Clinical Safety and Feasibility of Minimally Invasive Colectomy Under Neuraxial Anesthesia in Frail Patients. An Initial Single Institution Experience.

Clinical Safety and Feasibility of Minimally Invasive Colectomy Under Neuraxial Anesthesia in Frail Patients. 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An Initial Single Institution Experience. Filippo Carannante, Valentina Miacci, Gennaro Melone, Renato Ricciardi, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4175925/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction. General anesthesia is the most widely used anesthesia technique for major abdominal surgery, but it may have longer recovery time, high cost and environmental impact. In addition, general anesthesia may be contraindicated in some frail patients. Our study aims to evaluate the feasibility and safety of performing colorectal surgery with minimally invasive technique, in frail patients, under spinal anesthesia. Then we compared this group of patients with a retrospective one, performing a propensity score match analysis. Materials and methods. From June 2021, 19 consecutive frail patients, undergoing elective laparoscopic colorectal oncological resection surgery under neuraxial anesthesia at Colorectal Surgery Unit of the Fondazione Policlinico Campus Bio-Medico in Rome were selected. A retrospective database prospectively maintained of these patients was performed. Results. We enrolled 17 patients. In all patients, the surgery was successfully completed under spinal anesthesia and laparoscopic technique. Some the patients experienced mild abdominal pain between I and II GPO (VAS between 3 and 5) treated with oral analgesics as needed. No patients experienced episodes of vomiting or nausea after surgery with gas channeling in I GPO. The average hospital stay was about 4 days (range 3–7). No patient required ICU admission, and 30 mortality was 0. Conclusions. Our preliminary data show that performing major surgery with minimally invasive technique under spinal anesthesia can be feasible and safe, if performed by experienced operators, and can be a viable alternative for the treatment of frail and/or high-risk patients. colorectal surgery colon cancer minimally invasive surgery frail patient neuroaxial anesthesia locoregional anesthesia Introduction General anesthesia is traditionally the most common anesthesia technique used to the most abdominal surgeries, while regional anesthesia is preferred for minor surgery, for example abdominal wall surgeries, or for patients with a high anesthesia risk 1 . There are a lot of disadvantages associated with general anesthesia such as side effects of drugs, longer hospitalization, significantly higher costs and environmental impact. Furthermore, general anesthesia may be contraindicated in some frail patients, such as elderly patients or those with cardiac or respiratory diseases 2 3 4 . Postoperative pulmonary complications have been reported in 4-22% of patients undergoing abdominal surgery under general anesthesia 5 6 . Patients with severe obstructive airway diseases have a 37% incidence of postoperative thoracic complications and avoiding general anesthesia with orotracheal intubation may reduce the risk of postoperative bronchospasm and decrease the risk of intensive care unit 7 . Nowadays, there is a renewed interest in the use of regional anesthesia techniques. Nevertheless, studies associating it with minimally invasive surgery techniques are limited to medium and small surgeries and do not consider major oncological surgery 8 9 . Technological innovation and increased anesthesiologic skills of individual practitioners have made possible performing combined thoracic spinal epidural anesthesia (CSE) safely, facilitating the performance of surgery in high-risk patients who would otherwise have required prolonged hospitalization and intensive care units 10 . In addition, the ERAS (Enhanced Recovery After Surgery) programs have been created to guarantee an optimal recovery and an early and safe return to daily activities after surgery. It also has devoted much attention to the use of peripheral block anesthesia techniques combined with general anesthesia, in association with minimally invasive surgical techniques, to guarantee the best post-operative pain control and reduce complications. At least, regional anesthesia can contribute to the reduction of the emission of anesthesia gases into the atmosphere 11 . Based on these assumptions, we decided to perform a cohort study at Colorectal Surgery Unit of the Fondazione Policlinico Universitario Campus Bio-Medico, to evaluate the feasibility and safety of performing elective oncological minimally invasive colorectal surgery, in frail or high-risk patients, with the exclusive use of neuraxial anesthesia. MATERIALS AND METHODS From June 2021, 19 consecutive frail patients, undergoing elective laparoscopic colorectal oncological resection surgery under neuraxial anesthesia at Colorectal Surgery Unit of the Fondazione Policlinico Campus Bio-Medico in Rome were selected. A retrospective database prospectively maintained of these patients was performed. The inclusion criteria were patients who were candidates to elective oncological surgery of the colon or rectum using a laparoscopic approach and patients classified as frail, elderly, suffering from multiple chronic such as cardiovascular, pulmonary and/or neurological diseases, frequently disabled and with unstable health status. Frail patients were defined using tests such as the Activities of Daily Living (ADL), the Instrumental Activities of Daily Living (IADL), the Cumulative Illness Rating Scale (CIRS), the Physical Activity Scale for the Elderly (PASE) and the Mini Mental State Examination (MMSE) 12 13 . We excluded all patients who refuse to give informed consent, underwent emergency surgery and suffering from inflammatory diseases of the colon or certified allergy to drugs used to neuraxial anesthesia. Our primary outcome is to assess the feasibility and safety of performing oncological minimally invasive colo-rectal surgery under neuraxial anesthesia, evaluating short-term outcomes such as post-operative complications, admission to the ICU, post-operative pain, hospital stay, 30-day readmission, 30-day re-intervention and 30-day mortality. This study was conducted according to the ethical principles outlined in the Declaration of Helsinki and the approval of the Institutional Ethics Committee was obtained. The patients have been informed about the anesthesiological and surgical procedures and an informed consent has been obtained. Anesthesiological management All the patients underwent combined spinal-epidural anesthesia (CSE) at T12-L1 intervertebral