Hindawi Publishing Corporation

BioMed Research International

Volume 2016, Article ID 9480539, 9 pages
http://dx.doi.org/10.1155/2016/9480539

Research Article
Comparison of Postoperative Events between Spinal
Anesthesia and General Anesthesia in Laparoscopic
Cholecystectomy: A Systemic Review and Meta-Analysis of
Randomized Controlled Trials

Xian-Xue Wang,1 Quan Zhou,2 Dao-Bo Pan,1 Hui-Wei Deng,1 Ai-Guo Zhou,1
Hua-Jing Guo,1 and Fu-Rong Huang1
1
Department of Anesthesiology, The First People’s Hospital of Changde City, Changde, Hunan 415003, China
2
Science & Education Division, The First People’s Hospital of Changde City, Changde, Hunan 415003, China

Correspondence should be addressed to Dao-Bo Pan; pdbxzyxy2013@163.com

Received 6 March 2016; Revised 30 May 2016; Accepted 13 June 2016

Academic Editor: Yukio Hayashi

Copyright © 2016 Xian-Xue Wang et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Laparoscopic cholecystectomy is usually carried out under general anesthesia. There were a few studies which have
found spinal anesthesia as a safe alternative. We aimed to evaluate the postoperative events between spinal anesthesia and general
anesthesia in patients undergoing laparoscopic cholecystectomy. Methods. We searched PubMed, Embase, and Cochrane Library
(from inception to January 2016) for eligible studies. The primary outcome was the visual analogue scale score. Secondary outcomes
included postoperative nausea and vomiting and urine retention 24 hours postoperatively. We calculated pooled risk ratios and 95%
confidence interval using random- or fixed-effects models. Results. Eight trials involving 723 patients were listed. Meta-analysis
showed that patients in spinal anesthesia groups have lower visual analogue scale score 24 hours postoperatively. There were
significant decreases in the occurrence of postoperative nausea and vomiting in spinal anesthesia group when compared with
general anesthesia group (odds ratios: 0.38, 95% confidence interval: 0.19–0.76; 𝑃 = 0.006) with heterogeneity accepted (𝐼2 = 13%;
𝑃 = 0.33), while urine retention rate was increased in patients with spinal anesthesia (odds ratios: 4.95, 95% confidence interval:
1.24–19.71; 𝑃 = 0.02) without any heterogeneity (𝐼2 = 0%; 𝑃 = 0.98). Conclusions. Spinal anesthesia may be associated with less
postoperative pain and postoperative nausea and vomiting compared with general anesthesia.

1. Introduction Combining a minimally invasive surgical procedure

with a less invasive anesthetic technique, spinal anesthesia
Laparoscopic cholecystectomy (LC) was the gold standard seems to further enhance the advantage of LC. Despite
for the surgical treatment of symptomatic cholelithiasis [1]. the mentioned advantage, the use of spinal anesthesia for
It may be awarded to minimally invasive nature of the pro- LC has still not gained popularity. Recently, some studies
cedure and associated with less postoperative pain, reduced have highlighted the feasibility and safety of performing LC
hospital stay, and earlier return to daily activities [2, 3]. under spinal anesthesia. The purpose of this study was to
LC is performed under general anesthesia and may be compare the postoperative effects between spinal anesthesia
involved in postoperative pain and nausea and vomiting and general anesthesia in patients undergoing LC.
(PONV). Spinal anesthesia was a less invasive anesthetic
technique that has lower morbidity and mortality rates,
compared with general anesthesia [4]. Patients who received 2. Methods
spinal anesthesia undergoing laparoscopy interventions were
usually awake, felt less pain, and tended to ambulate earlier This systematic review was conducted according to the
with no intubation and/or extubation [5, 6]. guidelines of the preferred reporting items for systematic
2 BioMed Research International

