Perkütan Nefrolitotomide Uygulanan Anestezi Yöntemlerinin Karşılaştırılması

To conduct a comprehensive meta-analysis of existing evidence to compare the safety and efficacy of sonography-guided percutaneous nephrolithotomy (PCNL) under local infiltration anesthesia and both general anesthesia (GA) and combined spinal-epidural anesthesia for upper urinary calculi. We conducted a systematic literature search in the EMBASE, MEDLINE, Cochrane databases, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Google Scholar to identify relevant studies published in English or Chinese up to March 2024. Literature reviewed included randomized and nonrandomized studies. The subject in the management of PCNL under local and GA of studies being patients who had a disease of upper urinary calculi were selected. The odds ratio and mean difference with 95% confidence intervals (CI) were calculated using fixed- or random-effects models. Two reviewers independently assessed the quality of all included studies, and the RevMan 5.3 and Stata 12.0 software was used to analyze the included studies. Seven studies with 899 patients showed that, comparing with PCNL under GA or combined spinal-epidural anesthesia, PCNL under local infiltration anesthesia offered a significantly shorter operative time (MD = -18.91, 95% CI: -26.47 to -11.35, P < .00001, I2 = 96%), lower hospitalization expenses (MD = -4097.43,95% CI: -4203.26 to 3991.59, P < .00001, I2 = 0%), lower complication rate (OR = 0.49, 95% CI: 0.33-0.73, P = .0005, I2 = 0%), shorter postoperative hospital stay (MD = -1.85, 95% CI: -2.47 to 1.24, P = .001, I2 = 85%). But no statistical significant difference was found in stone-free rate between PCNL under local infiltration anesthesia and GA or combined spinal-epidural anesthesia (OR = 1.67, 95% CI: 0.54-5.15, P = .37, I2 = 41%). This meta-analysis compared efficacy and safety of PCNL under local infiltration anesthesia and both GA and combined spinal-epidural anesthesia for upper urinary calculi. Both of them were safe and effective for patients of upper urinary calculi. PCNL under local anesthesia offered a shorter operative time, lower hospitalization expenses, lower complication rate and shorter postoperative hospital stay for upper urinary calculi.

Inguinal hernia repair is one of the most common operations performed in General Surgery accounting for about 10-15% of all surgeries. Inguinal hernia repair can be done under local, spinal or general anaesthesia. Although specialized hernia centres routinely use local anaesthesia for uncomplicated open inguinal hernia repair, very few surgeons adopt this technique, and prefer performing surgery under spinal or general anaesthesia. We compared the short-term outcomes following open inguinal hernia mesh repair under local, spinal and general anaesthesia in our hospital. (1) To compare the post-operative pain scores among the three groups. (2) To compare the duration of surgery in minutes, the duration of analgesia, analgesic requirement, the time of return to normal activity such as walking, the time of initiation of diet, and the time of voiding after the surgery. Also to compare any complications, such as urinary retention, need for catheterization, nausea and/or emesis, and the length of hospital stay. (3) To observe the impact on health-related quality of life according to EuroQol and patient satisfaction and acceptance of the type of anaesthesia for the procedure. A single centre non-randomised, prospective, observational study was performed in 135 patients undergoing inguinal hernia repair under local (LA), spinal (SA) or general anaesthesia (GA), with 45 patients in each arm, over the span of one year. After approval from the Ethical Committee, and proper informed consent, patients above 18years of age who were to undergo uncomplicated open inguinal hernioplasty were recruited for the study. Lichtensteins tension-free hernioplasty was performed in all cases. The duration of the procedure was calculated from the time of induction or infiltration of local or spinal anaesthesia, till the end of dressing, or extubation in case of general anaesthesia. The duration of analgesia was calculated from the end of the procedure to the feeling of first pain as recorded in the questionnaire. A standard postoperative protocol was employed to determine the pain scores for the first 7days and also to compare the short-term outcomes i.e., duration of analgesia, return to normal activity, complications, post-operative nausea and emesis, analgesic requirement, urinary retention, length of hospital stay, health-related quality of life and patient satisfaction and acceptance were recorded according to standard proforma and EuroQol questionnaire. All the statistical analysis was carried out by SPSS version 16.0. The mean pain scores were lower in the LA group as compared to SA and GA groups from POD-1 to POD-6 (p < 0.001). However, the values from the 7th post-operative days were similar in all three groups and statistically insignificant (p = 0.09). The outcomes such as duration of analgesia, return to activity such as walking, time of first meal and time of discharge from the hospital were all better in the LA group (p < 0.001). The results concerning nausea, vomiting, analgesic use and urinary retention all favour LA. No difference was found among the three groups concerning overall satisfaction and quality of life. In a general surgical setting, we found that local anaesthesia is well tolerated and associated with significantly lower pain scores in the immediate post-operative period and also requires less analgesic use when compared with general and spinal anaesthesia. Patients in the LA group can resume basic activities such as walking, voiding, and initiating diet almost immediately after the procedure and there were no incidences of retention of urine, which was a significant advantage over the other two types of anaesthesia. Patients who were graded as ASA 4 and 5, who were unfit for general anaesthesia, were able to undergo the surgery under local anaesthesia with no postoperative complications. Moreover, the complications and risks of spinal and general anaesthesia are avoided without compromising the quality of surgery and its outcomes. The duration of the surgery as well as hospital stay is significantly less in patients undergoing surgery under local anaesthesia and most cases can be done as a daycare procedure, which is significantly advantageous, especially in low-income settings, with no difference in the health-related quality of life or patient satisfaction and acceptance.

Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review

Background: Percutaneous nephrolithotomy (PCNL) now a days is the treatment of choice for most renal stones, staghorn calculi and stones resistant to shock wave lithotripsy. Mostly PCNL is done under general anesthesia. However, it can be done under spinal anaesthesia which can have advantages like easier technique, faster discharge, reduced cost and recovery time and most important patient satisfaction. Aim: Unfortunately, few research studies have been conducted to compare regional and general anesthesia with respect to operative parameters. In the present study, we compared surgical outcomes and complications between percutaneous nephrolithotomy under spinal and general anesthesia. Materials and Method: 60 patients were divided into two groups of 30 each (GA/SA), who were undergone percutaneous nephrolithotomy under spinal and general anaesthesia. Patient’s general characteristics, stone features, surgical outcomes, and complications were compared between the two groups. All qualitative data and quantitative data were analyzed by chi square and student’s t test respectively. P value <0.05 was considered statistically significant. Result: The two groups were similar in terms of mean age and stone size, number, and type. Furthermore, they did not differ significantly in terms of general characteristics, treatment outcomes or complications excluding postoperative fever. However, mean hospital stay was significantly shorter in the regional anesthesia group than in the general anesthesia group (8.2±1.6 days vs. 12.5±2.8) days, respectively, (p=0.0001), Also, the postoperative fever rate was significantly higher in the general anesthesia group (82.5% vs 50%) respectively. (p=0.012). The treatment cost was 30$ in GA group and 10 $ in spinal group which was statistically significant. Also analgesia requirement on day 1 was more in GA group than SA group which was statistically significant. Conclusion: Regional anaesthesia is as effective as general anaesthlesia during percutaneous nephrolithotomy and is associated with shorter hospital stays, lower rates of postoperative fever, lower analgesic requirement and treatment cost.

