Epidural anaesthesia for laparoscopic cholecystectomy in a patient with scleroderma.

Editor—We read the report by van Zundert and colleagues with great interest and also believe that regional anaesthesia is a good option for laparascopic cholecystectomy in patients with severe pulmonary disease. We also would like to share our experience with a 38-year-old patient with scleroderma requiring laparoscopic cholecystectomy for recurrent cholecystitis. She had a 9-year history of scleroderma with skin, respiratory, cardiovascular and gastrointestinal system manifestations. Preoperative evaluation revealed dyspnoea, effort-induced palpitation, Raynauld’s phenomenon and movement restrictions in her extremities. Neck and extremity movements were severely restricted, and she had difficulty opening her mouth. Thoracic highresonance computer tomography of both lungs showed a ground-glass appearance and local septal thickening of the basal parts of the posterior and lateral segments of the inferior lobes were seen. Regional anaesthesia was planned because of severe pulmonary and multiple visceral involvements, and the patient’s restricted mouth and neck movements. Lateral positioning of the patient before the epidural procedure was quite difficult owing to restricted joint movement. Under sterile conditions, local anaesthesia was performed at the level of L1-L2 using prilocaine 2% (2 ml). The epidural space was 2 cm from the skin, and a catheter was inserted 6 cm cephalad. Prilocaine 2% (20 ml) was administered into the epidural space. As the effect of epidural anaesthesia began, warming and colour change in the patient’s lower extremities were noted. Ten minutes later, epidural anaesthesia was effective to the level of T4. Surgery was started after 12 min and completed by 62 min, without complications. Oxygen saturation levels obtained intraoperatively by pulse oximeter were 98–100%. The effect of epidural anaesthesia disappeared completely after 2.5 h. The patient was given NSAIDs twice and was free of pain in the postoperative 24 h. No additional doses of local anaesthetic via the epidural catheter were required. Scleroderma (progressive systemic sclerosis) is a multisystem disease, involving the musculoskeletal, gastrointestinal, pulmonary, renal and cardiac systems, that can pose a significant challenge for the anaesthetist. It is important for the anaesthetist to determine the anaesthesia management in these patients to minimize potential complications. As van Zundert and colleagues noted, there is never a right way to anaesthetize such patients with severe pulmonary problems. Despite its obvious advantages when used in patients with scleroderma, regional anaesthesia may not always be preferable. The prolonged effect of local anaesthetics, technical difficulties owing to a thickened skin and the affected subcutaneous tissue, and difficulty in positioning patients may limit its utility. However, each case should be evaluated independently with regard to relative risks and the best outcome for either procedure in such a challenging condition as scleroderma.