space after ultrasound evaluation of neuraxial structures. Ropivacaine 12 mg, fentanyl 20 mcg and dexmedethomidine 5 mcg were diluted in 5 mL of saline solution and injected intrathecally 14 15 . Intrathecal Fentanyl was used to shorten the onset of spinal anesthesia, while dexmedethomidine was administered to prolong neuraxial blockade 16 . Subsequently, peridural catheter was placed to manage postoperative analgesia according to ERAS recommendations. Before starting surgery, the extension of sensory block to T4 dermatome was verified through pinprick test. During surgery, a mild sedation was administered through an i.v. target-controlled infusion remifentanil (0.8-1 ng/ml effect site concentration). Postoperatively, multimodal analgesia was given through i.v. dexamethasone 4 mg, acetaminophen 1g every 8 hours, ketorolac 30 mg every 12 hours. In addition, a continuous infusion of ropivacaine 0.2% 5 mL/h was given through epidural catheter during the first 48 hours postoperatively. Statistical analysis Patient characteristics were summarized using basic descriptive statistics. Continuous variables were presented as mean values ± standard deviation and compared with a t-test on individual samples. For categorical data, the χ2 test was used and the results were expressed as percentages. All statistical analyses were performed with StataCorp2019 STATA Statistical Software: release 16 (College Station,TX: StataCorp LLC). Continuous variables are represented by the mean and median. Continuous variables are represented by the median (minimum-maximum) or mean ± standard deviations (SD). To analyze differences in categorical variables, the chi-square test or Fisher's exact test was applied. The Wilcoxon rank-sum test was used to compare the continuous variables between the groups. p < 0.05 indicated that the differences between the two groups were statistically significant. RESULTS Nineteen patients, classified as frail, were enrolled in our analysis. Two of these patients refused surgery under spinal anaesthesia, so 17 patients were included in the study. The average age was 80.9 years. In all patients, the operation was successfully completed under neuroaxial anaesthesia and with laparoscopic technique. Abdominal wall analgesia with preoperative Tap Block technique was performed in all patients. The most common comorbidities were identified in all patients and are shown in Table 1. The 29.4% of the patients suffered from COPD, the 15% suffered from Hypertension, the 35.3% suffered from diabetes and the 47% suffered from obesity. All patients in the post-operative period followed the indications of the ERAS protocol for colorectal surgery: rehabilitation and early re-feeding (same day of surgery or in I POD). Three patients experienced episodes of vomiting or nausea after surgery, treated with drugs. 14 patients had first flatus in I POD, 2 patients in III POD and 1 patient in IV POD. The hospital stay average was about 4.5 days (range 3-8). One patient (5.9%) been complicated by an anastomotic leakage treated with the use of endosponge. One patient (5.9%) been complicated by bleeding treated, immediately, by our endoscopist. One patient (5.9%) suffered from pneumonia treated with the use of IV antibiotics and oral antibiotics after discharge. No patients been affected from wound infection. Two patients (11.8%) suffered from abdominal pain that required IV painkillers. No patients required admission to intensive care unit and no patients were readmitted to hospital at 30 days for complications or re-intervention and the 30-day mortality was 0 (Table 2). DISCUSSION Currently, the gold standard to manage intraoperative analgesia in major abdominal surgery is certainly general anesthesia. The use of neuraxial anesthesia in abdominal surgery is mainly reserved for superficial surgery involving the abdominal wall. Not by chance, literature lacks experiences reporting its use in major surgery. The use of spinal anesthesia in abdominal surgery found its first scientific evidence in a few clinical cases performed as an emergency in extremely fragile patients who could not have withstood general anesthesia. 17 As early as 2003, Hamad et al. 18 published a feasibility study on regional anesthesia used to perform laparoscopic cholecystectomy. Subsequently, Kar et al. 19 published the clinical series with the highest number of patients (291) undergoing laparoscopic cholecystectomy surgery, establishing spinal anesthesia as a feasible and safe anesthesia technique for the management of patients undergoing to this type of surgery. Moreover, the use of neuraxial anesthesia can avoid numerous important complications, especially in that group of patients defined as frail, in whom the anesthesiologic risk is very high. Rare is the experience in the literature that report its use in major surgery and above all are been performed in emergencies, in patients who could not have sustained general anesthesia. Experiences from other branches of surgery demonstrate how this anesthesiologic practice is now universally accepted. The most common example is the gynecological and the obstetric surgery where, as we know, the combined spinal-epidural anesthesia, in the management of the parturient is today the gold standard. It allows the surgical act to be performed with the patient completely awake and guarantees the pregnant woman effective analgesia without the use of opioids. As already mentioned, the use of general anesthesia, while guarantees better control over the striated muscles, through the use of neuromuscular blockers, and a longer duration of the anesthesia itself, often puts the patient at risk of complications, primarily respiratory. 20 21 22 The endotracheal intubation, for example, which is still considered indispensable as it guarantees protection of the airways from the risk of aspiration during hypnosis, induced by anesthetic agents and myorelaxation induced by neuromuscular blockers, is characterized by the risk of post-operative bronchospasm, and an increased risk of admission to the ICU. The avoidance of the intubation, due to the spinal anesthesia, reduces the risk of intensive care unit stay 23 , which in our case series proves to be reduced. The unnecessary administration of drugs nullifies the clinical risks associated with them; for example, residual neuro-muscular blockade and opioid oversedation, which, as is well known, can lead to alveolar hypoventilation due to reduced respiratory rate and/or inefficiency of the diaphragmatic bellows and respiratory muscles. This concept is very important even more in frail patients, where there are morpho-functional alterations responsible of the reduction of the respiratory performance which, if