If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
Electronic Letters to:
|
|
E-letters: Electronic letters published:
-
![[Read E-letter]](/icons/misc/sectionDOWN.gif)
Reply Letter
- Andre VAN ZUNDERT, JAW WILDSMITH (14 August 2007)
-
Re: Laparoscopic cholesystectomy under spinal anesthesia
- iftikhar ahmed (20 June 2007)
-
Laparoscopic cholesystectomy under spinal anesthesia
- George Tzovaras, Konstantinos Pratsas, Stavroula Georgopoulou (18 June 2007)
|
|
|||
|
Andre VAN ZUNDERT, Professor of Anesthesiology Catharina Hospital Eindhoven - Netherlands, JAW WILDSMITH
Send letter to journal:
|
Reaction to the Letters-to-The Editor: Laparoscopic cholecystectomy under spinal anaesthesia – Tzovaras G. et al Greece (18.06.2007) and Ahmed I., Leicester (20.06.2007)) We thank Tzovaras & colleagues and Ahmed for their interest in our work1, and would comment as follows. There is no doubt that clinicians have been slow, perhaps even reluctant because of the effects of pneumoperitoneum, to apply regional anaesthetic techniques to laparoscopic surgery. We are pleased to learn that Tzovaras & colleagues also are working in this field and look forward to reading their study once it is published. They criticise two aspects of our paper: use of a segmental thoracic approach to spinal anaesthesia and its application in day case surgery. On the first point we can only refer them back to the points made in our paper; on the second we would note that there are clearly national differences in the procedures which are judged suitable for day case surgery (Greek practice must be very conservative if patients undergoing inguinal hernia repair under local anaesthesia are kept in hospital overnight). Whether the segmental thoracic approach to spinal anaesthesia offers definitive benefit over the traditional lumbar one will require further comparison and evaluation, not its dismissal as being dangerous simply to permit day case surgery. There is more to it than that, as we tried to make clear, although the facilitation of day case surgery is a useful end in itself. In response to Ahmed's comments we would note that the device used for combined spinal-epidural anaesthesia in the study was from the PortexTM Regional Anaesthesia Tray (Smiths, Hythe, Kent). The hubs of both spinal and epidural (Tuohy) needles do have distance markings on them, thus allowing us to measure the distance the spinal needle is introduced once the Tuohy needle is in the epidural space. Like Tzovaras & colleagues Ahmed seems ready to dismiss our method as dangerous without full acknowledgement of the points made by ourselves in regard to both the technique used and the caution required. If the recommendation to allow the spinal needle to project beyond the tip of the epidural needle only until the injection port is visible were to be followed then dural puncture would almost inevitably fail, as perhaps can be seen by reference to our earlier case report2. The obliquity of the needle's insertion and the anterior position of the thoracic segment of the spinal cord are key factors. References 1. van Zundert AAJ, Stultiens G, Jakimowicz JJ, Peek D, van der Ham WGJM, Korsten HHM, Wildsmith JAW. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007; 98: 682-6 2. van Zundert AAJ, Stultiens G, Jakimowicz JJ, van den Borne BEEM, van der Ham WGJM, Wildsmith JAW. Segmental spinal anaesthesia for cholecystectomy in a patient with severe lung disease. Br J Anaesth 2007; 96: 464-6 THERE ARE NO COMPETING FINANCIAL INTERESTS NO FUNDING WAS ASKED FOR – NOR WAS ANY FINANCIAL RENUMERATION OBTAINED. A.A.J. van Zundert*, Eindhoven, Netherlands J.A.W. Wildsmith, Dundee, UK *E-mail: zundert@iae.nl A.A.J. van Zundert, M.D., Ph.D. F.R.C.A., Professor of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Therapy, Catharina Hospital – Brabant Medical School, Michelangelolaan 2, NL-5623 EJ Eindhoven, The Netherlands J.A.W. Wildsmith, M.D., F.R.C.A., Professor Emeritus, Department of Anaesthesia, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK" Conflict of Interest:None declared |
|||
|
|
|||
|
iftikhar ahmed, anaesthetist University Hospitals Leicester NHS Trust
Send letter to journal:
|
