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Wegner GRM, Wegner BFM, Huntermann R, Pinto ML, Vieira JAP, de Souza AP, Bezerra FJL. Comparative efficacy of perioperative lidocaine infusion versus thoracic epidural analgesia for pain management in abdominal surgery: systematic review and meta-analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2025; 75:844616. [PMID: 40164382 PMCID: PMC11999601 DOI: 10.1016/j.bjane.2025.844616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2024] [Revised: 02/28/2025] [Accepted: 02/28/2025] [Indexed: 04/02/2025]
Abstract
BACKGROUND Recent randomized clinical trials have compared the perioperative use of Intravenous (IV) lidocaine and Thoracic Epidural Analgesia (TEA) for postoperative analgesia in patients undergoing abdominal surgery. METHODS A systematic search was conducted on Embase, Web of Science (all databases), Cochrane Library, and PubMed on March 25, 2024, adhering to the Cochrane Handbook and PRISMA guidelines. RESULTS Out of 1261 screened studies, 6 were included. TEA provided superior pain relief on a 0 to 10 pain scale at rest compared to IV lidocaine at 2 (n = 335, MD = -0.72, 95% CI -0.19 to -1.25, p = 0.007423, I2 = 83%) and 24 hours postoperatively (n = 402; MD = -0.18, 95% CI -0.12 to -0.23; p < 0.000001, I2 = 18%). However, no statistically significant differences were observed on pain scores at rest at 48 and 72 hours. TEA provided superior pain relief on a 0 to 10 pain scale during coughing at 24 hours postoperatively (n = 360; MD = -0.36, 95% CI -0.19 to -0.52, p = 0.000019, I2 = 2%), but no statistically significant differences were observed in pain scores on coughing at 48 and 72 hours. There were no statistically significant differences in postoperative nausea and vomiting, time to first flatus, or length of hospital stay. CONCLUSIONS TEA provides more effective postoperative pain relief compared to IV lidocaine during the first postoperative day, as evidenced by analyses of pain both at rest and during coughing.
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Affiliation(s)
| | - Bruno F M Wegner
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Ramon Huntermann
- Centro Universitário para o Desenvolvimento do Alto Vale do Itajaí, Rio do Sul, SC, Brazil
| | - Manoela L Pinto
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
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Coppens S, Dewinter G, Hoogma DF, Raudsepp M, Vogelaerts R, Brullot L, Neyrinck A, Van Veer H, Dreelinck R, Rex S. Safety and efficacy of high thoracic epidural analgesia for chest wall surgery in young adolescents: A retrospective cohort analysis and a new standardised definition for success rate. Eur J Anaesthesiol 2024; 41:873-880. [PMID: 39363622 DOI: 10.1097/eja.0000000000002064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
BACKGROUND Chest wall surgery for the correction of pectus excavatum or pectus carinatum has gained increased interest in recent years. Adequate pain treatment, respiratory physiotherapy and early ambulation are key to improving the outcomes. Although thoracic epidural analgesia is highly effective, its safety is controversial, leading to extensive scrutiny and questioning of its role. OBJECTIVES We hypothesise that thoracic epidural analgesia is effective and well tolerated to use in adolescents, with a high success rate and low pain scores. DESIGN Observational retrospective cohort study. SETTING All adolescent cases in a high-volume academic tertiary chest wall surgery centre between March 1993 and December 2017 were included. PATIENTS A total of 1117 patients aged from 12 to 19 years of age and receiving either Ravvitch, Nuss or Abramson chest wall reconstruction for pectus excavatum were identified in our institutional chest wall surgery database. After applying selection and exclusion criteria, 532 patients were included in the current analysis. MAIN OUTCOME MEASURES The primary endpoint of this study was the safety of epidural analgesia, assessed by the incidence of acute adverse events. Secondary endpoints were block success rates using a specific novel definition, and analgesic efficacy using recorded postoperative pain scores. RESULTS More than 60% of patients experienced one or more adverse events. However, all events were minor and without consequences. No serious or long-term adverse events were detected. The success rate of thoracic epidural placement was 81%. Low postoperative pain scores were observed. CONCLUSION Thoracic epidural analgesia is an extremely effective pain control technique, with a surprisingly high number of minor adverse events but safe with regard to serious adverse events. TRIAL REGISTRATION The local research ethics committee approved and registered this study on 16 May 2022 (registration number: S66594).
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Affiliation(s)
- Steve Coppens
- From the Department of Anesthesiology, University Hospitals of Leuven (SC, GD, DFH, MR, RV, LB, AN, RD, SR), Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven (SC, GD, DFH, AN, HvV, SR) and Department of Thoracic Surgery, University Hospitals of Leuven, Leuven, Belgium (HvV)
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Kumar L, Anantharaman R, Thomas DE, Nair AS, Kartha AP, Kumar K. Evaluation of the analgesic efficacy of a low dose of intrathecal morphine in laparoscopic abdominal surgery: A randomised control trial. J Minim Access Surg 2024:01413045-990000000-00096. [PMID: 39611553 DOI: 10.4103/jmas.jmas_141_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/30/2024] [Indexed: 11/30/2024] Open
Abstract
INTRODUCTION Intrathecal opioid is an analgesic option in laparoscopic surgery. We assessed primarily the intraoperative opioid requirement amongst patients receiving intrathecal morphine (ITM) (Group M) versus standard care (Group C) for abdominal surgery. The secondary outcomes were intraoperative haemodynamic changes, extubation on table and pain scores in the intensive care unit (ICU) at 6 th hourly intervals for 24 h postoperatively. PATIENTS AND METHODS Patients undergoing laparoscopic abdominal surgery were randomised into Group M ( n = 30) that received ITM at 2 μg/kg while Group C ( n = 30) was control. A rise in mean arterial pressure > 20% from baseline was treated sequentially with 0.3 mg /kg propofol and 0.5 μg/kg fentanyl intravenously (IV). Pain management in the ICU included paracetamol 1G IV 8 th hourly for all patients, while nefopam 20 mg and fentanyl 0.5 μg/kg IV were the second and third tiers of pain management. RESULTS Intraoperatively, 10 patients in Group M versus 26 in Group C needed additional fentanyl ( P < 0.001) and 15 versus 26 patients needed additional propofol ( P = 0.0024). Pain scores were superior in Group M at all time points in the ICU and at ambulation and during incentive spirometry. Thirteen patients in Group C versus 3 in Group M needed nefopam at the time of shifting to the ICU ( P = 0.004) and 10 patients versus 1 at 8 h in the ICU ( P = 0.003) while pain management at 16 h and 24 h was comparable. CONCLUSION Pre-operative ITM at 2 μg/kg reduces intraoperative opioid requirement and improves analgesia 24 h postoperatively amongst patients undergoing major laparoscopic abdominal surgery without delay in extubation or changes in haemodynamics.
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Affiliation(s)
- Lakshmi Kumar
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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Kato A, Numata M, Izukawa S, Ohgimi T, Okamoto H, Atsumi Y, Kazama K, Asari M, Numata K, Sawazaki S, Watanabe T, Mikayama Y, Godai T, Higuchi A, Saeki H, Hatori S, Mushiake H, Matsumoto S, Rino Y, Saito A, Shiozawa M. Prospective observational study comparing the perioperative outcomes of laparoscopic colectomy with or without epidural anesthesia: the Kanagawa Yokohama Colorectal Cancer Study Group (KYCC) 1806. Surg Today 2024; 54:1353-1359. [PMID: 38702438 DOI: 10.1007/s00595-024-02856-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/31/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE There have been no adequate comparisons of the efficacy, safety, and efficiency of analgesia after laparoscopic colorectal resection (LAC), with and without epidural anesthesia (EDA). METHODS This was a multicenter prospective observational study of patients undergoing LAC. The primary end point was the mean visual analog scale (VAS) score on postoperative days (PODs) 1-7. The secondary end points were the highest VAS, complication rate, days to first ambulation and fatigue, length of hospital stay, and time to commencement of surgery. RESULTS We compared an EDA group (Group E, n = 48) and a no-EDA group (Group O, n = 48) after matching. The mean VAS was not significantly different between the groups (28.7 vs. 30.1, p = 0.288). On assessing the secondary end points, the highest VAS was not significantly different between the groups. In fact, the VAS was lower in Group E only on POD 2. There was no difference in the incidence of complications, the time to first postoperative evacuation was shorter in Group E, and postoperative hospitalization was similar. The time to surgery was shorter in Group O. CONCLUSION These results suggest that LAC without EDA is a feasible option, but with the early and regular use of adjunctive measures to provide more stable analgesia.
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Affiliation(s)
- Aya Kato
- Department of Gastroenterological Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, Kanagawa, 241-8515, Japan
- Department of Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Masakatsu Numata
- Department of Gastroenterological Surgery, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan.
| | - Shota Izukawa
- Department of Surgery, Saiseikai Yokohama Nanbu Hospital, 3-2-10 Konandai, Konan-ku, Yokohama, Kanagawa, 234-0054, Japan
| | - Takashi Ohgimi
- Department of Gastroenterological Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, Kanagawa, 241-8515, Japan
| | - Hironao Okamoto
- Department of Surgery, Hiratsuka Kyosai Hospital, 9-11 Oiwake, Hiratsuka, Kanagawa, 254-8502, Japan
| | - Yosuke Atsumi
- Department of Gastroenterological Surgery, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Keisuke Kazama
- Department of Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Masahiro Asari
- Department of Gastroenterological Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, Kanagawa, 241-8515, Japan
| | - Koji Numata
- Department of Gastroenterological Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, Kanagawa, 241-8515, Japan
| | - Sho Sawazaki
- Department of Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Takuo Watanabe
- Department of Surgery, Saiseikai Yokohama Nanbu Hospital, 3-2-10 Konandai, Konan-ku, Yokohama, Kanagawa, 234-0054, Japan
| | - Yo Mikayama
- Department of Gastroenterological Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, Kanagawa, 241-8515, Japan
| | - Teni Godai
- Department of Surgery, Fujisawa Shonandai Hospital, 2345 Takakura, Fujisawa, Kanagawa, 252-0802, Japan
| | - Akio Higuchi
- Department of Surgery, Yokohama Minami Kyosai Hospital, 1-21-1 Mutsuurahigasi, Kanazawa-ku, Yokohama, Kanagawa, 236-0037, Japan
| | - Hiroyuki Saeki
- Department of Surgery, Yokohama Minami Kyosai Hospital, 1-21-1 Mutsuurahigasi, Kanazawa-ku, Yokohama, Kanagawa, 236-0037, Japan
| | - Shinsuke Hatori
- Department of Surgery, Hiratsuka Kyosai Hospital, 9-11 Oiwake, Hiratsuka, Kanagawa, 254-8502, Japan
| | - Hiroyuki Mushiake
- Department of Surgery, Saiseikai Yokohama Nanbu Hospital, 3-2-10 Konandai, Konan-ku, Yokohama, Kanagawa, 234-0054, Japan
| | - Satomi Matsumoto
- Department of Surgery, Yokohama Minami Kyosai Hospital, 1-21-1 Mutsuurahigasi, Kanazawa-ku, Yokohama, Kanagawa, 236-0037, Japan
| | - Yasushi Rino
- Department of Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Aya Saito
- Department of Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Manabu Shiozawa
- Department of Gastroenterological Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, Kanagawa, 241-8515, Japan
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Riquoir C, Vela J, Lascano R, Urrejola G, Bellolio F, Molina ME, Miguieles R, Larach JT. Laparoscopic colon surgery: time to leave the urinary catheter in the operating room? Updates Surg 2024; 76:2655-2661. [PMID: 39465472 DOI: 10.1007/s13304-024-02023-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 10/16/2024] [Indexed: 10/29/2024]
Abstract
INTRODUCTION 'Fast track' guidelines have incorporated multimodal measures to optimize perioperative outcomes in surgery, with laparoscopy being a pivotal component for its advantages in early recovery. In this setting, current recommendations regarding the use of a urinary catheter suggest its removal within the first 24-hours postoperatively. However, few studies have assessed the feasibility of leaving the operating room without it. The purpose of this study is to compare the perioperative outcomes of patients undergoing elective laparoscopic colonic resections leaving the operating room with and without a urinary catheter. METHODS A retrospective study was conducted utilizing prospectively collected data from patients undergoing elective colon resections over a 17-month period. The patients were classified into two groups based on the presence or absence of a urinary catheter upon leaving the operating room, and subsequently, their perioperative outcomes were compared. RESULTS A total of 107 patients met the inclusion criteria (n = 28 with a urinary catheter and n = 79 without). Cancer was the most prevalent diagnosis (83.2%), and right hemicolectomy the most frequently performed surgery (32.7%). Two events of urinary catheter reinsertions were reported, both in the no-catheter group (0% vs 2.53%, p = 0.969), and there were no cases of urinary tract infections. The overall and severe complications rates exhibited no significant differences (25% vs. 26.6%, p = 1, and 7.14% vs. 5.06%, p = 1) and the length of stay was similar (p = 0.220). CONCLUSION Removing the urinary catheter before leaving the operating room appears to be safe and associated with very low rates of urinary retention in selected patients undergoing laparoscopic colonic or upper rectal resections.