associated with a series of iatrogenic factors, will determine a significant increase in the risk of post-operative respiratory insufficiency, together with the atelectasis due to the disappearance of diaphragmatic tone and the pneumoperitoneum. This study testifies the renewed interest in the use of regional anesthesia techniques, finally taking it into consideration for major oncological surgery. The aim of our study is to demonstrate the feasibility and safety of using neuraxial anesthesia for oncological colo-rectal surgery with a minimally invasive approach. All in concordance with the ERAS protocol, which was created with the aim of guarantee an optimal hospitalization and an early and safe return to daily activities after surgery. Following this aim, in order to guarantee the best control of post-operative pain and reduce complications, this protocol, have devoted more attention to less invasive anesthesia, through the regional anesthesia and the peripheral nerve block. Thus, evaluating the outcomes of patients undergoing colorectal oncological resection under regional anesthesia, it can be stated that no patient has any major complications that would discourage the continuation of the study. Our study has several limitations, in particular the small sample size and the retrospective analysis but this case series open to the possibility to perform prospective study in which compare patients who underwent to general anesthesia and regional anesthesia. As a first analysis, our study has shown encouraging results. CONCLUSIONS Our study shows that neuraxial anesthesia, when performed by an experienced anesthesiologist, can be considered a practically feasible alternative to conventional forms of anesthesia for patients planning for major colorectal surgery, with a reduction in intensive care unit admissions and post-operative pulmonary complications. However, higher number of patients and further comparative studies are necessary to ensure greater scientific awareness of the use of neuraxial anesthesia in major colorectal surgery with minimally invasive approach. Declarations Funding: None Author Contribution FC, GC, VM and GTC: study conception and design, acquisition of data, analysis, and interpretation of data, writing manuscript. GM, FDA, VC, RR: acquisition of data and analysis. GC and GP: analysis and interpretation of data, proof reading. FC, GTC, MC and MC: review and proof reading. Conflicts of interest: The authors disclose no conflicts. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. References Marik PE. Propofol: Therapeutic indications and side-effects. Curr Pharm Des. 2004;10:3639–49. Mingus ML. Recovery advantages of regional anesthesia compared with general anesthesia: Adult patients. J Clin Anesth. 1995;7:628–33. Rashiq S, Gallant B, Grace M, Jolly DT. Recovery characteristics following induction of anaesthesia with a combination of thiopentone and propofol. Can J Anaesth. 1994;41:1166–71 Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: Results from overview of randomised trials. BMJ. 2000;321:1493. Garibaldi RA, Britt MR, Coleman ML, Reading JC, Pace NL. Risk factors for postoperative pneumonia. American Journal of Medicine 1981;70:677–80. Hall JC, Tarala RA, Hall JL, Mander J. A multivariate analysis of the risk of pulmonary complications after laparotomy. Chest 1991;99:923–7. Wong DH, Weber EC, Schell MJ, Wong AB, Anderson CT, Barker SJ. Factors associated with postoperative pulmonary complica- tions in patients with severe chronic obstructive pulmonary disease. Anesthesia and Analgesia 1995;80:276–84. Hamad MA, El-Khattary OA. Laparoscopic cholecystectomy under spinal anesthesia with nitrous oxide pneumoperitoneum: A feasibility study. Surg Endosc. 2003;17:1426–8. Kar M, Kar JK, Debnath B. Experience of laparoscopic cholecystectomy under spinal anesthesia with low-pressure pneumoperitoneum-- prospective study of 300 cases. Saudi J Gastroenterol. 2011 May-Jun;17(3):203-7. doi: 10.4103/1319-3767.80385. PMID: 21546725; PMCID: PMC3122092 Mohamed Hamdy Ellakany. Thoracic spinal anesthesia is safe for patients undergoing abdominal cancer surgery Anesth Essays Res. 2014 May-Aug; 8(2): 223–228. doi: 10.4103/0259-1162.134516: 10.4103/0259- 1162.134516 Marie-Luise Rübsam, Philippe Kruse, Yvonne Dietzler, Miriam Kropf, Birgit Bette, Alexander Zarbock, Se-Chan Kim, Christian Hönemann. A call for immediate climate action in anesthesiology: routine use of minimal or metabolic fresh gas flow reduces our ecological footprint. Can J Anaesth. 2023 Mar;70(3):301-312. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-56. doi: 10.1093/gerona/56.3.m146. Sciacchitano S, Carola V, Nicolais G, Sciacchitano S, Napoli C, Mancini R, Rocco M, Coluzzi F. To Be Frail or Not to Be Frail: This Is the Question-A Critical Narrative Review of Frailty. J Clin Med. 2024 Jan 26;13(3):721. doi: 10.3390/jcm13030721. Kumar CM, Corbett WA, Wilson RG. Spinal anaesthesia with a micro-catheter in high-risk patients undergoing colorectal cancer and other major abdominal surgery. Surg Oncol. 2008 Aug;17(2):73-9. doi: 10.1016/j.suronc.2007.10.025. MoriT, Takahashi K, YasunoM. Radical resection with autonomicnerve preservation and lymphnode dissection techniques in lower rectal cancer surgery and its results: the impact of lateral lymph node dissection. Langenbecks Arch Surg 1998; 383: 409-415 Del Buono R, Pascarella G, Costa F, Terranova G, Leoni ML, Barbara E, Carassiti M, Agrò FE. Predicting difficult spinal anesthesia: development of a neuraxial block assessment score. Minerva Anestesiol. 2021 Jun;87(6):648-654. doi: 10.23736/S0375- 9393.20.14892-2. Epub 2020 Dec 16. PMID: 33325214. Pascarella G, Costa F, Hazboun A, Del Buono R, Strumia A, Longo F, Ruggiero A, Schiavoni L, Mattei A, Cataldo R, Agrò FE, Carassiti M. Ultrasound predictors of difficult spinal anesthesia: a prospective single- blind observational study. Minerva Anestesiol. 2023 Nov;89(11):996-1002. doi: 10.23736/S0375- 9393.22.16990-7. Epub 2023 Feb 21. PMID: 36800810. Prabhakar A, Lambert T, Kaye RJ, Gaignard SM, Ragusa J, Wheat S, Moll V, Cornett EM, Urman RD, Kaye AD. Adjuvants in clinical regional anesthesia practice: A comprehensive review. Best Pract Res Clin Anaesthesiol. 2019 Dec;33(4):415-423. doi: 10.1016/j.bpa.2019.06.001. Epub 2019 Jul 2. Erratum in: Best Pract Res Clin Anaesthesiol. 2021 Dec;35(4):E3-E4. PMID: 31791560. Kumar CM, Corbett WA, Wilson RG. Spinal anaesthesia with a micro-catheter in high-risk patients undergoing colorectal cancer and other major abdominal surgery. Surg Oncol. 