscopy: Prospective study comparing three anaesthetic methods

The aim of this study was to compare recovery time and satisfaction of patients operated under two anaesthetic techniques. A randomised-controlled trial that enrolled ASA I-II patients submitted to ambulatory knee arthroscopy was designed. Patients included were randomly assigned to one of the three study groups: general intravenous anaesthesia (TIVA), spinal anaesthesia with lidocaine (LIDO), and spinal anaesthesia with prilocaine (PRILO). Spinal groups did not receive supplementary sedation. Major outcome measures considered were both the time to discharge from the post-anaesthesia care unit (PACU) and from the day-case surgical unit (DSU), the incidence of adverse events, postoperative need for analgesics and patients satisfaction. One hundred and twenty patients were enrolled. Mean time from the patients comes into operating room to discharge from PACU was 125 ± 27 min for the PRILO group, 109 ± 24 min for the LIDO group and 106 ± 34 min for the TIVA group (P < 0.01). Time to discharge from the ASU was 279 ± 37 min for the PRILO group, 261 ± 53 min for the TIVA group and 241 ± 36 min for the LIDO group (P < 0.001). No significant differences were observed in the appearance of adverse events, the need for postoperative analgesics and the degree of patient satisfaction among the study groups. A shorter recuperation time was observed in the LIDO group, but more TIVA patients preferred to have the same anesthetic again. All three anaesthetic methods are useful for ambulatory knee arthroscopy.     

Vasectomy reversal with ultrasonography‐guided spermatic cord block

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Vasectomy reversal is often performed in general or neuraxial anaesthesia. Even though the site of vasectomy reversal is easily amenable to regional/local anaesthesia, spermatic cord blocks are rarely applied because of their risk of vascular damage within the spermatic cord. Recently, we described the technique of ultrasonography (US)‐guided spermatic cord block for scrotal surgery, which, thanks to the US guidance, at the same time avoids the risk of vascular damage of blindly performed injections and the risks of general and neuraxial anaesthesia. Vasectomy reversal can easily be done in regional anaesthesia with the newly described technique of US‐guided spermatic cord block without the risks of vascular damage by a blindly performed injection and the risks of standard general and neuraxial anaesthesia. In addition, this technique grants long‐lasting postoperative pain relief and patients recover more quickly. Microsurgical conditions are excellent and patient satisfaction is high. Thanks to these advantages, more patients undergoing vasectomy reversal might avoid general or neuraxial anaesthesia.

OBJECTIVE

• ? To assess the success rate, microsurgical conditions, postoperative recovery, complications and patient satisfaction of ultrasonography (US)‐guided spermatic cord block in patients undergoing microscopic vasectomy reversal and to compare them to a control group with general or neuraxial anaesthesia.

PATIENTS AND METHODS

• ? The present study comprised a prospective series of 10 consecutive patients undergoing US‐guided spermatic cord block for microscopic vasectomy reversal.
• ? The cohort was compared with 10 patients in a historical control group with general or neuraxial anaesthesia.

RESULTS

• ? Nineteen of 20 (95%) blocks were successful, defined as no pain >3 on the Visual Analogue Scale (VAS), no additional analgesics and/or no conversion to general anaesthesia. Median pain was 0 on the VAS (range 0–5). Additional analgesics were requested in one (5%) block, and there was no conversion to general anaesthesia.
• ? Microsurgical conditions were excellent.
• ? In the spermatic cord block vs general/neuraxial anaesthesia groups, median times (range) between surgery and first postoperative analgesics, alimentation, mobilization and hospital discharge were 12 (2–14) vs 3 (1–6), 1 (0.25–3) vs 4 (3–6), 2 (1–3) vs 6 (3–10), and 4 (3–11) vs 8.5 (6–22) h, respectively.
• ? No complications were reported after the spermatic cord block.
• ? Patient satisfaction was excellent.

CONCLUSIONS

• ? US‐guided spermatic cord block for microscopic vasectomy reversal is highly successful and provides long‐lasting perioperative analgesia.
• ? Times to alimentation, mobilization and hospital discharge are shorter under US‐guided spermatic cord block than under general/neuraxial anaesthesia.
• ? Additional anaesthetic pain management might, however, be required unexpectedly with US‐guided spermatic cord block.

