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M. H. Elfawal et al.338
However, unpredictability of spread, failure rate and complications has prompted the modification of this technique to ensure more accuracy in defining the paravertebral space.
4.2.2 Neurostimulation Technique
This technique in paravertebral blockade has been in use since 1998, since it allows more accurate localization of the intercostal nerve and thus lowers compli­cation rate [29].
A nerve stimulator with an initial current of 5 mA and 9 V is connected to a 21G insulated needle which is then advanced perpendicularly to the skin. First the contraction of the Paraspinal muscles is detected, which subsequently ceases when the needle reaches the costo-transverse ligament. After piercing the latter, a proper muscular response is noted, being that of the intercostal muscles. The needle is then adjusted into a position to allow muscular response while reducing the cur­rent. The intensity is directly related to the distance between the tip of the needle and the intercostal muscle. The position of the needle is considered optimal when the current is between 0.4–0.8 mA [29].
The distance between the skin and the paravertebral space is then measured, after which the insulated needle is removed and the Tuohy needle inserted at the same depth measured [15].
4.2.3 Ultrasound Guided Technique
The utilization of ultrasound as a guide has enhanced the accuracy of needle and subsequent catheter placement into the paravertebral space. A linear array trans­ducer is placed 2.5 cm laterally to the spinous process in an oblique axis and the goal is to obtain a sonographic image consisting of the pleura (anteriorly), the cos­totransverse ligament (posteriorly) and the bony prominences (Fig. 6) [30]. Thus the ultrasound technique permits the visualization of the needle, the spread of the anesthetic solution and direct vision of the placement of the catheter.
After visualizing the landmarks, the needle is inserted into the paravertebral space, then the anesthetic solution is deposited which translates by the parietal pleura bulging anteriorly on the ultrasound image (Fig. 7) [31].

4.3 Mechanism and Spread of Anesthetic

Ipsilateral Block of the somatic and sympathetic nerves is achieved by local anes­thetic injection in the paravertebral space including the posterior ramus in multiple adjacent dermatomes.
In that area the nerves are devoid of fascial sheath which facilitates penetration of anesthetic agents [32].
LSG Under Block Anesthesia (PVB)
Fig. 6 Sonogram of the paravertebral space. [30] Source Luyet, C., Eichenberger, U., Greif, R., Vogt, A., Farkas, Z. S., & Moriggl, B. (2009). Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: An imaging study. British Journal of Anaesthesia, 102(4), 534–539
339
Fig. 7 Local anesthetic injection in the paravertebral space. [31] Source Bondár, A., Szűcs, S., &Iohom, G. (2010). Thoracic paravertebral blockade. Medical Ultrasonography, 12(3), 223–227
M. H. Elfawal et al.340
Concerning longitudinal spread it is thought that a single paravertebral space blocked can result in anesthesia of a mean of 5 dermatomes somatic wise, and a mean of 8 dermatomes sympathetic wise [33].
This ipsilateral spread of the anesthetic agent is through the heads of the ribs along the vertebral bodies [34].
It also has been demonstrated that injections ventral to the endothoracic fascia facilitates longitudinal spread versus unpredictable spread in case of dorsal infil­tration [35].
Concerning the contralateral spread of the block, it was proven that one of the ways this is possible is by the drug penetrating the epidural space through the intervertebral foramen [36].
Between the pleura and the endothoracic fascia there’s the subserous fascia which acts as a channel of communication between the paravertebral spaces on both sides, anterior to the vertebral body, which provides another possibility for the spread of the block to the contralateral side [16].