2008 Aug;17(2):73-9. doi: 10.1016/j.suronc.2007.10.025. MoriT, Takahashi K, YasunoM. Radical resection with autonomicnerve preservation and lymphnode dissection techniques in lower rectal cancer surgery and its results: the impact of lateral lymph node dissection. Langenbecks Arch Surg 1998; 383: 409-415 Havenga K, Enker WE, McDermott K, Cohen AM, Minsky BD, Guillem J. Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J AmColl Surg 1996; 182: 495-502 Nano M, Levi AC, Borghi F, Bellora P, Bogliatto F, Garbossa Det al. Observations on surgical anatomy for rectal cancer surgery. Hepatogastroenterology 1998; 45: 717-726 Godlewski G, Prudhomme M. Embryology and anatomy of the rectum. Basis of surgery. Surg Clin North Am 2000; 80: 319-343 Patricio J, Bernades A, Nuno D, Falcao F, Silveira L. Surgical anatomy of the arterial blood-supply of the human rectum. Surg Radiol Anat 1988; 10: 71-75. Wong DH, Weber EC, Schell MJ, Wong AB, Anderson CT, Barker SJ. Factors associated with postoperative pulmonary complications in patients with severe chronic obstructive pulmonary disease. Anesthesia and Analgesia 1995;80:276–84. Tables Table 1 . Pre-operative characteristics Spinal A. N. of patients 19 Refused spinal anaesthesia 2 N. of patient studied 17 Age (year) 80.9 ± 7.5 Male gender (%) 11 (64,7) BMI 26.3 ± 3.8 Associated medical conditions (%) COPD Hypertension Diabetes mellitus Obesity 5 (29.4) 15 (88.2) 6 (35.3) 8 (47) Tumor location (%) Right colon Transverse colon Left colon Rectum 10 (58.8) 1 (5.9) 4 (23.5) 2 (11.8) Table 2 . Intra and post-operative characteristics Spinal A. N. of patients 17 Blood loss (range) 150 mL (100-400) Conversion to open surgery (%) 0 (0) ICU recovery (%) 0 (0) Hospital stay (range) 4.4 days (3-8) Post-operative complications (%) Anastomotic leakage Ileus Bleeding Nausea/vomiting Pneumonia UTI Wound infection Abdominal pain (NRS>5) 1 (5.9) 3 (17.6) 1 (5.9) 3 (17.6) 1 (5.9) 0 (0) (0) 2 (11.8) Readmission 0 (0) Reoperation 0 (0) 30-day mortality 0 (0) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4175925","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":285186942,"identity":"50d153d6-aa97-49fc-b2f6-7723727063e0","order_by":0,"name":"Filippo Carannante","email":"","orcid":"","institution":"Colorectal Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico di Roma","correspondingAuthor":false,"prefix":"","firstName":"Filippo","middleName":"","lastName":"Carannante","suffix":""},{"id":285186943,"identity":"0362b27e-be0b-45ef-93fe-8f8e4cb4ec30","order_by":1,"name":"Valentina 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Policlinico Universitario Campus Bio-Medico di Roma","correspondingAuthor":false,"prefix":"","firstName":"Gabriella","middleName":"Teresa","lastName":"Capolupo","suffix":""}],"badges":[],"createdAt":"2024-03-27 12:03:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4175925/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4175925/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56559564,"identity":"eaa56ed8-75d1-4346-b71b-79ebc2a53955","added_by":"auto","created_at":"2024-05-15 19:46:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":487819,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4175925/v1/f828d9c2-c2c1-44da-b8b2-cc36c3452d84.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eClinical Safety and Feasibility of Minimally Invasive Colectomy Under Neuraxial Anesthesia in Frail Patients. An Initial Single Institution Experience.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGeneral anesthesia is traditionally the most common anesthesia technique used to the most abdominal surgeries, while regional anesthesia is preferred for minor surgery, for example abdominal wall surgeries, or for patients with a high anesthesia risk \u003csup\u003e1\u003c/sup\u003e. There are a lot of disadvantages associated with general anesthesia such as side effects of drugs, longer hospitalization, significantly higher costs and environmental impact. Furthermore, general anesthesia may be contraindicated in some frail patients, such as elderly patients or those with cardiac or respiratory diseases \u003csup\u003e2\u003c/sup\u003e \u003csup\u003e3\u003c/sup\u003e \u003csup\u003e4\u003c/sup\u003e. Postoperative pulmonary complications have been reported in 4-22% of patients undergoing abdominal surgery under general anesthesia \u003csup\u003e5\u003c/sup\u003e \u003csup\u003e6\u003c/sup\u003e. Patients with severe obstructive airway diseases have a 37% incidence of postoperative thoracic complications and avoiding general anesthesia with orotracheal intubation may reduce the risk of postoperative bronchospasm and decrease the risk of intensive care unit\u003csup\u003e7\u003c/sup\u003e. Nowadays, there is a renewed interest in the use of regional anesthesia techniques. Nevertheless, studies associating it with minimally invasive surgery techniques are limited to medium and small surgeries and do not consider major oncological surgery \u003csup\u003e8\u003c/sup\u003e \u003csup\u003e9\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTechnological innovation and increased anesthesiologic skills of individual practitioners have made possible performing combined thoracic spinal epidural anesthesia (CSE) safely, facilitating the performance of surgery in high-risk patients who would otherwise have required prolonged hospitalization and intensive care units \u003csup\u003e10\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition, the ERAS (Enhanced Recovery After Surgery) programs have been created to guarantee an optimal recovery and an early and safe return to daily activities after surgery. It also has devoted much attention to the use of peripheral block anesthesia techniques combined with general anesthesia, in association with minimally invasive surgical techniques, to guarantee the best post-operative pain control and reduce complications. At least, regional anesthesia can contribute to the reduction of the emission of anesthesia gases into the atmosphere\u003csup\u003e11\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on these assumptions, we decided to perform a cohort study at Colorectal Surgery Unit of the Fondazione Policlinico Universitario Campus Bio-Medico, to evaluate the feasibility and safety of performing elective oncological minimally invasive colorectal surgery, in frail or high-risk patients, with the exclusive use of neuraxial anesthesia.\u0026nbsp;\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eFrom June 2021, 19 consecutive frail patients, undergoing elective laparoscopic colorectal oncological resection surgery under neuraxial anesthesia at Colorectal Surgery Unit of the Fondazione Policlinico Campus Bio-Medico in Rome were selected. A retrospective database prospectively maintained of these patients was performed.