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Affiliation(s)
- Christophe Riquoir
- Division of Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier Vela
- Colorectal Surgery Unit, Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Raquel Lascano
- Coordinator of the Optimized Recovery Program (PRO UC), Red Salud UC-Christus, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gonzalo Urrejola
- Colorectal Surgery Unit, Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Felipe Bellolio
- Colorectal Surgery Unit, Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - María Elena Molina
- Colorectal Surgery Unit, Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rodrigo Miguieles
- Colorectal Surgery Unit, Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - José Tomás Larach
- Colorectal Surgery Unit, Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Huang L, Zhang T, Wang K, Chang B, Fu D, Chen X. Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients. Pain Ther 2024; 13:745-766. [PMID: 38836984 PMCID: PMC11254899 DOI: 10.1007/s40122-024-00619-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/21/2024] [Indexed: 06/06/2024] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.
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Affiliation(s)
- Li Huang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Tianhao Zhang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Kaixin Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Bingcheng Chang
- The Second Affiliated Hospital of Guizhou, University of Traditional Chinese Medicine, Guiyang, 550003, China
| | - Daan Fu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Ministry of Education, Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Wuhan, China.
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Ministry of Education, Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Wuhan, China.
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Ciftci Y, Radomski SN, Johnson BA, Johnston FM, Greer JB. Adoption of an Enhanced Recovery After Surgery Protocol Increases Cost of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy and Does not Improve Outcomes. Ann Surg Oncol 2024; 31:5390-5399. [PMID: 38777898 DOI: 10.1245/s10434-024-15320-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 04/04/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay (LOS) and complications. The impact of ERAS protocols on the cost of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has not been studied. PATIENTS AND METHODS We performed a retrospective cohort analysis of patients undergoing CRS-HIPEC from 2016-2022 at a single quaternary center. Propensity score matching was used to create pre-and post-ERAS cohorts. Cost, overall and serious complications, and intensive care unit (ICU) length of stay (LOS) between the two cohorts were compared using the Mann-Whitney U-test for continuous variables and χ2 test for categorical variables. RESULTS Our final matched cohort consisted of 100 patients, with 50 patients in both the pre- and post-ERAS groups. After adjusting for patient complexity and inflation, the median total cost [$75,932 ($67,166-102,645) versus $92,992 ($80,720-116,710), p = 0.02] and operating room cost [$26,817 ($23,378-33,121) versus $34,434 ($28,085-$41,379), p < 0.001] were significantly higher in the post-ERAS cohort. Overall morbidity (n = 22, 44% versus n = 17, 34%, p = 0.40) and ICU length of stay [2 days (IQR 1-3) versus 2 days (IQR 1-4), p = 0.70] were similar between the two cohorts. A total cost increase of $22,393 [SE $13,047, 95% CI (-$3178 to $47,965), p = 0.086] was estimated after implementation of ERAS, with operating room cost significantly contributing to this increase [$8419, SE $1628, 95% CI ($5228-11,609), p < 0.001]. CONCLUSIONS CRS-HIPEC ERAS protocols were associated with higher total costs due to increased operating room costs at a single institution. There was no significant difference in ICU LOS and complications after the implementation of the ERAS protocol.
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Affiliation(s)
- Yusuf Ciftci
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Blake A Johnson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Abernethy EK, Aly EH. Postoperative Ileus after Minimally Invasive Colorectal Surgery: A Summary of Current Strategies for Prevention and Management. Dig Surg 2024; 41:79-91. [PMID: 38359801 PMCID: PMC11025667 DOI: 10.1159/000537805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 02/12/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Postoperative ileus (POI) is one of the most common postoperative complications after colorectal surgery and prolongs hospital stays. Minimally invasive surgery (MIS) has reduced POI, but it remains common. This review explores the current methods for preventing and managing POI after MIS. SUMMARY Preoperative interventions, including optimising nutrition, preoperative medicationn, and mechanical bowel preparation with oral antibiotics, may have a role in preventing POI. Transversus abdominis plane blocks and lidocaine could replace epidural analgesia in MIS. Fluid overload should be avoided; in some cases, goal-directed fluid therapy may aid in achieving this. Pharmacological agents, such as prucalopride and dexmedetomidine, could target mechanisms underlying POI. New strategies to stimulate vagal nerve activity may promote postoperative gastrointestinal motility. Preoperative bowel stimulation could potentially reduce POI following loop ileostomy closure. However, the evidence base for several interventions remains weak and requires further corroboration with robust studies. KEY MESSAGES Despite the increasing use of MIS, POI remains a major issue following colorectal surgery. Further strategies to prevent POI are rapidly emerging. Studies using standardised definitions and perioperative care will help validate these interventions and remove barriers to accurate meta-analysis. Future studies should focus on establishing the impact of these interventions on POI after MIS specifically.
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Affiliation(s)
| | - Emad H Aly
- University of Aberdeen, Aberdeen, UK
- Aberdeen Royal Infirmary, Aberdeen, UK
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Koch F, Green M, Dietrich M, Moikow L, Ritz JP. [The "Big Five" of Invasiveness - the Usefulness of Drains, Probes and Catheters in Colorectal Surgery]. Zentralbl Chir 2023; 148:406-414. [PMID: 34666401 DOI: 10.1055/a-1533-2612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The perioperative management of colorectal resections is often dominated by traditional procedures and a strong focus on safety. Evidence-based measures such as those established in Fast Track or ERAS programs, are rarely applied in a standardised manner. As part of elective colorectal surgery, many patients therefore continue to routinely receive central venous access, peridural catheters, urinary catheters, drains and/or gastric tubes ("Big Five" of invasiveness). This article presents the currently available evidence on these measures in colorectal surgery. In addition, results relating to the "Big Five" from the author's own centre are presented. This review shows that the "Big Five" of invasiveness are clinically unnecessary or supported by evidence. In addition, they often impair the patient's function.
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Affiliation(s)
- Franziska Koch
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Martina Green
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Melanie Dietrich
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Lutz Moikow
- Klinik für Anästhesiologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Jörg-Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Germany
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Koehler A, Koch F, El-Ahmar M, Ristig M, Lehmann K, Ritz JP. Necessity of routine perioperative epidural catheter placement in laparoscopic colorectal resections: a retrospective data analysis. Langenbecks Arch Surg 2023; 408:335. [PMID: 37624426 DOI: 10.1007/s00423-023-03074-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 08/17/2023] [Indexed: 08/26/2023]
Abstract
PURPOSE Whether epidural anesthesia leads to further improvement in the postoperative course of colorectal procedures is under discussion. The aim of this study was to evaluate the effects of minimally invasive colorectal oncological interventions without epidural anesthesia (EDA). METHODS This retrospective data analysis included the clinical data of all patients who underwent minimally invasive oncological colorectal resection at our clinic between January 2013 and April 2019. Of 385 patients who met the inclusion criteria, 183 (group I; 47.5% of 385) received EDA, and 202 (group II; 52.5% of 385) received transversus abdominis plane block instead. The relevant target parameters were evaluated and compared between the groups. The postoperative complications were graded according to the Clavien-Dindo classification. RESULTS The patients in group I (n=183; women, 77; men, 106; age 66.8 years) were younger (p=0.0035), received a urinary catheter more often (99.5% versus [vs.] 28.2% p<0.001), required longer, more frequent arterenol treatment (1.1 vs. 0.6 days; p<0.001), and had a longer intermediate care unit stay than those in group II (2.8 vs. 1.1 days; p<0.001). Postoperative pain levels were not significantly different between the groups (p=0.078). The patients in group I were able to ambulate later than those in group II (4 vs. 2 days; p<0.001). The difference in the postoperative day of the first defecation was not significant between the groups (p=0.236). The incidence of postoperative complications such as bleeding (p=0.396), anastomotic leaks (p=0.113), and wound infections (p=0.641) did not differ between the groups. The patients in group I had significantly longer hospital stays than those in group II (12.2 vs. 9.4 days; p<0.001). CONCLUSION EDA can be safely omitted from elective minimally invasive colorectal resections, and its omission is not accompanied by any relevant disadvantages to the patient.
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Affiliation(s)
- A Koehler
- Clinic for General and Visceral Surgery, Helios Clinics in Schwerin, University Campus of the MSH Medical School Hamburg, Wismarsche Strasse 393-397, Schwerin, 19055, Germany.
- Department of General and Visceral Surgery, Charité Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - F Koch
- Clinic for General and Visceral Surgery, Helios Clinics in Schwerin, University Campus of the MSH Medical School Hamburg, Wismarsche Strasse 393-397, Schwerin, 19055, Germany
| | - M El-Ahmar
- Clinic for General and Visceral Surgery, Helios Clinics in Schwerin, University Campus of the MSH Medical School Hamburg, Wismarsche Strasse 393-397, Schwerin, 19055, Germany
| | - M Ristig
- Clinic for General and Visceral Surgery, Helios Clinics in Schwerin, University Campus of the MSH Medical School Hamburg, Wismarsche Strasse 393-397, Schwerin, 19055, Germany
| | - K Lehmann
- Department of General and Visceral Surgery, Charité Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - J-P Ritz
- Clinic for General and Visceral Surgery, Helios Clinics in Schwerin, University Campus of the MSH Medical School Hamburg, Wismarsche Strasse 393-397, Schwerin, 19055, Germany
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11
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Owada Y, Murata Y, Hamaguchi Y, Yamada K, Inomata S, Ogawa K, Ohara Y, Akashi Y, Enomoto T, Maruo K, Tanaka M, Oda T. Comparison of postoperative analgesic effects of thoracic epidural analgesia and rectus sheath block in laparoscopic abdominal surgery: A randomized controlled noninferiority trial. Asian J Endosc Surg 2023; 16:423-431. [PMID: 36958287 DOI: 10.1111/ases.13180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/18/2023] [Accepted: 03/04/2023] [Indexed: 03/25/2023]
Abstract
INTRODUCTION In the Enhanced Recovery After Surgery program, abdominal wall blocks are strongly recommended as postoperative multimodal analgesia for laparoscopic abdominal surgery. The purpose of this study was to compare the efficacy of single-shot rectus sheath block (RSB) with that of thoracic epidural analgesia (TEA) as a method of multimodal analgesia in patients receiving conventional laparoscopic abdominal surgery. METHODS A noninferiority comparison was performed. Patients scheduled for laparoscopic gastric or colorectal surgery were enrolled in this study. Patients were divided randomly into two groups: TEA and RSB. The primary endpoint was the numerical rating scale (NRS) score upon coughing as of 24 hours after surgery. RESULTS In total, 80 patients were randomly assigned to receive TEA (n = 42) or RSB (n = 38). Three patients were excluded from the TEA group after randomization. The NRS score on coughing as of 24 hours after surgery was significantly lower in the TEA group than in the RSB group (least square mean: 3.59 vs 6.39; 95% confidence interval for the difference: 1.87 to 3.74, P < .001). The NRS scores upon coughing and at rest were significantly lower in the TEA group than in the RSB group as of 4, 24 and 48 hours after surgery. Patient satisfaction with postoperative analgesia was significantly higher in the TEA group. Postoperative adverse events were not significantly different between groups. CONCLUSION This is the first report of comparing RSB with TEA in laparoscopic surgery. TEA may be recommended as a multimodal analgesia protocol for laparoscopic gastric and colorectal surgery.