     

Spinal versus general anesthesia for orthopedic surgery: anesthesia drug and supply costs

Total hip or knee replacement surgeries are common orthopedic interventions that can be performed with spinal anesthesia (SA) or general anesthesia (GA). No study has investigated the economic aspects associated with the two anesthetic techniques for this common surgery. We randomized 40 patients to receive either SA or GA and analyzed the drug and supply costs for anesthesia und recovery. Anesthesia-related times, hemodynamic variables, and pain scores were also recorded. Total costs per case without personnel costs were almost half in the SA group compared with the GA group; this was a result of less cost for anesthesia (P < 0.01) and for recovery (P < 0.05). This finding was supported by a sensitivity analysis. There were no relevant differences regarding anesthesia-related times. Patients in the GA group were admitted to the postanesthesia care unit with a higher pain score and needed more analgesics than patients in the SA group (both P < 0.01). We conclude that SA is a more cost-effective alternative to GA in patients undergoing hip or knee replacement, as it is associated with lower fixed and variable costs. Moreover, SA seems to be more effective, as patients in the SA group showed lower postoperative pain scores during their stay in the postanesthesia care unit.     

Lumbar spine instrumented fusion surgery under spinal anaesthesia versus general anaesthesia-A retrospective study of 239 cases

ObjectiveConventionally spinal surgeries are done under general anaesthesia (GA). Plenty of literature is available on lumbar spine non-instrumented surgeries under spinal anaesthesia (SA) but handful of literature is there on lumbar spinal instrumented fusion surgeries under SA. We retrospectively analysed the data of 131 patients operated under SA and 108 patients under GA. Aim of the study was to evaluate the safety, advantages and disadvantages of doing lumbar spine instrumented fusion surgeries under SA.In time of COVID-19 pandemic, aerosol generating procedure like intubation, can be avoided if lumbar spine instrumented fusion surgeries are performed under SA.Methods239 patients aged between 20 and 79 years operated from January 2014 to December 2019 were included in this study. Indications for surgery were lumbar canal stenosis, degenerative or lytic spondylolisthesis. They underwent L4-L5 or L5-S1 fusion surgeries either TLIF or pedicle screw fixation postero lateral fusion (PLF) and decompression. Out of 239 patients,131 were operated under SA and 108 patients under GA. Heart rate, mean arterial pressure (MAP), blood loss, operating room time, post-op pain relief and need of analgesics, cost of surgery and anaesthesia related complications were analysed.ResultsThe study found significantly less blood loss (p<.05), less OR time, better post-op analgesia and lesser incidence of nausea and vomiting in SA (8.4%) than GA (29.6%). We observed average 10% cost reduction in SA. This study did not find any prone position related complication in regional anaesthesia but one transient brachial plexus palsy and one post-op shoulder pain in GA group.ConclusionSA is a safe alternative to GA for lumbar spine instrumented fusion surgery with significant less blood loss, OR time, better post-op analgesia, average 10% overall cost reduction and no reported prone-position related complications.     

Inguinal Hernia Repair: Local or General Anaesthesia?

INTRODUCTION

Specialist hernia centres and public hospitals with a dedicated hernia service (Plymouth Hernia Service) have achieved remarkable results for inguinal hernia repair with the use of local anaesthesia and set the standards for groin hernia surgery. There is minimal data in the literature as to whether such results are reproducible in the National Health Service in the UK.

PATIENTS AND METHODS

A retrospective analysis of all inguinal hernia repairs performed in one district general hospital over a 9-year period was performed. The outcome measures were type of anaesthesia used, early and late postoperative complications and recurrence. A postal questionnaire survey was conducted to obtain satisfaction rates. In addition, a postal questionnaire survey of consultant surgeons in Wales was performed to determine the use of local anaesthesia and day-case rates for inguinal hernia repair.

