Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery

Pain, opioid consumption, and epidural anesthesia in patients with inflammatory bowel disease undergoing laparoscopic subtotal colectomy: an observational cohort study

BACKGROUND

Surgery is often needed to provide disease control in patients with inflammatory bowel disease. Studies document increased postoperative pain and complicated perioperative courses. This study examines postoperative pain and opioid consumption in patients with inflammatory bowel disease undergoing laparoscopic subtotal colectomy. Furthermore, the impact of epidural anesthesia is investigated.

METHODS

This study encompassed an observational cohort of patients with inflammatory bowel disease undergoing subtotal colectomy in the period 1 January 2018 to 30 June 2023 at a university hospital in Denmark. Demographic and perioperative data, opioid consumption, pain scores, and procedural data of epidural anesthesia were retrieved from patient records. Data were stratified according to the use of epidural anesthesia.

RESULTS

The study included 153 patients. Overall, 45% of patients received epidural anesthesia. Opioid consumption in the postoperative care unit was 9.2 mg (3.3-15.8 mg) and 3.8 mg (0-15 mg) (P = 0.04) in patients without and with epidural anesthesia, respectively. Correspondingly, opioid consumption during the first 24 h postoperatively was 23.3 mg (10-33 mg) and 6.8 mg (0-21.7 mg) (P < 0.001). Numerical rating scale (NRS) pain in the postoperative care unit was 3.5 (2-4.6) and 2.7 (1.3-4.3) in patients without and with epidural anesthesia, respectively (P = 0.1645). Thirty percent of patients treated with epidural anesthesia experienced ≥ 1 adverse event(s) related to epidural anesthesia.

CONCLUSIONS

Our study demonstrates a relatively low consumption of opioids and low pain scores in the early postoperative period following laparoscopic subtotal colectomy regardless of the use of epidural anesthesia. Epidural anesthesia was associated with a substantial frequency of adverse events.

Effectiveness of tramadol or topic lidocaine compared to epidural or opioid analgesia on postoperative analgesia in laparoscopic colorectal tumor resection

BACKGROUND

Chronic postoperative pain is the most common postoperative complication that impairs quality of life. Postoperative pain gradually develops into neuropathic pain. Multimodal analgesia targets multiple points in the pain pathway and influences the mechanisms of pain chronification.

PATIENTS AND METHODS

We investigated whether a lidocaine patch at the wound site or an infusion of metamizole and tramadol can reduce opioid consumption during laparoscopic colorectal surgery and whether the results are comparable to those of epidural analgesia. Patients were randomly divided into four groups according to the type of postoperative analgesia. Group 1 consisted of 20 patients who received an infusion of piritramide. Group 2 consisted of 21 patients who received an infusion of metamizole and tramadol. Group 3 consisted of 20 patients who received patient-controlled epidural analgesia. Group 4 consisted of 22 patients who received piritramide together with a 5% lidocaine patch on the wound site. The occurrence of neuropathic pain was also investigated.

RESULTS

Piritramide consumption was significantly lowest in group 3 on the day of surgery and on the first and second day after surgery. Group 4 required significantly less piritramide than group 1 on the day of surgery and on the first and second day after surgery. The group with metamizole and tramadol required significantly less piritramide than groups 1 and 4 on the first and second day after surgery. On the day of surgery, this group required the highest amount of piritramide.

CONCLUSIONS

Weak opioids such as tramadol in combination with non-opioids such as metamizole were as effective as epidural analgesia in terms of postoperative analgesia and opioid consumption. A lidocaine patch in combination with an infusion of piritramide have been able to reduce opioid consumption.

A novel and alternative treatment method for moderate diabetic foot ulcer: tibial periosteal distraction

OBJECTIVE

Researchers have proposed a novel surgical treatment for moderate diabetic foot ulcer: tibial periosteal distraction (TPD) which could improve affected limb microcirculation. We aimed to describe the method and therapeutic effects of this technique.

METHODS

We provided a technical guide to perform TPD surgery for the treatment of moderate diabetic foot ulcer of who had been treated in our department. The demographic information had been collected at the time of their admission. The patients were followed up at 3, 6, and 12 months after the operation with the ulcer area, skin temperature of the medial malleolus, transcutaneous oxygen pressure of the medial malleolus, ankle brachial index, dorsalis pedis artery pulsation, 12 item short form survey quality of life scale score, and visual analogue scale.

RESULTS

A total of 35 patients with type 2 diabetes were included in this study, including 19 males and 16 females, with an average age of 62.49 ± 10.34 years and a maximum age of 87 years. The ulcers of all patients were cured, and the average healing time of ulcers was 8.09 ± 2.28 weeks, with no associated complications. The microcirculation indexes of the affected foot were significantly improved (p < 0.05). Three cases showed new vessels regeneration in the affected limbs according to their computed tomography angiography (CTA) results.

CONCLUSION

TPD surgery technique is a simple procedure that significantly increases the efficacy and reduces the complications of moderate diabetic foot ulcer patients, which could accelerate the formation of collateral circulation.

Comparison of Ultrasound-guided Bilateral Anterior Quadratus Lumborum Block at the Lateral Supra-arcuate Ligament with Conventional Epidural Block in Patients Undergoing Laparoscopic Radical Gastrectomy: A Randomized Controlled Study

Background

To test the novel ultrasound (US)-guided bilateral anterior quadratus lumborum block (QLBA) at the lateral supra-arcuate ligament (supra-LAL) technique combined with postoperative intravenous analgesia was a viable alternative approach of conventional thoracic epidural analgesia (TEA) for laparoscopic radical gastrectomy (LRG).

Methods

Three hundred and four patients scheduled for LRG were randomized 1:1 into QLBA group: receiving a novel pathway of US-guided bilateral QLBA at the supra-LAL before general anesthesia (GA) and patient-controlled intravenous analgesia (PCIA) after surgery, and TEA group: receiving TEA before GA and patient-controlled epidural analgesia following surgery. The difference in procedure time between the treatment groups was set as the primary endpoint.

Results

Compared to TEA, procedure time was significantly shorter in the QLBA group (13.19 ± 0.78 vs. 15.65 ± 3.49, P = 0.001). At 5-10 min after block, QLBA group achieved more dermatomes coverage of cold sensory block with both P < 0.001 and less influence on mean artery pressure. Intraoperative consumption of propofol and remifentanil were comparable between the two groups (1116.21 ± 199.76 vs. 1166.45 ± 125.31 ug, P = 0.245 and remifentanil 1.83 ± 0.41 vs. 1.81 ± 0.37 ng, P = 0.988). However, the QLBA group was associated with less intraoperative consumption of norepinephrine and atropine, shorter time to urinary catheter removal, and out-of-bed activity. No significant difference in extubation time, pain scores at rest and exercising across all time points postoperation was observed between two groups.

