Laparoscopic cholecystectomy under neuraxial anesthesia compared with general anesthesia: Systematic review and meta-analyses.

BACKGROUND: Pneumoperitoneum during laparoscopic cholecystectomy (LC) can cause hypercapnia, hypoxemia, hemodynamic changes and shoulder pain. General anesthesia (GA) enables the control of intraoperative pain and ventilation. The need for GA has been questioned by studies suggesting that neuraxial anesthesia (NA) is adequate for LC.

STUDY OBJECTIVE: To quantify the prevalence of intraoperative pain and to verify whether evidence on the maintenance of ventilation, circulation and surgical anesthesia during NA compared with GA is consistent.

DESIGN: Systematic review with meta-analyses.

SETTING: Anesthesia for laparoscopic cholecystectomy.

PATIENTS: We searched Medline, Cochrane and EBSCO databases up to 2016 for randomized controlled trials that compared LC in the two groups under study, neuraxial (subarachnoid or epidural) and general anesthesia.

MEASUREMENTS: The primary outcome was the prevalence of intraoperative pain referred to the shoulder in the NA group. Hemodynamic and respiratory outcomes and adverse effects in both groups were also collected.

MAIN RESULTS: Eleven comparative studies were considered eligible. The pooled prevalence of shoulder pain was 25%. Intraoperative hypotension and bradycardia occurred more frequently in patients who received NA, with a risk ratio of 4.61 (95% confidence interval [CI] 1.70-12.48, p=0.003) and 6.67 (95% CI 2.02-21.96, p=0.002), respectively. Postoperative nausea and vomiting was more prevalent in patients who submitted to GA. The prevalence of postoperative urinary retention did not differ between the techniques. Postoperative headache was more prevalent in patients who received NA, while the postoperative pain intensity was lower in this group. Performing meta-analyses on hypertension, hypercapnia and hypoxemia was not possible.

CONCLUSIONS: NA as sole anesthetic technique, although feasible for LC, was associated with intraoperative pain referred to the shoulder, required anesthetic conversion in 3.4% of the cases and did not demonstrate evidence of respiratory benefits for patients with normal pulmonary function.