Laparoscopic gastrostomy and jejunostomy - Safety and cost with local vs general anesthesia

Background and Hypothesis: General anesthesia is used for laparoscopic ente ral access because pneumoperitoneum requires relaxation of the abdominal mu scles. We wanted to determine whether these procedures could be performed w ith similar results and cost under local anesthesia. Design: Randomized controlled study with 30-day follow-up including a cost- benefit analysis. Setting: University-affiliated hospitals. Patients: Forty-eight patients (32 men, 16 women; mean age, 67 years) under going laparoscopic gastrostomies (n = 32) and jejunostomies (n = 16). Intervention: Twenty-four patients underwent laparoscopic gastrostomy (n = 15) and jejunostomy (n = 9) under local anesthesia with intravenous conscio us sedation and monitored anesthesia care. Twenty-four patients had general anesthesia. Main Outcome Measures: Conversion to general anesthesia, complications, and cost. Results: Ten patients under local anesthesia had periods of deep sedation a nd 1 required conversion to general anesthesia. One patient under general a nesthesia required conversion to open gastrostomy. No patients had intraope rative aspiration; however, 4 aspirated after the procedure. One patient di ed of myocardial infarction during the 30-day follow-up. We found no signif icant difference in the total mean cost and actual procedure time. The surg eon's fee accounted for 31% of the total cost. Conclusions: Some patients undergoing laparoscopic enteral access may requi re deep sedation and a rare patient may require general anesthesia. Clinica l conditions and surgeon preference, therefore, should determine whether lo cal anesthesia is suitable for laparoscopic gastrostomies and jejunostomies , and in what setting, since there is no difference in success rate or comp lications when compared with general anesthesia. Potential savings are poss ible from the operating room (26% of total cost) or anesthesiologist (12% o f total cost) if these procedures are performed in an endoscopy suite witho ut monitored anesthesia care.