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Affiliation(s)
- Yohei Owada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yuya Murata
- Department of Anesthesiology, University of Tsukuba Hospital, 2-1-1 Amakubo, Tsukuba, Ibaraki, 305-8576, Japan
| | - Yuto Hamaguchi
- Department of Anesthesiology, University of Tsukuba Hospital, 2-1-1 Amakubo, Tsukuba, Ibaraki, 305-8576, Japan
| | - Kumiko Yamada
- Department of Anesthesiology, University of Tsukuba Hospital, 2-1-1 Amakubo, Tsukuba, Ibaraki, 305-8576, Japan
| | - Shinichi Inomata
- Department of Anesthesiology, Institution of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Koichi Ogawa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yusuke Ohara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yosihimasa Akashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tsuyoshi Enomoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kazushi Maruo
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Makoto Tanaka
- Department of Anesthesiology, Institution of Clinical Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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12
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Falcone F, Laganà AS, Casarin J, Chiofalo B, Barra F, Garzon S, Ghezzi F, Vizza E, Malzoni M. Evaluation of Peri-Operative Management in Women with Deep Endometriosis Who are Candidates for Bowel Surgery: A Survey from the Italian Society of Gynecologic Endoscopy. J Minim Invasive Gynecol 2023; 30:462-472. [PMID: 36754274 DOI: 10.1016/j.jmig.2023.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/28/2023] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
STUDY OBJECTIVE There is great consensus that the implementation of the enhanced recovery after surgery (ERAS) approach is beneficial for surgical patients, but there is a paucity of data concerning its application in women with deep endometriosis (DE) who are candidates for bowel surgery. The survey described herein was aimed at gathering detailed information on perioperative management of DE patients who were undergoing sigmoid/rectal (discoid or segmental) resection within the Italian Society of Gynecologic Endoscopy (SEGI) group. DESIGN Baseline survey. SETTING National survey conducted within the main Italian cooperative group in minimally invasive gynecologic surgery (SEGI). PATIENTS The study did not involve patients. INTERVENTIONS A 63-item questionnaire covering ERAS items for gynecologic/elective colorectal surgery was sent to SEGI centers. Only questionnaires from centers that reported performing ≥10 sigmoid/rectal resections per year were considered for this analysis. MEASUREMENTS AND MAIN RESULTS Thirty-three of 38 (86.8%) of the questionnaires were analyzed. The rates of concordance with the ERAS guidelines were 40.4%, 64.4%, and 62.6% for preoperative, intraoperative, and postoperative items, respectively. The proportion of overall agreement was 56.6%. Preoperative diet, fasting and bowel preparation, correction of anemia, avoidance of peritoneal drains, postoperative feeding, and early mobilization were the most controversial items. Comparative analysis revealed that the referred rates of complete disease removal and conversion to open surgery were significantly different depending on case volume (p = .044 and p = .003, respectively) and gynecologist's/surgeon's experience (p = .042 and p = .022, respectively), with higher chances of obtaining a complete laparoscopic/robotic excision of endometriosis in centers that reported ≥30 DE surgeries performed per year and/or ≥90% of bowel resections performed by a gynecologist/general surgeon specifically dedicated to DE management. In contrast, the rates of concordance with the ERAS guidelines were not significantly different according to case volume (p = .081) or gynecologist's/surgeon's experience (p = .294). CONCLUSION This is the first study on DE conducted on a national scale. The current survey results revealed suboptimal compliance with the ERAS recommendations and underline the need to improve the quality of perioperative care in DE patients undergoing sigmoid/rectal resection. This study is a first step toward building a consistent, structured reporting platform for the SEGI units and facilitating wide implementation and standardization of the ERAS protocol for DE patients in Italy.
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Affiliation(s)
- Francesca Falcone
- Endoscopica Malzoni, Center for Advanced Endoscopic Gynecologic Surgery, Avellino, Italy (Dr. Falcone and Dr. Malzoni).
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, ARNAS "Civico-Di Cristina-Benfratelli," University of Palermo, Palermo, Italy (Dr. Laganà)
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy (Dr. Casarin and Dr. Ghezzi)
| | - Benito Chiofalo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy (Dr. Chiofalo and Dr. Vizza)
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Metropolitan Area of Genoa, Genoa, Italy (Dr. Barra); Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy (Dr. Barra)
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy (Dr. Garzon)
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy (Dr. Casarin and Dr. Ghezzi)
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy (Dr. Chiofalo and Dr. Vizza)
| | - Mario Malzoni
- Endoscopica Malzoni, Center for Advanced Endoscopic Gynecologic Surgery, Avellino, Italy (Dr. Falcone and Dr. Malzoni)
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13
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Levy BE, Castle JT, Ebbitt LM, Kennon C, McAtee E, Davenport DL, Evers BM, Bhakta A. Opioid Use After Colorectal Resection: Identifying Preoperative Risk Factors for Postoperative Use. J Surg Res 2023; 283:296-304. [PMID: 36423479 DOI: 10.1016/j.jss.2022.10.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Appropriate prescribing practices are imperative to ensure adequate pain control, without excess opioid dispensing across colorectal patients. METHODS National Surgical Quality Improvement Program, Kentucky All Scheduled Prescription Electronic Reporting, and patient charts were queried to complete a retrospective study of elective colorectal resections, performed by a fellowship-trained colorectal surgeon, from January 2013 to December 2020. Opioid use at 14 d and 30 d posthospital discharge converted into morphine milligram equivalents (MMEs) were analyzed and compared across preadmission and inpatient factors. RESULTS One thousand four hundred twenty seven colorectal surgeries including 56.1% (N = 800) partial colectomy, 24.1% (N = 344) low anterior resection, 8.3% (N = 119) abdominoperineal resection, 8.4% (N = 121) sub/total colectomy, and 3.0% (N = 43) total proctocolectomy. Abdominoperineal resection and sub/total colectomy patients had higher 30-day postdischarge MMEs (P < 0.001, P = 0.041). An operative approach did not affect postdischarge MMEs (P = 0.440). Trans abdominal plane blocks do not predict postdischarge MMEs (0.616). Epidural usage provides a 15% increase in postdischarge MMEs (P = 0.020). Age (P < 0.001), smoking (P < 0.001), chronic obstructive pulmonary disease (P = 0.006, < 0.001), dyspnea (P = 0.001, < 0.001), albumin < 3.5 (P = 0.085, 0.010), disseminated cancer (P = 0.018, 0.001), and preadmission MMEs (P < 0.001) predict elevated 14-day and 30-day postdischarge MMEs. CONCLUSIONS We conclude that perioperative analgesic procedures, as enhanced recovery pathway suggests, are neither predictive nor protective of postoperative discharge MMEs in colorectal surgery. Provider should account for preoperative risk factors when prescribing discharge opioid medications. Furthermore, providers should identify appropriate adjunct procedures to improve discharge opioid prescription stewardship.
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Affiliation(s)
- Brittany E Levy
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky
| | - Jennifer T Castle
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky
| | - Laura M Ebbitt
- College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Caleb Kennon
- Department of Anesthesiology Residency Program, University of Kentucky, Lexington, Kentucky
| | - Erin McAtee
- Division of UK Healthcare Outcomes and Optimal Patient Services, University of Kentucky, Lexington, Kentucky
| | - Daniel L Davenport
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Division of UK Healthcare Outcomes and Optimal Patient Services, University of Kentucky, Lexington, Kentucky
| | - B Mark Evers
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Avinash Bhakta
- Department of Surgery, General Surgery Residency Program, University of Kentucky, Lexington, Kentucky; Division of Colon and Rectal Surgery, University of Kentucky, Lexington, Kentucky.
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14
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Cox PBW, Pisters TPRM, de Korte-de Boer D, Pennings CH, Melenhorst J, Buhre WFFA. Thoracic epidural analgesia vs. patient-controlled intravenous analgesia for patients undergoing open or laparoscopic colorectal cancer surgery: An observational study. EUROPEAN JOURNAL OF ANAESTHESIOLOGY AND INTENSIVE CARE 2023; 2:e0013. [PMID: 39916756 PMCID: PMC11783615 DOI: 10.1097/ea9.0000000000000013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/09/2025]
Abstract
BACKGROUND Thoracic epidural analgesia (TEA) is an invasive technique with potential side effects but is widely used in enhanced recovery after surgery (ERAS) programmes in colorectal cancer surgery. The effects of TEA on postoperative length of hospital stay (LOS) or morbidity is still debated. OBJECTIVES The main objective was to evaluate the postoperative analgesic effectiveness of TEA compared with patient-controlled intravenous analgesia (PCIA) after open or laparoscopic colorectal surgery, and whether TEA contributes to enhanced recovery. DESIGN A retrospective single-centre, observational study. SETTING Dutch tertiary-care university hospital. PATIENTS All consecutive adult patients undergoing colorectal cancer surgery from 1 January 2014 to 31 December 2016, with ASA status I-IV, were included. Exclusion criteria were hypersensitivity to opioid or local anaesthetic substances, or the use of multiple secondary anaesthetic techniques. MAIN OUTCOME MEASURES The primary outcome, postoperative pain assessed with a Numeric Rating Scale on postoperative days 1 to 3 inclusive. Secondary endpoints were LOS, the incidence of epidural related side effects, major complications and the 5-year survival rate. Using linear mixed models, pain scores were compared between patients who received TEA and PCIA. RESULTS Of 422 enrolled patients, 110 (32%) received TEA and 234 (68%) PCIA. Patients in the TEA group had lower pain scores: estimated NRS difference at rest; -0.79; 95% CI, -1.1 to -0.49; P < 0.001 and during movement -1.06; 95% CI, -1.39 to -0.73; P < 0.001. LOS, 30-day complication rate and overall survival at 5 years did not differ between the groups. CONCLUSIONS TEA in open or laparoscopic colorectal surgery is associated with moderately better postoperative pain control but does not affect LOS, postoperative morbidity, mortality nor long-term survival. The current clinical indication for TEA in colorectal surgery remains unchanged. TRIAL REGISTRATION International clinical trial registration number: ISRCTN11426678; retrospectively registered 26 February 2021.
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Affiliation(s)
- P Boris W Cox
- From the Department of Anaesthesiology and Pain Medicine (PBWC, TPRMP, D deK deB, CHP, WFFAB), and the Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands (JM)
| | - Tom P R M Pisters
- From the Department of Anaesthesiology and Pain Medicine (PBWC, TPRMP, D deK deB, CHP, WFFAB), and the Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands (JM)
| | - Dianne de Korte-de Boer
- From the Department of Anaesthesiology and Pain Medicine (PBWC, TPRMP, D deK deB, CHP, WFFAB), and the Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands (JM)
| | - Christoph H Pennings
- From the Department of Anaesthesiology and Pain Medicine (PBWC, TPRMP, D deK deB, CHP, WFFAB), and the Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands (JM)
| | - Jarno Melenhorst
- From the Department of Anaesthesiology and Pain Medicine (PBWC, TPRMP, D deK deB, CHP, WFFAB), and the Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands (JM)
| | - Wolfgang F F A Buhre
- From the Department of Anaesthesiology and Pain Medicine (PBWC, TPRMP, D deK deB, CHP, WFFAB), and the Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands (JM)
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15
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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16
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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17
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Schmidt AP, Bevilacqua Filho CT. The impact of anesthesia on postoperative outcomes: the effect of regional anesthesia on the incidence of surgical site infections. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:1-2. [PMID: 36709076 PMCID: PMC9995259 DOI: 10.1016/j.bjane.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- André P Schmidt
- Hospital de Clínicas de Porto Alegre (HCPA), Serviço de Anestesia e Medicina Perioperatória, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Instituto de Ciências Básicas da Saúde (ICBS), Departamento de Bioquímica, Porto Alegre, RS, Brazil; Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Santa Casa de Porto Alegre, Serviço de Anestesia, Porto Alegre, RS, Brazil; Hospital Nossa Senhora da Conceição, Serviço de Anestesia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Medicina, Programa de Pós-graduação em Ciências Pneumológicas, Porto Alegre, RS, Brazil; Faculdade de Medicina da Universidade de São Paulo (FMUSP), Programa de Pós-Graduação em Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, São Paulo, SP, Brazil.
