Question:

We have a dilemma. My husband has pdeudocholinesterase defic., and difficulty intubating. However, 2 yrs ago they overcame that because we knew in advance. So he had emergency quad by-pass surgery and then a year later emergency gallbladder (gangrenous) removal.

That was a year ago. His memory and cognitive ability decreased significantly and the neurologist relates it to post pump syndrome from the heart surgery as well as general anesthesia. (my husband did have 2 hips repl. under spinal) This neurologist said he strongly recommends not having any more general anesthesia unless it`s life threatening. Well, after the gallbladder surgery last year, he developed a hernia in the umbilical area. We have put it off for a year because of the anesthesia problem, but it`s getting larger. Today the surgeon said it`s still elective at this point, but because of the size and location it can`t be done without general anesthesia. He said as it gets bigger it could create a more difficult surgery in the future.

Dilemma? Have it repaired and risk more cognitive problems (he can still drive, handle money, etc. but concerned about any future memory/cogn loss) or wait? Don`t know where to turn…. Thanks

Answer:

Quite a dilemma for you.

The cause of postoperative cognitive dysfunction is unresolved. It is clearly something that happens in a significant number of elderly patients. What is not clear is whether there is a connection between POCD and general anesthesia. One study which compared the incidence of POCD in patients who had regional anesthesia vs. general anesthesia found no difference. It may be the state of inflammation associated with tissue injury and healing that causes the problem, not the anesthesia.

Cardiac surgery is a special case. During bypass (heart-lung machine) a unique set of conditions are created, that may include lower blood pressure, lower hemoglobin concentrations, inflammation cause by trauma to blood cells passing through the machine and circuit, and emboli (tiny particles) dislodged from the aorta and passing to the brain. This causes a much higher rate of neuro-psychologic compromise than any other surgery, including hernia operations.

Removal of a gangrenous gall bladder is also a major insult to the body. Some patients with this condition are very sick indeed. So this may, once more, be a condition more likely than others to cause brain problems.

There is one (controversial) study showing greater long term problems – even mortality – in patients who have prolonged, deep anesthesia. So your husband may get the best results in terms of avoiding memory and cognitive problems from a quick operation by a really skillful surgeon, and using careful monitoring of the depth of anesthesia. Regional anesthesia is an intuitively attractive option, but, as stated above, there is no study evidence of less problems, and regional may or may not be possible depending on the location and extent of the surgery.

It would be helpful to pay attention to all other factors that might help with recovery, such as proper treatment of background conditions like diabetes and high blood pressure, stopping smoking or alcohol abuse, getting adequate nutrition, etc.

Hope this helps you to weigh up the risks and benefits of proceeding with surgery. Also a good idea to talk directly with your anesthesiologist ahead of time.

For more information:

Go to the Anesthesia health topic.