Ahmed Ömer HALAT, Muhammet İrfan DÖNMEZ, Murat GÖNEN, Ömer Erkam ARSLAN, Betül BAŞARAN

AĞIR OBEZİTE HASTALARIN SPİNAL ANESTEZİ ALTINDA PERKÜTAN NEFROLİTİTOMİ UYGULANMASI POSTOPERATİF ERKEN DÖNEM İYİLEŞME VE CERRAHİ SONUÇLARINI ETKİLER Mİ?

Amaç: Bu çalışmanın birincil amacı, spinal anestezi altında perkütan nefrolititomi (PNL) uygulanan hastalarda ağır obezitenin erken postoperatif seyir üzerinde zararlı bir etkisinin olup olmadığını değerlendirmektir. İkinci olarak, ağır obezitenin cerrahi sonuçları değiştirip değiştirmediğini belirlemektir. Gereç ve Yöntem: Çalışmaya kliniğimizde ≥2cm böbrek taşı nedeniyle PNL operasyonu yapılan 100 hasta dahil edildi. Buna göre birinci grupta VKİ<35 kg/m2 olanlar, ikinci grupta ise ciddi derecede obez BKİ≥35 kg/m2 olanlar oluşturuldu. Yaş, cinsiyet, taş yükü, ameliyat öncesi/sonrası hemoglobin seviyeleri, giriş sayısı ve bölgeleri, ameliyat süresi, perioperatif komplikasyonlar ve 24. saatte Görsel Analog Skala skoru, PACU yatış/taburculuk Aldrete skorları ve PACU kalış süresi kaydedildi. Bulgular: Grup 1’de VAS puanı 5,0±1,3 iken grup 2’de 5,3±1,8 idi (p=0,32). Hastanede kalış süresi VKİ <35 kg/m2 olan hastalarda 3,3±1,3 gün, VKİ≥35 kg/m2 olan hastalarda 3,0±1,0 idi (p=0,36). Ağır obez grupta %98, normal vücut kitle indeksi grubunda %96 taşsızlık oranı saptandı ve gruplar arasında anlamlı fark yoktu (p=0,672). Gruplar arasında PACU taburcu Aldrete skorları açısından istatistiksel olarak anlamlı fark vardı (Grup 1 ve 2’de sırasıyla 9,9±0,3 ve 9,6±0,4) (p=0,03). Son olarak PACU’da zaman aralığı grup 1’de 39,0±7,5 dk iken grup 2’de 58,8±14,0 dk idi (p<0,0001). Sonuç: Şiddetli obezite, spinal anestezi altında PNL uygulanan hastalarda cerrahi sonuçları değiştirmez ve bize göre PNL’de spinal anestezi, obez ve morbid obez hastalarda renal taş(lar) için güvenli ve etkili bir anestezi yöntemidir.

Anahtar Kelimeler:

obezite, PACU, PNL, spinal anestezi, prospektif

DOES SEVERE OBESITY EFFECT EARLY POSTOPERATIVE RECOVERY AND SURGICAL OUTCOMES IN PATIENTS UNDERGOING PERCUTANEOUS NEPHROLITHOTOMY UNDER SPINAL ANESTHESIA?

Objective: The primary aim of this study is to evaluate if severe obesity has any deleterious effect on the early postoperative course in patients undergoing percutaneous nephrolithotomy (PNL) under spinal anesthesia, and the secondary aim is to determine whether severe obesity changes surgical results. Material and Method: The study included 100 patients who underwent a PNL operation for kidney stones of ≥2cm in our clinic. Accordingly, those with BMI <35 kg/m2 formed the first while the severely obese BMI ≥35 kg/m2 formed the second group. Age, gender, stone burden, pre/postoperative hemoglobin levels, number and regions of access, duration of surgery, perioperative complications and Visual Analogue Scale score at 24h, PACU admission/ discharge Aldrete scores, and PACU length of stay were recorded. Results: The VAS score was 5.0±1.3 in group 1 while it was 5.3±1.8 in group 2 (p=0.32). The length of the hospital stay was 3.3±1.3 days in patients with BMI <35 kg/m2 and 3.0±1.0 in patients with BMI ≥35 kg/m2 (p=0.36). A 98% stone-free rate was found in the severely obese group and 96% in the normal BMI group, and there was no significant difference between the groups (p=0.672). There was a statistically significant difference in terms of PACU discharge Aldrete scores between groups (9.9±0.3 vs. 9.6±0.4 in groups 1 and 2, respectively) (p=0.03). Finally, the time interval in PACU was 39.0±7.5 mins in group 1 while it was 58.8±14.0 mins in group 2 (p<0.0001). Conclusions: Severe obesity does not alter surgical outcomes in patients undergoing PNL under spinal anesthesia, and in our opinion, spinal anesthesia in PNL is a safe and effective anesthesia modality for renal stone(s) in obese and morbidly obese patients.