| | - Clóvis T Bevilacqua Filho
- Hospital de Clínicas de Porto Alegre (HCPA), Serviço de Anestesia e Medicina Perioperatória, Porto Alegre, RS, Brazil
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Hirano Y, Kaneko H, Konishi T, Itoh H, Matsuda S, Kawakubo H, Uda K, Matsui H, Fushimi K, Daiko H, Itano O, Yasunaga H, Kitagawa Y. Short-Term Outcomes of Epidural Analgesia in Minimally Invasive Esophagectomy for Esophageal Cancer: Nationwide Inpatient Data Study in Japan. Ann Surg Oncol 2022; 29:8225-8234. [PMID: 35960454 DOI: 10.1245/s10434-022-12346-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/12/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Studies have shown that epidural analgesia (EDA) is associated with a decreased risk of pneumonia and anastomotic leakage after esophagectomy, and several guidelines strongly recommend EDA use after esophagectomy. However, the benefit of EDA use in minimally invasive esophagectomy (MIE) remains unclear. OBJECTIVE The aim of this retrospective study was to compare the short-term outcomes between patients with and without EDA undergoing MIE for esophageal cancer. METHODS Data of patients who underwent oncologic MIE (April 2014-March 2019) were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting (IPTW), propensity score matching, and instrumental variable analyses were performed to investigate the associations between EDA use and short-term outcomes, adjusting for potential confounders. RESULTS Among 12,688 eligible patients, EDA was used in 9954 (78.5%) patients. In-hospital mortality, respiratory complications, and anastomotic leakage occurred in 230 (1.8%), 2139 (16.9%), and 1557 (12.3%) patients, respectively. In stabilized IPTW, EDA use was significantly associated with decreased in-hospital mortality (odds ratio [OR] 0.46 [95% confidence interval 0.34-0.61]), respiratory complications (OR 0.74 [0.66-0.84]), and anastomotic leakage (OR 0.77 [0.67-0.88]). EDA use was also associated with decreased prolonged mechanical ventilation, unplanned intubation, nonsteroidal anti-inflammatory drug use, acetaminophen use, postoperative length of stay, and total hospitalization costs and increased vasopressor use. One-to-three propensity score matching and instrumental variable analyses demonstrated equivalent results. CONCLUSIONS EDA use in oncologic MIE was associated with low in-hospital mortality as well as decreased respiratory complications, and anastomotic leakage, suggesting the potential advantage of EDA use in MIE.
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Affiliation(s)
- Yuki Hirano
- Department of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan.
| | - Hidehiro Kaneko
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hidetaka Itoh
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazuaki Uda
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Osamu Itano
- Department of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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19
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Holtz M, Liao N, Lin JH, Asche CV. Economic Outcomes and Incidence of Postsurgical Hypotension With Liposomal Bupivacaine vs Epidural Analgesia in Abdominal Surgeries. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2022; 9:86-94. [PMID: 36168593 PMCID: PMC9473799 DOI: 10.36469/001c.37739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/09/2022] [Indexed: 06/16/2023]
Abstract
Background: Epidural analgesia can be associated with high costs and postsurgical risks such as hypotension, despite its widespread use and value in providing opioid-sparing pain management. We tested the hypothesis that liposomal bupivacaine (LB) might be a reliable alternative to epidural analgesia in this real-world study. Objectives: To compare economic outcomes and hypotension incidence associated with use of LB and epidural analgesia for abdominal surgery. Methods: This retrospective analysis identified records of adults who underwent abdominal surgeries between January 2016 and September 2019 with either LB administration or traditional epidural analgesia using the Premier Healthcare Database. Economic outcomes included length of stay, hospital costs, rates of discharge to home, and 30-day hospital readmissions. Secondary outcomes included incidence of postsurgical hypotension and vasopressor use. Subgroup analyses were stratified by surgical procedure (colorectal, abdominal) and approach (endoscopic, open). A generalized linear model adjusted for patient and hospital characteristics was used for all comparisons. Results: A total of 5799 surgical records (LB, n=4820; epidural analgesia, n=979) were included. Compared with cases where LB was administered, cases of epidural analgesia use were associated with a 1.6-day increase in length of stay (adjusted rate ratio [95% confidence interval (CI), 1.2 [1.2-1.3]]; P<.0001) and $6304 greater hospital costs (adjusted rate ratio [95% CI], 1.2 [1.2-1.3]]; P<.0001). Cost differences were largely driven by room-and-board fees. Epidural analgesia was associated with reduced rates of discharge to home (P<.0001) and increased 30-day readmission rates (P=.0073) compared with LB. Epidural analgesia was also associated with increased rates of postsurgical hypotension (30% vs 11%; adjusted odds ratio [95% CI], 2.8 [2.3-3.4]; P<.0001) and vasopressor use (22% vs 7%; adjusted odds ratio [95% CI], 3.1 [2.5-4.0]; P<.0001) compared with LB. Subgroup analyses by surgical procedure and approach were generally consistent with overall comparisons. Discussion: Our results are consistent with previous studies that demonstrated epidural analgesia can be associated with higher utilization of healthcare resources and complications compared with LB. Conclusions: Compared with epidural analgesia, LB was associated with economic benefits and reduced incidence of postsurgical hypotension and vasopressor use.
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Affiliation(s)
| | - Nick Liao
- Pacira Biosciences, Inc, Parsippany, New Jersey
| | | | - Carl V Asche
- Department of Internal Medicine, University of Illinois College of Medicine, Peoria, Illinois
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20
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El-Ahmar M, Koch F, Köhler A, Moikow L, Ristig M, Ritz JP. Laparoscopic rectal resection without epidural catheters-does it work? Int J Colorectal Dis 2022; 37:2031-2040. [PMID: 36001167 DOI: 10.1007/s00384-022-04242-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Placement of an epidural catheter (EC) in colorectal resections is still recommended as a valid measure to achieve a low level of pain. However, EC is associated with increased invasiveness and with an increased risk of bladder emptying disorders and a decrease in blood pressure, which all relate to delayed mobilization. Preliminary data shows that EC placement may not be necessary for laparoscopic colon resections. The aim of this prospective study was to investigate how the omission of EC placement influences short-term postoperative outcomes in laparoscopic rectal resections. METHODS All laparoscopic rectal resections occurring between 2013 and 2020 were prospectively examined. Resections from January 2013 to February 2018 (group A) were compared with resections from March 2018 to December 2020 (group B; after the internal change of the perioperative pain regime). In addition to EC placement, the other target parameters of our study were urinary catheter placement during the inpatient stay, postoperative pain > 3 days on a numerical rating scale (NRS), mobilization in the first 5 postoperative days, time until the first postoperative bowel movement, postoperative complications according to Clavien-Dindo, intermediate care unit stay (IMC stay) in days, and hospital length of stay in days. RESULTS In the entire study period, 221 laparoscopic rectal resections were performed: 122 in group A and 99 resections in group B. The frequency of EC placement and urinary catheter placement, postoperative IMC stay, and hospital length of stay was significantly lower in group B (p < 0.05). The postoperative mobilization of patients in group B was possible more quickly. There were no differences in the level of pain, time until the first postoperative bowel movement, and postoperative complications according to Clavien-Dindo. CONCLUSION Omission of EC placement in laparoscopic rectal resections led to faster mobilization, a shorter IMC stay, and a shorter hospital stay without increasing the pain level. Postoperative complications did not change when an EC was not placed. Therefore, routine EC placement in laparoscopic rectal resections is unnecessary.
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Affiliation(s)
- M El-Ahmar
- Department of General and Visceral Surgery, Helios Kliniken Schwerin, 19055, Schwerin, Germany.
| | - F Koch
- Department of General and Visceral Surgery, Helios Kliniken Schwerin, 19055, Schwerin, Germany
| | - A Köhler
- Department of General and Visceral Surgery, Helios Kliniken Schwerin, 19055, Schwerin, Germany
| | - L Moikow
- Department of Anesthesiology, Helios Kliniken Schwerin, 19055, Schwerin, Germany
| | - M Ristig
- Department of General and Visceral Surgery, Helios Kliniken Schwerin, 19055, Schwerin, Germany
| | - J-P Ritz
- Department of General and Visceral Surgery, Helios Kliniken Schwerin, 19055, Schwerin, Germany
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21
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Pirie K, Traer E, Finniss D, Myles PS, Riedel B. Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions. Br J Anaesth 2022; 129:378-393. [PMID: 35803751 DOI: 10.1016/j.bja.2022.05.029] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/27/2022] [Accepted: 05/28/2022] [Indexed: 11/02/2022] Open
Abstract
Poorly controlled postoperative pain is associated with increased morbidity, negatively affects quality of life and functional recovery, and is a risk factor for persistent pain and longer-term opioid use. Up to 10% of opioid-naïve patients have persistent opioid use after many types of surgeries. Opioid-related side-effects and the opioid abuse epidemic emphasise the need for alternative, opioid-minimising, multimodal analgesic strategies, including neuraxial (epidural/intrathecal) techniques, truncal nerve blocks, and lidocaine infusions. The preference for minimally invasive surgical techniques has changed anaesthetic and analgesic requirements in abdominal surgery compared with open laparotomy, leading to a decline in popularity of epidural anaesthesia and an increasing interest in intrathecal morphine and truncal nerve blocks. Limited research exists on patient quality of recovery using specific analgesic techniques after intra-abdominal surgery. Poorly controlled postoperative pain after major abdominal surgery should be a research priority as it affects patient-centred short-term and long-term outcomes (including quality of life scores, return to function measurements, disability-free survival) and has broad community health and economic implications.
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Affiliation(s)
- Katrina Pirie
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - Emily Traer
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Damien Finniss
- Department of Anaesthesia & Pain Management, Royal North Shore Hospital, Sydney, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
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22
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Bajracharya GR, Esa WAS, Mao G, Leung S, Cohen B, Maheshwari K, Kessler HP, Gorgun E, Sessler DI, Turan A. Regional analgesia and surgical site infections after colorectal surgery: a retrospective cohort analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 73:10-15. [PMID: 35803369 PMCID: PMC9801205 DOI: 10.1016/j.bjane.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 06/09/2022] [Accepted: 06/15/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The effect of regional analgesia on perioperative infectious complications remains unknown. We therefore tested the hypothesis that a composite of serious infections after colorectal surgery is less common in patients with regional analgesia than in those given Intravenous Patient-Controlled Analgesia (IV-PCA) with opiates. METHODS Patients undergoing elective colorectal surgery lasting one hour or more under general anesthesia at the Cleveland Clinic Main Campus between 2009 and 2015 were included in this retrospective analysis. Exposures were defined as regional postoperative analgesia with epidurals or Transversus Abdominis Plane blocks (TAP); or IV-PCA with opiates only. The outcome was defined as a composite of in-hospital serious infections, including intraabdominal abscess, pelvic abscess, deep or organ-space Surgical Site Infection (SSI), clostridium difficile, pneumonia, or sepsis. Logistic regression model adjusted for the imbalanced potential confounding factors among the subset of matched surgeries was used to report the odds ratios along with 95% confidence limits. The significance criterion was p < 0.05. RESULTS A total of 7811 patients met inclusion and exclusion criteria of which we successfully matched 681 regional anesthesia patients to 2862 IV-PCA only patients based on propensity scores derived from potential confounding factors. There were 82 (12%) in-hospital postoperative serious infections in the regional analgesia group vs. 285 (10%) in IV-PCA patients. Regional analgesia was not significantly associated with serious infection (odds ratio: 1.14; 95% Confidence Interval 0.87‒1.49; p-value = 0.339) after adjusting for surgical duration and volume of intraoperative crystalloids. CONCLUSION Regional analgesia should not be selected as postoperative analgesic technique to reduce infections.
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Affiliation(s)
- Gausan Ratna Bajracharya
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Cleveland Clinic, Anesthesiology Institute, Departments of General Anesthesia, Cleveland, USA
| | - Wael Ali Sakr Esa
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Cleveland Clinic, Anesthesiology Institute, Departments of General Anesthesia, Cleveland, USA
| | - Guangmei Mao
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Cleveland Clinic, Departments of Quantitative Health Science, Cleveland, USA
| | - Steve Leung
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Metro Health, Department of Radiology, Cleveland, USA
| | - Barak Cohen
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Tel-Aviv University, Sackler Faculty of Medicine, Tel-Aviv Medical Center, Division of Anesthesia, Critical Care, and Pain Management, Tel-Aviv, Israel
| | - Kamal Maheshwari
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA,Cleveland Clinic, Anesthesiology Institute, Departments of General Anesthesia, Cleveland, USA
| | | | - Emre Gorgun
- Cleveland Clinic, Department of Colorectal Surgery, Cleveland, USA
| | - Daniel I. Sessler
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA
| | - Alparslan Turan
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Departments of General Anesthesia, Cleveland, USA.