Conclusion

Compared with conventional TEA, the novel technique combined with PCIA was an equivalent effective multimodal analgesic protocol for LRG. There were some advantages of technical simplicity with shorter procedure time, wider anesthetized dermatomes, less influence on intraoperative hemodynamic variables, fewer postoperative adverse events, and improved several sensible parameters of postoperative recovery.

Trial Registration

The study was registered in the Chinese Clinical Trial Registry on November 02, 2022 (ChiCTR2200065325).

Drugs used for pain management in gastrointestinal surgery and their implications

Pain is the predominant symptom troubling patients. Pain management is one of the most important aspects in the management of surgical patients leading to early recovery from surgical procedures or in patients with chronic diseases or malignancy. Various groups of drugs are used for dealing with this; however, they have their own implications in the form of adverse effects and dependence. In this article, we review the concerns of different pain-relieving medicines used postoperatively in gastrointestinal surgery and for malignant and chronic diseases.

Comparison between the effects of epidural and intravenous patient-controlled analgesia on postoperative disability-free survival in patients undergoing thoracic and abdominal surgery: A post hoc analysis

BACKGROUND

Thoracic epidural analgesia (TEA) and intravenous patient-controlled analgesia (IV-PCA) are widely used to mitigate immediate postoperative pain; however, their effects on long-term disability-free survival are poorly documented. This study aimed to compare the effects of postoperative TEA and IV-PCA on disability-free survival in patients who underwent thoracic or abdominal surgery.

METHODS

This post hoc analysis of a prospective observational study included 845 inpatients aged ≥55 years that underwent elective thoracic and abdominal surgery between 1 April 2016 and 28 December 2018 in a tertiary care hospital. Inverse probability of treatment weighted (IPTW) using stabilized inverse propensity scores was adopted to minimize bias. The primary outcome in this study was disability-free survival, defined as survival with a 12-item World Health Organization Disability Assessment Schedule 2.0 score of <16%, assessed at 3 months and 1 year after surgery.

RESULTS

The final analysis included 601 patients who received TEA and 244 who received IV-PCA. After IPTW, the weighted incidence of disability-free survival at 3 months and 1 year was 60.5% and 61.4% in the TEA group and 78.3% and 66.2% in the IV-PCA group, respectively. The adjusted OR for disability-free survival at 3 months and 1 year was 0.84 (95% confidence interval [CI]: 0.50-1.39) and 1.21 (95% CI: 0.72-2.05), respectively, for the TEA group.

CONCLUSION

No significant differences were observed in the disability-free survival at 3 months and 1 year after elective thoracic and abdominal surgery in patients aged ≥55 years who received TEA or IV-PCA.

SIGNIFICANCE STATEMENT

This study is the first in our setting to document the long-term effects of patient-controlled analgesia. In a post hoc analysis of our prospective cohort study, we show that although differences in chronic postsurgical pain exist at 3 months post-surgery, disability-free survival rates at 1 year do not differ irrespective of the choice of patient-controlled analgesia. The findings of this study highlight the need for shared decision-making between clinicians and patients.

Postoperative ileus-Establishing a porcine model

BACKGROUND

Postoperative ileus (POI), characterized by absent gastrointestinal motility, is a frequent complication following major abdominal surgery, with no current effective treatment possibilities. For further research in the treatment of this condition, we aimed to establish a porcine model of POI.

METHODS

A total of 12 Landrace pigs, weighing 60 kg, were included. Five animals were used as pilots to establish the surgical procedure, five animals received the same reproducible surgical procedure developed in the pilot experiments, while two animals were used as control. The primary endpoint was number of days to first stool. Intestinal motility was monitored using the SmartPill system.

KEY RESULTS

Four of the five pigs who underwent the final surgical procedure passed first stool on the third postoperative day (POD), and one passed first stool on the fifth POD. SmartPill data showed retention of the capsule in the stomach in four of five pigs with usable traces.

CONCLUSION AND INFERENCES

An experimental porcine model of POI was established, forming the basis for future studies in POI.

Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients

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.

The effect of early oral postoperative feeding on the recovery of intestinal motility after gastrointestinal surgery: a systematic review and meta-analysis of randomized clinical trials

Background and aims

Postoperative ileus is a frequent condition, leading to complications and a longer hospital stay. Few studies have demonstrated the benefit of early oral feeding in preventing ileus after gastrointestinal surgery. This study aims to evaluate the efficacy of early versus delayed oral feeding on the recovery of intestinal motility, length of hospital stay, and complications.

Methods

We conducted a systematic review and meta-analysis of randomized control trials, searching PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and the ClincalTrials.gov until 31 December 2022. We evaluated the first passage of the stool, the first flatus, complications, length of postoperative stay, and vomiting. We assessed the risk of bias using the Cochrane risk of bias tool (version 2) for randomized trials and the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation methodology.

Results

We included 34 studies with a median sample size of 102 participants. With a moderate certainty of the evidence, the early oral feeding may reduce the time taken for the first passage of the stool (MD -0.99 days; CI 95% -1.25, -0.72), the first flatus (MD -0.70 days; CI 95% -0.87, -0.53), and the risk of complications (RR 0.69; CI 95% 0.59-0.80), while with a low certainty of evidence, it may reduce the length of stay (MD -1.31 days; CI 95% -1.59, -1.03). However, early feeding likely does not affect the risk of vomiting (RR 0.90; CI 95% 0.68, 1.18).

Conclusion

This review suggests that early oral feeding after gastrointestinal surgery may lead to a faster intestinal recovery, shorter postoperative stays, and fewer complications. However, careful interpretation is needed due to high heterogeneity and the moderate-to-low quality of evidence. Future studies should focus on the type and starting time of early oral feeding.

Erector spinae plane block for postoperative pain

BACKGROUND

Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects.

OBJECTIVES

To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects.

MAIN RESULTS

We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome.

AUTHORS' CONCLUSIONS

ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.

A prospective randomized study of multimodal analgesia combined with single injection transversus abdominis plane block versus epidural analgesia against postoperative pain after laparoscopic colon cancer surgery

PURPOSE

Transversus abdominis plane (TAP) block is a safe, effective, and promising analgesic procedure, but TAP block only cannot overcome postoperative pain. We conducted a prospective randomized study to evaluate postoperative pain control using multimodal analgesia (MA) combined with a single injection TAP block compared with epidural analgesia (EA) after laparoscopic colon cancer surgery.

