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The difficulty of choosing between two risks: laparoscopic or open cholecystectomy in the presence of a large patent foramen ovale
170
Correspondence
The difficulty of choosing between two risks: laparoscopic or open cholecystectomy in the presence of a large patent foramen ovale To the Editor: Thoma et al. [1] present the case of an obese patient who was scheduled for an emergent laparoscopic cholecystectomy and who had a large patent foramen ovale (PFO) with a right-to-left shunt. The authors chose the laparoscopic approach after considering the pros and cons. Occurrence of gas embolism is particularly frequent during laparoscopic procedures. For example, a recent study using transesophageal echocardiography as the diagnostic tool reported that all patients undergoing total laparoscopic hysterectomy had right atrial gas embolism, and one third had a high grade of gas embolism [2]. As outlined by the authors, there is a contrast between the high frequency of a PFO and the low occurrence of a complication during laparoscopy. The authors developed a consensus plan, but additional points should have been considered: monitoring with Bispectral Index or entropy (a abrupt in such indices indicating an ischemic cerebral event) [3]; electrocardiographic (ECG) monitoring regarding an ischemic event; anesthesia with short-acting drugs allowing early postoperative neurologic examination; and early postoperative detection of myocardial ischemia (ECG and troponin). Furthermore, prolonged surveillance is mandatory due to possible trapping of gas in the portal circulation and delayed release [4]. It would be helpful to have guidelines in certain additional situations: 1) Surgical cases with a high risk of air embolism, such as neurosurgical procedures performed in the sitting position. Patent foramen ovale is often screened for during the pre-anesthetic evaluation and the sitting position is contraindicated in its presence. A Swiss anesthesiology team proposed another approach, which is to close the PFO 2 to 4 weeks before surgery [5]. 2) Orthopedic cases with the risk of bone cement implementation syndrome. Pigot et al. [6] closed a PFO before hip replacement in a patient having suffered two consecutive cerebellar ischemic strokes. 3) When a coelioscopy is planned in a patient known to have a PFO. Marc Fischler MD (Professor of Anesthesiology) Department of Anesthesia, Hôpital Foch 92150 Suresnes, France E-mail address: [email protected] doi: 10.1016/j.jclinane.2010.12.003
References [1] Thoma MS, Maa J, Schiller NB, Litt L. Cholecystectomy in the presence of a large patent foramen ovale: laparoscopic or open? J Clin Anesth 2010;22:553-6.
[2] Kim CS, Kim JY, Kwon JY, et al. Venous air embolism during total laparoscopic hysterectomy: comparison to total abdominal hysterectomy. Anesthesiology 2009;111:50-4. [3] Chazot T, Liu N, Tremelot L, Joukovsky P, Fischler M. Detection of gas embolism by bispectral index and entropy monitoring in two cases. Anesthesiology 2004;101:1053-4. [4] Root B, Levy MN, Pollack S, Lubert M, Pathak K. Gas embolism death after laparoscopy delayed by qtrappingq in portal circulation. Anesth Analg 1978;57:232-7. [5] Fathi AR, Eshtehardi P, Meier B. Patent foramen ovale and neurosurgery in sitting position: a systematic review. Br J Anaesth 2009;102:588-96. [6] Pigot B, Kirkham D, Eyrolles L, Rosencher N, Safran D, Cholley B. Preventive closure of a patent foramen ovale before total hip replacement. Br J Anaesth 2009;102:888-9.
Reply We appreciate Dr. Fischler's thoughtful letter in response to our case report [1]. We agree with his important comments regarding: vigilance in electrocardiographic monitoring for cardiac ischemia that might result from sudden profound hypotension or gas occlusion in coronary arteries; the benefits of short-acting anesthesia agents to assure early emergence and neurological assessment; and the importance of prolonged postoperative monitoring. Dr. Fischler also suggests that a bispectral index or entropy brain monitor be used to assure early detection of pulmonary emboli or paradoxical emboli. He cites two cases described in his Letter to the Editor in Anesthesiology [2], in which brain function monitoring provided additional information to dramatic capnographic changes that occurred within seconds, and were pathognomonic for pulmonary embolus. However, there has been no prospective clinical study showing that the use of such monitors would improve outcomes after pulmonary or cerebral embolic phenomena. In addition, a Practice Advisory from the ASA [3] concluded that “brain function monitoring is not routinely indicated for patients undergoing general anesthesia…" and “Brain function monitors currently have the status of the many other monitoring modalities that are currently used in selected situations at the discretion of individual clinicians." With regard to his comment about preoperative patent foramen ovale closure, we refer Dr. Fischler to our discussion of this subject on the second page of our case report. We inquired with interventional cardiologists about this matter, and there was unanimity about it having much greater risk than doing laparoscopic surgery. Dr. Fischler's call for guidelines about embolus detection during orthopedic surgery and laparoscopy in general (bcœlioscopieQ en français) is laudable but beyond the scope of our focused, word-limited case report. Lawrence Litt PhD, MD (Professor of Anesthesia) Mark S. Thoma MD (Chief Resident) Department of Anesthesia and Perioperative Care University of California, San Francisco San Francisco, CA E-mail address: [email protected]