reviews and meta-analyses (PRISMA) [7]. We prospectively 2.5. Assessment of Risk of Bias. Two reviewers (Xian-Xue
registered our system review at PROSPERO (registration Wang and Quan Zhou) independently evaluated the risk of
number: CRD42015017169). Our study is a meta-analysis, so bias according to the recommendations from the Cochrane
ethics approval and consent are not required. Collaboration [9]. The main categories consisted of random
sequence generation, allocation concealment, blinding of
participants and personnel, blinding of outcome assessment,
2.1. Data Sources and Search Strategy. PubMed, Embase, and
incomplete outcome data, selective reporting, and other
Cochrane Library databases were searched from inception
biases. Each domain was assessed as “high risk,” “low risk,”
to January 2016 for relevant studies investigating the effect
or “unclear risk.” Namely, the judgment was “low risk” for
between spinal anesthesia and general anesthesia. The follow-
the item with sufficient and correct information. And the
ing search terms were used: general anesthesia, “anesthesia,
judgment was “high risk” for the item reported incorrectly. If
general”, spinal anesthesia, “anesthesia, spinal”, “cholecystec-
the information of the item was insufficient or unsanctioned,
tomy, laparoscopy”, laparoscopy cholecystectomy, “cholecys-
the judgment was “unclear risk.” An “unclear risk” judgment
tectomy, celioscopic”, “cholecystectomies, celioscopy”, and
should also be made if the item was reported, but the risk of
celioscopy cholecystectomy. A hand search in reference
bias is unknown. The disagreement was solved by a senior
sections of included trials, published meta-analyses, and
reviewer (Dao-Bo Pan).
relevant review articles was conducted to identify additional
articles. If duplicated data were presented in several studies,
only the most recent, largest, or most complete study was 2.6. Statistical Analysis. Odds ratio (OR) or weighted mean
included. difference (WMD) with 95% confidence interval (CI) was
used as a common measure of the effect between spinal
anesthesia and general anesthesia. 𝐼2 value was used to
2.2. Study Selection. Original studies included were based estimate statistical heterogeneity. When 𝐼2 < 50%, het-
on PICOS (patient, intervention, comparison, outcome, and erogeneity could be accepted and the fixed-effects model
study design) as follows: (a) P, American Society of Anesthesi- was adopted. Otherwise, the randomized-effects model was
ology (ASA) I/II grade adult patients undergoing laparoscopy adopted and sensitivity analysis used. Whenever heterogene-
cholecystectomy; (b) I and C, spinal anesthesia and general ity was present, several sensitivity analyses were carried out to
anesthesia, respectively; (c) O, pain score, the incidence identify potential sources. We also investigated the influence
of PONV, and urine retention; (d) S, only randomized of a single study on the overall pooled estimate by omitting
controlled trials (RCTs) included. Only English was set. one study in each turn. Owing to the limited number (below
10) of studies included in each analysis, publication bias was
2.3. Data Extraction. Characteristics of patients (number not assessed. A 𝑃 value < 0.05 was considered statistically
of patients, American Society of Anesthesiologist (ASA) significant. Risk-of-bias assessment was conducted by using
rating, age, gender, and type of surgery and anesthesia) Review Manager, version 5.3 (the Cochrane Collaboration,
and trials design (intervention, follow-up time, and reported Software Update, Oxford, UK). Power analyses of individual
outcomes) were also recorded. If the data mentioned above studies and meta-analysis were all conducted by the software,
were unavailable in the article, the corresponding authors version 4.1.0.
were contacted for missing information. All data were
independently extracted using a standard data collection 3. Results
form by 2 reviewers (Xian-Xue Wang and Quan Zhou),
and then the collected data were checked and entered into 3.1. Identification of Eligible Studies. A total of 186 poten-
Review Manager analyses software (RevMan) version 5.3. All tially relevant abstracts were detected. After duplicates were
discrepancies were checked and a consensus was reached by deleted, one hundred and thirty-three unique abstracts
discussion with a third author (Dao-Bo Pan) involved. A remained. After looking at the abstracts, seventeen publica-
record of reasons for excluding studies was kept. tions seemed to meet the inclusion criteria. For the remaining
17 articles, nine of them were excluded for the following rea-
2.4. Assessment of Study Quality. A critical evaluation of sons: unpublished studies, no available data on the outcome
the included studies quality was performed by 2 reviewers of interest in [15–17], non-English [14], retrospective study
(Xian-Xue Wang and Quan Zhou) by using a 5-point Jadad [18], and same data [19, 20]. Finally, the remaining 8 studies
scale [8]. The main categories consisted of the following 5 [1, 4, 10–14, 21] with existing data met our selection criteria
items: “was the study described as randomized? (1),” “was and were included in the systematic review. The flow diagram
the method used to generate the sequence of randomization of search strategy and study selection was shown in Figure 1.
described and appropriate (random numbers, computer-
generated, etc.)? (1),” “was the study described as double- 3.2. Study Characteristics. The characteristics of all included
blind? (1),” “was the method of double-blinding described studies were submitted in Table 1. All were adult patients
and appropriate (identical placebo, active placebo, dummy, undergoing LC. High Jadad score of the studies included was
etc.)? (1),” and “was there a description of withdrawals and 7 (range from 4 to 5). Publication bias was not studied.
dropouts? (1).” A score of 4 to 5 was considered a high These studies were expected to be released between 2008
methodological quality. and 2014. Sample size of included studies ranged from 20
BioMed Research International 3

Table 1: Characteristics of trials included in systematic review.