Clinical handling, risk and benefit of a heparin-coated cardiopulmonary bypass system combined with reduced systemic heparinization in coronary bypass surgery was investigated in a prospective, randomized clinical study. 243 patients (Pts.) were divided into 3 groups: group A (n = 83) had a standard uncoated extracorporeal circulation (ECC) set, and systemic heparin was administered in an initial dose of 400 IE/kg body weight. During ECC activated clotting time (ACT) was kept > or = 480 sec. Group B (n = 77) had the same ECC set completely coated with low-molecular-weight heparin; i.v. heparin was given in the same dose as in group A, ACT was kept at the same level. Group C (n = 83) had the same coated ECC set as group B, but i.v. heparin was reduced to 150 IE/kg, and was set to be > or = 240 sec during ECC ACT. The same circulatory components were used in all 3 groups including roller pumps, coronary suction and an open cardiotomy reservoir. In the postoperative clinical course, recovery was not significantly different between groups, especially with respect to organ dysfunction; but there was significantly reduced postoperative bleeding where heparin-coated ECC and low-dose systemic heparinization were both used. This circulatory technique was also associated with a distinctly lower need for postoperative blood replacement. We conclude that heparin-coated extracorporeal circulation combined with either full-dose or reduced systemic heparinization can be used effectively with the same standard equipment and procedures as in uncoated technology. Combination with low-dose i.v. heparin leads to significantly decreased blood loss and less need for blood replacement.

A Randomized, Single-Blind Clinical Trial Comparing Robotic-Assisted Fluoroscopic-Guided with Ultrasound-Guided Renal Access for Percutaneous Nephrolithotomy.

As the indications for and the volume of arthroscopic rotator cuff repair increase, it is important to optimize perioperative care to minimize postoperative complications and health care costs. We sought to investigate if the anesthesia type used affects the rate of postoperative complications in patients undergoing arthroscopic rotator cuff repairs. We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing arthroscopic rotator cuff repair from 2014 to 2018. Patients were divided into 3 cohorts: general anesthesia, regional anesthesia, and combined general plus regional anesthesia. Bivariate and multivariate analyses with stepwise technique were performed on data related to patient demographics, smoking history, functional status, medical comorbidities (ie, bleeding disorders, chronic obstructive pulmonary disease, and dialysis), and postoperative outcomes within 30 days of discharge. To assess the independent risk factors for postoperative complications, demographics and medical comorbidities were included in the multivariate analyses for any variables that derived P values <.20. Of 24,677 total patients undergoing arthroscopic rotator cuff repair, 15,661 (63.5%) had general anesthesia, 889 (3.6%) had regional anesthesia, and 8127 (32.9%) received combined general plus regional anesthesia. Patients who received general anesthesia rather than regional anesthesia were more frequently white (76.8% vs 74.8%, respectively) and had a medical history of hypertension (47.9% vs 41.8%, respectively), smoking (14.9% vs 12.4%, respectively), and chronic obstructive pulmonary disease (3.4% vs 1.6%, respectively). Compared with patients receiving general anesthesia, those receiving combined general plus regional were more likely to have higher American Society of Anesthesiologists class and a smoking history. Following adjustment, patients who underwent regional anesthesia had a decreased risk for postoperative admission compared with patients who had general anesthesia. Patients who underwent combined regional plus general anesthesia had decreased rates of wound complications and readmission compared with those who received general anesthesia. Among patients undergoing arthroscopic rotator cuff repair, this retrospective study found a significantly higher rate of respiratory and cardiac comorbidities with general anesthesia compared with regional anesthesia. When controlling for these confounders, the use of regional anesthesia was still associated with lower rates of postoperative readmission compared with the general and combined subgroups. Patients receiving combined general plus regional anesthesia had decreased rates of wound complications and readmittance compared with general anesthesia. These findings may influence anesthetic choice in minimizing postoperative complications for rotator cuff repairs.

Con: General anesthesia and regional anesthesia are equally acceptable choices for carotid endarterectomy

Objective To compare the safety and efficacy of percutaneous nephrolithotomy (PCNL) performed under local anesthesia (LA). Methods From June 2017 to September 2018, 120 patients with renal stones who underwent percutaneous nephrolithotomy were randomly enrolled into general anesthesia group(n=60) and local anesthesia group (n=60) .The residual stone rate, length of surgery, preoperative anxiety, postoperative hospital stay, hospital costs, postoperative pain and complications in both groups were compared. Results There were statistically significant in preoperative anxiety, postoperative hospital stay, hospital costs, postoperative activity time, postoperative feeding time between the two groups(P<0.05). Conclusions Local anesthesia is feasible and safe in PCNL operations, it has the advantages of quick recovery and low cost. It is worth to be applied. Key words: Urinary Calculi; Nephrostomy, Percutaneous

Cardiac outcomes after regional or general anesthesia. Do we have the answer?