METHODS

Sixty-seven patients scheduled for elective laparoscopic colon cancer surgery were enrolled in this study and randomized into EA and MA groups. The primary endpoint was the frequency of additional analgesic use until postoperative day (POD) 2. The VAS score, blood pressure, time to bowel movement, time to mobilization, postoperative complications, and length of hospital stay were also compared between the two groups.

RESULTS

Sixty-four patients (EA group, n = 33; MA group, n = 31) were analyzed. The patient characteristics did not differ markedly between the two groups. The frequency of additional analgesic use was significantly lower in the MA group than in the EA group (P < 0.001), whereas the VAS score did not differ markedly between the two groups. The postoperative blood pressure on the day of surgery was significantly lower in the MA group than in the EA group (P = 0.016), whereas urinary retention was significantly higher in the EA group than in the MA group (P < 0.001).

CONCLUSION

MA combined with a single injection TAP block after laparoscopic colon cancer surgery may be comparable to EA in terms of analgesia and superior to EA in terms of urinary retention.

The Role of Regional Anaesthesia and Acute Pain Services in Value-Based Healthcare

Value-based healthcare prioritizes patient outcomes and quality relative to costs, shifting focus from service volume to delivered value. This review explores the significant role of regional anaesthesia (RA) and acute pain services (APS) within the evolving value-based healthcare (VBHC) framework. At the heart of VBHC is the goal to enhance patient outcomes while simultaneously optimizing operational efficiency and reducing costs. The review underscores the need for VBHC and illustrates how integrating RA/APS with Enhanced Recovery Protocols can lead to improved outcomes, aligning directly with the goals of the Triple Aim. Several clinical studies show that RA improves patient outcomes, enhances operating room efficiency, and reduces costs. This is complemented by a discussion on the integration of RA and APS into the VBHC model, highlighting emerging value-based payment structures and strategies for their successful implementation. By merging specialized RA/APS protocols with standardized clinical practices, significant improvements in operating room efficiency and associated economic benefits are observed. Across the healthcare spectrum, from providers to payers, this synergy results in enhanced operational efficiency and communication, raising the standard of patient care. Additionally, the potential of RA and APS to address the opioid crisis, through alternative pain management methods, is emphasized. Globally, the shift towards VBHC requires international collaboration, sharing of best practices, and efficient resource allocation, with RA and APS playing a crucial role. In conclusion, as healthcare moves toward a value-driven model, RA and APS become increasingly essential, signaling a future of refined, patient-centered care.

Erector spinae plane block for postoperative pain

BACKGROUND

Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects.

OBJECTIVES

To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects.

MAIN RESULTS

We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome.

AUTHORS' CONCLUSIONS

ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.

Risk factors for post-operative ileus in patients with anterior resection for rectal cancer. A single center cohort

BACKGROUND

Postoperative ileus (POI) is a major cause of morbidity in patients undergoing colorectal surgery. The aim of our study was to evaluate potential risk factors for POI in cases with anterior resection for rectal cancer.

METHODS

A retrospective cohort study was performed on 136 patients who underwent open anterior resection for rectal cancer between 2004 and 2018 at a single tertiary referral center. POI was defined as reinsertion of nasogastric tube or nil per os by postoperative day 4 and/or administration of neostigmine postoperatively. Uni- and multivariate analysis was performed to identify potential risk factors for POI.

RESULTS

POI was observed in 18 patients (13.2%). Epidural anesthesia, type of ostomy, and history of abdominal surgery were not found to be related with POI. Advanced age was a statistically significant risk factor both in the uni- and in the multivariate analyses. An increase in age by 1 year was found to increase the odds of POI by 5% [95%CI: 0.4%-9.7%; p = 0.032].

CONCLUSION

Increased age was identified as a non-modifiable, patient-related risk factor for POI after anterior resection for rectal cancer. This finding is of particular importance as it turns the focus on the elderly patient and underlines the need for close clinical observation of this subgroup and liberal use of preventive and/or therapeutic measures postoperatively.

Efficacy of local anaesthetic infiltration via wound catheters after open hepatic surgery: a systematic review and meta-analysis

BACKGROUND

This study analysed whether local anaesthetic wound catheter infiltration (LA-WCI) as an adjunct to intravenous patient-controlled analgesia (IV-PCA) provides superior outcomes compared to IV-PCA alone following liver resection.

METHODS

A systematic review and meta-analysis was conducted for randomised control trials (RCTs) comparing LA-WCI with IV-PCA(LA-WCI group) versus IV-PCA alone (IV-PCA group). PubMed and the Cochrane Library were searched for relevant articles.

RESULTS

Six RCTs with a total of 440 patients were included. Opioid use in the initial 48 h was less in the LA-WCI group [MD -21.27 mg (-39.39,-3.15), p = 0.02]. Pain scores were lower in the LA-WCI group at rest at POD0 (post-operative day 0)6-8 h (p = 0.0009), POD1AM(p = 0.01), POD1PM(p = 0.02) and POD2 (p = 0.0006), and exertion at POD0 0-2 h (p = 0.05), POD1AM(p = 0.03), POD1PM(p = 0.03), POD2 (p = 0.03) and POD3 (p = 0.01). LA-WCI group had reduced length of hospital stay [MD -1.32 days (-2.23,-0.40),p = 0.005], time to ambulation [MD -5.94 h (-8.47,-3.42),p = 0.00001] and incidence of nausea and vomiting (PONV) [OR 0.17 (0.07,0.43),p = 0.0002]. No differences were observed in length of intensive care unit (ICU) stay or incidence of surgical site infections.

DISCUSSION

LA-WCI as an adjunct to opiate IV-PCA post-hepatectomy reduces opioid use, pain scores at multiple time points at rest and exertion, length of hospital stay, time to ambulation and PONV. However, LA-WCI use does not alter length of ICU stay or incidence of wound infection.

Extradural anaesthesia-analgesia in dogs undergoing cholecystectomy: A single centre retrospective study

Objectives

To assess the effects of extradural anaesthesia-analgesia (EAA) in dogs undergoing cholecystectomy.

Materials and methods

Medical records of dogs undergoing cholecystectomy between 2011 and 2019 were retrieved and allocated to two groups depending if analgesia was provided systemically (group SA) or extradurally (EAA). Preoperative data, intraoperative antinociceptive medications, postoperative analgesia, perioperative complications, and food intake were compared.