Dear editor it was interesting to read van Zundert AAJ and coleagues[1] commendable effort to explore potentials for broadening the scope of anaesthetic armamentarium by performing laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia but I would like to share some observations on the study. Spinal cord damage is a potentially disastrous complication of spinal anaesthesia or indeed dural puncture for any reason,[2] although rare but the risk of neurological complication subsequent to spinal anaesthesia is rather real[3] than theoretical with permanent neurological deficit occurring in 1 in 10000[4]. A combination of patient, equipment and technique related errors can lead to spinal cord damage[5]. The pencil point spinal needles, used by van Zundert and colleague[1] in their study, are now widely used in comparison to traditional ‘cutting’ type needle due to lower incidence of post dural puncture headache with the former. The safety of pencil point needles, often referred as ‘atraumatic’, have been questioned[6] and a higher incidence of paraesthesiae, in comparison to cutting needles, 12% with standard spinal technique[7]and 26% with CSE technique[8] has been noted. Paraesthesiae indicates contact of needle with either the spinal cord or cauda equine and have been associated with increased likelihood of subsequent neurological deficit[9]. Pencil point needles have side injection port, a millimetre from the tip and are blunt in nature therefore a greater length of needle has to be inserted and a little extra force is required, with subsequent risk of ‘overshoot’[5] and are more likely to damage if comes in contact with nerves roots or spinal cord in comparison to ‘cutting’ needle[10]. The blunt tip of pencil point needles might also first ‘tent’ the dura before penetrating it and subsequently may narrow the space between arachnoid matter and cord[11]. The technique described in their study[1] involves measuring the depth of dura matter from skin at 10th thoracic inter-space with a 27 SWG pencil point needle advanced through 16 SWG touhy needle after the epidural space has been identified, till it touches the dura but not actually penetrates it. The spinal needle was then further advanced but not more than 14 mm to penetrate into subarachnoid space.1 out of 20 patients in the study did experience transient paraesthesia, the significance of which is difficult to ascertain but the technique caries all the risk factors, as mentioned above, and can be considered inherently dangerous with potential to cause spinal cord damage particularly in the absence of an accurate and reliable method of assessment of length of spinal needle advanced into the subarachnoid space. As I understood, Van Zundert and colleague[1] didn’t use spinal needle with measurement markings on it, although I believe no such spinal needles are commercially available, neither, they marked the needle by any ink or marker. In the absence of commercially available spinal needle with marking on it, Van Zundert and colleague should have marked the spinal needle in vitro by passing it through the touhy needle till the injection port is visible beyond the bevel of touhy needle and under no circumstance the spinal needle should have been advanced beyond that marking and if no CSF is aspirated up to that mark then procedure should have been abandoned. I strongly believe that patient safety takes precedence over unnecessary risks to be taken for the success of the procedure. References 1. Van Zundert AAJ, Stuliens G, Jakimowicz JJ et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: A feasibility study. Br J Anaeasth 2007; 98(5): 682-6. 2. Fettes PDW, Leslie K, McNabb S, Smith PJ. Effect of flexion on the conus medullaris: a case series using magnetic resonance imaging. Anaesthesia, 2006; 61: 521-3. 3. Reynolds F, Damage to conus medullaris following spinal anaesthesia. Anaesthesia, 2002; 88: 760-3. 4. Auroy Y, Narchi p, Messiah A, Litt L, Rouvier B, Samii K. Serious complications related to regional anaesthesia. Anesthesiology, 1997; 87: 479-86. 5. Fettes P, Wildsmith JAW. Somebody else’s nervous system. Br J Anaesth, 2002; 88: 760-3. 6. Turner MA, Shaw M. Atraumatic spinal needles. Anaesthesia, 1993; 48: 452. 7. Hopkinson JM, Samaan AK, Russell IF, Birks RJs, Patrick MR. A comparative multicentre trial of spinal needles for caesarean section. Anaesthesia, 1997; 52: 998-1014. 8. Turner MA, Reifenberg NA. Combined spinal epidural anaesthesia. The single space double-barrel technique. Int J Obstet Anesth , 1995; 4: 158- 60. 9. Horlocker TT, McGregor DG, Matsushige DK, Schroeder DR, Besse JA, the Perioperative Outcomes Group. A retrospective review of 4767 consecutive spinal anesthetics: central nervous system complications. Anesth Analg 1997; 84: 578–84 10. Rice ASC, McMahon SB. Peripheral nerve injury caused by injection needles used in regional anaesthesia: influence of bevel configuration, studied in a rat model. Br J Anaesth 1992; 69: 433–8 11. Dittman M, Lehmann K. Physical properties (diameter, flowrate and tip geometry) of the latest spinal needles and their effect on tenting. In: Van Zundert A, ed. Highlights in Regional and Pain Therapy. IV. Barcelona: Permanyer Publications, 1995; 112–4 Conflict of Interest:None declared |