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23
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Jayaprabhu NB, Avula J, Chandy TT, Varghese G, Yadav B, Rebekah G. A Randomized Controlled Trial Comparing Intravenous Lidocaine Infusion With Thoracic Epidural for Perioperative Analgesia and Quality of Recovery After Surgery in Laparoscopic Left-Sided Colon and Sphincter-Sparing Rectal Resection Surgery. Cureus 2022; 14:e23758. [PMID: 35509732 PMCID: PMC9059900 DOI: 10.7759/cureus.23758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2022] [Indexed: 11/12/2022] Open
Abstract
Background Protocols for Enhanced Recovery after Surgery (ERAS) have been constantly evolving, and the best method of managing perioperative pain, especially in laparoscopic surgeries, is still debatable. The primary goal of these protocols is to steer toward opioid-sparing analgesia. Intravenous lidocaine, which has both analgesic and anti-inflammatory properties, may improve the overall recovery of patients. Objectives The aim of this randomized controlled trial was to compare the efficacy of intravenous lidocaine infusion (IVL) with thoracic epidural analgesia (TEA) in the management of perioperative pain and recovery in the laparoscopic left-sided colon and sphincter-sparing rectal surgery. Methods In this study, 37 patients were randomized to either the IVL group or the TEA group. IVL infusion was started before the surgical incision and stopped 30 minutes after transferring the patient to the postanesthesia care unit (PACU). Postoperative pain scores, opioid consumption, rescue analgesic doses, quality of recovery scores, time to discharge, and adverse events were recorded prospectively. Data were analyzed using two independent sample t-test and paired t-test, with p < 0.05 taken as statistically significant. Results The mean difference of overall NRS (numerical rating scale) pain scores in the ward was significantly higher in the IVL group as compared to the TEA group, which was 3.58 (2.29) vs 2.23 1.95) (p < 0.001). The IVL group required more mean rescue opioid boluses than the TEA group, which was 11.36 (8.684) vs 5.96 (6.215) (p < 0.001). However, both IVL and TEA groups had similar pain scores intraoperatively and in the PACU. Conclusions TEA provides better analgesia and decreased opioid requirements compared to intravenous lidocaine during the 24-hour period in the ward after laparoscopic left-sided colon and sphincter-sparing rectal surgery, although there was no difference in the quality of recovery between IVL and TEA groups.
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Affiliation(s)
| | - Jyothi Avula
- Anaesthetics, New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton, GBR
- Department of Anaesthesiology, Christian Medical College Vellore, Vellore, IND
| | - Tony T Chandy
- Department of Anaesthesiology, Christian Medical College Vellore, Vellore, IND
| | - Gigi Varghese
- Department of Colorectal Surgery, Royal Stoke University Hospital (RSUH) University Hospitals of North Midlands NHS Trust (UHNM), Stoke On Trent, GBR
- Department of Colorectal Surgery, Christian Medical College Vellore, Vellore, IND
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical College Vellore, Vellore, IND
| | - Grace Rebekah
- Department of Biostatistics, Christian Medical College Vellore, Vellore, IND
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24
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Toh JWT, Collins GP, Pathma-Nathan N, El-Khoury T, Engel A, Smith S, Richardson A, Ctercteko G. Attitudes towards Enhanced Recovery after Surgery (ERAS) interventions in colorectal surgery: nationwide survey of Australia and New Zealand colorectal surgeons. Langenbecks Arch Surg 2022; 407:1637-1646. [PMID: 35275247 PMCID: PMC9283181 DOI: 10.1007/s00423-022-02488-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 03/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Whilst Enhanced Recovery after Surgery (ERAS) has been widely accepted in the international colorectal surgery community, there remains significant variations in ERAS programme implementations, compliance rates and best practice recommendations in international guidelines. METHODS A questionnaire was distributed to colorectal surgeons from Australia and New Zealand after ethics approval. It evaluated specialist attitudes towards the effectiveness of specific ERAS interventions in improving short term outcomes after colorectal surgery. The data were analysed using a rating scale and graded response model in item response theory (IRT) on Stata MP, version 15 (StataCorp LP, College Station, TX). RESULTS Of 300 colorectal surgeons, 95 (31.7%) participated in the survey. Of eighteen ERAS interventions, this study identified eight strategies as most effective in improving ERAS programmes alongside early oral feeding and mobilisation. These included pre-operative iron infusion for anaemic patients (IRT score = 7.82 [95% CI: 6.01-9.16]), minimally invasive surgery (IRT score = 7.77 [95% CI: 5.96-9.07]), early in-dwelling catheter removal (IRT score = 7.69 [95% CI: 5.83-9.01]), pre-operative smoking cessation (IRT score = 7.68 [95% CI: 5.49-9.18]), pre-operative counselling (IRT score = 7.44 [95% CI: 5.58-8.88]), avoiding drains in colon surgery (IRT score = 7.37 [95% CI: 5.17-8.95]), avoiding nasogastric tubes (IRT score = 7.29 [95% CI: 5.32-8.8]) and early drain removal in rectal surgery (IRT score = 5.64 [95% CI: 3.49-7.66]). CONCLUSIONS This survey has demonstrated the current attitudes of colorectal surgeons from Australia and New Zealand regarding ERAS interventions. Eight of the interventions assessed in this study including pre-operative iron infusion for anaemic patients, minimally invasive surgery, early in-dwelling catheter removal, pre-operative smoking cessation, pre-operative counselling, avoidance of drains in colon surgery, avoiding nasogastric tubes and early drain removal in rectal surgery should be considered an important part of colorectal ERAS programmes.
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Affiliation(s)
- James Wei Tatt Toh
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia. .,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia.
| | - Geoffrey Peter Collins
- Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia.,The University of Notre Dame, Sydney, Australia
| | - Nimalan Pathma-Nathan
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia
| | - Toufic El-Khoury
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia.,The University of Notre Dame, Sydney, Australia
| | - Alexander Engel
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Royal North Shore Hospital, Sydney, Australia
| | - Stephen Smith
- Colorectal Department, John Hunter Hospital, Newcastle, Australia
| | - Arthur Richardson
- Upper Gastrointestinal Department, Westmead Hospital, Sydney, Australia
| | - Grahame Ctercteko
- Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, Australia.,Colorectal Department, Division of Surgery and Anaesthetics, Westmead Hospital, Cnr Hawkesbury and Darcy Rd, Westmead, Sydney, NSW, 2145, Australia
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25
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Cheung CK, Adeola JO, Beutler SS, Urman RD. Postoperative Pain Management in Enhanced Recovery Pathways. J Pain Res 2022; 15:123-135. [PMID: 35058714 PMCID: PMC8765537 DOI: 10.2147/jpr.s231774] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/30/2021] [Indexed: 12/05/2022] Open
Abstract
Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.
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Affiliation(s)
- Christopher K Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet O Adeola
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sascha S Beutler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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26
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Kumar L, Jayadevan D, Varghese R, Balakrishnan S, Shyamsundar P, Kesavan R. Evaluation of analgesic effects and hemodynamic responses of epidural ropivacaine in laparoscopic abdominal surgeries: Randomised controlled trial. J Anaesthesiol Clin Pharmacol 2022; 38:245-251. [PMID: 36171946 PMCID: PMC9511868 DOI: 10.4103/joacp.joacp_153_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 04/09/2021] [Accepted: 05/14/2021] [Indexed: 11/04/2022] Open
Abstract
Background and Aims: The role of epidural analgesia in laparoscopic surgeries remains controversial. We evaluated intraoperative analgesic effects of epidural ropivacaine versus intravenous fentanyl in laparoscopic abdominal surgery and assessed postoperative analgesic requirements, hemodynamic changes, time to ambulation, and length of stay (LOS) in the ICU. Material and Methods: Seventy-two American Society of Anesthesiologists physical status I–III adult patients undergoing elective laparoscopic abdominal surgeries were randomized to either 0.5 mg/kg/h intravenous fentanyl (Group C) or 0.2% epidural ropivacaine at 5–8 mL/h (Group E) infusions intraoperatively and 0.25 m/kg/h fentanyl and 0.1% epidural ropivacaine infusions respectively postoperatively. Variations in mean arterial pressure (MAP) of 20% from baseline were points of intervention for propofol and analgesia with fentanyl or vasopressors. The number of interventions and total doses of fentanyl and vasopressors were noted. Postoperative analgesia was assessed at 0, 6, 12, and 24 h and when pain was reported with numerical rating scale and objective pain scores. Chi-square test and Student’s t-test were used for categorical and continuous variable analysis. Results: Intraoperatively, 14 patients versus 4 needed additional fentanyl and 26 versus 14 needed additional propofol in groups C and E respectively (P = 0.007, P = 0.004). MAP at 0, 6 and 18 h was lower in Group E. Pain scores were better in Group E at 6,18, and 24 h postoperatively. Time to ambulation was comparable but LOS ICU was prolonged in Group E (P = 0.05) Conclusion: Epidural ropivacaine produces superior intraoperative analgesia and improved postoperative pain scores without affecting ambulation but increases vasopressor need and LOS ICU in comparison with intravenous fentanyl in laparoscopic abdominal surgeries.
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27
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Daghmouri MA, Chaouch MA, Oueslati M, Rebai L, Oweira H. Regional techniques for pain management following laparoscopic elective colonic resection: A systematic review. Ann Med Surg (Lond) 2021; 72:103124. [PMID: 34925820 PMCID: PMC8648937 DOI: 10.1016/j.amsu.2021.103124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Pain management is an integral part of Enhanced Recovery After Surgery (ERAS) following laparoscopic colonic resection. A variety of regional and neuraxial techniques were proposed, but their efficacy is still controversial. This systematic review evaluates published evidence on analgesic techniques and their impact on postoperative analgesia and recovery for laparoscopic colonic surgery patients. Methods We conducted bibliographic research on May 10, 2021, through PubMed, Cochrane database, and Google scholar. We retained meta-analysis and randomized clinical trials. We graded the strength of clinical data and subsequent recommendations according to the Oxford Centre for Evidence-Based Medicine. Results Twelve studies were included. Thoracic epidural analgesia improved postoperative analgesia and bowel function following laparoscopic colectomy. However, it lengthens the hospital stay. Transversus abdominis plane block was as effective as thoracic epidural analgesia concerning pain control but with better postoperative recovery and lower length of hospital stay. Moreover, Lidocaine intravenous infusion improved postoperative pain management and recovery; Quadratus lumborum block provided similar postoperative analgesia and recovery. Finally, wound infiltration reduced postoperative pain without improving recovery of bowel function, and it could be proposed as an alternative to thoracic epidural analgesia. Conclusions Several analgesic techniques have been investigated. We found that abdominal wall blocks were as effective as thoracic epidural analgesia for pain management but with lower hospital stay and better recovery. We registered this review on PROSPERO (ID: CRD42021279228).
First systematic review assessing the efficacy of analgesic techniques following laparoscopic elective colonic resection. Only colonic resection was evaluated contrary to other studies, including rectal surgery. High-quality studies (randomized controlled trials and meta-analyses) were assessed.