RESULTS

A total of 577 hernia repairs were performed during the study period. Of these, 369 (64%) repairs were performed under local anaesthesia (LA) and 208 (36%) under general anaesthesia (GA). Day-case repair was achieved in 70% (400) of cases. The day-case rates were significantly higher under LA compared to GA (82.6% versus 42.6%; P < 0.05). Patients operated under LA had lower postoperative analgesic requirements and lower incidence of urinary retention compared with the GA group (P < 0.05). There were 7 (1.2%) recurrences at a median follow-up of 5.1 years (range, 10.3–2.5 years). Postal questionnaire revealed higher satisfaction rates with LA compared to GA repair. Only 15% of surgeons in Wales offer the majority of their patients local anaesthetic repair.

CONCLUSIONS

The use of LA results in increased day-case rates, lesser postoperative analgesic requirements and fewer micturition problems. The excellent results obtained by specialist hernia centres can be reproduced by district general hospitals by increasing the use of LA to repair inguinal hernias.     

Day surgery for gynaecological laparoscopy: Clinical results from an RCT

This randomized controlled trial compared the clinical outcome from inpatient and ambulatory laparoscopy for benign gynaecological conditions. While 658 consecutive patients were considered for inclusion into the study, data from 26 inpatients and 40 ambulatory cases were analysed. Inpatient surgery was undertaken by more senior surgeons (p < 0.001), but complication rates were similar. For remedial surgery (but not diagnostic), ambulatory laparoscopy had shorter anaesthetic and operating times (p < 0.05) than inpatient surgery. Both inpatient and ambulatory patients reported significant improvements (p < 0.01) in immediate postoperative pain; similar proportions (64% and 74%, respectively) experienced postoperative nausea; 39% of inpatients and 58% of ambulatory patients reported problems after hospital discharge. Severity of pelvic pain was lower for both groups 1 month after operation in comparison to preoperative levels (inpatients: from 8.0 to 5.0, ambulatory: 6.0 to 3.0; on a 0–10 VAS). It was concluded that clinical and patient outcome was similar for the patients undergoing inpatient and ambulatory surgery for gynaecological laparoscopy.     

Impact of postoperative blood pressure control on regression of left ventricular mass following valve replacement for aortic stenosis

Objective: Considerable left ventricular (LV) hypertrophy sometimes remains after aortic valve replacement (AVR) for aortic stenosis. For this issue, most previous studies have focused solely on transprosthetic pressure gradient, although true problem is not the pressure gradient itself but an elevated LV pressure. This study investigated the impact of blood pressure on postoperative LV mass regression, which had been overlooked in previous studies. Methods: Seventy-nine adult patients with pure aortic stenosis who were treated with AVR using bileaflet mechanical valves underwent echocardiography before surgery, around 6 months later (‘early’), and 2–3 years later (31.7±14.7 months, ‘late’). Patients were divided into two groups whether postoperative systolic blood pressure was below (n=47; N group) or above 130 mmHg (n=32; H group) following recommendation of WHO-ISH and JNC 7th report. Preoperative LV mass (g/m²) did not differ significantly (232±80 vs. 243±76, P=0.91). Results: LV mass became significantly smaller and regression was significantly more effective in N group than in H group both at ‘early’ (145±43 vs. 180±54, regression against preoperative value 34.6±19.1 vs. 19.9±26.6%, P=0.007) and ‘late’ (132±41 vs. 178±51, regression 41.1±16.0 vs. 21.0±27.0%, P<0.001) evaluations. Regression between ‘early’ and ‘late’ evaluations was significant only in N group (P=0.012). The LV mass index returned to the normal range at ‘late’ evaluation in 52.1% of N group and 12.5% of H group patients (P<0.001), and 25 out of 29 patients without residual LV hypertrophy were N group patients. Multivariate analyses revealed that preoperative LV mass index (P<0.001) and postoperative systolic blood pressure (P=0.007) showed significant influence on postoperative LV mass index, and postoperative systolic blood pressure alone significantly (P<0.001) influenced the regression ratio of the LV mass against the preoperative value. No prosthesis related variables (size, orifice area index, pressure gradient) had significant influence. Conclusions: For LV mass regression after AVR, postoperative blood pressure appeared to be more important than prosthesis selection. Controlling the systolic blood pressure below 130 mmHg was beneficial, which coincided with recommendation of WHO-ISH and JNC 7th report despite the pressure drop due to prosthesis in the aortic position.     