Number of patients
(spinal Study Intra-abdominal
Study Patient characteristics Primary end point Jadad score
anesthesia/general design CO2 pressure
anesthesia)
Pain score (VAS),
Adult patients
nausea/vomiting, urinary
Tiwari et al., 2013 undergoing
110/114 RCT 8–10 mmHg retention, hypotension, 5
[10] laparoscopic
headache, back pain, sore
cholecystectomy
throat
Adult patients
Pain score (VAS), PONV,
undergoing
Bessa et al., 2012 [1] 86/90 RCT 10 mmHg urine retention, postoperative 4
laparoscopic
spinal headache, wound sepsis
cholecystectomy
Adult patients
Tzovaras et al., undergoing Pain score (VAS), PONV,
49/48 RCT ≤10 mmHg 5
2008 [11] laparoscopic urinary retention, dizziness
cholecystectomy
Adult patients Pain score (VAS), PONV,
Kalaivani et al., undergoing urinary retention,
23/25 RCT 12 mmHg 3
2014 [12] laparoscopic postoperative spinal headache,
cholecystectomy wound sepsis
Adult patients
Pain score (VAS), PONV,
Bessa et al., 2010 undergoing
30/30 RCT ≤15 mmHg urine retention, postoperative 4
[4] laparoscopic
spinal headache, wound sepsis
cholecystectomy
Adult patients
Pain score (VAS), patient
undergoing
Ellakany, 2013 [13] 20/20 RCT ≤10 mmHg satisfaction, surgeon 4
laparoscopic
satisfaction
cholecystectomy
Pain score (VAS), PONV,
Adult patients
urine retention, shoulder pain,
Imbelloni et al., undergoing
34/33 RCT ≤8 mmHg pruritus, duration of the 5
2010 [14] laparoscopic
sensorial blockade, duration
cholecystectomy
of the motor blockade
Adult patients Pain score (VAS), shoulder
undergoing pain, nausea, urinary
Ross et al. 2013 [21] 10/10 RCT 12–15 mmHg 5
laparoscopic retention, severe abdominal
cholecystectomy pain, dizziness
PONV: postoperative nausea and vomiting.

to 224. All were randomized controlled trials and primary Heterogeneity was noted among the studies (𝐼2 = 82%; 𝑃 =
end points were VAS, PONV, and urine retention. One 0.02); randomized-effects model was selected.
study compared epidural anesthesia with general anesthesia
in patients undergoing LC [21]. Intra-abdominal carbon 3.4. VAS Score 4 Hours Postoperatively. VAS 4 hours postop-
dioxide pressure was lower in all studies: four studies with eratively was investigated in 5 trials [1, 4, 11–13]. Compared
carbon dioxide at maximum intra-abdominal pressure of with general group, VAS score in the spinal group was
10 mmHg and one study set below 8 mmHg. Carbon diox- statistically significantly reduced (WMD = −2.00, 95% CI:
ide pneumoperitoneum pressure was from 12 to 15 mmHg −2.97 to −1.04, 𝑃 < 0.0001) (Figure 3). Heterogeneity was
in 3 studies. No significant side effects were observed observed among the studies (𝐼2 = 88%; 𝑃 < 0.00001).
between spinal anesthesia and general anesthesia groups Subsequently, we performed sensitivity analyses to consider
(Table 1). potential sources of heterogeneity. Exclusion of any single
study did not resolve the heterogeneity; thus, randomized-
3.3. VAS Score 2 Hours Postoperatively. Three studies have effects model was selected.
examined the VAS 2 hours postoperatively [1, 4, 12].
The aggregated results of these four studies suggest that 3.5. VAS Score 8 Hours Postoperatively. As shown in Figure 4,
the VAS score in the spinal group was associated with a signif- four studies [1, 11–13] were incorporated into the meta-
icant reduction compared with the general group (WMD = analysis. VAS score in the spinal group 8 hours postopera-
−2.29, 95% CI: −3.81 to −0.77, 𝑃 = 0.003) (Figure 2). tively was significantly reduced (WMD = −1.13, 95% CI:
4 BioMed Research International

Records identified through

database searching (n = 186)

Records after duplicates

were removed (n = 133)

Records excluded based on

title and abstract review
Records screened (n = 133) (n = 116)

Potentially relevant records

Unpublished studies (n = 2)
screened (n = 17)

Full-text articles excluded with

reasons (n = 7)
No available data for outcome
of interest (n = 3)
Non-English (n = 1)
Retrospective study (n = 1)

Full-text articles assessed for Same data (n = 2)

eligibility (n = 15)

Studies included in quantitative

synthesis (meta-analysis) (n = 8)

Figure 1: Flow diagram of search strategy and study selection.

Spinal group General group Mean difference Mean difference

Study or subgroup Weight
Mean SD Total Mean SD Total IV, random, 95% CI IV, random, 95% CI
Bessa et al., 2010 5.38 2.5 30 6.8 2.12 30 44.5% −1.42 [−2.59, −0.25]
Bessa et al., 2012 3.51 2 86 6.49 2 90 55.5% −2.98 [−3.57, −2.39]
Kalaivani et al., 2014 0 0 23 3.76 1.34 25 Not estimable

Total (95% CI) 139 145 100.0% −2.29 [−3.81, −0.77]

Heterogeneity: 𝜏2 = 0.99; 𝜒2 = 5.42, df = 1 (P = 0.02); I2 = 82%
−100 −50 0 50 100
Test for overall effect: Z = 2.95 (P = 0.003)
Spinal group General group

Figure 2: VAS 2 hours postoperatively.