|||
|
|
|||
|
George Tzovaras, Assist. Professor of Surgery University Hospital of Larissa, Greece, Konstantinos Pratsas, Stavroula Georgopoulou
Send letter to journal:
|
Dear Editor We have read with interest the paper by Van Zundert et al (1) published in May issue of BJA and we would like to comment on this, sharing with the authors our experience on the topic. We published a year ago or so the first feasibility study on performing laparoscopic cholecystectomy with classic CO2 pneumoperitoneum under spinal anesthesia in fit patients (2); in addition, the preliminary results of a controlled randomized study of ours comparing spinal to general anesthesia for laparoscopic cholecystectomy are going to appear soon in Archives of Surgery (3). From our studies, it is evident that spinal anesthesia is not only feasible and safe for laparoscopic cholecystectomy, but it is also associated with some advantages for the patients, mainly better postoperative pain control. We have therefore recently extended the use of spinal anesthesia in other laparoscopic procedures like ventral and inguinal hernia repair. Based on our experience, we believe that spinal anesthesia has a place in laparoscopic procedures and could evolve as a routine method of anesthesia in laparoscopic surgery. The technique of segmental thoracic spinal anesthesia described by Van Zundert et al lies on the same attitude and theoretically constitutes an even more specific method of anesthesia for laparoscopic cholecystectomy. However, it is more difficult to perform and technically demanding method that could sometimes cause neurological side effects from puncturing the spinal cord itself, as it is emphasized in the text by the authors. It is not a method that could be easily and safely applied by the majority of anesthetists, in contrast to the lumbar spinal anesthesia we used in our studies. As such, segmental spinal anesthesia could be considered as an invasive procedure rather than a minimally invasive one. The intraoperative incidents from the cardiovascular point of view are similar between the two spinal techniques; the only advantage the segmental spinal anesthesia offers is the avoidance of urinary retention that we have observed in a small number of patients in our trial (~6%) and, also, the possibility of day case surgery for the majority of patients. However, spinal anesthesia does not by definition preclude day case surgery. In our country in particular, laparoscopic cholecystectomy traditionally is not considered as day surgery by both the average patient and the surgeon no matter which anesthetic method is used; even in the case of open inguinal hernia repair under local anesthesia the patient usually stays overnight in hospital. Taking into account the advantages and disadvantages of these two methods of spinal anesthesia we consider it dangerous to suggest routine use of segmental thoracic spinal anesthesia for laparoscopic cholecystectomy in fit patients in order to achieve day case surgery for its own sake. Any other potential advantage over general anesthesia can be achieved by classic (lumbar) spinal anesthesia which has all the characteristics of the minimally invasive anesthesia and it is easily performed by the vast majority of anesthetists. George Tzovaras, MD * Konstantinos Pratsas, MD ** Stavroula Georgopoulou, MD ** Departments of Surgery * and Anesthesiology ** University Hospital of Larissa, Greece References 1. Van Zundert AA, Stultiens G, Jakimowicz JJ, Peek D, van der Ham WG, Korsten HH, Wildsmith JA. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007; 98: 682-686. 2. Tzovaras G, Fafoulakis F, Pratsas K, Georgopoulou S, Stamatiou G, Hatzitheofilou C. Laparoscopic cholecystectomy under spinal anesthesia: a pilot study. Surg Endosc 2006; 20: 580-582. 3. Tzovaras G, Fafoulakis F, Georgopoulou S, Pratsas K, Stamatiou G, Hatzitheofilou C. Spinal versus general anesthesia for laparoscopic cholecystectomy: Interim analysis of a controlled randomized trial. Arch Surg in press. Conflict of Interest:None declared |
|||