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Affiliation(s)
| | - Mohamed Ali Chaouch
- Department of Visceral Surgery, Fattouma Bourguiba Hospital, University of Monastir, Tunisia
| | - Maroua Oueslati
- Department of Anesthesia, Trauma Center of Ben Arrous, University of Manar, Tunisia
| | - Lotfi Rebai
- Department of Anesthesia, Trauma Center of Ben Arrous, University of Manar, Tunisia
| | - Hani Oweira
- Department of Surgery, Universitätsmedizin Mannheim, S, Heidelberg University, Mannheim, Germany
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Bumblyte V, Rasilainen SK, Ehrlich A, Scheinin T, Kontinen VK, Sevon A, Vääräniemi H, Schramko AA. Purely ropivacaine-based TEA vs single TAP block in pain management after elective laparoscopic colon surgery within an upgraded institutional ERAS program. Surg Endosc 2021; 36:3323-3331. [PMID: 34480217 PMCID: PMC8415194 DOI: 10.1007/s00464-021-08647-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 07/16/2021] [Indexed: 11/28/2022]
Abstract
Background The aim of this study was to compare thoracic epidural analgesia (TEA) with transversus abdominis plane (TAP) block in post-operative pain management after laparoscopic colon surgery. Methods One hundred thirty-six patients undergoing laparoscopic colon resection randomly received either TEA or TAP with ropivacaine only. The primary endpoint was opioid requirement up to 48 h postoperatively. Intensity of pain, time to onset of bowel function, time to mobilization, postoperative complications, length of hospital stay, and patients’ satisfaction with pain management were also assessed. Results We observed a significant decrease in opioid consumption on the day of surgery with TEA compared with TAP block (30 mg vs 14 mg, p < 0.001). On the first two postoperative days (POD), the balance shifted to opioid consumption being smaller in the TAP group: on POD 1 (15.2 mg vs 10.6 mg; p = 0.086) and on POD 2 (9.2 mg vs 4.6 mg; p = 0.021). There were no differences in postoperative nausea/vomiting or time to first postoperative bowel movement between the groups. No direct blockade-related complications were observed and the length of stay was similar between TEA and TAP groups. Conclusion TEA is more efficient for acute postoperative pain than TAP block on day of surgery, but not on the first two PODs. No differences in pain management-related complications were detected. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08647-z.
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Affiliation(s)
- Vilma Bumblyte
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Jorvi Hospital, P.O. Box 00029 HUS, Espoo, Finland
| | - Suvi K Rasilainen
- Department of Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, Jorvi Hospital, Espoo, Finland
| | - Anu Ehrlich
- Department of Surgery and Department of Anaesthesiology, Central Finland Central Hospital, Jyvaskyla, Finland
| | - Tom Scheinin
- Department of Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, Jorvi Hospital, Espoo, Finland
| | - Vesa K Kontinen
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Jorvi Hospital, P.O. Box 00029 HUS, Espoo, Finland
| | - Aino Sevon
- Medical Faculty, University of Helsinki, Helsinki, Finland
| | - Heikki Vääräniemi
- Department of Surgery and Department of Anaesthesiology, Central Finland Central Hospital, Jyvaskyla, Finland
| | - Alexey A Schramko
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Jorvi Hospital, P.O. Box 00029 HUS, Espoo, Finland.
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Ashcroft J, Singh AA, Ramachandran B, Habeeb A, Hudson V, Meyer J, Simillis C, Davies RJ. Reducing ileus after colorectal surgery: A network meta-analysis of therapeutic interventions. Clin Nutr 2021; 40:4772-4782. [PMID: 34242917 DOI: 10.1016/j.clnu.2021.05.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/21/2021] [Accepted: 05/27/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Several treatment strategies for avoiding post-operative ileus have been evaluated in randomised controlled trials. This network meta-analysis aimed to explore the relative effectiveness of these different therapeutic interventions on ileus outcome measures. METHODS A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing treatments for post-operative ileus following colorectal surgery. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis. RESULTS A total of 48 randomised controlled trials were included in this network meta-analysis reporting on 3614 participants. Early feeding was found to be the best treatment for time to solid diet tolerance and length of hospital stay with a probability of P = 0.96 and P = 0.47, respectively. Early feeding resulted in significantly shorter time to solid diet tolerance (Mean Difference (MD) 58.85 h; 95% Credible Interval (CrI) -73.41, -43.15) and shorter length of hospital stay (MD 2.33 days; CrI -3.51, -1.18) compared to no treatment. Epidural analgesia was ranked best treatment for time to flatus (P = 0.29) and time to stool (P = 0.268). Epidural analgesia resulted in significantly shorter time to flatus (MD -18.88 h; CrI -33.67, -3.44) and shorter time to stool (MD -26.05 h; 95% CrI -66.42, 15.65) compared to no intervention. Gastrograffin was ranked best treatment to avoid the requirement for post-operative nasogastric tube insertion (P = 0.61) however demonstrated limited efficacy (OR 0.50; CrI 0.143, 1.621) compared to no intervention. Nasogastric and nasointestinal tube insertion, probiotics, and acupuncture were found to be least efficacious as interventions to reduce ileus. CONCLUSION This network meta-analysis identified early feeding as the most efficacious therapeutic intervention to reduce post-operative ileus in patients undergoing colorectal surgery, in addition to highlighting other therapies that require further investigation by high quality study. In patients undergoing colorectal surgery, emphasis should be placed on early feeding as soon as can be appropriately initiated to support the return of gastrointestinal motility.
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Affiliation(s)
- James Ashcroft
- Department of Surgery, University of Cambridge, Cambridge, UK
| | | | - Bhavna Ramachandran
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Amir Habeeb
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Victoria Hudson
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jeremy Meyer
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Constantinos Simillis
- Cambridge Colorectal Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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AbdelRady MM, AboElfadl GM, Othman Mohamed EA, abdel-rehim MG, Ali AH, saad imbaby AS, Ali W. Effect of small dose ketamine on morphine requirement after intestinal surgery: A randomized controlled trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1941690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Marwa Mahmoud AbdelRady
- Lecturer in Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ghada Mohammad AboElfadl
- Assistant Professor in Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Mohamed Galal abdel-rehim
- Professor in Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ali Hamdi Ali
- Lecturer in Clinical Pathology Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed Said saad imbaby
- Associate Lecturer in Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - WesamNashat Ali
- Lecturer in Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
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Association of Perioperative Regional Analgesia with Postoperative Patient-Reported Pain Outcomes and Opioid Requirements: Comparing 22 Different Surgical Groups in 23,911 Patients from the QUIPS Registry. J Clin Med 2021; 10:jcm10102194. [PMID: 34069496 PMCID: PMC8160876 DOI: 10.3390/jcm10102194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/14/2021] [Accepted: 05/15/2021] [Indexed: 11/21/2022] Open
Abstract
(1) Background: In many surgical procedures, regional analgesia (RA) techniques are associated with improved postoperative analgesia compared to systemic pain treatment. As continuous RA requires time and experienced staff, it would be helpful to identify settings in which continuous RA has the largest benefit. (2) Methods: On the basis of 23,911 data sets from 179 German and Austrian hospitals, we analyzed the association of perioperative RA with patient-reported pain intensity, functional impairment of movement, nausea and opioid use for different surgeries. Regression analyses adjusted for age, sex and preoperative pain were performed for each surgery and the following groups: patients receiving continuous RA (surgery and ward; RA++), RA for surgery only (RA+−) and patients receiving no RA (RA−−). (3) Results: Lower pain scores in the RA++ compared to the RA−− group were observed in 13 out of 22 surgeries. There was no surgery where pain scores for RA++ were higher than for RA−−. If maximal pain, function and side effects were combined, the largest benefit of continuous RA (RA++) was observed in laparoscopic colon and sigmoid surgery, ankle joint arthrodesis, revision (but not primary) surgery of hip replacement, open nephrectomy and shoulder surgery. The benefit of RA+− was lower than that of RA++. (4) Discussion: The additional benefit of RA for the mentioned surgeries is larger than in many other surgeries in clinical routine. The decision to use RA in a given surgery should be based on the expected pain intensity without RA and its additional benefits.
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Bowker B, Calabrese RO, Barber E. Postoperative Ileus. PHYSICIAN ASSISTANT CLINICS 2021. [DOI: 10.1016/j.cpha.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Erector Spinae Plane Block for Perioperative Analgesia after Percutaneous Nephrolithotomy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073625. [PMID: 33807296 PMCID: PMC8036507 DOI: 10.3390/ijerph18073625] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 12/11/2022]
Abstract
Erector spinae plane block was recently introduced as an alternative to postoperative analgesia in surgical procedures including thoracoscopies and mastectomies. There are no clinical trials regarding erector spinae plane block in percutaneous nephrolithotomy. The aim of our study was to test the efficacy and safety of erector spinae plane block after percutaneous nephrolithotomy. We analyzed 68 patients, 34 of whom received erector spinae plane block. The average visual analogue scale score 24 h postoperatively was the primary endpoint. The secondary endpoints were nalbuphine consumption and the need for rescue analgesia. Safety measures included the mean arterial pressure, Ramsey scale score, and rate of nausea and vomiting. The visual analogue scale, blood pressure, and Ramsey scale were assessed simultaneously at 1, 2, 4, 6, 12, and 24 h postoperatively. The average visual analogue scale was 2.9 and 3 (p = 0.65) in groups 1 (experimental) and 2 (control), respectively. The visual analogue scale after 1 h postoperatively was significantly lower in the erector spinae plane block group (2.3 vs. 3.3; p = 0.01). The average nalbuphine consumption was the same in both groups (46 mL vs. 47.2 mL, p = 0.69). The need for rescue analgesia was insignificantly different in both groups (group 1, 29.4; group 2, 26.4%; p = 1). The mean arterial pressure was similar in both groups postoperatively (91.8 vs. 92.5 mmHg; p = 0.63). The rate of nausea and vomiting was insignificantly different between the groups (group 1, 17.6%; group 2, 14.7%; p = 1). The median Ramsey scale in all the measurements was two. Erector spinae plane block is an effective pain treatment after percutaneous nephrolithotomy but only for a very short postoperative period.
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Fu J, Zhang G, Qiu Y. Erector spinae plane block for postoperative pain and recovery in hepatectomy: A randomized controlled trial. Medicine (Baltimore) 2020; 99:e22251. [PMID: 33031265 PMCID: PMC10545310 DOI: 10.1097/md.0000000000022251] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 09/24/2019] [Accepted: 08/17/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The randomized controlled study aimed to examine the efficacy of preoperative ultrasound-guided erector spinae plane (ESP) block combined with ropivacaine in patients undergoing hepatectomy. METHODS A total of 60 patients were randomized to ESP block group receiving ropivacaine (Group A) and control group (Group B), n = 30 per group. Visual analog scale (VAS) was recorded in both the groups during rest and movement at the various time intervals. Both the groups were also compared for time to initial anal exhaust, analgesic usage, early postoperative complications and side-effects, walk distance after the operation, time to out-of-bed activity, and duration of hospital stay. RESULTS No significant differences were observed in the demographic characteristics. For group A, when compared to group B, VAS scores during rest and movement within post-operative 24 hours were decreased, the time of first anus exhaust and ambulation were earlier, analgesic consumption and the incidence of postoperative nausea, vomiting and headache was reduced, the duration of hospital stay were shorter with longer walk distance. CONCLUSION ESP block combined with ropivacaine treatment effectively reduced early postoperative pain and improved recovery after hepatectomy.
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Abd ElRahman EM, Kharoub MS, Shora A, Emara NA, Balbaa MA. Early Outcome of Enhanced Recovery Programs Versus Conventional Perioperative Care in Elective Open Left Side Colonic Carcinoma Surgery: Analysis of 80 Cases. Indian J Surg Oncol 2020; 11:372-377. [PMID: 33013113 DOI: 10.1007/s13193-020-01074-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 04/01/2020] [Indexed: 10/24/2022] Open
Abstract
According to recent clinical practice guidelines, enhanced recovery programs (ERP) have been practiced to improve surgical outcomes and decrease cost. However, these are still opposed by the traditional measures in the treatment of colorectal carcinoma that is still practiced with the concept of protection of anastomosis and decrease postoperative complications. The aim of this study was to report our experience in ERP in elective open left side colonic carcinoma surgery in comparison with the conventional perioperative care. The current prospective multicenter randomized controlled study included a total of 80 adult patients with left side colonic cancer who were eligible for elective colonic resection. Included patients were randomly divided into two equal groups: group (A) where conventional perioperative care was performed and group (B) where ERP were applied. Follow-up was designed for at least 1 month to evaluate and compare hospital stay and postoperative complications. There was no statistically significant difference between the two groups as regards demographic data and preoperative comorbidities. There were statistically significant less pain (P = 0.24), less postoperative nausea and vomiting (P = 0.045), and less hospital stay (P < 0.001) in group B than group A. Otherwise, there was no statistically significant difference in comparing the rest of postoperative surgical or non-surgical complications or rates of readmissions between the two groups. ERP are safe, reliable, simple, and applicable in open left side cancer colon surgery with no negative impact over the postoperative complications in comparison with the conventional care.
