Catarci Stefano, Zanfini Bruno Antonio, Capone Emanuele, Vassalli Francesco, Frassanito Luciano, Biancone Matteo, Di Muro Mariangela, Fagotti Anna, Fanfani Francesco, Scambia Giovanni, Draisci Gaetano
Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy.
Department of Critical Care and Perinatal Medicine, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy.
J Clin Med. 2023 Jul 19;12(14):4775. doi: 10.3390/jcm12144775.
Adequate pain management for abdominal hysterectomy is a key factor to decrease postoperative morbidity, hospital length of stay and chronic pain. General anesthesia is still the most widely used technique for abdominal hysterectomy. The aim of this study was to assess the efficacy and safety of blended anesthesia (spinal and general anesthesia) compared to balanced general anesthesia in patients undergoing hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis.
We retrospectively collected data from adult ASA 1 to 3 patients scheduled for laparoscopic or mini-laparotomic hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis. Exclusion criteria were age below 18 years, ASA > 3, previous chronic use of analgesics, psychiatric disorders, laparotomic surgery with an incision above the belly button and surgery extended to the upper abdomen for the presence of cancer localizations (e.g., liver, spleen or diaphragm surgery). The cohort of patients was retrospectively divided into three groups according to the anesthetic management: general anesthesia and spinal with morphine and local anesthetic (Group 1), general anesthesia and spinal with morphine (Group 2) and general anesthesia without spinal (Group 3).
NRS was lower in the spinal anesthesia groups (Groups 1 and 2) than in the general anesthesia group (Group 3) for every time point but at 48 h. The addition of local anesthetics conferred a small but significant NRS decrease ( = 0.009). A higher percentage of patients in Group 3 received intraoperative sufentanil (52.2 ± 18 mcg in Group 3 vs. Group 1 31.8 ± 16.2 mcg, Group 2 44.1 ± 15.6, < 0.001) and additional techniques for postoperative pain control (11.4% in Group 3 vs. 2.1% in Group 1 and 0.8% in Group 2, < 0.001). Intraoperative hypotension (MAP < 65 mmHg) lasting more than 5 min was more frequent in patients receiving spinal anesthesia, especially with local anesthetics (Group 1 25.8%, Group 2 14.6%, Group 3 11.6%, < 0.001), with the resulting increased need for vasopressors. Recovery-room discharge criteria were met earlier in the spinal anesthesia groups than in the general anesthesia group (Group 1 102 ± 44 min, Group 2 91.9 ± 46.5 min, Group 3 126 ± 90.7 min, < 0.05). No differences were noted in postoperative mobilization or duration of ileus.
Intrathecal administration of morphine with or without local anesthetic as a component of blended anesthesia is effective in improving postoperative pain control following laparoscopic or mini-laparotomic hysterectomy, in reducing intraoperative opioid consumption, in decreasing postoperative rescue analgesics consumption and the need for any additional analgesic technique. We recommend managing postoperative pain with a strategy tailored to the patient's physical status and the type of surgery, preventing and treating side effects of pain treatments.
腹部子宫切除术中充分的疼痛管理是降低术后发病率、住院时间和慢性疼痛的关键因素。全身麻醉仍是腹部子宫切除术最广泛使用的技术。本研究的目的是评估在接受卵巢癌、子宫内膜癌或宫颈癌或纤维瘤病的子宫切除术（有或无淋巴结清扫）的患者中，与平衡全身麻醉相比，联合麻醉（脊髓麻醉和全身麻醉）的有效性和安全性。
我们回顾性收集了计划接受腹腔镜或小切口剖腹子宫切除术（有或无卵巢癌、子宫内膜癌或宫颈癌或纤维瘤病的淋巴结清扫）的成年ASA 1至3级患者的数据。排除标准为年龄低于18岁、ASA>3、既往长期使用镇痛药、精神疾病、腹部切口高于肚脐的剖腹手术以及因癌症定位（如肝脏、脾脏或膈肌手术）而扩展至上腹部的手术。根据麻醉管理，将患者队列回顾性分为三组：全身麻醉联合脊髓注射吗啡和局部麻醉药（第1组）、全身麻醉联合脊髓注射吗啡（第2组）和单纯全身麻醉（第3组）。
除48小时外，脊髓麻醉组（第1组和第2组）在每个时间点的数字疼痛评分量表（NRS）均低于全身麻醉组（第3组）。添加局部麻醉药使NRS有小幅但显著的降低（P = 0.009）。第3组中有更高比例的患者术中接受了舒芬太尼（第3组为52.2±18微克，第1组为31.8±16.2微克，第2组为44.1±15.6微克，P<0.001）以及用于术后疼痛控制的额外技术（第3组为11.4%，第1组为2.1%，第2组为0.8%，P<0.001）。接受脊髓麻醉的患者术中低血压（平均动脉压<65 mmHg）持续超过5分钟更为常见，尤其是使用局部麻醉药时（第1组为25.8%，第2组为14.6%，第3组为11.6%，P<0.001），因此对血管加压药的需求增加。脊髓麻醉组比全身麻醉组更早达到恢复室出院标准（第1组为102±44分钟，第2组为91.9±46.5分钟，第3组为126±90.7分钟，P<0.05）。术后活动或肠梗阻持续时间方面未观察到差异。
作为联合麻醉的一部分，鞘内注射吗啡（有或无局部麻醉药）在改善腹腔镜或小切口剖腹子宫切除术后的疼痛控制、减少术中阿片类药物消耗、降低术后补救性镇痛药消耗以及减少对任何额外镇痛技术的需求方面是有效的。我们建议根据患者的身体状况和手术类型制定个性化策略来管理术后疼痛，预防和治疗疼痛治疗的副作用。
