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General Versus Neuraxial Anesthesia for Appendectomy: A Multicenter International Study
*Mohamad El Moheb1, *Ava Mokhtari1, *Kelsey Han1, *Majed El Hechi1, *Zhenyi Jia2, *Napaporn Kongkaewpaisan3, *Manasnun Kongwibulwut4, *Gabriel Rodriguez1, *Camilo Ortega5, *Huanlong Qin6, *Jun Yang2, *Renyuan Gao7, *Zhiguo Wang8, *Zhiguang Gao9, *Supparerk Prichayudh10, *Gwendolyn van der Wilden11, *Stephanie Santin12, *Marcelo A.F. Ribeiro Jr13, *Napakadol Noppakunsomboom3, *Joseph Sakran14, *Bellal Joseph15, *Ramzi Alami16, Haytham Kaafarani1
1Massachusetts General Hospital, Harvard Medical School, Boston, MA;2Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China3Siriraj Hospital, Mahidol University, Bangkok, Thailand4Chulalongkorn University, Bangkok, Thailand5Hospital Departamental Villavicencio, Villavicencio, Colombia6Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China7Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, Shanghai, China8Changzheng Hospital, Navy Medical University, Shanghai, China9Shanghai East Hospital of Tongji University, Shanghai, China10King Chulalongkorn Memorial Hospital, Bangkok, Thailand11Leiden University Medical Center, Leiden, Netherlands12Hospital Brasil Rede D´Or, São Paulo, Brazil13Hospital Servidor Publico Estadual IAMSPE, Hospital Moriah, São Paulo, Brazil14The Johns Hopkins University, Baltimore, MD;15University of Arizona, Tucson, AZ;16American University of Beirut, Beirut, Lebanon

Objective: In resource-limited countries, open appendectomy is still performed under general anesthesia (GA) or neuraxial anesthesia (NA). We sought to compare the postoperative outcomes of appendectomy under NA vs. GA. Design/Setting: Post-hoc analysis of the International Patterns of Opioid Prescribing (iPOP) multicenter study. Patients: Patients ≥16 years-old who underwent appendectomy under GA vs. NA (spinal or epidural) from October 2016 to March 2017. Interventions: N/A. Main outcome measures: Postoperative complications (e.g. surgical site infection, wound dehiscence, pneumonia), length of stay (LOS) and pain severity, using univariate then multivariable logistic regression models adjusting for age, gender, race, body mass index, smoking, history of opioid use, emergency status, and country. Results: A total of 655 patients from 7 countries were included:353 NA and 302 GA. Table 1 compares the two groups. In summary, NA patients were younger and had a lower rate of complications and a shorter hospital LOS. In multivariable analyses, NA was independently associated with less postoperative complications (OR, 95%CI: 0.22 [0.05-0.87]) and shorter hospital LOS (LOS>3 days, OR:0.42 [0.26-0.67]) compared to GA. There was no difference in postoperative pain severity between the two groups. Conclusions: Open appendectomy performed under NA is associated with improved outcomes compared to that performed under GA. Further randomized controlled studies should examine the safety and value of NA in lower abdominal surgery.
Table 1. Characteristics of patients undergoing open appendectomy under general anesthesia (GA) versus neuraxial anesthesia (NA)
NA (n=353)GA (n=302)p-value
Age, mean (SD)34.4 (14.2)40.7 (17.9)<0.001
Male158 (44.8%)141 (46.7%)0.81
Race
White7 (2.0%)7 (2.3%)<0.001
Black2 (0.6%)0 (0.0%)
Asian189 (53.5%)145 (48.0%)
Hispanic140 (39.7%)140 (46.4%)
Other15 (4.2%)10 (3.3%)
Current smoker8 (2.5%)11 (3.7%)0.39
Prehospital opioid use1 (0.3%)5 (1.7%)0.074
Emergency procedure1 (0.3%)3 (1.0%)0.34
Country
USA0 (0%)6 (2.0%)<0.001
Lebanon0 (0%)3 (1.0%)
Colombia138 (39.1%)139 (46.0%)
China80 (22.7%)89 (29.5%)
Thailand109 (30.9%)57 (18.9%)
Netherlands0 (0%)5 (1.7%)
Brazil26 (7.4%)3 (1.0%)
Postoperative complications9 (2.6%)18 (6.0%)0.031
Wound-related5 (1.4%)6 (2.0%)0.76
Infectious2 (0.6%)1 (0.3%)1.00
Non-infectious0 (0%)0 (0%)
Other2 (0.6%)10 (3.3%)0.04
Hospital LOS
0-3 days214 (60.6%)124 (41.1%)<0.001
> 3 days139 (39.4%)178 (58.9%)
30-Day readmission4 (1.1%)4 (1.3%)1.00
Return to OR6 (1.7%)7 (2.3%)0.59
Intraoperative adverse events4 (1.1%)5 (1.7%)0.74
ICU1 (0.3%)0 (0.0%)1.00
Pain severity
None/mild155 (87.1%)70 (72.2%)0.002
Moderate/severe23 (12.9%)27 (27.8%)


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