4.4 Anesthetic Drugs

Drugs that were used are the following: (Bupivacaine,levobupivacaine and ropi­vacaine) alone or with either epinephrine, Fentanyl,Clonidine or corticosteroids, and lidocaine with or without epinephrine.
The dose depends on the surgery and the number of dermatomes that are required to block, but as a general consensus 15 ml in adults is enough to cover 3 dermatomes, and 0.5 mg/kg in children will cover 4 dermatomes [13].
So it is proven that at least 3 to 4 spaces can be covered by one blocked level [10].
Bupivacaine is an amide local anesthetic that can produce long lasting anesthe­sia [37].
As adjuncts to bupivacaine, fentanyl and clonidine can be added which reduce the local anesthetic dose initially administered.
Average onset of anesthesia is around 30 min, and enhancement postoperative pain relief is noticed. However, their use can be limited by their side effects which are nausea/vomiting when it comes to fentanyl and hypotension concerning cloni­dine [38].
Lasts in average for around 14 to 15 h with relative variations [39].

4.5 Complications

In 2001 Naja and Lonnqvist prospectively studied the failure and complications rates of paravertebral blockade in 620 adults. Failure rate was 6.1% in adults, while the complications were the following [40] (Table 2).
They reported also that pneumothorax and vascular puncture risk were higher when it comes to bilateral block.
LSG Under Block Anesthesia (PVB)
Table 2 Complication rate of paravertebral block
Complication Inadvertent vascular puncture 6.8 Hypotension 4 Intrathecal\epidural spread 1 Pleural puncture 0.8 Pneumothorax 0.5
Source Naja MZ, Lonnqvist PA. Somatic paravertebral nerve blockade: incidence of failed block and complications. Anaesthesia. 2001;56:1184–8 (102)
341
Rate (%)
In 2005, a case of contralateral Harlequin and ipsilateral Horner syndrome was documented post paravertebral block for a breast operation and it was thought to be due to the spread of analgesics to the stellate ganglion [41].
Also a case of pulmonary hemorrhage was seen in a patient that underwent a paravertebral block, however, this patient suffered from a previous thoracic sur­gery which resulted in paravertebral space fibrosis, making loss of resistance less evident [42].
This technique lacks systemic toxicity by the anesthetic drug due to the mod­erately slow absorption time (Tmax = 15-30 min) [43]; however there’s one docu- mented case where the patient suffered a seizure following systematic spread [44].
4.6 Paravertebral Blockade (PVB) vs General Anesthesia
(GA) a Review of Data
4.6.1 Abdominal Surgeries
Multiple authors compared GA to PVB in different abdominal surgeries. In all reviewed articles, superiority of the PVB technique was noticed, whether through the decrease in post op vomiting, pain or any post op adverse events. Some of those most important articles discussing that are listed in Table 3 [35, 4651].
4.6.2 First Paravertebral Block in Sleeve Gastrectomy
Kanawati et al. conducted a case series in 2015 where they performed a paraver­tebral block on 5 patients undergoing sleeve gastrectomy. A bilateral block was performed, with 4–5 ml of local anesthetic infiltrated at the thoracic level from T6 through T11, guided by a nerve stimulator. The nerve stimulator was used as well to secure a cervical block to relieve shoulder pain in these patients brought on by abdominal insufflation for laparoscopy. Patients were hemodynamically stable, conscious and cooperative throughout the operation. In that case series paraverte­bral block proved to be a satisfactory alternative to general anesthesia [45].
In our study (unpublished data), a total of 210 participants were included of which 48 constituted the PVB group and 162 patients composed the GA group. Both groups were similar in baseline demographic factors, with patients in PVB
M. H. Elfawal et al.342
Outcome
Intervention (n)
(n)
30 Unilateral TPVB (30) Faster readiness for discharge
And longer mean duration of analgesia in PVB
group
No difference in patient nor surgeon satisfaction
between groups
vomited
No difference in post op pain
and vomiting in TPVB group
in TPVB group, however no difference concerning
post op nausea and vomiting
nausea and vomiting with TPVB
24 Unilateral TPVB (24) More nausea in GA group, however only one patient
herniorrhaphy
25 Bilateral TPVB + GA Lower 24 h morphine intake and less post op nausea
30 Bilateral TPVB + GA Fewer patients requiring analgesics supplementation
herniorrhaphy
cholecystectomy
cholecystectomy
less post op nausea in TPVB group
intake with the TPVB technique
3 failed TPVB(excluded)
Lower post op fentanyl consumption in the TPVB
group
One patient with hydropneumothorax in each group
(24)
30 Bilateral TPVB (30) Lesser analgesic intake, shorter hospital stay and
28 Unliteral TPVB + GA (27) Higher patient satisfaction and lower 24 h morphine
repair
24 Unilateral TVPB + GA
nephrolithotomy
nephrolithotomy
Author Surgery Generalanesthesiacontrol
Table 3 Characteristics and outcomes reported from studies that used PVB in abdominal and urological surgeries
Akcaboy et al. (46) Open inguinal
Hadzic et al. [19] Open inguinal
Agarwal et al. [47] laparoscopic
Naja et al. [35] laparoscopic
Moussa [48] Donorhepatectomy 12 Bilateral TPVB + GA (12) Lower morphine consumption and less post op
Abou Zeid et al. [49] Ventral hernia
Elm Ak et al. [50] Percutaneous
Borle et al. [51] Percutaneous
Legend: TPVB: thoracic paravertebral block; GA: General anesthesia.
LSG Under Block Anesthesia (PVB)
343
suffering from higher number and advanced stage of comorbidities than the GA group. Mean operative time was similar in between the two groups. Intra-operative complications were scarce among both study groups. GA group requested a sec­ond dose of analgesia earlier than PVB group, When comparing pain management post-op, In the Post Anesthesia Care Unit, the patients in the PVB group did not ask for pain killers, as compared to GA group where at least 20% of the patients asked for an additional analgesia dose, There was a significant statistical differ­ence in the number of doses received by the two groups when compared for anal­gesia requirements in the postoperative period. This reflects the important effect of the paravertebral blockade in post-operative analgesia on top of its role as an anesthetic technique. After at least 1 year postoperatively, the mean percentage of excess weight were similar.