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Affiliation(s)
- Emad M Abd ElRahman
- General Surgery Department, Faculty of Medicine, Benha University, Benha, Egypt
| | - Mohamed S Kharoub
- General Surgery Department, Faculty of Medicine, Benha University, Benha, Egypt
| | - Ahmed Shora
- General Surgery Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Nabil A Emara
- Department of Anesthesiology, Faculty of Medicine, Benha University, Benha, Egypt
| | - M Ashraf Balbaa
- General Surgery Department, Faculty of Medicine, Menoufia University, Shebin El Kom, Egypt
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Weledji EP. Perspectives on paralytic ileus. Acute Med Surg 2020; 7:e573. [PMID: 33024568 PMCID: PMC7533151 DOI: 10.1002/ams2.573] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 07/22/2020] [Accepted: 08/16/2020] [Indexed: 12/26/2022] Open
Abstract
Paralytic ileus is the condition where the motor activity of the bowel is impaired, usually not associated with a mechanical cause. Although the condition may be self‐limiting, it is serious and if prolonged and untreated will result in death in much the same way as in acute mechanical obstruction. Management of paralytic ileus depends on the knowledge of the most likely cause and the perceived chance of resolution without operation. Postoperative ileus is the single largest factor influencing length of hospital stay after bowel resection, and has great implications for patients and resource utilization. Early diagnosis and correct management is essential in reducing complications. This article briefly outlined the plausible pathophysiological mechanisms and clinical implications of paralytic ileus.
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Affiliation(s)
- Elroy Patrick Weledji
- Department of Surgery, Faculty of Health Sciences University of Buea Bomaka Buea S.W. Region PO Box 63 Cameroon
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Mujukian A, Truong A, Tran H, Shane R, Fleshner P, Zaghiyan K. A Standardized Multimodal Analgesia Protocol Reduces Perioperative Opioid Use in Minimally Invasive Colorectal Surgery. J Gastrointest Surg 2020; 24:2286-2294. [PMID: 31515761 DOI: 10.1007/s11605-019-04385-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/27/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multimodal analgesia protocols are becoming a common part of enhanced recovery pathways after colorectal surgery. However, few protocols include a robust intraoperative component in addition to pre-operative and post-operative analgesics. METHOD A prospective cohort study was performed in an urban teaching hospital in patients undergoing minimally invasive colorectal surgery before and after implementation of a multimodal analgesia protocol consisting of pre-operative (gabapentin, acetaminophen, celecoxib), intraoperative (lidocaine and magnesium infusions, ketorolac, transversus abdominis plane block), and post-operative (gabapentin, acetaminophen, celecoxib) opioid-sparing elements. The main outcome measure was use of morphine equivalents in the first 24-h post-operative period. RESULTS The study cohort (n = 71) included 41 patients before and 30 patients after implementation of a multimodal analgesia protocol. Mean age of the entire study cohort was 47 ± 19.7 years and 46% were male. Patients undergoing surgery post-multimodal analgesia vs. pre-multimodal analgesia had significantly lower use of IV morphine equivalents in first 24-h post-operative period (5.8 ± 6.4 mg vs. 22.8 ± 21.3 mg; p = 0.005) and first 48-h post-operative period (7.6 ± 9.4 mg vs. 42 ± 52.9 mg; p = 0.0008). This reduction in IV morphine equivalent use post-multimodal analgesia was coupled with improved pain scores in the post-operative period. Post-operative hospital length of stay, post-operative ileus, and overall complications were not significantly different between groups. CONCLUSIONS Multimodal analgesia incorporating pre-operative, intraoperative, and post-operative opioid-sparing agents is an effective method for reducing perioperative opioid utilization and pain after minimally invasive colorectal surgery.
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Affiliation(s)
- Angela Mujukian
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA, 90048, USA
| | - Adam Truong
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA, 90048, USA
| | - Hai Tran
- Department of Pharmacy, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Rita Shane
- Department of Pharmacy, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip Fleshner
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA, 90048, USA
| | - Karen Zaghiyan
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA, 90048, USA.
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Peltrini R, Cantoni V, Green R, Greco PA, Calabria M, Bucci L, Corcione F. Efficacy of transversus abdominis plane (TAP) block in colorectal surgery: a systematic review and meta-analysis. Tech Coloproctol 2020; 24:787-802. [PMID: 32253612 DOI: 10.1007/s10151-020-02206-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 03/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Multimodal opioid-sparing analgesia is a key component of the enhanced recovery after surgery (ERAS) protocol for postoperative pain management. Transversus abdominis plane (TAP) block has contributed to the implementation of this approach in different kinds of surgical procedures. The aim of this study was to evaluate the efficacy of TAP block and its impact on recovery in colorectal surgery. METHODS A comprehensive literature search of the PubMed, Embase, and Scopus databases was conducted. Studies that compared TAP block to a control group (no TAP block or placebo) after colorectal resections were included. The effects of TAP block in patients undergoing colorectal surgery were assessed, including the technical aspects of the procedure. Two measures were used to evaluate the effectiveness of postoperative pain control: a numeric pain rating score at rest and on coughing or movement at 24 h following surgery and the opioid requirement at 24 h. Clinical aspects of recovery were postoperative ileus, surgical site infection, postoperative nausea and vomiting, and length of hospital stay. RESULTS Sixteen studies were included in the analysis. Data showed that TAP block is a safe procedure associated with a significant reduction in the pain score at rest [WMD - 0.91 (95% CI - 1.56; - 0.27); p < 0.05] and on coughing or movement [WMD - 0.36 (95% CI - 0.72; - 0.01); p < 0.05] at 24 h after surgery and a significant decrease in morphine consumption in the TAP block group the day after surgery [WMD - 2.07 (95% CI - 2.63; - 1.51); p < 0.001]. CONCLUSIONS TAP block appears to provide both an effective analgesia and a significant reduction in opioid use on the first postoperative day after colorectal surgery. Its use does not seem to lead to increased postoperative complications.
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Affiliation(s)
- R Peltrini
- Department of Public Health, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy.
| | - V Cantoni
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - R Green
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - P A Greco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - M Calabria
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - L Bucci
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - F Corcione
- Department of Public Health, University of Naples Federico II, Via Pansini 5, 80131, Naples, Italy
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Gallegos G, Morgan CJ, Scott G, Benz D, Ness TJ. Effect of Neuraxial Analgesic Procedures on Intraoperative Hemodynamics During Routine Clinical Care of Gynecological and General Surgeries: A Case-Control Query of Electronic Data. J Pain Res 2020; 13:1163-1172. [PMID: 32547179 PMCID: PMC7250300 DOI: 10.2147/jpr.s252760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/09/2020] [Indexed: 11/23/2022] Open
Abstract
Background The purpose of this study was to determine whether neuraxial analgesic procedures affect intraoperative hemodynamics and/or postoperative outcomes. Previous studies have examined effects in small samples of patients in highly controlled research environments. This study examined “real-world” data from a large sample of subjects receiving routine clinical cares. Methods A matched case–control analysis of electronic medical records from a large, academic hospital was performed. Patients who underwent neuraxial procedures preoperatively for postoperative analgesia for abdominal surgery (n=1570) were compared with control patients matched according to age, sex, ASA class and type of surgical procedure. Intraoperative hemodynamic measures, fluids and pressor utilization were quantified. Postoperative outcomes were determined based on the changes in laboratory values, the ordering of imaging studies and admission to an intensive care unit during the seven days following surgery as well as 30-day mortality. Results Medical records of 1082 patients who received an epidural catheter placement and 488 patients who received a lumbar intrathecal morphine injection were compared with an equal number of matched control patients. Preoperative placement of an epidural catheter for the management of postoperative pain was demonstrated to be associated with significant reductions in mean arterial pressure intraoperatively and poorer postoperative outcomes (more intensive care unit [ICU] admissions, more myocardial injuries) when compared with controls. A similar analysis of preoperatively administered intrathecal morphine injections was not associated with intraoperative alterations in blood pressure and had improved outcomes (less ICU admissions) in comparison with controls. Conclusion In a “real-world” sample, intrathecal morphine administration proved to be highly beneficial as a neuraxial analgesic procedure as it was not associated with intraoperative hypotension and was associated with improved clinical outcomes, in contrast to opposite findings associated with epidural catheter placement. There should be a careful consideration of elective neuraxial method utilized for postoperative pain control, with the present study raising significant concerns related to the use of epidural analgesia and its potential effect on clinical outcomes.
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Affiliation(s)
- Gabriel Gallegos
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - Charity J Morgan
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - Garrett Scott
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - David Benz
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
| | - Timothy J Ness
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA
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Kwon HM, Kim DH, Jeong SM, Choi KT, Park S, Kwon HJ, Lee JH. Does Erector Spinae Plane Block Have a Visceral Analgesic Effect?: A Randomized Controlled Trial. Sci Rep 2020; 10:8389. [PMID: 32439926 PMCID: PMC7249264 DOI: 10.1038/s41598-020-65172-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 04/17/2020] [Indexed: 11/16/2022] Open
Abstract
The visceral analgesic efficacy of erector spinae plane block (ESPB) is still a matter of debate. This study attempted to investigate the visceral analgesic efficacy of ESPB in clinical setting. After randomized, we performed ultrasound-guided bilateral rectus sheath block (RSB), which was aimed to prevent postoperative somatic pain on all patients who underwent laparoscopic cholecystectomy (LC). Ultrasound-guided bilateral ESPB at T7 level was performed only to the intervention group to provide the visceral analgesic block. The intraoperative requirement for remifentanil (P = 0.021) and the cumulative fentanyl consumption at postoperative 24-hours was significantly lower in the ESPB group (206.5 ± 82.8 μg vs.283.7 ± 102.4 μg, respectively; P = 0.004) compared to non-ESPB group. The ESPB group consistently showed lower accumulated analgesic consumption compared with those in the non-ESPB group at all observed time-points (all P < 0.05) after 2 hours and the degree of the accumulated analgesic consumption reduction was greater (P = 0.04) during the 24-hour postoperative period. Pain severity was lower in the ESPB group at 6-hours postoperatively. The significantly reduced opioid consumption in ESPB group may imply that while preliminary and in need of confirmation, ESPB has potential visceral analgesic effect. Therefore, performing ESPB solely may be feasible in inducing both somatic and visceral analgesia.
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Affiliation(s)
- Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, 05505, Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, 05505, Korea
| | - Sung-Moon Jeong
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, 05505, Korea
| | - Kyu Taek Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, 05505, Korea
| | - Sooin Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, 05505, Korea
| | - Hyun-Jung Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, 05505, Korea
| | - Jong-Hyuk Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, 05505, Korea.
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Messias BA, Botelho RV, Saad SS, Mocchetti ER, Turke KC, Waisberg J. Serum C-reactive protein is a useful marker to exclude anastomotic leakage after colorectal surgery. Sci Rep 2020; 10:1687. [PMID: 32015374 PMCID: PMC6997159 DOI: 10.1038/s41598-020-58780-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 01/21/2020] [Indexed: 01/16/2023] Open
Abstract
Anastomotic leakage is a complication of colorectal surgery. C-reactive protein (CRP) is an acute-phase marker that can indicate surgical complications. We determined whether serum CRP levels in patients who had undergone colorectal surgery can be used to exclude the presence of anastomotic leakage and allow safe early discharge. We included 90 patients who underwent colorectal surgery with primary anastomosis. Serum CRP levels were measured retrospectively on postoperative days (PODs) 1 - 7. Patients with anastomotic leakage (n = 11) were compared to those without leakage (n = 79). We statistically analysed data and plotted receiver operating characteristic curves. The incidence of anastomotic leakage was 12.2%. Diagnoses were made on PODs 3 - 24. The overall mortality rate was 3.3% (18.2% in the leakage group, 1.3% in the non-leakage group; P < 0.045). CRP levels were most accurate on POD 4, with a cutoff level of 180 mg/L, showing an area under the curve of 0.821 and a negative predictive value of 97.2%. Lower CRP levels after POD 2 and levels <180 mg/L on POD 4 may indicate the absence of anastomotic leakage and may allow safe discharge of patients who had undergone colorectal surgery with primary anastomosis.