Correspondence
The difficulty of choosing between two risks: laparoscopic or open cholecystectomy in the presence of a large patent foramen ovale To the Editor: Thoma et al. [1] present the case of an obese patient who was scheduled for an emergent laparoscopic cholecystectomy and who had a large patent foramen ovale (PFO) with a right-to-left shunt. The authors chose the laparoscopic approach after considering the pros and cons. Occurrence of gas embolism is particularly frequent during laparoscopic procedures. For example, a recent study using transesophageal echocardiography as the diagnostic tool reported that all patients undergoing total laparoscopic hysterectomy had right atrial gas embolism, and one third had a high grade of gas embolism [2]. As outlined by the authors, there is a contrast between the high frequency of a PFO and the low occurrence of a complication during laparoscopy. The authors developed a consensus plan, but additional points should have been considered: monitoring with Bispectral Index or entropy (a abrupt in such indices indicating an ischemic cerebral event) [3]; electrocardiographic (ECG) monitoring regarding an ischemic event; anesthesia with short-acting drugs allowing early postoperative neurologic examination; and early postoperative detection of myocardial ischemia (ECG and troponin). Furthermore, prolonged surveillance is mandatory due to possible trapping of gas in the portal circulation and delayed release [4]. It would be helpful to have guidelines in certain additional situations: 1) Surgical cases with a high risk of air embolism, such as neurosurgical procedures performed in the sitting position. Patent foramen ovale is often screened for during the pre-anesthetic evaluation and the sitting position is contraindicated in its presence. A Swiss anesthesiology team proposed another approach, which is to close the PFO 2 to 4 weeks before surgery [5]. 2) Orthopedic cases with the risk of bone cement implementation syndrome. Pigot et al. [6] closed a PFO before hip replacement in a patient having suffered two consecutive cerebellar ischemic strokes. 3) When a coelioscopy is planned in a patient known to have a PFO. Marc Fischler MD (Professor of Anesthesiology) Department of Anesthesia, Hôpital Foch 92150 Suresnes, France E-mail address: [email protected] doi: 10.1016/j.jclinane.2010.12.003
References [1] Thoma MS, Maa J, Schiller NB, Litt L. Cholecystectomy in the presence of a large patent foramen ovale: laparoscopic or open? J Clin Anesth 2010;22:553-6.
[2] Kim CS, Kim JY, Kwon JY, et al. Venous air embolism during total laparoscopic hysterectomy: comparison to total abdominal hysterectomy. Anesthesiology 2009;111:50-4. [3] Chazot T, Liu N, Tremelot L, Joukovsky P, Fischler M. Detection of gas embolism by bispectral index and entropy monitoring in two cases. Anesthesiology 2004;101:1053-4. [4] Root B, Levy MN, Pollack S, Lubert M, Pathak K. Gas embolism death after laparoscopy delayed by qtrappingq in portal circulation. Anesth Analg 1978;57:232-7. [5] Fathi AR, Eshtehardi P, Meier B. Patent foramen ovale and neurosurgery in sitting position: a systematic review. Br J Anaesth 2009;102:588-96. [6] Pigot B, Kirkham D, Eyrolles L, Rosencher N, Safran D, Cholley B. Preventive closure of a patent foramen ovale before total hip replacement. Br J Anaesth 2009;102:888-9.
Reply We appreciate Dr. Fischler's thoughtful letter in response to our case report [1]. We agree with his important comments regarding: vigilance in electrocardiographic monitoring for cardiac ischemia that might result from sudden profound hypotension or gas occlusion in coronary arteries; the benefits of short-acting anesthesia agents to assure early emergence and neurological assessment; and the importance of prolonged postoperative monitoring. Dr. Fischler also suggests that a bispectral index or entropy brain monitor be used to assure early detection of pulmonary emboli or paradoxical emboli. He cites two cases described in his Letter to the Editor in Anesthesiology [2], in which brain function monitoring provided additional information to dramatic capnographic changes that occurred within seconds, and were pathognomonic for pulmonary embolus. However, there has been no prospective clinical study showing that the use of such monitors would improve outcomes after pulmonary or cerebral embolic phenomena. In addition, a Practice Advisory from the ASA [3] concluded that “brain function monitoring is not routinely indicated for patients undergoing general anesthesia…" and “Brain function monitors currently have the status of the many other monitoring modalities that are currently used in selected situations at the discretion of individual clinicians." With regard to his comment about preoperative patent foramen ovale closure, we refer Dr. Fischler to our discussion of this subject on the second page of our case report. We inquired with interventional cardiologists about this matter, and there was unanimity about it having much greater risk than doing laparoscopic surgery. Dr. Fischler's call for guidelines about embolus detection during orthopedic surgery and laparoscopy in general (bcœlioscopieQ en français) is laudable but beyond the scope of our focused, word-limited case report. Lawrence Litt PhD, MD (Professor of Anesthesia) Mark S. Thoma MD (Chief Resident) Department of Anesthesia and Perioperative Care University of California, San Francisco San Francisco, CA E-mail address: [email protected]