References

1. Robinson DH, Toledo AH. Historical development of modern Anesthesia. J Invest Surg.
2012;25(3):141-s9.
2. Potyk DK, Raudaskoski P. Overview of anesthesia for primary care physicians.
WJM.1998;168(6).
3. Segula D. Complications of obesity in adults: a short review of the literature. Malawi Med J.
2014 Mar; 26(1).
4. American society of anesthesiologists (ASA) [internet]. 905 16th Street, N.W.
Suite 400 Washington, DC. 20006. Updated in October 15, 2014, cited in July 19, 2019. Available form: https://www.asahq.org/standards-and-guidelines/
asa-physical-status-classification-system.
5. Tassoudis V, Ieropoulos H, Karanikolas M, Vretzakis G, Bouzia A, Mantoudi E. et al.
Bronchospasm in obese patients undergoing elective laparoscopic surgery under general anesthesia. Springer Plus. 2016; 5(1).
6. Piskin O, Altinsoy B, Cimencan M, Aydin B, Okyay D, Kucukosman G. The effect of bariat-
ric anaesthesia on postoperative pulmonary functions. J Pak Med Assoc. 2017;67(4):561–7.
7. Goulding ST, Hovell BC. Anaesthetic experience of vertical banded gastroplasty. Br J
Anaesth. 1995;75(3):301–6.
8. Lindauer B, Steurer MP, Müller MK, Dullenkopf A. Anesthetic management of patients
undergoing bariatric surgery: two year experience in a single institution in Switzerland. BMC Anesthesiology. 2014; 14(1).
9. Richardson J. Fin-de-siecle renaissance of Paravertebral analgesia. Pain Rev. 1997.
10. Eason M, Wyatt R. Paravertebral thoracic block-a reappraisal. Anaesthesia.
1979;34(7):638–42.
11. Batra RK, Krishnan K, Agarwal A. Paravertebral block. J Anaesthesiol Clin Pharmacol.
2011;27(1):5–11.
12. Macintosh RR, Bryce-Smith R. Local analgesia-abdominal surgery, 2nd edn. 1962; p. 26.
Livingstone, Edinburgh.
13. Richardson J, Lönnqvist PA. Thoracic paravertebral block. Br J Anaesth. 1998;81(2):230–8.
14. Lönnqvist PA, Hildingsson U. The caudal boundary of the thoracic paravertebral space.
Anaesthesia. 1992;47(12):1051–2.
15. Karmakar MK, Kwok WH, Kew J. Thoracic paravertebral block: radiological evidence of
contralateral spread anterior to the vertebral bodies. Br J Anaesth. 2000;84(2):263–5.
16. Weltz CR, Greengrass R, Klein S. A randomized prospective trial comparing paravertebral
block and general anesthesia for operative treatment of breast cancer. 2001 Jan.
M. H. Elfawal et al.344
17. Buggy DJ, Kerin MJ. Paravertebral analgesia with Levobupivacaine increases postoperative
flap tissue oxygen tension after immediate Latissimus Dorsi breast reconstruction compared with intravenous opioid analgesia. Anesthesiology. 2004;100(2):375–80.
18. Buckenmaier CC, Steele SM, Nielsen KC, Martin AH, Klein SM. Bilateral continu-
ous paravertebral catheters for reduction mammoplasty. Acta Anaesthesiol Scand. 2002;46(8):1042–5.
19. Hadzic A, Kerimoglu B, Loreio D. Paravertebral blocks provide superior same-day recov-