BioMed Research International 5

Spinal group General group Mean difference Mean difference

Study or subgroup Weight
Mean SD Total Mean SD Total IV, random, 95% CI IV, random, 95% CI
Bessa et al., 2010 4.25 1.51 30 5.07 2.29 30 18.6% −0.82 [−1.80, 0.16]
Bessa et al., 2012 4.51 2.5 86 6.25 1.75 90 20.9% −1.74 [−2.38, −1.10]
Tzovaras et al., 2008 1.02 1 49 3.51 2 48 20.9% −2.49 [−3.12, −1.86]
Kalaivani et al., 2014 0.45 1.35 23 4.16 1.22 25 20.3% −3.71 [−4.44, −2.98]
Ellakany, 2013 1.2 1.2 20 2.3 1.6 20 19.3% −1.10 [−1.98, −0.22]

Total (95% CI) 208 213 100.0% −2.00 [−2.97, −1.04]

Heterogeneity: 𝜏2 = 1.05; 𝜒2 = 32.79, df = 4 (P < 0.00001); I2 = 88%
−100 −50 0 50 100
Test for overall effect: Z = 4.08 (P < 0.0001)
Spinal group General group

Figure 3: VAS 4 hours postoperatively.

Spinal group General group Mean difference Mean difference

Study or subgroup Weight
Mean SD Total Mean SD Total IV, fixed, 95% CI IV, fixed, 95% CI
Bessa et al., 2012 4.26 2.25 86 4.76 2.25 90 28.6% −0.50 [−1.16, 0.16]
Tzovaras et al., 2008 1.53 1.5 49 2.76 1.75 48 30.0% −1.23 [−1.88, −0.58]
Kalaivani et al., 2014 3.55 0.9 23 4.92 1.38 25 29.6% −1.37 [−2.02, −0.72]
Ellakany, 2013 1.6 1.4 20 3.4 1.9 20 11.8% −1.80 [−2.83, −0.77]

Total (95% CI) 178 183 100.0% −1.13 [−1.49, −0.77]

Heterogeneity: 𝜒2 = 5.67, df = 3 (P = 0.13); I2 = 47%
−100 −50 0 50 100
Test for overall effect: Z = 6.23 (P < 0.00001)
Spinal group General group

Figure 4: VAS 8 hours postoperatively.

−1.49 to −0.77, 𝑃 < 0.00001) (Figure 4). Heterogeneity was 24 hours. The results of these studies suggested that the
accepted among the studies (𝐼2 = 47%; 𝑃 = 0.13); fixed- overall PONV rate significantly reduced in the spinal group
effects model was selected. (OR: 0.38, 95% CI: 0.19–0.76; 𝑃 = 0.006) with heterogeneity
accepted (𝐼2 = 13%; 𝑃 = 0.33).
3.6. VAS Score 24 Hours Postoperatively. Figure 5 outlines the
VAS score 24 hours postoperatively. The results of these stud- 3.8. Postoperative Urine Retention within 24 Hours. Seven
ies [4, 10–13] suggested that the VAS score was significantly studies [1, 4, 10–12, 14, 21] provide evidence on the incidence
reduced in the spinal group when compared with the general of postoperative urine retention between spinal group and
group (WMD = −0.68, 95% CI: −1.26 to −0.10, 𝑃 < 0.02) general group. Two studies [1, 21] compared the incident rates
(Figure 5). Subsequently, we performed sensitivity analyses to of urine retention (at 2 and 8 hours, resp.) and found no
consider potential sources of heterogeneity. Exclusion of the statistically significant difference between spinal group and
trial conducted by Tiwari et al. [10] resolved the heterogeneity general group (𝑃 > 0.05). The remaining 5 studies [4, 10, 11,
but did not change the results (WMD = −1.00, 95% CI: 13, 22] reported urine retention during a period of 24 hours
−1.18 to −0.82, 𝑃 < 0.00001; 𝑃 for heterogeneity = 0.16; and could perform meta-analysis. As shown in Figure 8,
𝐼2 = 47%) (Figure 6). Further exclusion of any single study the results of these studies suggested that the overall urine
did not materially change the overall combined RR. retention rate significantly increased in the spinal group (OR:
4.95, 95% CI: 1.24–19.71; 𝑃 = 0.02) without any heterogeneity
(𝐼2 = 0%; 𝑃 = 0.98).
3.7. Postoperative Nausea and Vomiting within 24 Hours. In
total, 7 studies [1, 4, 10–12, 14, 21] provided evidence on
the incidence of postoperative nausea and vomiting (PONV) 3.9. Quality Assessment. This systematic review included 8
between spinal group and general group. One study [1] RCTs: the baseline characteristics of patients were reported
compared the incident rates of PONV at 8 hours and found in all trials, and four trials mentioned the method of random-
the incidence rate significantly decreased in the spinal group ness (Figure 9).
(6.9% in spinal group versus 22.2% in general group; 𝑃 =
0.004), while another study [21] found that one patient in 3.10. Power Analysis. Although the statistical results were
spinal group versus three patients in general group experi- indicated in some studies, a portion of the primary data was
enced nausea, which is not statistically significant between unavailable. The available data were reassessed by a power
the two groups. The remaining 5 studies [4, 10, 11, 13, 22] analysis with an alpha level of 0.05 (Table 2). The power of
reported PONV during a period of 24 hours and could an individual study ranged from 5% to 100%. The power
perform meta-analysis. Figure 7 outlines the PONV within of the meta-analysis with respect to VAS score (2 hours, 4
6 BioMed Research International