Subacute pain and function after fast-track hip and knee arthroplasty

In a well-defined fast-track setup for total hip and knee arthroplasty, with a multimodal analgesic regimen consisting of intra-operative local anaesthetic infiltration and oral celecoxib, gabapentin and paracetamol for 6 days postoperatively, we conducted a prospective, consecutive, observational study. The purpose was to describe the prevalence and intensity of subacute postoperative pain and opioid related side effects, use of analgesics and functional ability 1–10 and 30 days postoperatively. Fast-track total hip and knee arthroplasty with early discharge (< 3 days) resulted in acceptable levels of pain and postoperative nausea and vomiting with concomitant low use of opioids in > 95% of patients after discharge before day 10 after total hip arthroplasty. However, after total knee arthroplasty 52% patients reported moderate pain (VAS 30–59 mm), and 16% severe pain (VAS ≥ 60 mm) when walking 1 month after surgery with a concomitant increase in the use of strong opioids. These results emphasise the need for improvement in analgesia after discharge following total knee arthroplasty, to facilitate rehabilitation.     

Rebound pain and postoperative pain profile following brachial plexus block compared to general anaesthesia—An observational study

Background

Regional anaesthesia has the benefit of reducing the need for systemic analgesia and therefore, potentially reducing undesired side effects. With the end of the sensory nerve block however, many patients report severe pain that requires therapy with opioids and often compromise the initial opioid sparing effect. This study aimed to characterise the postoperative pain profile and the phenomenon of rebound pain after axillary brachial plexus anaesthesia (RA) compared to general anaesthesia (GA).

Design

Single-centre observational, stratified cohort study.

Setting

The study was conducted at University Hospital Marburg from May 2020 until September 2022.

Participants

One hundred thirty-two patients receiving elective hand and forearm surgery were enrolled in this study.

Interventions

Group RA received ultrasound-guided brachial plexus anaesthesia via the axillary approach with 30 mL of prilocaine 1% and 10 mL ropivacaine 0.2%. Group GA received balanced or total intravenous general anaesthesia.

Main Outcome Measures

Primary endpoint were integrated pain scores (IPS) within 24 h postoperatively. Secondary endpoints were pain scores (NRS 0–10), morphine equivalents, patient satisfaction, quality of recovery and opioid-related side effects.

Results

One hundred thirty-two patients were analysed of which 66 patients received brachial plexus block and 66 patients received general anaesthesia. Following RA significantly lower IPS were seen directly after surgery (p < .001) and during the post-anaesthesia care unit interval (p < .001) but equalised after 3 h at the ward. No overshoot in pain scores or increased opioid consumption could be detected. Patient satisfaction and postoperative recovery were comparable between both groups.

Conclusion

The IPS and NRS was initially lower in the RA group, increased with fading of the block until equal to the GA group and equal thereafter. Although various definitions of rebound pain were met during this phase, the opioid sparing effect of regional anaesthesia was not counteracted by it. The incidence of episodes with uncontrolled, severe pain did not differ between groups. We found no clinical implications of rebound pain in this setting, since the RA group did not show higher pain scores than the GA group at any time point. Trial Registration: German Clinical Trials Register (DRKS00021764).     

Preemptive analgesia with controlled-release oxycodone is successful in prevention of post-inguinal herniorrhaphy pain

In a double-blind randomized study, controlled-release (CR) oxycodone (OxyContin ®) administration was assessed against placebo to ascertain the extent of postinguinal herniorrhaphy pain control. Patients received a single dose of CR oxycodone (40 mg orally) or placebo 40 min before surgery.

When post-surgical pain was first reported, a visual analogue scale (VAS) was used to assess pain score. Postoperative pain-free time, dolestin (opiod) and dipyrone (antipyretic) consumption were assessed 24 h after the surgery. Postoperative pain-free time in the CR oxycodone group (Group I) was 655±548 min versus 112±71.5 min in the placebo group (Group II) (P<0.02). Postoperative 24 h dolestin consumption was 8.3±19.5 mg (Group I) versus 120.1±89.2 mg (P=0.004) (Group II). Postoperative 24 h dipyrone consumption in Group I was 0.58±0.67 g versus 1.42±1.0 g in Group II (P=0.004). Accordingly, 41.7% of patients in Group I demonstrated a need for postoperative analgesic drugs was versus 100% of the patients in Group II (P=0.037). Conclusions: Preemptive administration of a single 40 mg oral dose of CR oxycodone significantly reduced both postoperative pain and consumption of analgesic agents, without causing side effects, and may be useful in an ambulatory surgery setting.     