ery over general anesthesia for patients undergoing inguinal hernia repair. Survey of Anesthesiology. 2006;50(6):274.
20. Klein SM, Pietrobon R, Nielsen KC, Steele SM, Warner DS, Moylan JA, et al. Paravertebral
somatic nerve block compared with peripheral nerve blocks for outpatient inguinal hernior­rhaphy. Reg Anesth Pain Med. 2002;27(5):476–80.
21. Jamieson BD, Mariano ER. Thoracic and lumbar paravertebral blocks for outpatient litho-
tripsy. J Clin Anesth. 2007;19(2):149–51.
22. Soni AK, Conacher ID, Waller DA, Hilton CJ. Video-assisted thoracoscopic placement of
paravertebral catheters: a technique for postoperative analgesia for bilateral thoracoscopic surgery. J Cardiothorac Vasc Anesth. 1995;9(6):778.
23. Ganapathy S, Nielsen KC, Steele SM. Outcomes after paravertebral blocks. Int Anesthesiol
Clin. 2005;43(3):185–93.
24. Tsai T, Rodriguez-Diaz C, Deschner B, Thomas K, Wasnick JD. Thoracic paravertebral
block for implantable cardioverter-defibrillator and laser lead extraction. J Clin Anesth. 2008;20(5):379–82.
25. Ben-David B, Swanson J, Nelson JB, Chelly JE. Multimodal analgesia for radical prostatec-
tomy provides better analgesia and shortens hospital stay. J Clin Anesth. 2007;19(4):264–8.
26. Chelly JE. Paravertebral Blocks Anesthesiology Clin. 2012;30:75–90.
27. James CD, Bowers JR. Aid to lumbar paravertebral sympathetic block. Anaesthesia.
1968;23(4):644–5.
28. Vaughan N, Dubey VN, Wee MYK, Isaacs R. Devices for accurate placement of epidural
Tuohy needle for Anaesthesia administration. Mechanical Sciences. 2014 Feb; 5(1):1–6.
29. Naja Z, Maaliki H, Al-Tannir M, El-Rajab M, Ziade F, Zeidan A. Repetitive paraverte-
bral nerve block using a catheter technique for pain relief in post-herpetic neuralgia. Br J Anaesth. 2006;96(3):381–3.
30. Luyet C, Eichenberger U, Greif R, Vogt A, Farkas ZS, Moriggl B. Ultrasound-guided para-
vertebral puncture and placement of catheters in human cadavers: an imaging study. Br J Anaesth. 2009;102(4):534–9.
31. Bondár A, Szűcs S, Iohom G. Thoracic paravertebral blockade. Medical Ultrasonography.
2010;12(3):223–7.
32. Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ. A prospective rand-
omized comparison of preoperative and continuous balanced epidural or paravertebral bupi­vacaine on post-thoracotomy pain, pulmonary function and stress responses. Br J Anaesth. 1999;83:387–92.
33. Cheema SPS, Ilsley D, Richardson J, Sabanathan S. A thermographic study of paravertebral
analgesia. Anaesthesia. 1995;50:118–21.
34. Moore DC. Intercostal nerve block: spread of India ink injected to the ribs costal groove. Br
J Anaesth. 1981;53:325.
35. Naja MZ, Ziade MF, Rajab ME, Tayara KE, Lönnqvist PA. Varying anatomical injection
points within the thoracic paravertebral space: Effect on spread of solution and nerve block­ade. Anaesthesia. 2004;59(5):459–63.