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were patients who were candidates to elective oncological surgery of the colon or rectum using a laparoscopic approach and patients classified as frail, elderly, suffering from multiple chronic such as cardiovascular, pulmonary and/or neurological diseases, frequently disabled and with unstable health status.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrail patients were defined using tests such as the Activities of Daily Living (ADL), the Instrumental Activities of Daily Living (IADL), the Cumulative Illness Rating Scale (CIRS), the Physical Activity Scale for the Elderly (PASE) and the Mini Mental State Examination (MMSE)\u003csup\u003e12\u003c/sup\u003e \u003csup\u003e13\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eWe excluded all patients who refuse to give informed consent, underwent emergency surgery and suffering from inflammatory diseases of the colon or certified allergy to drugs used to neuraxial anesthesia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur primary outcome is to assess the feasibility and safety of performing oncological minimally invasive colo-rectal surgery under neuraxial anesthesia, evaluating short-term outcomes such as post-operative complications, admission to the ICU, post-operative pain, hospital stay, 30-day readmission, 30-day re-intervention and 30-day mortality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted according to the ethical principles outlined in the Declaration of Helsinki and the approval of the Institutional Ethics Committee was obtained. The patients have been informed about the anesthesiological and surgical procedures and an informed consent has been obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnesthesiological management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the patients underwent combined spinal-epidural anesthesia (CSE) at T12-L1 intervertebral space after ultrasound evaluation of neuraxial structures. Ropivacaine 12 mg, fentanyl 20 mcg and dexmedethomidine 5 mcg were diluted in 5 mL of saline solution and injected intrathecally \u003csup\u003e14\u003c/sup\u003e \u003csup\u003e15\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIntrathecal Fentanyl was used to shorten the onset of spinal anesthesia, while dexmedethomidine was administered to prolong neuraxial blockade\u003csup\u003e16\u003c/sup\u003e. Subsequently, peridural catheter was placed to manage postoperative analgesia according to ERAS recommendations.\u003c/p\u003e\n\u003cp\u003eBefore starting surgery, the extension of sensory block to T4 dermatome was verified through pinprick test. During surgery, a mild sedation was administered through an i.v. target-controlled infusion remifentanil (0.8-1 ng/ml effect site concentration). Postoperatively, multimodal analgesia was given through i.v. dexamethasone 4 mg, acetaminophen 1g every 8 hours, ketorolac 30 mg every 12 hours. In addition, a continuous infusion of ropivacaine 0.2% 5 mL/h was given through epidural catheter during the first 48 hours postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient characteristics were summarized using basic descriptive statistics. Continuous variables were presented as mean values ± standard deviation and compared with a t-test on individual samples. For categorical data, the χ2 test was used and the results were expressed as percentages. All statistical analyses were performed with StataCorp2019 STATA Statistical Software: release 16 (College Station,TX: StataCorp LLC).\u003c/p\u003e\n\u003cp\u003eContinuous variables are represented by the mean and median. Continuous variables are represented by the median (minimum-maximum) or mean ± standard deviations (SD). To analyze differences in categorical variables, the chi-square test or Fisher's exact test was applied. The Wilcoxon rank-sum test was used to compare the continuous variables between the groups. \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05 indicated that the differences between the two groups were statistically significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eNineteen patients, classified as frail, were enrolled in our analysis. Two of these patients refused surgery under spinal anaesthesia, so 17 patients were included in the study. The average age was 80.9 years. In all patients, the operation was successfully completed under neuroaxial anaesthesia and with laparoscopic technique. Abdominal wall analgesia with preoperative Tap Block technique was performed in all patients. The most common comorbidities were identified in all patients and are shown in Table 1. The 29.4% of the patients suffered from COPD, the 15% suffered from Hypertension, the 35.3% suffered from diabetes and the 47% suffered from obesity.\u003c/p\u003e\n\u003cp\u003eAll patients in the post-operative period followed the indications of the ERAS protocol for colorectal surgery: rehabilitation and early re-feeding (same day of surgery or in I POD).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThree patients experienced episodes of vomiting or nausea after surgery, treated with drugs. 14 patients had first flatus in I POD, 2 patients in III POD and 1 patient in IV POD. The hospital stay average was about 4.5 days (range 3-8). One patient (5.9%) been complicated by an anastomotic leakage treated with the use of endosponge. One patient (5.9%) been complicated by bleeding treated, immediately, by our endoscopist. One patient (5.9%) suffered from pneumonia treated with the use of IV antibiotics and oral antibiotics after discharge. No patients been affected from wound infection. Two patients (11.8%) suffered from abdominal pain that required IV painkillers. No patients required admission to intensive care unit and no patients were readmitted to hospital at 30 days for complications or re-intervention and the 30-day mortality was 0 (Table 2).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eCurrently, the gold standard to manage intraoperative analgesia in major abdominal surgery is certainly general anesthesia. The use of neuraxial anesthesia in abdominal surgery is mainly reserved for superficial surgery involving the abdominal wall. Not by chance, literature lacks experiences reporting its use in major surgery. The use of spinal anesthesia in abdominal surgery found its first scientific evidence in a few clinical cases performed as an emergency in extremely fragile patients who could not have withstood general anesthesia.\u003csup\u003e17\u003c/sup\u003e As early as 2003, Hamad et al.\u003csup\u003e18\u003c/sup\u003e published a feasibility study on regional anesthesia used to perform laparoscopic cholecystectomy. Subsequently, Kar et al.