Results

Overall 41 medical records were included in the study: 19 and 22 dogs were allocated to groups SA and EAA, respectively. In group EAA, an extradural catheter was placed preoperatively in 8 dogs; in the remaining, it was placed postoperatively but an extradural injection was performed preoperatively. The extradural catheter tip was between the 4th lumbar and the 10th thoracic vertebrae. Intraoperatively, nociception was more likely to occur in group SA [OR 55.42 (2.97–1,035.06)]. During the first 24 and 48 h postoperatively, more dogs in group SA required methadone [OR 24 (2.81–268.4) and OR 11.56 (2.37–45.06), respectively] and additional analgesic drugs [OR 25 (3.47–281.9) and OR 35.29 (1.86–668.2), respectively] compared to group EAA. Voluntary postoperative food intake was also significantly higher in group EAA.

Clinical significance

Compared to systemic analgesia, the use of extradural anaesthesia-analgesia reduced perioperative analgesic requirement and promoted postoperative food intake in dogs undergoing cholecystectomy.

Ultrasound-guided erector spinae plane block for pain management after gastrectomy: a randomized, single-blinded, controlled trial

Background

Open gastrectomy causes severe postoperative pain. Therefore, we investigated the opioid-sparing effect of the ultrasound-guided bilateral erector spinae plane block (ESPB) after open gastrectomy.

Methods

Adult patients undergoing open gastrectomy were randomly assigned to either the ESPB group (ESPB + fentanyl based intravenous patient-controlled analgesia [IV-PCA]) or a control group (fentanyl based IV-PCA only). The primary outcome was total fentanyl equivalent consumption during the first 24 hour postoperatively. Secondary outcomes were pain intensities using a numeric rating scale at the postanesthesia care unit (PACU) and at 3, 6, 12, and 24 hour postoperatively, and the amount of fentanyl equivalent consumption during the PACU stay and at 3, 6, and 12 hour postoperatively, and the time to the first request for rescue analgesia.

Results

Fifty-eight patients were included in the analysis. There was no significant difference in total fentanyl equivalent consumption during the first 24 hour postoperatively between the two groups (P = 0.471). Pain intensities were not significantly different between the groups except during the PACU stay and 3 hour postoperatively (P < 0.001, for both). Time to the first rescue analgesia in the ward was longer in the ESPB group than the control group (P = 0.045).

Conclusions

Ultrasound-guided ESPB did not decrease total fentanyl equivalent consumption during the first 24 hour after open gastrectomy. It only reduced postoperative pain intensity until 3 hour postoperatively compared with the control group. Ultrasound-guided single-shot ESPB cannot provide an efficient opioid-sparing effect after open gastrectomy.

Enhanced Antitumor Activity of Lidocaine Nanoparticles Encapsulated by a Self-Assembling Peptide

Although local anesthetics (LAs) such as lidocaine have been traditionally used for pain relief, their antitumor activity has attracted more and more attentions in recent years. However, since nearly all LAs used in clinic are in their hydrochloride forms with small molecular weight and high water-solubility, their fast absorption and clearance greatly limit their antitumor activity in vivo. To better exploit the antitumor activity of LAs, lidocaine nanoparticles (LNPs) are prepared by using a self-assembling peptide to encapsulate the hydrophobic base form of lidocaine. In cultured A375 human melanoma cells, the LNPs show much higher cellular uptake level than the clinic formulation of lidocaine hydrochloride, which leads to enhanced efficacy in inhibiting the proliferation, migration and invasion of the cells, as well as in inducing cell apoptosis. Compared with lidocaine hydrochloride, LNPs can also significantly slow down the release rate of lidocaine. In nude mice, LNPs can effectively inhibit the development of solid tumors from seeded A375 cells and prevent the recurrence of tumors after surgical excision. These results indicate that by using self-assembling peptide to fabricate nanoparticle formulations of local anesthetics, their antitumor activity can be significantly enhanced, suggesting a potential postoperative treatment to prevent tumor recurrence after surgical excision.

Spinal anesthesia alleviates dextran sodium sulfate-induced colitis by modulating the gut microbiota

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic disease with recurrent intestinal inflammation. Although the exact etiology of IBD remains unknown, the accepted hypothesis of the pathogenesis to date is that abnormal immune responses to the gut microbiota are caused by environmental factors. The role of the gut microbiota, particularly the bidirectional interaction between the brain and gut microbiota, has gradually attracted more attention.

AIM

To investigate the potential effect of spinal anesthesia on dextran sodium sulfate (DSS)-induced colitis mice and to detect whether alterations in the gut microbiota would be crucial for IBD.

METHODS

A DSS-induced colitis mice model was established. Spinal anesthesia was administered on colitis mice in combination with the methods of cohousing and fecal microbiota transplantation (FMT) to explore the role of spinal anesthesia in IBD and identify the potential mechanisms involved.

RESULTS

We demonstrated that spinal anesthesia had protective effects against DSS-induced colitis by alleviating clinical symptoms, including reduced body weight loss, decreased disease activity index score, improved intestinal permeability and colonic morphology, decreased inflammatory response, and enhanced intestinal barrier functions. Moreover, spinal anesthesia significantly increased the abundance of Bacteroidetes, which was suppressed in the gut microbiota of colitis mice. Interestingly, cohousing with spinal anesthetic mice and FMT from spinal anesthetic mice can also alleviate DSS-induced colitis by upregulating the abundance of Bacteroidetes. We further showed that spinal anesthesia can reduce the increase in noradrenaline levels induced by DSS, which might affect the gut microbiota.

CONCLUSION

These data suggest that microbiota dysbiosis may contribute to IBD and provide evidence supporting the protective effects of spinal anesthesia on IBD by modulating the gut microbiota, which highlights a novel approach for the treatment of IBD.

Complications and Mortality after Surgeries in Patients with Prior Stroke Who Received General and Neuraxial Anesthesia: A Propensity-Score Matched Study

Patients who previously suffered a stroke have increased risks of mortality and complications after surgeries, but the optimal anesthesia method is not fully understood. We aimed to compare the outcomes after surgeries for stroke patients who received general anesthesia (GA) and neuraxial anesthesia (NA). Using health insurance research data, we identified 36,149 stroke patients who underwent surgeries from 1 January 2008 to 31 December 2013. For balancing baseline covariates, the propensity-score-matching procedure was used to select adequate surgical patients who received GA and NA at a case-control ratio of 1:1. Multiple logistic regressions were applied to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative mortality and complications between surgical patients with prior stroke who received GA and NA. Among the 4903 matched pairs with prior stroke, patients with GA had higher risks of pneumonia (OR 2.00, 95% CI 1.62-2.46), pulmonary embolism (OR 3.30, 95% CI 1.07-10.2), acute renal failure (OR 3.51, 95% CI 1.13-2.10), intensive care unit stay (OR 3.74, 95% CI 3.17-4.41), and in-hospital mortality (OR 2.02, 95% CI 1.16-3.51) than those who received NA. Postoperative adverse events were associated with GA in patients aged more than 60 years and those who received digestive surgery (OR 3.11, 95% CI 2.08-4.66). We found that stroke patients undergoing GA had increased postoperative complications and mortality after surgery compared with those who received NA. However, these findings need more validation and evaluation by clinical trials.