Spinal group General group Mean difference Mean difference

Study or subgroup Weight
Mean SD Total Mean SD Total IV, random, 95% CI IV, random, 95% CI
Ellakany, 2013 0.8 0.7 20 2.3 1.5 20 18.2% −1.50 [−2.23, −0.77]
Tzovaras et al., 2008 1.02 1 49 2.02 1.5 48 21.3% −1.00 [−1.51, −0.49]
Tiwari et al., 2013 0.5 0.5 110 1.5 1 114 24.7% −1.00 [−1.21, −0.79]
Bessa et al., 2010 3.21 1.93 30 3.3 1.91 30 14.9% −0.09 [−1.06, 0.88]
Kalaivani et al., 2014 3.8 0.97 23 3.48 0.94 25 20.9% 0.32 [−0.22, 0.86]

Total (95% CI) 232 237 100.0% −0.68 [−1.26, −0.10]

Heterogeneity: 𝜏2 = 0.34; 𝜒2 = 25.72, df = 4 (P < 0.0001); I2 = 84%
−100 −50 0 50 100
Test for overall effect: Z = 2.30 (P = 0.02)
Spinal group General group

Figure 5: VAS 24 hours postoperatively.

Spinal group General group Mean difference Mean difference

Study or subgroup Weight
Mean SD Total Mean SD Total IV, fixed, 95% CI IV, fixed, 95% CI
Ellakany, 2013 0.8 0.7 20 2.3 1.5 20 6.3% −1.50 [−2.23, −0.77]
Tzovaras et al., 2008 1.02 1 49 2.02 1.5 48 12.7% −1.00 [−1.51, −0.49]
Tiwari et al., 2013 0.5 0.5 110 1.5 1 114 77.5% −1.00 [−1.21, −0.79]
Bessa et al., 2010 3.21 1.93 30 3.3 1.91 30 3.5% −0.09 [−1.06, 0.88]
Kalaivani et al., 2014 3.8 0.97 23 3.48 0.94 25 0.0% 0.32 [−0.22, 0.86]

Total (95% CI) 209 212 100.0% −1.00 [−1.18, −0.82]

Heterogeneity: 𝜒2 = 5.19, df = 3 (P = 0.16); I2 = 42%
Test for overall effect: Z = 10.80 (P < 0.00001) −100 −50 0 50 100
Spinal group General group

Figure 6: VAS 24 hours postoperatively after sensitivity analyses were performed.

Spinal group General group Odds ratio Odds ratio

Study or subgroup Weight
Events Total Events Total M-H, fixed, 95% CI M-H, fixed, 95% CI
Tiwari et al., 2013 0 110 6 114 22.3% 0.08 [0.00, 1.36]
Bessa et al., 2010 1 30 7 30 23.7% 0.11 [0.01, 0.99]
Imbelloni et al., 2010 1 34 3 33 10.4% 0.30 [0.03, 3.07]
Kalaivani et al., 2014 4 23 7 25 19.4% 0.54 [0.14, 2.17]
Tzovaras et al., 2008 7 49 8 48 24.3% 0.83 [0.28, 2.51]

Total (95% CI) 246 250 100.0% 0.38 [0.19, 0.76]

Total events 13 31
Heterogeneity: 𝜒2 = 4.62, df = 4 (P = 0.33); I2 = 13%
0.01 0.1 1 10 100
Test for overall effect: Z = 2.75 (P = 0.006)
Spinal group General group

Figure 7: Postoperative nausea and vomiting within 24 hours.

Spinal group General group Odds ratio Odds ratio

Study or subgroup Weight
Events Total Events Total M-H, fixed, 95% CI M-H, fixed, 95% CI
Bessa et al., 2010 1 30 0 30 20.5% 3.10 [0.12, 79.23]
Tzovaras et al., 2008 3 49 0 48 20.2% 7.30 [0.37, 145.24]
Kalaivani et al., 2014 2 23 0 25 18.5% 5.93 [0.27, 130.34]
Imbelloni et al., 2010 0 34 0 33 Not estimable
Tiwari et al., 2013 4 110 1 114 40.8% 4.26 [0.47, 38.76]

Total (95% CI) 246 250 100.0% 4.95 [1.24, 19.71]

Total events 10 1
Heterogeneity: 𝜒2 = 0.18, df = 3 (P = 0.98); I2 = 0%
0.01 0.1 1 10 100
Test for overall effect: Z = 2.27 (P = 0.02)
Spinal group General group

Figure 8: Urine retention 24 hours postoperatively.

BioMed Research International 7

Random sequence generation (selection bias)

Allocation concealment (selection bias)
Blinding of participants and personnel (performance bias)
Blinding of outcome assessment (detection bias)
Incomplete outcome data (attrition bias)
Selective reporting (reporting bias)
Other biases

0 25 50 75 100
(%)
Low risk of bias
Unclear risk of bias
High risk of bias
(a)

Blinding of participants and personnel (performance bias)

Blinding of outcome assessment (detection bias)
Random sequence generation (selection bias)

Incomplete outcome data (attrition bias)

Allocation concealment (selection bias)

Selective reporting (reporting bias)

Other biases

Bessa et al., 2010 + + + + ? ? ?