Type of anaesthesia and patient acceptance in groin hernia repair: A multicentre randomised trial

Background Groin hernia repair can be performed under general (GA), regional (RA), or local (LA) anaesthesia. This multicentre randomised trial evaluates patient acceptance, satisfaction, and quality of life with these three anaesthetic alternatives in hernia surgery. Methods One hundred and thirty-eight patients at three hospitals were randomised to one of three groups, GA, RA, or LA. Upon discharge, they were asked to complete a specially designed questionnaire with items focusing on pain, discomfort, recovery, and overall satisfaction with the anaesthetic method used. The global quality-of-life instrument EuroQol was used for estimation of health perceived. Results Significantly more patients in the LA group than in the RA group felt pain during surgery (P<0.001). This pain was characterised as light or moderate and for the majority of LA patients was felt during infiltration of the anaesthetic agent. Postoperatively, patients in the LA group first felt pain significantly later than patients in the other two groups (P=0.012) and significantly fewer LA patients consumed analgesics more than three times during the first postoperative day (P=0.002). The results concerning nausea, vomiting, and time to first meal all favour LA. No difference was found among the three groups concerning overall satisfaction and quality of life.Conclusion In a general surgical setting, we found LA to be well tolerated and associated with significant advantages compared to GA and RA.     

Spainal anesthesia improves the early recovery profile of patients undergoing ambulatory knee arthroscopy

PURPOSE: We compared the recovery profiles, postoperative complications, perioperative OR utilization times, and times to discharge of patients undergoing ambulatory knee arthroscopy under spinal anesthesia (SA) or general anesthesia (GA). METHODS: In this randomized, prospective study, 84 ASA I-II patients were randomized to receive either SA with 50 mg of 1% lidocaine, or a standardized GA. Postoperative pain, nausea and vomiting, sedation, OR utilization, postanesthesia care unit (PACU), and ambulatory surgical unit (ASU) recovery were compared. RESULTS: Patients in the GA group had more pain in the PACU than the SA group (61% vs 15%, P <0.01), and a higher incidence of PACU analgesic use (59% vs 7.5%, P <0.01). Patients in the SA group were able to drink and eat sooner than the GA group (83 +/- 23 vs 95 +/- 22 min, P <0.05 and 88 +/- 27 vs 105 +/- 29 min, P <0.01, respectively). The times to sit, walk, and void were similar. The length of PACU and ASU stay between the GA and SA groups were similar (67 +/- 17 vs 60 +/- 19 min, P >0.05 and 122 +/- 27 vs 127.9 +/- 31 min, P >0.05, respectively). The incidence of backache was higher in the SA group (35 vs 13.6%, P <0.05) than the GA group. However, the incidence of sore throat was higher in the GA compared to the SA group (25% vs 2.5%, P <0.01). CONCLUSIONS: SA with 50 mg of 1% lidocaine provides an improved recovery profile for ambulatory knee arthroscopy. Discharge times were similar, and with the exception of backache and sore throat, the incidence of complications was similar.     

One-week recovery profiles after spinal, propofol, isoflurane and desflurane anaesthesia in ambulatory knee arthroscopy