\u003csup\u003e19\u003c/sup\u003e published the clinical series with the highest number of patients (291) undergoing laparoscopic cholecystectomy surgery, establishing spinal anesthesia as a feasible and safe anesthesia technique for the management of patients undergoing to this type of surgery.\u003c/p\u003e\n\u003cp\u003eMoreover, the use of neuraxial anesthesia can avoid numerous important complications, especially in that group of patients defined as frail, in whom the anesthesiologic risk is very high. Rare is the experience in the literature that report its use in major surgery and above all are been performed in emergencies, in patients who could not have sustained general anesthesia.\u003c/p\u003e\n\u003cp\u003eExperiences from other branches of surgery demonstrate how this anesthesiologic practice is now universally accepted. The most common example is the gynecological and the obstetric surgery where, as we know, the combined spinal-epidural anesthesia, in the management of the parturient is today the gold standard. It allows the surgical act to be performed with the patient completely awake and guarantees the pregnant woman effective analgesia without the use of opioids.\u003c/p\u003e\n\u003cp\u003eAs already mentioned, the use of general anesthesia, while guarantees better control over the striated muscles, through the use of neuromuscular blockers, and a longer duration of the anesthesia itself, often puts the patient at risk of complications, primarily respiratory. \u003csup\u003e20\u003c/sup\u003e \u003csup\u003e21\u003c/sup\u003e \u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe endotracheal intubation, for example, which is still considered indispensable as it guarantees protection of the airways from the risk of aspiration during hypnosis, induced by anesthetic agents and myorelaxation induced by neuromuscular blockers, is characterized by the risk of post-operative bronchospasm, and an increased risk of admission to the ICU. The avoidance of the intubation, due to the spinal anesthesia, reduces the risk of intensive care unit stay\u003csup\u003e23\u003c/sup\u003e, which in our case series proves to be reduced.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe unnecessary administration of drugs nullifies the clinical risks associated with them; for example, residual neuro-muscular blockade and opioid oversedation, which, as is well known, can lead to alveolar hypoventilation due to reduced respiratory rate and/or inefficiency of the diaphragmatic bellows and respiratory muscles. This concept is very important even more in frail patients, where there are morpho-functional alterations responsible of the reduction of the respiratory performance which, if associated with a series of iatrogenic factors, will determine a significant increase in the risk of post-operative respiratory insufficiency, together with the atelectasis due to the disappearance of diaphragmatic tone and the pneumoperitoneum.\u003c/p\u003e\n\u003cp\u003eThis study testifies the renewed interest in the use of regional anesthesia techniques, finally taking it into consideration for major oncological surgery. The aim of our study is to demonstrate the feasibility and safety of using neuraxial anesthesia for oncological colo-rectal surgery with a minimally invasive approach. All in concordance with the ERAS protocol, which was created with the aim of guarantee an optimal hospitalization and an early and safe return to daily activities after surgery. Following this aim, in order to guarantee the best control of post-operative pain and reduce complications, this protocol, have devoted more attention to less invasive anesthesia, through the regional anesthesia and the peripheral nerve block.\u003c/p\u003e\n\u003cp\u003eThus, evaluating the outcomes of patients undergoing colorectal oncological resection under regional anesthesia, it can be stated that no patient has any major complications that would discourage the continuation of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study has several limitations, in particular the small sample size and the retrospective analysis but this case series open to the possibility to perform prospective study in which compare patients who underwent to general anesthesia and regional anesthesia. As a first analysis, our study has shown encouraging results.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eOur study shows that neuraxial anesthesia, when performed by an experienced anesthesiologist, can be considered a practically feasible alternative to conventional forms of anesthesia for patients planning for major colorectal surgery, with a reduction in intensive care unit admissions and post-operative pulmonary complications. However, higher number of patients and further comparative studies are necessary to ensure greater scientific awareness of the use of neuraxial anesthesia in major colorectal surgery with minimally invasive approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eFC, GC, VM and GTC: study conception and design, acquisition of data, analysis, and interpretation of data, writing manuscript. GM, FDA, VC, RR: acquisition of data and analysis. GC and GP: analysis and interpretation of data, proof reading. FC, GTC, MC and MC: review and proof reading.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e The authors disclose no conflicts.\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMarik PE. Propofol: Therapeutic indications and side-effects. Curr Pharm Des. 2004;10:3639\u0026ndash;49.\u003c/li\u003e\n\u003cli\u003eMingus ML. Recovery advantages of regional anesthesia compared with general anesthesia: Adult patients. J Clin Anesth. 1995;7:628\u0026ndash;33.\u003c/li\u003e\n\u003cli\u003eRashiq S, Gallant B, Grace M, Jolly DT. Recovery characteristics following induction of anaesthesia with a combination of thiopentone and propofol. Can J Anaesth. 1994;41:1166\u0026ndash;71\u003c/li\u003e\n\u003cli\u003eRodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: Results from overview of randomised trials. BMJ. 2000;321:1493.\u003c/li\u003e\n\u003cli\u003eGaribaldi RA, Britt MR, Coleman ML, Reading JC, Pace NL. Risk factors for postoperative pneumonia. American Journal of Medicine 1981;70:677\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eHall JC, Tarala RA, Hall JL, Mander J. A multivariate analysis of the risk of pulmonary complications after laparotomy. Chest 1991;99:923\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eWong DH, Weber EC, Schell MJ, Wong AB, Anderson CT, Barker SJ. Factors associated with postoperative pulmonary complica- tions in patients with severe chronic obstructive pulmonary disease. Anesthesia and Analgesia 1995;80:276\u0026ndash;84.\u003c/li\u003e\n\u003cli\u003eHamad MA, El-Khattary OA. Laparoscopic cholecystectomy under spinal anesthesia with nitrous oxide pneumoperitoneum: A feasibility study. Surg Endosc. 