Spinal VS general anesthesia for transabdominal preperitoneal (TAPP) repair of inguinal hernia: prospective randomized study

Background: General anesthesia has been used as standard for laparoscopic hernia repair by the transabdominal preperitoneal (TAPP) approach. Regional anesthesia has been occasionally applied in high risk patients where general anesthesia is contraindicated. This randomized clinical trial compares spinal anesthesia with general anesthesia for TAPP inguinal hernia repair in non-high risk patients.Methods: Seventy adult American Society of Anesthesiologists I, II and III patients undergoing elective TAPP inguinal hernia repair were randomized to either general or spinal anesthesia. Results: Postoperative morphine consumption was significantly less imme-diately postoperatively (p<0,001) in the spinal anesthesia group. Post-operative pain was also significantly decreased within the first 8 hours postoperatively (p<0,05) in the spinal anesthesia group. Conclusions: Spinal anesthesia offers some advantages in patient analgesia during the early postoperative period after TAPP inguinal hernia repair and can be proposed as an effective alternative method of anesthesia for TAPP repair.Εισαγωγή: Η γενική αναισθησία έχει χρησιμοποιηθεί ως πρότυπο για την λαπαροσκοπική αποκατάσταση της κήλης υπό την προσέγγιση της διακοιλιακής προπεριτοναϊκής (TAPP) αποκατάστασης. Η περιοχική αναισθησία έχει κατά καιρούς χρησιμοποιηθεί σε ασθενείς υψηλού κινδύνου, όπου αντενδείκνυται γενική αναισθησία. Αυτή η τυχαιοποιημένη κλινική μελέτη συγκρίνει τη ραχιαία αναισθησία με γενική αναισθησία για τη λαπαροσκοπική αποκατάσταση TAPP βουβωνοκήλης σε ασθενείς μη υψηλού κινδύνου.Μέθοδος: Εβδομήντα ενήλικες ασθενείς ASA Ι, ΙΙ και ΙΙΙ που υποβλήθηκαν σε εκλεκτική TAPP αποκατάσταση βουβωνοκήλης τυχαιοποιήθηκαν να λάβουν γενική ή ραχιαία αναισθησία για τη διενέργεια αυτής.Αποτελέσματα: Η μετεγχειρητική κατανάλωση μορφίνης ήταν σημαντικά μικρότερη αμέσως μετεγχειρητικά (p<0,001) στην ομάδα της ραχιαίας αναισθησίας. Ο μετεγχειρητικός πόνος, επίσης μειώθηκε σημαντικά κατά τις πρώτες 8 ώρες μετεγχειρητικά (p<0,05) στην ομάδα της ραχιαίας αναισθησίας.Συμπεράσματα: Η ραχιαία αναισθησία προσφέρει κάποια πλεονεκτήματα στην αναλγησία του ασθενούς κατά την πρώιμη μετεγχειρητική περίοδο μετά από TAPP αποκατάσταση βουβωνοκήλης και μπορεί να προταθεί ως μια αποτελεσματική και εναλλακτική μέθοδος αναισθησίας για τη διενέργεια αυτής

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)