There are comprehensive findings on the immediate recovery of patients from different types of anaesthesia, but more information is needed on how patients manage at home after ambulatory surgery. One hundred and seventy-three elective knee arthroscopy patients were randomised into four different anaesthesia groups to receive either spinal anaesthesia (SA) with 5% lidocaine or general anaesthesia (GA) with propofol infusion, isoflurane inhalation or desflurane inhalation. The patients were interviewed over the phone on the next day and asked to complete a questionnaire after 1 week. One hundred and sixty-eight patients (97%) were reached by phone. The questionnaire was returned by 163 patients (94%). After 24 h, all the patients were satisfied with the type of anaesthesia they had received, but 2% of the SA patients would have chosen GA and 4.3% of the GA patients would have chosen SA for the next operation. Based on the questionnaires returned after 1 week, 8.3% of the SA patients would have wanted to have GA, and 4.7% of the GA patients would have wanted to have SA in the future. The incidence of nausea (4.2%) and vomiting (1.8%) was very low in the whole series, with no differences between the anaesthesia groups. Headache after 24 h was experienced by 15.7% of the SA and 10.3% of the GA patients. After 1 week, SA patients reported headache upon standing in 13.5% of the cases, backache in 36.5% and lower leg pain in 59.6%. The corresponding figures for GA patients were 4.5, 9.9 and 39.6% (P<0.05). In spite of the good immediate recovery profile in the all anaesthesia groups, the fact that SA patients reported a higher incidence of headache, backache and lower leg pain after 1 week may be signs of post spinal headache and transient neurologic symptoms (TNS). For overall patient comfort, GA might be a better anaesthetic choice in ambulatory surgery.     

Assessment of patient satisfaction after regional anaesthesia in two institutions

OBJECTIVES: This study was designed to assess patient satisfaction after regional anaesthesia for limb surgery. METHODS: An anaesthesia satisfaction questionnaire was developed, validated (Kappa coefficient) and submitted to 314 patients operated in two institutions (one university hospital with anaesthesiology residents and one specialised in orthopaedics with experienced anaesthesiologists). Items explored were information modalities, pain and anxiety during procedure and global satisfaction rated with four levels (very satisfied [VS], satisfied [S], partially satisfied [PS], non-satisfied [NS]). Patients were interviewed by telephone at postoperative D1 and D8 by a pharmacist student not involved in the patient's care. RESULTS: Inspite of a high level of patient satisfaction at D8 (VS: 50%, S: 44%), some interesting aspects should be emphasised: a) sedation given before nerve block was not efficient to reduce anxiety and pain during procedure; b) VS levels decreased from D1 (56%) to D8 (50%) mainly because of late postoperative pain (after discharge) and discomforts; c) willingness to undergo the same nerve block again (294/314) was not correlated with patient's satisfaction since among PS and NS patients, a majority (9/15) wished for a block in case of renewed limb surgery; d) multivariate analysis showed that VS level was highly correlated with the quality of communication by the anaesthesiologist mainly for informations about pre and postoperative periods. No correlation was found with pain level during procedure; e) satisfaction levels were not different in the two institutions. CONCLUSION: This study has emphasised some important factors of patient satisfaction which were not sufficiently taken into account in our daily practice.     

Laparoscopic total extraperitoneal inguinal hernia repair under spinal anesthesia: a study of 480 patients

OBJECTIVES: Laparoscopic total extraperitoneal inguinal hernia repair (TEP) is conventionally performed under general anesthesia (GA), and regional anesthesia is usually preferred in patients where GA is contraindicated. In this paper, we present our experience of over 8 years of using spinal anesthesia (SA) as the first choice with the contention that it is a better alternative to GA. METHODS: SA was used in 480 patients over the last 8 years, and 464 patients underwent unilateral TEP. Strangulated and obstructed hernia patients were excluded, but irreducible hernia patients were included. Sedation was given if required, and the conversion to GA was done in patients not responding to sedation or with failure of SA. Comparative control included TEP performed under GA in our initial 49 patients. RESULTS: Three (0.63%) patients required a conversion to GA. Hypotension requiring support was recorded in 75 (15.63%) patients. Postoperatively, 2.08% (10) patients had vomiting, as compared to 30.61% (15 patients) in patients administered GA. In all, 35.83% (172) of patients required injectable diclofenac for their abdominal pain within 2 hours postoperatively, and oral analgesic was required in 301 (62.71%) patients within the first 24 hours, while 89.80% (44) patients operated an under GA required injectable analgesics in the immediate postoperative period and subsequent oral analgesia request was the same as in patients with SA. Postural headache, persisting for an average of 2.6 days, was seen in 25 (5.21%) patients postoperatively. Average time to discharge was 2.3 days. Kernofsky's performance status showed a 98.6% satisfaction level in patients. CONCLUSIONS: TEP done under SA has a number of advantages over GA and should be used routinely.