Published online May 16, 2021. doi: 10.4253/wjge.v13.i5.137
Peer-review started: December 11, 2020
First decision: January 29, 2021
Revised: February 9, 2021
Accepted: April 11, 2021
Article in press: April 11, 2021
Published online: May 16, 2021
Processing time: 147 Days and 5.5 Hours
In an effort to further reduce the morbidity and mortality profile of laparoscopic cholecystectomy, the outcomes of such procedure under regional anesthesia (RA) have been evaluated. In the context of cholecystectomy, combining a minimally invasive surgical procedure with a minimally invasive anesthetic technique can potentially be associated with less postoperative pain and earlier ambulation.
To evaluate comparative outcomes of RA and general anesthesia (GA) in patients undergoing laparoscopic cholecystectomy.
A comprehensive systematic review of randomized controlled trials with subsequent meta-analysis and trial sequential analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards.
Thirteen randomized controlled trials enrolling 1111 patients were included. The study populations in the RA and GA groups were of comparable age (P = 0.41), gender (P = 0.98) and body mass index (P = 0.24). The conversion rate from RA to GA was 2.3%. RA was associated with significantly less postoperative pain at 4 h [mean difference (MD): - 2.22, P < 0.00001], 8 h (MD: -1.53, P = 0.0006), 12 h (MD: -2.08, P < 0.00001), and 24 h (MD: -0.90, P < 0.00001) compared to GA. Moreover, it was associated with significantly lower rate of nausea and vomiting [risk ratio (RR): 0.40, P < 0.0001]. However, RA significantly increased postoperative headaches (RR: 4.69, P = 0.03), and urinary retention (RR: 2.73, P = 0.03). The trial sequential analysis demonstrated that the meta-analysis was conclusive for most outcomes, with the exception of a risk of type 1 error for headache and urinary retention and a risk of type 2 error for total procedure time.
Our findings indicate that RA may be an attractive anesthetic modality for day-case laparoscopic cholecystectomy considering its associated lower postoperative pain and nausea and vomiting compared to GA. However, its associated risk of urinary retention and headache and lack of knowledge on its impact on procedure-related outcomes do not justify using RA as the first line anesthetic choice for laparoscopic cholecystectomy.
Core Tip: Despite the existence of solid level 1 evidence from multiple randomized controlled trials on comparative outcomes of general anesthesia and regional anesthesia (RA) in laparoscopic cholecystectomy and demonstration of feasibility of laparoscopic cholecystectomy under RA, lack of knowledge on the impact of RA on specific procedure related outcomes may discourage surgeons from selecting RA as the first choice of anesthesia for laparoscopic cholecystectomy. Considering our findings, we encourage use of RA in patients who are not fit for general anesthesia but do not hesitate to highlight that available evidence does not justify using RA as the first line anesthetic choice for laparoscopic cholecystectomy.