36. Kappis M. Sensibilitat und lokale anasthesie im chirurgischen gebeit der bauchkokle mit
besonderer berucksichtigung der splanchnicusanasthesie. Beitr Klin Chir. 1919;115:161–75.
37. Kopacz DJ, Allen HW, Thompson GE. A comparison of epidural levobupivacaine 0.75%
with racemic bupivacaine for lower abdominal surgery. Anesth Analg. 2000; 90:642–8.
LSG Under Block Anesthesia (PVB)
38. Burlacu CL, Frizelle HP, Moriarty DC, Buggy DJ. Fentanyl and clonidine as adjunctive
analgesics with levobupivacaine in paravertebral analgesia for breast surgery. Anaesthesia. 2006;61(10):932–7.
39. Finnetry O, Carney J, Mcdonnel JG. Trunk blocks for abdominal sugery. Anaesthesia.
2010;65:76–83.
40. Naja MZ, Lonnqvist PA. Somatic paravertebral nerve blockade: incidence of failed block and
complications. Anaesthesia. 2001;56:1184–8.
41. Burlacu CL, Buggy DJ. Coexisting harlequin and Horner syndromes after high thoracic para-
vertebral anesthesia. Br J Anaesth. 2005;95:822–4.
42. Thomas PW, Sanders DJ, Berrisford RG. Pulmonary haemorrhage after percutaneous para-
vertebral block. Br J Anaesth. 1999;83:668–9.
43. Lonnqvist PA. Plasma concentrations of lignocaine after thoracic paravertebral blockade in
infants and children. Anaesthesia. 1993; 48:958–60.
44. Snowden CP, Bower S, Conacher ID. Plasma bupivacaine levels in paravertebral blockade in
adults. Anaesthesia. 1994; 49:546.
45. Kanawati S, Fawal H, Maaliki H, Naja ZM. Laparoscopic sleeve gastrectomy in five awake
obese patients using paravertebral and superficial cervical plexus blockade. Anaesthesia. 2015;70:993–5.
46. Akcaboy EY, Akcaboy ZN, Gogus N. Comparison of paravertebral block versus fast-track
general anesthesia via laryngeal mask airway in outpatient inguinal herniorrhaphy. J Anesth. 2010;24:687–93.
47. Agarwal A, Batra RK, Chhabra A, et al. The evaluation of efficacy and safety of paraverte-
bral block for perioperative analgesia in patients undergoing laparoscopic cholecystectomy. Saudi J Anaesth. 2012;6(344–9):31.
48. Moussa A. Opioid saving strategy: bilateral single-site thoracic paravertebral block in right
lobe donor hepatectomy. Middle East J Anesthesiol. 2008;19:789–801.
49. Abou Zeid HA, Al-Ghamdi AMA, Abdel-Hadi MS-A, Zakaria HM, Al-Quorain AAA,
Shawkey MN. Bilateral paravertebral block in advanced schistosomal liver disease: a pro­spective study. Saudi J Gastroenterol. 2004; 10:67–77.
50. Ak K, Gursoy S, Duger C, et al. Thoracic paravertebral block for postoperative pain manage-
ment in percutaneous nephrolithotomy patients: a randomized controlled clinical trial. Med Princ Pr. 2013;22:229–33.
51. Borle AP, Chhabra A, Subramaniam R, et al. Analgesic efficacy of paravertebral bupivacaine
during percutaneous nephrolithotomy: an observer blinded, randomized controlled trial. J Endourol. 2014;28:1085–90.
345