2003;17:1426\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eKar M, Kar JK, Debnath B. Experience of laparoscopic cholecystectomy under spinal anesthesia with low-pressure pneumoperitoneum-- prospective study of 300 cases. Saudi J Gastroenterol. 2011 May-Jun;17(3):203-7. doi: 10.4103/1319-3767.80385. PMID: 21546725; PMCID: PMC3122092\u003c/li\u003e\n\u003cli\u003eMohamed Hamdy Ellakany. Thoracic spinal anesthesia is safe for patients undergoing abdominal cancer surgery Anesth Essays Res. 2014 May-Aug; 8(2): 223\u0026ndash;228. doi: 10.4103/0259-1162.134516: 10.4103/0259- 1162.134516\u003c/li\u003e\n\u003cli\u003eMarie-Luise R\u0026uuml;bsam, Philippe Kruse, Yvonne Dietzler, Miriam Kropf, Birgit Bette, Alexander Zarbock, Se-Chan Kim, Christian H\u0026ouml;nemann. A call for immediate climate action in anesthesiology: routine use of minimal or metabolic fresh gas flow reduces our ecological footprint. Can J Anaesth. 2023 Mar;70(3):301-312.\u003c/li\u003e\n\u003cli\u003eFried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-56. doi: 10.1093/gerona/56.3.m146.\u003c/li\u003e\n\u003cli\u003eSciacchitano S, Carola V, Nicolais G, Sciacchitano S, Napoli C, Mancini R, Rocco M, Coluzzi F. To Be Frail or Not to Be Frail: This Is the Question-A Critical Narrative Review of Frailty. J Clin Med. 2024 Jan 26;13(3):721. doi: 10.3390/jcm13030721. \u003c/li\u003e\n\u003cli\u003eKumar CM, Corbett WA, Wilson RG. Spinal anaesthesia with a micro-catheter in high-risk patients undergoing colorectal cancer and other major abdominal surgery. Surg Oncol. 2008 Aug;17(2):73-9. doi: 10.1016/j.suronc.2007.10.025.\u003c/li\u003e\n\u003cli\u003eMoriT, Takahashi K, YasunoM. Radical resection with autonomicnerve preservation and lymphnode dissection techniques in lower rectal cancer surgery and its results: the impact of lateral lymph node dissection. Langenbecks Arch Surg 1998; 383: 409-415\u003c/li\u003e\n\u003cli\u003eDel Buono R, Pascarella G, Costa F, Terranova G, Leoni ML, Barbara E, Carassiti M, Agr\u0026ograve; FE. Predicting difficult spinal anesthesia: development of a neuraxial block assessment score. Minerva Anestesiol. 2021 Jun;87(6):648-654. doi: 10.23736/S0375- 9393.20.14892-2. Epub 2020 Dec 16. PMID: 33325214.\u003c/li\u003e\n\u003cli\u003ePascarella G, Costa F, Hazboun A, Del Buono R, Strumia A, Longo F, Ruggiero A, Schiavoni L, Mattei A, Cataldo R, Agr\u0026ograve; FE, Carassiti M. Ultrasound predictors of difficult spinal anesthesia: a prospective single- blind observational study. Minerva Anestesiol. 2023 Nov;89(11):996-1002. doi: 10.23736/S0375- 9393.22.16990-7. Epub 2023 Feb 21. PMID: 36800810.\u003c/li\u003e\n\u003cli\u003ePrabhakar A, Lambert T, Kaye RJ, Gaignard SM, Ragusa J, Wheat S, Moll V, Cornett EM, Urman RD, Kaye AD. Adjuvants in clinical regional anesthesia practice: A comprehensive review. Best Pract Res Clin Anaesthesiol. 2019 Dec;33(4):415-423. doi: 10.1016/j.bpa.2019.06.001. Epub 2019 Jul 2. Erratum in: Best Pract Res Clin Anaesthesiol. 2021 Dec;35(4):E3-E4. PMID: 31791560.\u003c/li\u003e\n\u003cli\u003eKumar CM, Corbett WA, Wilson RG. Spinal anaesthesia with a micro-catheter in high-risk patients undergoing colorectal cancer and other major abdominal surgery. Surg Oncol. 2008 Aug;17(2):73-9. doi: 10.1016/j.suronc.2007.10.025.\u003c/li\u003e\n\u003cli\u003eMoriT, Takahashi K, YasunoM. Radical resection with autonomicnerve preservation and lymphnode dissection techniques in lower rectal cancer surgery and its results: the impact of lateral lymph node dissection. Langenbecks Arch Surg 1998; 383: 409-415\u003c/li\u003e\n\u003cli\u003eHavenga K, Enker WE, McDermott K, Cohen AM, Minsky BD, Guillem J. Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J AmColl Surg 1996; 182: 495-502\u003c/li\u003e\n\u003cli\u003eNano M, Levi AC, Borghi F, Bellora P, Bogliatto F, Garbossa Det al. Observations on surgical anatomy for rectal cancer surgery. Hepatogastroenterology 1998; 45: 717-726\u003c/li\u003e\n\u003cli\u003eGodlewski G, Prudhomme M. Embryology and anatomy of the rectum. Basis of surgery. Surg Clin North Am 2000; 80: 319-343\u003c/li\u003e\n\u003cli\u003ePatricio J, Bernades A, Nuno D, Falcao F, Silveira L. Surgical anatomy of the arterial blood-supply of the human rectum. Surg Radiol Anat 1988; 10: 71-75.\u003c/li\u003e\n\u003cli\u003eWong DH, Weber EC, Schell MJ, Wong AB, Anderson CT, Barker SJ. Factors associated with postoperative pulmonary complications in patients with severe chronic obstructive pulmonary disease. Anesthesia and Analgesia 1995;80:276\u0026ndash;84.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003cem\u003ePre-operative characteristics\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"584\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.28767123287672%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.71232876712329%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpinal A.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.28767123287672%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN. of patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.71232876712329%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.28767123287672%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRefused spinal anaesthesia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.71232876712329%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.28767123287672%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN. of patient studied\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.71232876712329%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.28767123287672%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.71232876712329%\"\u003e\n \u003cp\u003e80.9 \u0026plusmn; 7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.28767123287672%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale gender (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.71232876712329%\"\u003e\n \u003cp\u003e11 (64,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.28767123287672%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.71232876712329%\"\u003e\n \u003cp\u003e26.3 \u0026plusmn; 3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.28767123287672%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssociated medical conditions (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;COPD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hypertension\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Diabetes mellitus \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Obesity \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.71232876712329%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (29.4)\u003c/p\u003e\n \u003cp\u003e15 (88.2)\u003c/p\u003e\n \u003cp\u003e6 (35.3)\u003c/p\u003e\n \u003cp\u003e8 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"73.28767123287672%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor location\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Right colon\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Transverse colon\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Left colon\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Rectum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.71232876712329%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (58.8)\u003c/p\u003e\n \u003cp\u003e1 (5.9)\u003c/p\u003e\n \u003cp\u003e4 (23.5)\u003c/p\u003e\n \u003cp\u003e2 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 2\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e. Intra and post-operative characteristics\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"459\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.3202614379085%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.6797385620915%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpinal A.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.3202614379085%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN. of patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.6797385620915%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.3202614379085%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood loss (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.6797385620915%\"\u003e\n \u003cp\u003e150 mL (100-400)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.3202614379085%\"\u003e\n \u003cp\u003e\u003cstrong\u003eConversion to open surgery (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.6797385620915%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.3202614379085%\"\u003e\n \u003cp\u003e\u003cstrong\u003eICU recovery (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.6797385620915%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.3202614379085%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital stay (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.6797385620915%\"\u003e\n \u003cp\u003e4.4 days (3-8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.3202614379085%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-operative complications (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Anastomotic leakage\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ileus\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bleeding\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Nausea/vomiting\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pneumonia\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;UTI\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Wound infection\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Abdominal pain (NRS\u0026gt;5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.6797385620915%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (5.9)\u003c/p\u003e\n \u003cp\u003e3 (17.6)\u003c/p\u003e\n \u003cp\u003e1 (5.9)\u003c/p\u003e\n \u003cp\u003e3 (17.6)\u003c/p\u003e\n \u003cp\u003e1 (5.9)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(0)\u003c/p\u003e\n \u003cp\u003e2 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.3202614379085%\"\u003e\n \u003cp\u003e\u003cstrong\u003eReadmission\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.6797385620915%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.3202614379085%\"\u003e\n \u003cp\u003e\u003cstrong\u003eReoperation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.6797385620915%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.3202614379085%\"\u003e\n \u003cp\u003e\u003cstrong\u003e30-day mortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.6797385620915%\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"colorectal surgery, colon cancer, minimally invasive surgery, frail patient, neuroaxial anesthesia, locoregional anesthesia","lastPublishedDoi":"10.21203/rs.3.rs-4175925/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4175925/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction.\u003c/h2\u003e \u003cp\u003eGeneral anesthesia is the most widely used anesthesia technique for major abdominal surgery, but it may have longer recovery time, high cost and environmental impact. In addition, general anesthesia may be contraindicated in some frail patients. Our study aims to evaluate the feasibility and safety of performing colorectal surgery with minimally invasive technique, in frail patients, under spinal anesthesia. Then we compared this group of patients with a retrospective one, performing a propensity score match analysis.\u003c/p\u003e\u003ch2\u003eMaterials and methods.\u003c/h2\u003e \u003cp\u003eFrom June 2021, 19 consecutive frail patients, undergoing elective laparoscopic colorectal oncological resection surgery under neuraxial anesthesia at Colorectal Surgery Unit of the Fondazione Policlinico Campus Bio-Medico in Rome were selected. A retrospective database prospectively maintained of these patients was performed.\u003c/p\u003e\u003ch2\u003eResults.\u003c/h2\u003e \u003cp\u003eWe enrolled 17 patients. In all patients, the surgery was successfully completed under spinal anesthesia and laparoscopic technique. Some the patients experienced mild abdominal pain between I and II GPO (VAS between 3 and 5) treated with oral analgesics as needed. No patients experienced episodes of vomiting or nausea after surgery with gas channeling in I GPO. The average hospital stay was about 4 days (range 3\u0026ndash;7). No patient required ICU admission, and 30 mortality was 0.\u003c/p\u003e\u003ch2\u003eConclusions.\u003c/h2\u003e \u003cp\u003eOur preliminary data show that performing major surgery with minimally invasive technique under spinal anesthesia can be feasible and safe, if performed by experienced operators, and can be a viable alternative for the treatment of frail and/or high-risk patients.\u003c/p\u003e","manuscriptTitle":"Clinical Safety and Feasibility of Minimally Invasive Colectomy Under Neuraxial Anesthesia in Frail Patients. An Initial Single Institution Experience.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-02 12:55:25","doi":"10.21203/rs.3.rs-4175925/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6553c11b-c0ba-4f9a-a301-31aba120bb84","owner":[],"postedDate":"April 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-15T19:38:31+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-02 12:55:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4175925","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4175925","identity":"rs-4175925","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}