Bessa et al., 2012 + + + ? + ? ?
Tzovaras et al., 2008 + + + + + ? ?
Kalaivani et al., 2014 + + ? ? + ? ?
Imbelloni et al., 2010 + + + + + ? ?
Ellakany, 2013 + ? + + + ? ?
Tiwari et al., 2013 + + + + + + ?

Ross et al., 2013 + + + ? + ? ?

(b)

Figure 9: (a) Risk of bias graph. (b) Risk of bias summary.

Table 2: Power analysis of the studies.

Study VAS (2 h) VAS (4 h) VAS (8 h) VAS (24 h) PONV (24 h) Urine retention (24 h)
Bessa et al., 2010 [4] 70% 37% NA 5% 64% 8%
Bessa et al., 2012 [1] 100% 100% 32% NA NA NA
Kalaivani et al., 2014 [12] 100% 100% 99% 33% 15% 21%
Tzovaras et al., 2008 [11] NA 100% 95% 97% 8% 27%
Ellakany, 2013 [13] NA 67% 91% 98% NA NA
Tiwari et al., 2013 [10] NA NA NA 100% 82% 19%
Imbelloni et al., 2010 [14] NA NA NA NA 18% NA
NA: not available.
8 BioMed Research International

hours, 8 hours, and 24 hours), PONV, and urine retention, and postoperative pain was lighter. And the occurrence rate
respectively, is shown in Table 2. Eleven of 23 outcomes were of PONV in spinal group was lower. At the same time,
less than 50%, while twelve outcomes were larger than 80%. there was no airway instrumentation and surgical stress
response reduced in spinal group. Moreover, the cost of spinal
anesthesia was lower. So spinal anesthesia may be a promis-
4. Discussion ing method of anesthesia for laparoscopy procedure, while
postoperative urine retention rate was higher in the spinal
In the present meta-analysis, we have reviewed and con-
anesthesia group when compared with general anesthesia
sidered the literature regarding the efficacy between spinal
group. It seems to be a significant factor to evaluate the
anesthesia and general anesthesia in decreasing postoperative
method of spinal anesthesia in patients undergoing LC.
VAS score, PONV, and urine retention in adult patients
undergoing LC. The pooled results from meta-analysis of In our meta-analysis, all the studies matched well (e.g.,
seven RCTs using both random-effects and fixed-effects sex, age, ASA grade, administration time, and way of
model suggest that spinal anesthesia shows beneficial effi- surgery), while several limitations should be taken into
cacy in preventing postoperative pain and PONV in adult account. First, the articles included in our meta-analysis
patients undergoing LC, while more patients exhibit urine mostly focus on postoperative indexes. In order to compre-
retention in the spinal group comparing with the general hensively evaluate the advantage of spinal anesthesia, some
group. Also, substantial heterogeneity across the studies was intraoperative indexes should be compared between two
observed. groups, such as pull reaction of patients and hemodynamic
indexes during operation and during surgery. Only three
LC, considered a minimally invasive surgery, is usually
studies [12, 14, 21] pay attention to the time of surgery;
done under general anesthesia. Our meta-analysis showed
all of them found that there was no statistical significance
that there are certain indications for spinal anesthesia in
between the two groups. Second, the intra-abdominal pres-
patients undergoing elective LC. Regional anesthesia reduced
sures among the articles of our study are different and have
the surgical stress response. In spinal anesthesia, there was
no unified standards, which may lead to bias of results. The
no airway instrumentation and there was a low incidence
duration of postoperative pain also should be concerned in
of deep vein thrombosis [22]. Our study suggested that
the two groups and prospective studies to see the duration
patients in the spinal group experienced significantly less
of analgesia of spinal anesthesia are needed. Third, VAS was
pain postoperatively. There were two reasons for the reduced
based on subjective feeling and default objective standard,
pain in the spinal anesthesia group. One was the persistent
resulting in possible overestimation or underestimation of
neuraxial blockade by spinal anesthesia, and it may be
the true effect of spinal anesthesia compared with general
the lower VAS score in the spinal group. The other factor
anesthesia. Fourth, our team mainly focused on studies
may be the point of low-pressure pneumoperitoneum. A
published in the English language and bias might be existent.
recent meta-analysis suggested that the use of low-pressure
The sample sizes of individual trials included were small
pneumoperitoneum seems to be effective in reducing pain
or moderate, which may be the reasons for lower power
after LC [23]. PONV, a complex multifactorial problem, is
in some study outcomes. The study number was below 10,
more frequent after general anesthesia compared with spinal
which is not statistically significant to assess publication
anesthesia. Sinha et al. [18] reported PONV rates of 2%
bias.
in spinal anesthesia patients undergoing LC, while 29% of
Spinal anesthesia may be associated with less postop-
patients in the general anesthesia group experienced PONV.
erative pain and PONV compared with general anesthesia.
For reduced PONV, a nasogastric tube was inserted usually
Considering the limitations above, our finding should be
in general patients undergoing LC to deflate the stomach and
elucidated carefully and large-scale studies were needed in
allow for better exposure of the operative field, but this is
order to confirm it.
not required in patients who have received spinal anesthesia
[11, 22].
In our meta-analysis, the power ranged from 5% to 100% Competing Interests
and 12 of 23 outcomes were larger than 80%. Power of 8
outcomes was lower than 50% and the lowest power came The authors declare that they have no competing interests.
from the 24-hour postoperative VAS score in Bessa et al.’s
study [4]. All the results tell us that there is no sufficient Authors’ Contributions
evidence on the effects and high level studies are still needed
[24–26]. Xian-Xue Wang and Dao-Bo Pan conceived the study, col-
To our knowledge, this is the first meta-analysis to lected the data, were involved in the design, and drafted
compare the application of spinal anesthesia with general the paper. Xian-Xue Wang, Dao-Bo Pan, and Quan Zhou
anesthesia in patients who undergo elective LC. Spinal participated in the design, collected the data, performed
anesthesia is feasible and safe for patients undergoing LC in statistical analysis, and contributed to drafting the paper. Hui-
low-pressure pneumoperitoneum and may be more effective Wei Deng, Ai-Guo Zhou, Fu-Rong Huang, and Hua-Jing Guo
than the general anesthesia. From these data, it appears helped in performing statistical analysis and in revising it
that postoperative VAS score of patients in spinal group critically for important intellectual content. All authors read
was significantly lower when compared with general group and agreed upon the final paper.
BioMed Research International 9