Ultrasound-guided bilateral erector spinae plane block in laparoscopic colon cancer surgery : A randomized controlled prospective trial

BACKGROUND

The efficacy of erector spinae plane block (ESPB) for pain control in other surgeries remains an interesting topic of discussion. This study aimed to evaluate the safety and efficacy and quality of recovery of ultrasound-guided bilateral ESPB in laparoscopic surgery for colon cancer.

MATERIAL AND METHODS

In this study 50 patients were included and randomly divided into the intervention group (E group, n = 25) and the control group (C group, n = 25). Patients in the E group received general anesthesia with preoperative bilateral ultrasound-guided ESPB, whereas patients in the C group received general anesthesia with saline injection in the erector spinae plane preoperatively. Data on intraoperative and postoperative anesthetic effects and the effect on enhanced recovery after surgery were recorded and analyzed.

RESULTS

Rocuronium consumption in the intervention group was 82.80 ± 21.70 mg, which was lower than that in the control group (P < 0.05). Visual analog scale scores at 2, 6, and 24 h after surgery in the intervention group were lower than those in the control group (F_between = 34.034, P = 0.000). The time to ambulation, consumption of ketorolac tromethamine, time to oral intake and hospital stay after operation in the intervention group were significantly lower than those in the control group (P < 0.05). The block area at the different baselines was significant (F_between = 3.211, P = 0.009). The association between baseline and time was significant (F_{baseline * time} = 3.268, P = 0.001).

CONCLUSION

This study confirmed that ultrasound-guided ESPB technology is safe and beneficial for patients with colon cancer undergoing laparoscopic colon surgery.

Ultrasound-Guided Anterior Quadratus Lumborum Block Reduces Postoperative Opioid Consumption and Related Side Effects in Patients Undergoing Total Hip Replacement Arthroplasty: A Propensity Score-Matched Cohort Study

Quadratus lumborum block (QLB) has been shown to be effective for pain relief after hip surgery. This study evaluated the efficacy of ultrasound-guided anterior QLB in pain control after total replacement hip arthroplasty (TRHA). A total of 115 patients receiving anterior QLB were propensity score-matched with 115 patients who did not receive the block. The primary outcome was opioid consumption at 24, 24-48, and 48 postoperative hours. Secondary outcomes included pain scores at the post-anesthesia care unit (PACU), 8, 16, 24, 32, 40, and 48 h length of hospital stay, time to first ambulation, and the incidence of opioid-related side effects. Postoperative opioid consumption 48 h after surgery was significantly lower in the QLB group. Resting, mean, worst, and the difference of resting pain scores compared with preoperative values were significantly lower in the QLB group during the 48 postoperative hours. The length of hospital stay was shorter in the QLB group. The incidence of postoperative nausea and vomiting was significantly lower in the QLB group during the 48 postoperative hours, except at the PACU. This study suggests that anterior QLB provides effective postoperative analgesia for patients undergoing THRA performed using the posterolateral approach.

Epidural Analgesia Is Associated with Prolonged Length of Stay After Open HPB Surgery in Over 27,000 Patients

BACKGROUND

The impact of epidural analgesia (EA) on postoperative morbidity and length of stay (LOS) after HPB surgery remains to be determined. These specific outcomes have been highlighted by the implementation of multiple enhanced recovery pathways (ERAS). The authors hypothesized that EA in the current environment may be associated with LOS and other outcomes.

METHODS

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) databases from 2014 to 2017 for patients undergoing open hepatopancreaticobiliary (HPB) surgery were included in a retrospective cohort analysis with propensity score matching (PSM) comparing EA with control.

RESULTS

Twenty-seven thousand two hundred eighteen patients underwent open HPB surgery, of which 6048 (22%) received EA. There was an increase use of EA over time (from 19.3 to 25.5%, p = 0.001). On PSM, EA was associated with more than half of a day increase in LOS for both pancreatic (p < 0.001) and hepatic surgery (p < 0.001). Furthermore, for pancreatic surgery, there was an increase in urinary tract infection (2.5% vs. 3.3%, p = 0.018), time to drain removal (7.8 vs. 8.7 days, p < 0.001), and discharge to rehabilitation (2.9% vs. 4.3%, p = 0.029). For hepatic surgery, there was an increase in blood transfusion requirements (17% vs. 20%, p = 0.019). There were no differences in overall morbidity and mortality.

CONCLUSION

In this cohort of over 27,000 patients with granular surgical details, there was a significant increase in LOS associated with EA after HPB surgery, along with increased procedure-specific UTI and blood transfusion. With the ever-increasing need for standardized and efficient patient care pathways that reduce LOS, alternative analgesic adjuncts may be considered to optimize patient outcomes.

Continuous epidural catheter for anaesthesia management and post-op pain relief in colorectal surgery, complicated by epidural haematoma and bilateral paraplegia: A case report

Introduction

Utilising epidural analgesia (EA) during major abdominal surgery in combination with general anaesthetic, is a proven approach to decrease anaesthetic requirement in patients with severe comorbidities, enhance recovery and improve pain management.

Case presentation

Herein we report a case of an 81-years-old female with bilateral lower limb sensory loss, saddle paraesthesia, paraplegia, and incontinence following a thoracic epidural catheterisation required for low anterior resection of rectal adenocarcinoma. The complication was reported by the patient on the third day of post-op.

Clinical discussion

The magnetic resonance imaging results revealed an extradural extramedullary hyperintense haematoma in the spinal cord at T12-L2 vertebral level. The neurological deficit was addressed urgently with laminectomy; and following implementation of intensive inpatient physiotherapy and rehabilitation regiment the patient restored mild motor function.

Conclusion

We believe the culprit of the acute focal neurology deficits in this patient could be due to the epidural catheterisation and the post-op local anaesthetic injections. From this case, we anecdotally recommend performing thoracolumbar MRI as part of pre-op workup in patients with long standing back issues or claudication, considering x-ray guided catheterisation in higher risk patients for epidural hematoma, and early and repeated neurological examination and rapid investigation for any mild neurological deficits.