Keywords:

obesity, PACU, PNL, spinal anesthesia, prospective,

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1. Keheila M, Leavitt D, Galli R, Motamedinia P, Theckumparampil N, Siev M, et al. Percutaneous nephrolithotomy in super obese patients (body mass index ≥ 50 kg/m²): overcoming the challenges. BJU Int 2016;117(2):300-6. [CrossRef]
2. Zhou X, Sun X, Chen X, Gong X, Yang Y, Chen C, et al. Effect of Obesity on Outcomes of Percutaneous Nephrolithotomy in Renal Stone Management: A Systematic Review and Meta-Analysis. Urol Int 2017;98(4):382-90. [CrossRef]
3. Scales CD Jr, Smith AC, Hanley JM, Saigal CS. Urologic Diseases in America Project. Prevalence of kidney stones in the United States. Eur Urol 2012;62(1):160-5. [CrossRef]
4. Ozgor F, Ucpinar B, Binbay M. Effect of Obesity on Prone Percutaneous Nephrolithotomy Outcomes: A Systemic Review. Urol J 2016;13(1):2471-8. PMID: 26945649.
5. Pareek G, Hedican SP, Lee FT Jr, Nakada SY. Shock wave lithotripsy success determined by skin-to-stone distance on computed tomography. Urology 2005;66(5):941-4. [CrossRef]
6. Doizi S, Letendre J, Bonneau C, Gil Diez de Medina S, Traxer O. Comparative study of the treatment of renal stones with flexible ureterorenoscopy in normal weight, obese, and morbidly obese patients. Urology 2015;85(1):38- 44. [CrossRef]
7. Sari E, Tepeler A, Yuruk E, Resorlu B, Akman T, Binbay M, et al. Effect of the body mass index on outcomes of flexible ureterorenoscopy. Urolithiasis 2013;41(6):499-504. [CrossRef]
8. Ramakumar S, Segura JW. Renal calculi. Percutaneous management. Urol Clin North Am 2000;27(4):617-22. [CrossRef]
9. Nouralizadeh A, Ziaee SA, Hosseini Sharifi SH, Basiri A, Tabibi A, Sharifiaghdas F. et al. Comparison of percutaneous nephrolithotomy under spinal versus general anesthesia: a randomized clinical trial. J Endourol 2013;27(8):974-8. [CrossRef]
10. Singh V, Sinha RJ, Sankhwar SN, Malik A. A prospective randomized study comparing percutaneous nephrolithotomy under combined spinal-epidural anesthesia with percutaneous nephrolithotomy under general anesthesia. Urol Int 2011;87(3):293-8. [CrossRef]
11. Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth 1995;7(1):89-91. [CrossRef]
12. Wu SD, Yilmaz M, Tamul PC, Meeks JJ, Nadler RB. Awake endotracheal intubation and prone patient selfpositioning: anesthetic and positioning considerations during percutaneous nephrolithotomy in obese patients. J Endourol 2009;23(10):1599-602. [CrossRef]
13. Gofrit ON, Shapiro A, Donchin Y, Bloom AI, Shenfeld OZ, Landau EH. et al. Lateral decubitus position for percutaneous nephrolithotripsy in the morbidly obese or kyphotic patient. J Endourol 2002;16(6):383-6. [CrossRef]
14. Nguyen TA, Belis JA. Endoscopic management of urolithiasis in the morbidly obese patient. J Endourol 1998;12(1):33-5. [CrossRef]
15. Basiri A, Kashi AH, Zeinali M, Nasiri MR, Valipour R, Sarhangnejad R. Limitations of Spinal Anesthesia for Patient and Surgeon During Percutaneous Nephrolithotomy. Urol J 2018;15(4):164-7. [CrossRef]