References [15] C. R. Chilvers, A. Goodwin, H. Vaghadia, and G. W. E. Mitchell,

“Selective spinal anesthesia for outpatient laparoscopy. V: phar-
[1] S. S. Bessa, K. M. Katri, W. N. Abdel-Salam, E.-S. A. El-Kayal, macoeconomic comparison vs general anesthesia,” Canadian
and T. A. Tawfik, “Spinal versus general anesthesia for day- Journal of Anesthesia, vol. 48, no. 3, pp. 279–283, 2001.
case laparoscopic cholecystectomy: a prospective randomized [16] P. H. Lennox, C. Chilvers, and H. Vaghadia, “Selective spinal
study,” Journal of Laparoendoscopic and Advanced Surgical anesthesia versus desflurane anesthesia in short duration out-
Techniques, vol. 22, no. 6, pp. 550–555, 2012. patient gynecological laparoscopy: a pharmacoeconomic com-
[2] J. B. Lichten, J. J. Reid, M. P. Zahalsky, and R. L. Friedman, parison,” Anesthesia and Analgesia, vol. 94, no. 3, pp. 565–568,
“Laparoscopic cholecystectomy in the new millennium,” Surgi- 2002.
cal Endoscopy, vol. 15, no. 8, pp. 867–872, 2001. [17] H.-W. Zhang, Y.-J. Chen, M.-H. Cao, and F.-T. Ji, “Laparoscopic
[3] P. A. Grace, A. Quereshi, J. Coleman et al., “Reduced postopera- cholecystectomy under epidural anesthesia: a retrospective
tive hospitalization after laparoscopic cholecystectomy,” British comparison of 100 patients,” The American Surgeon, vol. 78, no.
Journal of Surgery, vol. 78, no. 2, pp. 160–162, 1991. 1, pp. 107–110, 2012.
[18] R. Sinha, A. K. Gurwara, and S. C. Gupta, “Laparoscopic chole-
[4] S. S. Bessa, I. A. El-Sayes, M. K. El-Saiedi, N. A. Abdel-Baki, and
cystectomy under spinal anesthesia: a study of 3492 patients,”
M. M. Abdel-Maksoud, “Laparoscopic cholecystectomy under
Journal of Laparoendoscopic & Advanced Surgical Techniques,
spinal versus general anesthesia: a prospective, randomized
vol. 19, no. 3, pp. 323–327, 2009.
study,” Journal of Laparoendoscopic and Advanced Surgical
Techniques, vol. 20, no. 6, pp. 515–520, 2010. [19] D. Mangar, R. Karlnoski, E. Camporesi et al., Laparo-Endoscopic
Single Site (LESS) Cholecystectomy with Regional Anesthesia,
[5] K. G. Pursnani, Y. Bazza, M. Calleja, and M. M. Mughal, Florida Gulf-to-Bay Anesthesiology, 2012.
“Laparoscopic cholecystectomy under epidural anesthesia in
[20] X. Liu, C. Wei, Z. Wang, and H. Wang, “Different anesthesia
patients with chronic respiratory disease,” Surgical Endoscopy,
methods for laparoscopic cholecystectomy,” Der Anaesthesist,
vol. 12, no. 8, pp. 1082–1084, 1998.
vol. 60, no. 8, pp. 723–728, 2011.
[6] P. H. Lennox, H. Vaghadia, C. Henderson, L. Martin, and [21] S. B. Ross, D. Mangar, R. Karlnoski et al., “Laparo-endoscopic
G. W. E. Mitchell, “Small-dose selective spinal anesthesia for single-site (LESS) cholecystectomy with epidural vs. general
short-duration outpatient laparoscopy: recovery characteristics anesthesia,” Surgical Endoscopy, vol. 27, no. 5, pp. 1810–1819,
compared with desflurane anesthesia,” Anesthesia & Analgesia, 2013.
vol. 94, no. 2, pp. 346–350, 2002.
[22] G. Tzovaras, F. Fafoulakis, K. Pratsas, S. Georgopoulou, G. Sta-
[7] D. Moher, A. Liberati, J. Tetzlaff, and D. G. Altman, “Preferred matiou, and C. Hatzitheofilou, “Laparoscopic cholecystectomy
reporting items for systematic reviews and meta-analyses: the under spinal anesthesia: a pilot study,” Surgical Endoscopy, vol.
PRISMA statement,” International Journal of Surgery, vol. 8, no. 20, no. 4, pp. 580–582, 2006.
5, pp. 336–341, 2010. [23] K. S. Gurusamy, J. Vaughan, and B. R. Davidson, “Low pressure
[8] A. R. Jadad, R. A. Moore, D. Carroll et al., “Assessing the quality versus standard pressure pneumoperitoneum in laparoscopic