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Epidural anaesthesia is a common practice in colorectal surgery for pain management.

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Epidural haematoma formation due to epidural anaesthesia in a colorectal surgical case

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Delayed presentation of neurological deficits: bilateral paraesthesia, paraplegia, and incontinence

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Identifying at risk patients, proactive thoracolumbar MRI imaging

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Recommend X-ray guided epidural catheter insertion and close neurological monitoring

Epidural analgesia and mortality after colorectal cancer surgery: A retrospective cohort study

Background

Epidural analgesia (EA) has been the standard of care after major abdominal surgery for many years. This study aimed to correlate EA with postoperative complications, short- and long-term mortality in patients with and without EA after open surgery (OS) and minimally invasive surgery (MIS) for colorectal cancer.

Methods

Patient, clinical and outcome data were obtained from the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry. All adult patients diagnosed with colorectal cancer without metastases who underwent elective curative MIS or OS for colorectal cancer between January 2016 and December 2018 and who had data recorded in both registries, were included in the study. Data were analyzed for OS and MIS procedures separately. A Poisson regression model was used to investigate the association between EA and the outcomes of interest.

Results

Five thousand seven hundred sixty-two patients were included in the study, 2712 in the MIS and 3050 patients in the OS group. After adjusting for patient specific and clinically relevant variables in the regression model, no statistically significant difference in risk for complications; 30-day, 90-day, and up to 3-year mortality following either MIS or OS could be detected between the EA+ and EA-cohorts.

Conclusions

In this large study cohort, EA as part of the comprehensive care provided was not associated with a reduction in postoperative complications risk or improved 30-day, 90-day, or 3-year survival after MIS or OS for colorectal cancer.

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No reduction in postoperative complications with epidural analgesia.

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No reduction in short-term mortality with epidural analgesia after colorectal surgery.

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No reduction in long-term mortality with epidural analgesia in colorectal cancer.

ROUX-IN-Y GASTROJEJUNAL BYPASS: WHICH ANESTHETIC TECHNIQUE HAS BEST RESULTS?

Background:

As the number of bariatric operations increases, there is a greater interest in knowledge, experience and skills in the operative and anesthetic management of obese people. Anesthetic recovery is an important point in the therapeutic approach and less adverse effects delaying discharge of these patients are necessary to be kept in mind by the surgical team.

Aim:

To compare anesthetic-analgesic techniques in the opioid-sparing era through epidural administration of local anesthetic associated with low-dose morphine vs. clonidine and analyze the impact of analgesia on the effectiveness of postoperative recovery by comparing these two techniques.

Methods:

Randomized, double-blind clinical trial with 66 patients candidates for Roux-en-Y gastrojejunal bypass divided into two groups: morphine group and clonidine group. Multimodal analgesia included epidural anesthesia with 0.375% ropivacaine 20 ml at the eighth thoracic vertebra with the association of morphine (morphine group) at a dose of 15 mcg / kg or clonidine (clonidine group) at a dose of 1 mcg / kg.

Results:

The groups were homogeneous and statistical significance was found when analyzing the difference in pain between them in the first postoperative period. The pain was higher in the clonidine group, as in this period, analgesic rescue was also better in this group. In the other times, there was no significance in the differences regarding pain and rescue. The return of intestinal motility in the morphine group was earlier in the first postoperative period. Nausea, vomiting and hospital discharge did not show significant differences between groups.

Conclusion:

Epidural anesthesia with low-dose morphine allowed less pain during the entire hospital stay, with a positive impact on patient recovery.

Surgical treatment of proximal femoral fractures in high-risk geriatric patients under peripheral regional anesthesia : A prospective feasibility study

BACKGROUND AND OBJECTIVE

Due to changing demographics geriatric patients with multiple comorbidities and proximal femoral fractures are an increasing patient population. In these patient groups, peripheral regional anesthesia could become increasingly more important besides established procedures, such as neuraxial or general anesthesia. The aim of this single center feasibility study was to evaluate a combined blockade technique of the lumbosacral plexus for three predefined subgroups depending on the type of hip fracture.

METHODS

We used a unilateral double injection three-step technique to block the sacral (parasacral block) and lumbar plexus (anterior quadratus lumborum and psoas compartment block, n = 78). The blockade was performed both under ultrasound guidance and simultaneous nerve stimulation and 20 ml ropivacaine 0.375% was injected at each of the 3 injection sites (total dose 225 mg).

RESULTS

In 42% of cases the surgery was opioid-free (n = 33). In 5 patients a conversion to general anesthesia (insertion of a laryngeal mask and pressure-controlled or pressure-supported ventilation) was necessary (6%). The overall success rate of combination anesthesia (peripheral nerve blocks with supplemental sedative (propofol 1-2 mg/kg*h) or analgesic (incremental doses of 5 µg sufentanil) medication) was 94%, regardless of fracture type and surgical treatment.

CONCLUSION

The combined anesthetic technique presented in this study enables surgical treatment of proximal femoral fractures. The associated effort and requirement for expert knowledge in regional anesthesia indicates that this method should be considered especially in cases with high anesthetic risk, suitable sonoanatomy, and non-compromised coagulation.

Variable Gut Function Recovery After Right vs. Left Colectomy May Be Due to Rectosigmoid Hyperactivity

It is established that gut function recovers slower after right vs. left colectomies with higher rates of prolonged post-operative ileus (PPOI), but the reason is unclear. Development of PPOI is multifactorial. A recent manometry study in right colectomy patients showed that the distal colon becomes hyperactive after surgery with predominantly cyclic motor patterns (CMPs). In this perspective, we evaluate the hypothesis that the slower gut recovery after right hemicolectomy could be induced by a functional obstruction due to hyperactive CMPs.

The Implementation of an Acute Pain Service for Patients Undergoing Open Ventral Hernia Repair with Mesh and Abdominal Wall Reconstruction

INTRODUCTION

In this retrospective cohort single-institutional study, we report the outcomes of implementing a standardized protocol of multimodal pain management with thoracic epidural analgesia via the acute pain service (APS) for patients undergoing ventral hernia repair with mesh placement and abdominal wall reconstruction.

METHODS

The primary outcome evaluated was postoperative 72-h opioid consumption, measured in intravenous morphine equivalents (MEQ). Secondary outcomes included hospital length of stay (LOS) among other outcomes. The two cohorts were the APS versus non-APS group, in which the former cohort had an APS providing epidural and multimodal analgesia and the latter utilized pain management per surgical team, which mostly consisted of opioid therapy. Using1:1 propensity-score-matched cohorts, Wilcoxon signed-rank test was used to calculate the differences in outcomes. A p < 0.05 was considered statistically significant.