16. Kuzgunbay B, Turunc T, Akin S, Ergenoglu P, Aribogan A, Ozkardes H. Percutaneous nephrolithotomy under general versus combined spinal-epidural anesthesia. J Endourol 2009;23(11):1835-8. [CrossRef]
17. Mazzucchi E, Vicentini FC, Marchini GS, Danilovic A, Brito AH, Srougi M. Percutaneous nephrolithotomy in obese patients: comparison between the prone and total supine position. J Endourol 2012;26(11):1437-42. [CrossRef]
18. Liu L, Zheng S, Xu Y, Wei Q. Systematic review and metaanalysis of percutaneous nephrolithotomy for patients in the supine versus prone position. J Endourol 2010;24(12):1941- 6. [CrossRef]
19. Borendal Wodlin N, Nilsson L, Carlsson P, Kjølhede P. Costeffectiveness of general anesthesia vs spinal anesthesia in fast-track abdominal benign hysterectomy. Am J Obstet Gynecol 2011;205(4):326.e1-7. [CrossRef]
20. McLain RF, Kalfas I, Bell GR, Tetzlaff JE, Yoon HJ, Rana M. Comparison of spinal and general anesthesia in lumbar laminectomy surgery: a case-controlled analysis of 400 patients. J Neurosurg Spine 2005;2(1):17-22. [CrossRef]
21. Ballestrazzi V, Zboralski C, Smith-Morel P, Boullet M, Willot I,Hochart D. et al. Intérêt de l’anesthésie péridurale suspendue dans la néphrolithotomie percutanée. A propos de 112 patients du service des voies urinaires du C.H.R. de Lille [Importance of suspended peridural anesthesia in percutaneous nephrolithotomy. Apropos of 112 patients in the urology service of the Regional Hospital Center of Lille]. Cah Anesthesiol 1988;36(2):85-8. French. PMID: 3365593.
22. Koo BC, Burtt G, Burgess NA. Percutaneous stone surgery in the obese: outcome stratified according to body mass index. BJU Int 2004;93(9):1296-9. [CrossRef]
23. El-Assmy AM, Shokeir AA, El-Nahas AR, Shoma AM, Eraky I,El-Kenawy MR. et al. Outcome of percutaneous nephrolithotomy: effect of body mass index. Eur Urol 2007;52(1):199-204. [CrossRef]
24. Fuller A, Razvi H, Denstedt JD, Nott L, Pearle M, Cauda F. et al: CROES PCNL Study Group. The CROES percutaneous nephrolithotomy global study: the influence of body mass index on outcome. J Urol 2012;188(1):138-44. [CrossRef]
25. Shohab D, Ayub R, Alam MU, Butt A, Sheikh S, Assad S. et al. Effect of body mass index on operative time, hospital stay, stone clearance, postoperative complications, and postoperative analgesic requirement in patients undergoing percutaneous nephrolithotomy. Turk J Urol 2015;41(4):177-80. [CrossRef]
26. Phillips NM, Street M, Kent B, Haesler E, Cadeddu M. Postanaesthetic discharge scoring criteria: key findings from a systematic review. Int J Evid Based Healthc 2013;11(4):275- 84. [CrossRef]
27. Parikh DA, Patkar GA, Ganvir MS, Sawant A, Tendolkar BA. Is segmental epidural anaesthesia an optimal technique for patients undergoing percutaneous nephrolithotomy? Indian J Anaesth 2017;61(4):308-314. [CrossRef]
28. Satman I, Omer B, Tutuncu Y, Kalaca S, Gedik S, Dinccag N. et al. TURDEP-II Study Group. Twelve-year trends in the prevalence and risk factors of diabetes and prediabetes in Turkish adults. Eur J Epidemiol 2013;28(2):169-80. [CrossRef]
29. NCD Risk Factor Collaboration (NCD-RisC). Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet 2016;387(10026):1377-96. [CrossRef]