Radical cystectomy in frail octogenarians in thoracic continuous spinal anesthesia and analgesia: a pilot study

Abstract

Background: Radical cystectomy (RC) is the gold standard therapy in nonmetastatic muscleinvasive bladder cancer and is usually performed under general anesthesia (GA). GA is high risk in most older patients due to comorbidities. Continuous spinal anesthesia (CSA) may be an alternative solution to reduce postoperative morbidity in elderly. The aim of this study was to assess the feasibility, morbidity, and mortality of RC performed under CSA in octogenarian patients. Methods: We retrospectively reviewed data of five frail patients aged ⩾80 who underwent RC in CSA. CSA was achieved starting with 2.5 mg hyperbaric bupivacaine plus 25 µg fentanyl. Postoperative analgesia was achieved through the intrathecal catheter, using continuous delivery of levo-bupivacaine 60 mg plus fentanyl 75 µg in 72 hours. Results: Surgery was completed in all cases in CSA. No patients required postoperative intensive care unit admission. Complications were Clavien I for four in three patients, Clavien II for seven in five patients, and Clavien IIIb for one patient. Postoperative consumption of painkillers was negligible. Oral feeding resumed within 3 days in all cases. The mean postoperative stay was 9.6 days. All patients were alive at 3 months of follow up. Conclusions: Management of muscle-invasive bladder cancer (MIBC) in older patients is becoming an important issue due to the continuous aging of the population. Age should not preclude RC, but careful management is mandatory because perioperative morbidity and mortality are increased in the elderly. Our preliminary results show that CSA and analgesia is a feasible option as an additional way to reduce morbidity and mortality in frail octogenarians who require RC.

Continuous thoracic spinal anesthesia with local anesthetic plus midazolam and ketamine is superior to local anesthetic plus fentanyl in major abdominal surgery

“…This is the first study to report the use of “opioid-free” TCSA for elective and urgent abdominal surgery in older patients with comorbidities. Our study confirms that CSA can be used as a primary anesthesiologic method for major abdominal surgery in elderly patients at serious risk for mortality and morbidity with GA [ [12] , [13] , [14] ].…”

“…Indeed, many studies described the use of CSA in high-risk patients undergoing cardiac, vascular, orthopedic, pelvic, and abdominal surgery who would be considered unlikely to survive general anesthesia [ 11 , 12 ]. This method provides significantly improved hemodynamic control, avoids invasive airway management, enhances intraoperative analgesia, and allows the maintenance of a postoperative analgesia with superior efficiency and minimal effect on mental status, carrying a considerable reduction in major postoperative complications compared to GA [ [3] , [4] , [5] ], particularly in the elderly.…”

“…Nevertheless, there are only a few reports in the literature regarding the use of TCSA in abdominal surgery, mainly requiring a higher level of sensorial block [ [12] , [13] , [14] ]. All these series describe a regimen of spinal anesthesia based on a combination of intrathecal local anesthetics and opioids, both intraoperatively and postoperatively.…”

“…The possibility of maintaining continuous postoperative spinal analgesia provides optimal pain management, sparing intravenous nonsteroidal anti-inflammatory drugs and opioids. Differently from lumbar spinal anesthesia, the safe use of thoracic spinal anesthesia in high-risk older patients undergoing surgery of the upper abdomen is described in only a few case reports and case series [ [12] , [13] , [14] ]. However, CSA has been implicated in specific complications, such as infection, postdural puncture headache, spinal hematoma, and cauda equina syndrome [ 15 ].…”

Unexpected duodenopancreatectomy in an “awake” gastrectomized patient: Case report and technical notes

“…Neuraxial anaesthesia techniques have been recently introduced in major surgery for elderly patients. It is estimated that the number of octogenarians in industrialized countries will quadruple by 2050 [ 2 , 14 ], and more often, this type of patient (occasionally very fragile and with a history of cancer) undergoes major abdominal surgery [ 3 ].…”