RESULTS

There were 83 patients, wherein 51 (61.4%) were in the APS group. Between matched cohorts, the non-APS cohort's median [quartiles] total opioid consumption during the first three days was 85.6 mg MEQs [58.9, 112.8 mg MEQs]. The APS cohort was 31.7 mg MEQs [16.0, 55.3 mg MEQs] (p < 0.0001). The non-APS hospital LOS median [quartiles] was 5 days [4, 7 days] versus 4 days [4, 5 days] in the APS group (p = 0.01).

DISCUSSION

A dedicated APS was associated with decreased opioid consumption by 75%, as well as a decreased hospital LOS. We report no differences in ICU length of stay, time to oral intake, time to ambulation or time to urinary catheter removal.

Peripherally Acting μ-Opioid Receptor Antagonists in the Management of Postoperative Ileus: a Clinical Review

Postoperative ileus (POI) and constipation are common secondary effects of opioids and carry significant clinical and economic impacts. μ-Opioid receptors mediate opioid analgesia in the central nervous system (CNS) and gastrointestinal-related effects in the periphery. Peripherally acting μ-opioid receptor antagonists (PAMORAs) block the peripheral effects of opioids in the gastrointestinal tract, while maintaining opioid analgesia in the CNS. While most are not approved for POI or postoperative opioid-induced constipation (OIC), PAMORAs have a potential role in these settings via their selective effects on the μ-opioid receptor. This review will discuss recent clinical trials evaluating the safety and efficacy of PAMORAs, with a focus on alvimopan (Entereg^®) and methylnaltrexone (Relistor^®) in patients with POI or postoperative OIC. We will characterize potential factors that may have impacted the efficacy observed in phase 3 trials and discuss future directions for the management and treatment of POI.

State-of-the-art colorectal disease: postoperative ileus

PURPOSE

Postoperative Ileus (POI) remains an important complication for patients after abdominal surgery with an incidence of 10-27% representing an everyday issue for abdominal surgeons. It accounts for patients' discomfort, increased morbidity, prolonged hospital stays, and a high economic burden. This review outlines the current understanding of POI pathophysiology and focuses on preventive treatments that have proven to be effective or at least show promising effects.

METHODS

Pathophysiology and recommendations for POI treatment are summarized on the basis of a selective literature review.

RESULTS

While a lot of therapies have been researched over the past decades, many of them failed to prove successful in meta-analyses. To date, there is no evidence-based treatment once POI has manifested. In the era of enhanced recovery after surgery or fast track regimes, a few approaches show a beneficial effect in preventing POI: multimodal, opioid-sparing analgesia with placement of epidural catheters or transverse abdominis plane block; μ-opioid-receptor antagonists; and goal-directed fluid therapy and in general the use of minimally invasive surgery.

CONCLUSION

The results of different studies are often contradictory, as a concise definition of POI and reliable surrogate endpoints are still absent. These will be needed to advance POI research and provide clinicians with consistent data to improve the treatment strategies.

Transvaginal hybrid-NOTES vs. traditional laparoscopic sigmoid resection for diverticulitis: a short-term comparative study

The aim was to compare short-term results of transvaginal hybrid-NOTES (NSR) with traditional laparoscopic technique in sigmoid resection (LSR) in cases of diverticulitis. Natural Orifice Transluminal Endoscopic Surgery has been evolved as a minimally invasive procedure to reduce the operative trauma due to the absence of specimen extraction through the abdominal wall causing less postoperative pain, and shorter hospital stay. Despite the increasing use and published case series of NSR for diverticulitis as a laparoscopic procedure with transvaginal stapling and specimen extraction, there are no studies comparing this procedure with LSR. Twenty NSR patients operated at the Cologne-Merheim Medical Center have been documented and compared with 20 female LSR patients matched for body mass index, American Society of Anesthesiologists-classification (ASA), Hansen/Stock classification, and age. To ensure comparability regarding peri- and postoperative care, only procedures performed by the same surgeon were included. Procedural time, intra- and postoperative complications, conversion rate, postoperative pain, the duration of an epidural catheter, analgesic consumption, and postoperative length of hospital stay were analyzed. There were no significant differences in the sum of pain levels (p = 0.930), length of procedure (p = 0.079), intra- and postoperative complications, as well as duration of an epidural catheter. On the contrary, there were significant positive effects for NSR on morphine requirement at day seven and eight (p = 0.019 and p = 0.035 respectively) as well as the postoperative length of hospital stay (p = 0.031). This retrospective study reveals significant positive effects for NSR compared to LSR regarding length of hospital stay as well as morphine consumption after removal of the epidural catheter, whereas there were no significant differences in complication rate and procedural time. In summary, NSR is an adequate alternative to traditional laparoscopic sigmoid resection considering the surgeons experience and the patient's personal preferences.

Perioperative factors predicting delayed enteral resumption and hospital length of stay in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: Retrospective cohort analysis from a single centre in India

Background and Aims:

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an extensive procedure associated with significant morbidity, delay in return of gastrointestinal function and discharge from hospital. Our aim was to assess perioperative factors influencing enteral resumption (ER) and length of stay in the hospital (LOS) in CRS-HIPEC.

Methods:

A retrospective analysis was conducted in a major tertiary cancer centre. Sixty-five patients who underwent CRS-HIPEC between July 2014 and March 2019 were included in the study. The perioperative data were collected from patient records. The primary outcome measure was day of oral resumption of 500 ml of clear fluids and secondary outcome was the LOS. Univariate and multivariate logistic regression analysis was done for the various continuous and categorical perioperative variables for both ER and LOS to elicit the magnitude of risk for both outcomes.

Results:

Univariate logistic regression revealed that peritoneal carcinomatosis index score (PCI), duration of surgery, blood loss and postoperative ventilation influenced both ER and LOS. Serum albumin, plasma usage and total peritonectomy affected only the LOS but not ER. Multivariate analysis showed that duration of surgery (P = 0.006) and quantum of intravenous fluid infused (P = 0.043) were statistically associated with ER, while serum albumin level (P = 0.025) and postoperative ventilation (P = 0.045) were independently predictive of LOS.

Conclusion:

CRS-HIPEC is an extensive surgery and multiple factors are associated with ER; of these, duration of surgery and intraoperative fluid therapy are significant factors. Low serum albumin and prolonged postoperative ventilation are associated with increased LOS.