of reports of randomized clinical trials: is blinding necessary?” cholecystectomy,” Cochrane Database of Systematic Reviews, vol.
Controlled Clinical Trials, vol. 17, no. 1, pp. 1–12, 1996. 3, Article ID CD006930, 2014.
[9] J. P. T. Higgins, D. G. Altman, P. C. Gøtzsche et al., “The [24] D. Wang, J.-X. Zhai, L.-M. Zhang, and D.-W. Liu, “Null genotype
Cochrane Collaboration’s tool for assessing risk of bias in of GSTT1 contributes to increased Parkinson’s disease risk in
randomised trials,” The British Medical Journal, vol. 343, no. Caucasians: evidence from a meta-analysis,” Molecular Biology
7829, Article ID d5928, 2011. Reports, vol. 41, no. 11, pp. 7423–7430, 2014.
[25] T. Mizuguchi, M. Kawamoto, M. Meguro et al., “Laparoscopic
[10] S. Tiwari, A. Chauhan, P. Chaterjee, and M. T. Alam, “Laparo-
hepatectomy: a systematic review, meta-analysis, and power
scopic cholecystectomy under spinal anaesthesia: a prospective,
analysis,” Surgery Today, vol. 41, no. 1, pp. 39–47, 2011.
randomised study,” Journal of Minimal Access Surgery, vol. 9, no.
2, pp. 65–71, 2013. [26] Z. Jia, C. Chen, Y. Wu et al., “No difference in clinical outcomes
after total knee arthroplasty between patellar eversion and non-
[11] G. Tzovaras, F. Fafoulakis, K. Pratsas, S. Georgopoulou, G. Sta- eversion,” Knee Surgery, Sports Traumatology, Arthroscopy, vol.
matiou, and C. Hatzitheofilou, “Spinal vs general anesthesia for 24, no. 1, pp. 141–147, 2016.
laparoscopic cholecystectomy: interim analysis of a controlled
randomized trial,” Archives of Surgery, vol. 143, no. 5, pp. 497–
501, 2008.
[12] V. Kalaivani, V. S. Pujari, M. R. Sreevathsa, B. V. Hiremath,
and Y. Bevinaguddaiah, “Laparoscopic cholecystectomy under
spinal anaesthesia vs. general anaesthesia: a prospective ran-
domised study,” Journal of Clinical and Diagnostic Research, vol.
8, no. 8, pp. NC01–NC04, 2014.
[13] M. Ellakany, “Comparative study between general and thoracic
spinal anesthesia for laparoscopic cholecystectomy,” Egyptian
Journal of Anaesthesia, vol. 29, no. 4, pp. 375–381, 2013.
[14] L. E. Imbelloni, M. Fornasari, J. C. Fialho, R. Sant’Anna, and
J. A. Cordeiro, “General anesthesia versus spinal anesthesia for
laparoscopic cholecystectomy,” Revista Brasileira de Anestesiolo-
gia, vol. 60, no. 3, pp. 217–227, 2010.
 MEDIATORS of

INFLAMMATION

The Scientific Gastroenterology Journal of

World Journal
Hindawi Publishing Corporation
Research and Practice
Hindawi Publishing Corporation
Hindawi Publishing Corporation
Diabetes Research
Hindawi Publishing Corporation
Disease Markers
Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal of International Journal of

Immunology Research
Hindawi Publishing Corporation
Endocrinology
Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Submit your manuscripts at

http://www.hindawi.com

BioMed
PPAR Research
Hindawi Publishing Corporation
Research International
Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal of
Obesity

Evidence-Based
Journal of Stem Cells Complementary and Journal of
Ophthalmology
Hindawi Publishing Corporation
International
Hindawi Publishing Corporation
Alternative Medicine
Hindawi Publishing Corporation Hindawi Publishing Corporation
Oncology
Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Parkinson’s
Disease

Computational and
Mathematical Methods
in Medicine
Behavioural
Neurology
AIDS
Research and Treatment
Oxidative Medicine and
Cellular Longevity
Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation
http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014