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Safety and Cost With Local vs General Anesthesia

Quan-Yang Duh, MD; Andrea L. Senokozlieff-Englehart, RN, MS; Yong S. Choe, MAS; Allan E. Siperstein, MD; Kathleen Rowland, BSN, RN; Lawrence W. Way, MD

Arch Surg. 1999;134:151-156.

Background and Hypothesis  General anesthesia is used for laparoscopic enteral access because pneumoperitoneum requires relaxation of the abdominal muscles. We wanted to determine whether these procedures could be performed with similar results and cost under local anesthesia.

Design  Randomized controlled study with 30-day follow-up including a cost-benefit analysis.

Setting  University-affiliated hospitals.

Patients  Forty-eight patients (32 men, 16 women; mean age, 67 years) undergoing laparoscopic gastrostomies (n=32) and jejunostomies (n=16).

Intervention  Twenty-four patients underwent laparoscopic gastrostomy (n=15) and jejunostomy (n=9) under local anesthesia with intravenous conscious sedation and monitored anesthesia care. Twenty-four patients had general anesthesia.

Main Outcome Measures  Conversion to general anesthesia, complications, and cost.

Results  Ten patients under local anesthesia had periods of deep sedation and 1 required conversion to general anesthesia. One patient under general anesthesia required conversion to open gastrostomy. No patients had intraoperative aspiration; however, 4 aspirated after the procedure. One patient died of myocardial infarction during the 30-day follow-up. We found no significant difference in the total mean cost and actual procedure time. The surgeon's fee accounted for 31% of the total cost.

Conclusions  Some patients undergoing laparoscopic enteral access may require deep sedation and a rare patient may require general anesthesia. Clinical conditions and surgeon preference, therefore, should determine whether local anesthesia is suitable for laparoscopic gastrostomies and jejunostomies, and in what setting, since there is no difference in success rate or complications when compared with general anesthesia. Potential savings are possible from the operating room (26% of total cost) or anesthesiologist (12% of total cost) if these procedures are performed in an endoscopy suite without monitored anesthesia care.

From the Surgical Service, Veterans Affairs Medical Center, San Francisco, and the Department of Surgery, University of California, San Francisco (Drs Duh and Way); Mount Zion Medical Center, University of California, San Francisco (Dr Siperstein); and Medical Nutrition Research and Development, Ross Products Division, Abbott Laboratories, Columbus, Ohio (Mss Senokozlieff-Englehart and Rowland and Mr Choe).

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