Chole under thoracic epidural

[Apollyon]

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Had a 450lb, 6'8" patient last night who has history of cholelithiasis and biliary colic, but is TERRIFIED (as his PMD put in the note, in capitals) of GA, for fear he won't wake up. I told him other options might be available. I looked into the thoracic epidural, but the literature I found seemed to all be from outside the US.

Is this routinely taught in residency and performed in the US? I know ortho does total hips under epidurals, and I wondered if there's any significant open abdominal surgery, including cholecystectomies, being done under them. This guy would not be a candidate for a lap chole.

Thanks!

 

[deleted126335]

Had a 450lb, 6'8" patient last night who has history of cholelithiasis and biliary colic, but is TERRIFIED (as his PMD put in the note, in capitals) of GA, for fear he won't wake up. I told him other options might be available. I looked into the thoracic epidural, but the literature I found seemed to all be from outside the US.

Is this routinely taught in residency and performed in the US? I know ortho does total hips under epidurals, and I wondered if there's any significant open abdominal surgery, including cholecystectomies, being done under them. This guy would not be a candidate for a lap chole.

Thanks!

I have done 2 open choles under lumbar epidural in 20 years. Both in my first few years out of residency. Both thin or normal sized patients with severe COPD. Both worked. Anything below and not including the diaphragm can be done with epidural or spinal. Don't think I would do this patient that way today. Don't think that I would even do the patients that I did under regional that way again.

 

[Planktonmd]

Open cholecystectomy can be done very nicely under thoracic epidural in the right patient.
I have done it 3 or 4 times over the past 10 years, one of them was for a patient with a severe muscular dystrophy ( can't remember the exact diagnosis) and the others were patients who had some terminal illnesses that I did not want to intubate.
Your patient on the other hand is a very bad candidate for this anesthetic technique.
Think about it: sub-diaphragmatic surgery on a morbidly obese patients who you are going to take away a good part of his respiratory reserve by the epidural and by placing him supine, how do you think he is going to do?

 

[proman]

Is this routinely taught in residency and performed in the US? I know ortho does total hips under epidurals, and I wondered if there's any significant open abdominal surgery, including cholecystectomies, being done under them. This guy would not be a candidate for a lap chole.

Thanks!

Why isn't he a candidate for lap? Has he seen a bariatric surgeon who's skilled at lap technique? Weight alone isn't a contraindication, there are appropriately long instruments. As for being terrified, he should have a preoperative meeting with his anesthesiologist (before day of surgery). That's the best way to alleviate anxiety.

 

[dhb]

I told him other options might be available.
Thanks!

Like loosing weight which might solve his gallbladder problems?

 

[militarymd]

Like loosing weight which might solve his gallbladder problems?

how about you are NOT eligible for care because you are too stinking FAT.....the Obama way.

 

[SleepIsGood]

Had a 450lb, 6'8" patient last night who has history of cholelithiasis and biliary colic, but is TERRIFIED (as his PMD put in the note, in capitals) of GA, for fear he won't wake up. I told him other options might be available. I looked into the thoracic epidural, but the literature I found seemed to all be from outside the US.

Is this routinely taught in residency and performed in the US? I know ortho does total hips under epidurals, and I wondered if there's any significant open abdominal surgery, including cholecystectomies, being done under them. This guy would not be a candidate for a lap chole.

Thanks!

I've done an suprarenal aortic aneursym repair under an epidural inserte around T12...worked pretty good. Didnt think the surgeon was going to go as high up in the abdomen...but when we found he did...no big deal.

 

[Apollyon]

Why isn't he a candidate for lap? Has he seen a bariatric surgeon who's skilled at lap technique? Weight alone isn't a contraindication, there are appropriately long instruments. As for being terrified, he should have a preoperative meeting with his anesthesiologist (before day of surgery). That's the best way to alleviate anxiety.

I told him first out that I wasn't an anesthesiologist, and that he definitely would have to speak with one. This is in a poor part of Hawai'i - I know bariatric surgeons to be cash-only businesses much of the time, and this guy doesn't have money. If there was a bariatric surgeon willing to take MedicAid, that would be fine, but I don't even know how many bariatric surgeons there are on O'ahu. I thought morbid obesity was a relative contraindication to laparascopic surgery.

 

[proman]

Laparoscopic bariatric surgery is well described but technically difficult (but so is open). It is associated with fewer postoperative complications (such as surgical site infection, DVT, pneumonia). Doesn't sound like this guy only needs his gallbladder out but should get referred to a bariatric surgeon. Medicaid does cover bariatric surgery (probably poorly, but it is covered). It would be worth traveling to a surgeon used to dealing with BMIs of 50. And, I'm sure difficult.

BTW, they've done CABGs with epidurals but just because you can doesn't mean you should.

 

[Apollyon]

He told me he actually has gone from 500lbs to 450, so that is working. I told him that weight loss would help with his diabetes. Interestingly, he had a great blood pressure.

 

[jwk]

I told him first out that I wasn't an anesthesiologist, and that he definitely would have to speak with one. This is in a poor part of Hawai'i - I know bariatric surgeons to be cash-only businesses much of the time, and this guy doesn't have money. If there was a bariatric surgeon willing to take MedicAid, that would be fine, but I don't even know how many bariatric surgeons there are on O'ahu. I thought morbid obesity was a relative contraindication to laparascopic surgery.

Lap choles are far easier on morbidly obese patients than open choles. Any general surgeon that does any significant amount of laparoscopic surgery should be able to do this case. They may have to make arrangements to get some long trocars and sheaths, but that's about it.

 

[militarymd]

He told me he actually has gone from 500lbs to 450, so that is working. I told him that weight loss would help with his diabetes. Interestingly, he had a great blood pressure.

how can you tell....blood pressure measurements in patients with conical arms are meaningless.

 

[Apollyon]

how can you tell....blood pressure measurements in patients with conical arms are meaningless.

Well, it was with the thigh cuff on his arm, and appeared to equally fill circumferentially. I hear you, though, about the conical arms. He had a radial pulse, so I knew his systolic was 90!

 

[Planktonmd]

Well, it was with the thigh cuff on his arm, and appeared to equally fill circumferentially. I hear you, though, about the conical arms. He had a radial pulse, so I knew his systolic was 90!

Wow, a systolic of 90 in a 450 lb patient!
Am I missing something here?

 

[Apollyon]

Wow, a systolic of 90 in a 450 lb patient!
Am I missing something here?

No, at least - pt had a radial pulse. The cuff said 119.

 

[psychbender]

He had a radial pulse, so I knew his systolic was 90!

You sure about that? SBP does not correlate to pulse location, despite what is often taught in ATLS. No data supports that notion, that the ACS put forth back in the 80s, which found its way into ATLS and the minds of doctors and medics everywhere.

Sorry, I'm in a ranting mood after having to correct some other myths being taught to the medic students at my hospital.