Local anaesthesia for carotid endarterectomy: Con: decrease the stress for all.

BACKGROUND Post-operative pain and discomfort is a common side effect of percutaneous nephrolithotomy (PCNL) surgery. The study intended to evaluate the efficacy of landmark guided erector spinae plane block (ESPB) in early post-operative pain relief following (PCNL) surgery. METHODS In this randomised prospective, single blind, interventional study, 70 patients aged 20 - 60 years of ASA grade I and II, scheduled for elective percutaneous nephrolithotomy (PCNL) surgery under general anaesthesia were included. Patients were randomly allotted into two groups of 35 each. Group 1 was the control group and received parenteral analgesia according to institutional protocol for postoperative pain relief. Group 2 was the study group and received landmark guided erector spinae plane block (ESPB) with 20 cc of 0.25 % bupivacaine for postoperative pain relief. Post-operatively patients were monitored for pain and Visual Analogue Scale (VAS) score was noted at 2nd, 4th and 6th hr and was maintained below 4 by providing them with additional analgesics if required. Time and doses of analgesics required were recorded. RESULTS All the statistical analysis was done using R-Studio 1.2.5001 software. MannWhitney-U test was used for quantitative variables of pain score. Proportion test was used for qualitative demographic data and for post-operative analgesics requirement. Both the groups were comparable on demographic variables. The average VAS score at 2nd and 4th hr was significantly lower in the study group than in the control group (P &lt; 0.05). The VAS score at 6th hr was comparable in both the groups. The analgesic requirement was significantly lower in study group as compared to the control group. CONCLUSIONS The landmark guided ESPB is an effective and simple method to alleviate immediate postoperative pain in PCNL surgeries under general anaesthesia. KEYWORDS Erector Spinae Plane Block, Percutaneous Nephrolithotomy Surgery, Postoperative Pain

Risks and benefits of local anesthesia versus general anesthesia in tonsillectomy

The Effect of Regional Anesthesia on Outcomes After Minimally Invasive Ivor Lewis Esophagectomy

Urinary retention and mortality after open repair of inguinal hernia may depend on the type of anaesthesia. The aim of this study was to investigate possible differences in urinary retention and mortality in adults after Lichtenstein repair under different types of anaesthesia. Systematic searches were conducted in the Cochrane, PubMed and Embase databases, with the last search on 1 August 2018. Eligible studies included adult patients having elective unilateral inguinal hernia repair by the Lichtenstein technique under local, regional or general anaesthesia. Outcomes were urinary retention and mortality, which were compared between the three types of anaesthesia using meta-analyses and a network meta-analysis. In total, 53 studies covering 11 683 patients were included. Crude rates of urinary retention were 0·1 (95 per cent c.i. 0 to 0·2) per cent for local anaesthesia, 8·6 (6·6 to 10·5) per cent for regional anaesthesia and 1·4 (0·6 to 2·2) per cent for general anaesthesia. No death related to the type of anaesthesia was reported. The network meta-analysis showed a higher risk of urinary retention after both regional (odds ratio (OR) 15·73, 95 per cent c.i. 5·85 to 42·32; P < 0·001) and general (OR 4·07, 1·07 to 15·48; P=0·040) anaesthesia compared with local anaesthesia, and a higher risk after regional compared with general anaesthesia (OR 3·87, 1·10 to 13·60; P=0·035). Meta-analyses showed a higher risk of urinary retention after regional compared with local anaesthesia (P < 0·001), but no difference between general and local anaesthesia (P=0·08). Local or general anaesthesia had significantly lower risks of urinary retention than regional anaesthesia. Differences in mortality could not be assessed as there were no deaths after elective Lichtenstein repair. Registration number: CRD42018087115 ( https://www.crd.york.ac.uk/prospero).