Elderly High Risk Patients Undergoing Laparoscopic Sleeve Gastrectomy

Kashif Saeed, Emanuele Lo Menzo, Samuel Szomstein and Raul J. Rosenthal

1 Scope of the Problem

1.1 Increasing of the Elderly Population

The definition of “elderly” has varied over time and according to the regional life expectancy. In most developed countries, age more than 65 years is considered elderly, although in developing nations this age is 60 years [1]. Life expectancy has increased substantially in all parts of the world and over the last century it has more than doubled [2]. According to the WHO, life expectancy at birth globally increased from 66.5 years in 2000 to 72 years in 2016 [3] and in the US has almost increased by 10 years from 69.9 years in 1959 to 78.87 years in 2019 [4].
Life expectancy is expected to continue to increase due to continued advance­ment in health and improvement in living conditions around the world. With increase in life expectancy, the proportion of elderly population will inevita­bly increase. According to recent statistics, there were 703 million people of age 65 years and older worldwide in 2019, and this number is projected to double by 2050 [5]. In the United States, the population of 65 years and older is projected to nearly double from 52 million in 2018 to 95 million by 2060 [6].
K. Saeed · E. Lo Menzo · S. Szomstein · R. J. Rosenthal (*) Department of General Surgery and Director, Bariatric and Metabolic Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, US e-mail: rosentr@ccf.org
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_34
347
K. Saeed et al.348
1.2 Prevalence of Obesity and Related Comorbidities
in the Elderly
Obesity is a global pandemic that is affecting people of all ages. With the increase in the elderly population, it is no wonder that the number of obese older individuals will increase as well. In fact, elderly subjects are more prone to develop obesity due to decreased resting energy expenditure [7, 8] and physical decline. In the US about 35% of adults aged 65 and over were obese in 2007–2010, representing over 8 million adults aged 6574, and almost 5 million adults aged 75 and over, and this number is predicted to double by 2050 [9].
Elderly subjects are more likely to develop obesity-associated comorbidities, as with increase in age there is decline in physiologic reserves [10] and obesity fur­ther accentuates this risk. In fact, the incidence of both diabetes and HTN surges in older individuals as the BMI increases. Increased age and obesity are consid­ered strongest factors for uncontrolled arterial hypertension and its incidence will rise the growth of the elderly obese population [11]. Similar trends are observed between elevated BMI and the risk of developing diabetes [12], coronary artery disease [13], and stroke [14]. Obesity has also been determined to be a major con­tributor to increase in incidence of osteoarthritis [15], erectile dysfunction, urinary incontinence [16] and decline in renal function in older individuals [17]. In addi­tion to the physical decline, elderly obese compared to non-obese are at increased risk of cognitive decline. One study found that for every 1.0 increase in BMI at age 70 years, Alzheimers disease risk increased by 36% [18].

1.3 Risks of Surgery in the Elderly

There are no contraindications per se for major surgery in elderly patients, and in fact, the number of surgical procedures is 55% higher in persons over the age of 65 than in persons below the age of 65 [19]. Increasing age causes a decline in physiologic function of almost every organ system of the body, making it more susceptible to the stress of surgery [20]. This has been well demonstrated in the lit­erature, with reported rates of 28% morbidity and 2.3% mortality after surgery in elderly and in patients above 80 years, postoperative morbidity of 51% and mor­tality of 7% [21, 22]. Despite this evidence, however, bariatric surgery continues to have low risk of complication and mortality, less than colonic surgery, cholecys­tectomy, and appendectomy [23].
1.3.1 Bariatric Surgery in Elderly
Two decades ago, bariatric surgery was not recommended in patients aged 60 years or older. The recommendations were based on the available evidence of increased mortality and morbidity, and less favorable outcomes in terms of