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Affiliation(s)
- Bruno A Messias
- Department of Surgery, General Hospital of Carapicuiba, Carapicuiba, SP, Brazil.
| | - Ricardo V Botelho
- Department of Surgery, State Public Servant Hospital (IAMSPE), São Paulo, SP, Brazil
| | - Sarhan S Saad
- Department of Surgery, Paulista Medical School, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Erica R Mocchetti
- Department of Surgery, General Hospital of Carapicuiba, Carapicuiba, SP, Brazil
| | - Karine C Turke
- Department of Surgery, State Public Servant Hospital (IAMSPE), São Paulo, SP, Brazil.,Department of Surgery, ABC Medical School, Santo André, SP, Brazil
| | - Jaques Waisberg
- Department of Surgery, State Public Servant Hospital (IAMSPE), São Paulo, SP, Brazil.,Department of Surgery, ABC Medical School, Santo André, SP, Brazil
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Xu YJ, Sun X, Jiang H, Yin YH, Weng ML, Sun ZR, Chen WK, Miao CH. Randomized clinical trial of continuous transversus abdominis plane block, epidural or patient-controlled analgesia for patients undergoing laparoscopic colorectal cancer surgery. Br J Surg 2020; 107:e133-e141. [DOI: 10.1002/bjs.11403] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 09/21/2019] [Accepted: 09/25/2019] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The optimal analgesia regimen after laparoscopic colorectal cancer surgery is unclear. The aim of the study was to characterize the beneficial effects of continuous transversus abdominis plane (TAP) blocks initiated before operation on outcomes following laparoscopic colorectal cancer surgery.
Methods
Patients undergoing surgery for colorectal cancer were divided randomly into three groups: combined general–TAP anaesthesia (TAP group), combined general–thoracic epidural anaesthesia (TEA group) and standard general anaesthesia (GA group). The primary endpoint was duration of hospital stay. Secondary endpoints included gastrointestinal motility, pain scores and plasma levels of cytokines.
Results
In total, 180 patients were randomized and 165 completed the trial. The intention-to-treat analysis showed that duration of hospital stay was significantly longer in the TEA group than in the TAP and GA groups (median 4·1 (95 per cent c.i. 3·8 to 4·3) versus 3·1 (3·0 to 3·3) and versus 3·3 (3·2 to 3·6) days respectively; both P < 0·001). Time to first flatus was earlier in the TAP group (P < 0·001). Visual analogue scale (VAS) scores during coughing were lower in the TAP and TEA groups than the GA group (P < 0·001). Raised plasma levels of vascular endothelial growth factor C, interleukin 6, adrenaline and cortisol were attenuated significantly by continuous TAP block.
Conclusion
Continuous TAP analgesia not only improved gastrointestinal motility but also shortened duration of hospital stay. A decreased opioid requirement and attenuating surgical stress response may be potential mechanisms. Registration number: ChiCTR-TRC-1800015535 (http://www.chictr.org.cn).
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Affiliation(s)
- Y J Xu
- Department of Anaesthesiology, Fudan University Shanghai Cancer Centre, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - X Sun
- Department of Anaesthesiology, Fudan University Shanghai Cancer Centre, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - H Jiang
- Department of Anaesthesiology, Fudan University Shanghai Cancer Centre, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Y H Yin
- Department of Anaesthesiology, Fudan University Shanghai Cancer Centre, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - M L Weng
- Department of Anaesthesiology, Fudan University Shanghai Cancer Centre, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Z R Sun
- Department of Anaesthesiology, Fudan University Shanghai Cancer Centre, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - W K Chen
- Department of Anaesthesiology, Fudan University Shanghai Cancer Centre, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - C H Miao
- Department of Anaesthesiology, Fudan University Shanghai Cancer Centre, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Montroni I, Ugolini G, Audisio RA. Principles of Cancer Surgery in Older Adults. GERIATRIC ONCOLOGY 2020:825-844. [DOI: 10.1007/978-3-319-57415-8_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Brown L, Gray M, Griffiths B, Jones M, Madhavan A, Naru K, Shaban F, Somnath S, Harji D, on behalf of NoSTRA (Northern Surgical Trainees Reseach Association). A multicentre, prospective, observational cohort study of variation in practice in perioperative analgesia strategies in elective laparoscopic colorectal surgery (the LapCoGesic study). Ann R Coll Surg Engl 2020; 102:28-35. [PMID: 31232611 PMCID: PMC6937613 DOI: 10.1308/rcsann.2019.0091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2019] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Enhanced recovery programmes are established as an essential part of laparoscopic colorectal surgery. Optimal pain management is central to the success of an enhanced recovery programme and is acknowledged to be an important patient reported outcome measure. A variety of analgesia strategies are employed in elective laparoscopic colorectal surgery ranging from patient-controlled analgesia to local anaesthetic wound infiltration catheters. However, there is little evidence regarding the optimal analgesia strategy in this cohort of patients. The LapCoGesic study aimed to explore differences in analgesia strategies employed for patients undergoing elective laparoscopic colorectal surgery and to assess whether this variation in practice has an impact on patient-reported and clinical outcomes. MATERIALS AND METHODS A prospective, multicentre, observational cohort study of consecutive patients undergoing elective laparoscopic colorectal resection was undertaken over a two-month period. The primary outcome measure was postoperative pain scores at 24 hours. Data analysis was conducted using SPSS version 22. RESULTS A total of 103 patients undergoing elective laparoscopic colorectal surgery were included in the study. Thoracic epidural was used in 4 (3.9%) patients, spinal diamorphine in 56 (54.4%) patients and patient-controlled analgesia in 77 (74.8%) patients. The use of thoracic epidural and spinal diamorphine were associated with lower pain scores on day 1 postoperatively (P < 0.05). The use of patient-controlled analgesia was associated with significantly higher postoperative pain scores and pain severity. DISCUSSION Postoperative pain is managed in a variable manner in patients undergoing elective colorectal surgery, which has an impact on patient reported outcomes of pain scores and pain severity.
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Affiliation(s)
- L Brown
- Northern Surgical Trainees Research Association, Department of Academic Surgery, University of Newcastle, Newcastle Upon Tyne, Tyne and Wear, UK
| | - M Gray
- Northern Surgical Trainees Research Association, Department of Academic Surgery, University of Newcastle, Newcastle Upon Tyne, Tyne and Wear, UK
| | - B Griffiths
- Northern Surgical Trainees Research Association, Department of Academic Surgery, University of Newcastle, Newcastle Upon Tyne, Tyne and Wear, UK
| | - M Jones
- Northern Surgical Trainees Research Association, Department of Academic Surgery, University of Newcastle, Newcastle Upon Tyne, Tyne and Wear, UK
| | - A Madhavan
- Northern Surgical Trainees Research Association, Department of Academic Surgery, University of Newcastle, Newcastle Upon Tyne, Tyne and Wear, UK
| | - K Naru
- Northern Surgical Trainees Research Association, Department of Academic Surgery, University of Newcastle, Newcastle Upon Tyne, Tyne and Wear, UK
| | - F Shaban
- Northern Surgical Trainees Research Association, Department of Academic Surgery, University of Newcastle, Newcastle Upon Tyne, Tyne and Wear, UK
| | - S Somnath
- Northern Surgical Trainees Research Association, Department of Academic Surgery, University of Newcastle, Newcastle Upon Tyne, Tyne and Wear, UK
| | - D Harji
- Northern Surgical Trainees Research Association, Department of Academic Surgery, University of Newcastle, Newcastle Upon Tyne, Tyne and Wear, UK
| | - on behalf of NoSTRA (Northern Surgical Trainees Reseach Association)
- Collaborators: Yousif Aawsaj, Paul Ainley, Rebecca Barnett, Philippa Burnell, Rachael Coates, Lucy Grant, Helen Hawkins, Ross Mclean, Lydia Newton, Komal Patel, Syed Shumon, Anisha Sukha, Savita Tarigabil, Laura Watson, Eleanor Whyte (Northern Surgical Trainees Research Association); David Borowski (University Hospital North Tees); Vikram Garud (Friarage Hospital, Northallerton); Stephen Holtham (Sunderland Royal Hospital); Reza Kalbassi (Wansbeck General Hospital); Seamus Kelly (North Tyneside General Hospital); Sophie Noblett (University Hospital North Durham); Sriram Subramonia (South Tyneside District General Hospital)
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45
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Altıparmak B, Korkmaz Toker M, Uysal AI, Kuşçu Y, Gümüş Demirbilek S. Ultrasound-guided erector spinae plane block versus oblique subcostal transversus abdominis plane block for postoperative analgesia of adult patients undergoing laparoscopic cholecystectomy: Randomized, controlled trial. J Clin Anesth 2019; 57:31-36. [DOI: 10.1016/j.jclinane.2019.03.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/10/2019] [Accepted: 03/03/2019] [Indexed: 11/16/2022]
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46
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Response to Comment on "Is It Time to Reconsider Postoperative Epidural Analgesia in Patients Undergoing Elective Ventral Hernia Repair?". Ann Surg 2019; 269:e67-e68. [PMID: 30985360 DOI: 10.1097/sla.0000000000002916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Postoperative ileus (POI) is a common complication following colon and rectal surgery, with reported incidence ranging from 10 to 30%. It can lead to increased morbidity, cost, and length of stay. Although definitions vary considerably in the literature, in its pathologic form, it can be characterized by a temporary inhibition of gastrointestinal motility after surgical intervention due to nonmechanical causes that prevents sufficient oral intake. Various risk factors for development of POI have been identified including increasing age, American Society of Anesthesiologists scores 3 to 4, open approach, operative difficulty, operative duration more than 3 hours, bowel handling, drop in hematocrit or need for a transfusion, increasing crystalloid administration, and delayed mobilization. While treatment is expectant and supportive, significant investigations into strategies to mitigate development of POI or shorten its duration have been undertaken with mixed results. There is significant evidence to suggest that a minimally invasive approach and multimodal pain regimens reduce the development of POI. The beneficial effect of chewing gum, alvimopan, and enhanced recovery after surgery protocols may decrease development of POI in selected groups of patients who undergo elective colorectal surgery, and shorten time to return of bowel function, but overall, the data remain inconclusive.
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Affiliation(s)
- Cristina R Harnsberger
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, Massachusetts
| | - Justin A Maykel
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, Massachusetts
| | - Karim Alavi
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, Massachusetts
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48
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Yi X, Huang Y, He Y, Chen C. Risk Factors Associated with Anastomotic Leakage in Colorectal Cancer. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1757-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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49
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Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urman RD, Chang GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS ®) Society Recommendations: 2018. World J Surg 2019; 43:659-695. [PMID: 30426190 DOI: 10.1007/s00268-018-4844-y] [Citation(s) in RCA: 1194] [Impact Index Per Article: 199.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Danderyd Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - M J Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, VA, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - M Hubner
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - J Nygren
- Department of Surgery, Ersta Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - N Demartines
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - N Francis
- Colorectal Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK
- University of Bath, Wessex House Bath, BA2 7JU, UK
| | - T A Rockall
- Department of Surgery, Royal Surrey County Hospital NHS Trust, and Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - T M Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland Middlemore Hospital, Auckland, New Zealand
| | - M Soop
- Irving National Intestinal Failure Unit, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - H D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, The Netherlands
| | - R D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G J Chang
- Department of Surgical Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - A Fichera
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, USA
| | - F Grass
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - E E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - W J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust and University of Surrey, Guildford, UK
| | - F Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - K E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - A Balfour
- Department of Colorectal Surgery, Surgical Services, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - G Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - O Ljungqvist
- Department of Surgery, Örebro University and University Hospital, Örebro & Institute of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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50
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Simpson JC, Bao X, Agarwala A. Pain Management in Enhanced Recovery after Surgery (ERAS) Protocols. Clin Colon Rectal Surg 2019; 32:121-128. [PMID: 30833861 DOI: 10.1055/s-0038-1676477] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Pain control is an integral part of Enhanced Recovery after Surgery (ERAS) protocols for colorectal surgery. While opioid therapy remains the mainstay of therapy for postsurgical pain, opioids have undesired side effects including delayed recovery of bowel function, respiratory depression, and postoperative nausea and vomiting. A variety of nonopioid systemic medical therapies as well as regional and neuraxial techniques have been described as improving pain control while reducing opioid use. Multimodal and preemptive analgesia as part of an ERAS protocol facilitates early mobility and early return of bowel function and decreases postoperative morbidity. In this review, we examine several multimodal therapies and their impact on postoperative analgesia, opioid use, and recovery for patients undergoing colorectal surgery.
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Affiliation(s)
- J Creswell Simpson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Xiaodong Bao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Aalok Agarwala
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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