Epidural Analgesia in Ventral Hernia Repair: An Analysis of 30-day Outcomes

BACKGROUND

Ventral hernia repair (VHR) is a common procedure associated with significant postoperative morbidity and prolonged hospital length of stay (LOS). The use of epidural analgesia in VHR has not been widely evaluated.

PURPOSE

To compare the outcomes of general anesthesia plus epidural analgesia (GA + EA) versus general anesthesia alone (GA) in patients undergoing ventral hernia repair.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify elective cases of VHR. Propensity score-matched analysis was used to compare outcomes in GA vs GA + EA groups. Cases receiving transverse abdominus plane blocks were excluded.

RESULTS

A total of 9697 VHR cases were identified, resulting in two matched cohorts of 521 cases each. LOS was significantly longer in the GA + EA group (5.58 days) vs the GA group (5.20 days, p = 0.008). No other statistically significant differences in 30-day outcomes were observed between the matched cohorts.

CONCLUSION

Epidural analgesia in VHR is associated with statistically significant, but not clinically significant increase in LOS and may not yield any additional benefit in cases of isolated, elective VHR. Epidural analgesia may not be beneficial in this surgical population. Future studies should focus on alternative modes of analgesia to optimize pain control and outcomes for this procedure.

Defining postoperative ileus and associated risk factors in patients undergoing radical cystectomy with an Enhanced Recovery After Surgery (ERAS) program

INTRODUCTION

Postoperative ileus (POI) is a common complication of radical cystectomy (RC), occurring in 1.6-23.5% of cases. It is defined heterogeneously in the literature. POI increases hospital length of stay and postoperative morbidity. Factors such as age, epidural use, length of procedure, and blood loss may impact POI. In this study, we aimed to evaluate risk factors that contribute to POI in a cohort of patients managed with a comprehensive Enhanced Recovery After Surgery (ERAS) protocol.

METHODS

A retrospective review of consecutive patients who underwent RC from March 2015 to December 2016 at Vancouver General Hospital was performed. POI was defined a priori as insertion of nasogastric tube for nausea or vomiting, or failure to advance to a solid diet by the seventh postoperative day. To illustrate heterogeneity in previous studies, we also evaluated POI using other previously reported definitions in the RC literature. The influence of potential risk factors for POI, including patient comorbidities, American Society of Anesthesiologists score, gender, age, prior abdominal surgery or radiation, length of operation, diversion type, extent of lymph node dissection, removal date of analgesic catheter, blood loss, and fluid administration volume was analyzed.

RESULTS

Thirty-six (27%) of 136 patients developed POI. Using other previously reported definitions for POI, the incidence ranged from <1-51%. Node-positive status and age at surgery were associated with POI on univariate analysis but not multivariable analysis.

CONCLUSIONS

A large range of POI incidence was observed using previously published definitions of POI. We advocate for a standardized definition of POI when evaluating RC outcomes. POI occurs frequently even with a comprehensive ERAS protocol, suggesting that additional measures are needed to reduce the rate of POI.

Effect of Chewing Gum on Gastrointestinal Function Recovery After Surgery of Gynecological Cancer Patients at Rajavithi Hospital: A Randomized Controlled Trial

Objective:

To evaluate the efficacy of postoperative gum-chewing compare with routine postoperative care on the recovery of gastrointestinal function after comprehensive surgical staging for gynecological cancer.

Materials and Methods:

A total of 82 patients who underwent comprehensive surgical staging for gynecological cancer at Rajavithi Hospital between October 1st, 2018 and June 30th, 2019 were randomly allocated into two groups: Gum-chewing group (n=40) and control group (n=42). In the gum-chewing group, patients were assigned to chew sugar-free gum for 30 minutes starting from the first postoperative morning then every 8 hours until the first passage of flatus. In the control group, patients have received routine postoperative care. The primary endpoint was time to first flatus after surgery. The secondary endpoints were time to first bowel sound, time to first defecation, time to first walk, postoperative analgesia and anti-emetic drug requirement, ileus symptoms, length of a hospital stay, and potential adverse events of gum-chewing, including dry mount, choking, and aspiration.

Results:

Chewing gum was statistically significant in reducing time to first flatus compared with routine postoperative care (median 24.7 (range 2.2-86.5) vs 35.4 (range 7.2-80.9) hours, p=0.025). The length of a hospital stay was also significantly shorter in the gum-chewing group (median 3.0 (range 1.0-8.8) vs 3.5 (range 1.8-50.0) days, p=0.023). There were no significant differences in time to first bowel sound, time to first defecation, time to first walk, postoperative analgesia and anti-emetic drug requirement, and ileus symptoms between both two groups. No adverse events related to postoperative gum-chewing were observed.

Conclusion:

Gum-chewing was associated with early recovery of gastrointestinal function in patients undergoing surgery for gynecological cancer. It is an inexpensive and physiologic intervention that appears to be reasonably safe and should be recommended as an adjunct in postoperative care of gynecological cancer surgery.

Achieving Opioid-Free Major Colorectal Surgery: Is It Possible?

INTRODUCTION

Opioid analgesia remains the mainstay of postoperative pain management strategies despite being associated with many adverse effects. A specific opioid-free protocol was designed to limit opioid usage.

OBJECTIVE

The aim of the study was to audit the opioid-free rate within this protocol and to identify factors that might contribute to opioid-free surgery.

METHODS

A retrospective study of all elective patients receiving abdominal colorectal surgery at the Center for Colon and Rectal Surgery at AdventHealth over 6 months was performed. Data on demographics, indications, perioperative management, outcomes, and inpatient and outpatient analgesic requirements were collected with subsequent analysis.

RESULTS

A total of 303 consecutive patient records were analyzed. Approximately two-thirds (67.7%) of patients did not receive narcotics once they left the postanesthesia care unit as an inpatient. One-third of patients (32.0%) did not receive narcotic analgesia within 30 days of surgery as an outpatient. Patients in the opioid-free cohort were significantly older and had a malignant indication, less perioperative morbidity, and a shorter length of stay.

CONCLUSIONS

Our study demonstrates that opioid-free analgesia is indeed possible in major colorectal surgery. Study limitations include its retrospective nature and that it is from a single institution. Despite these limitations, this study provides proof of concept that opioid-free colorectal surgery is possible within a specific protocol.

Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery

Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.

Effects of a metabolic optimized fast track concept (MOFA) on bowel function and recovery after surgery in patients undergoing elective colon or liver resection: a randomized controlled trial

Background

Enhanced recovery after surgery programs (ERAS) using thoracic epidural anesthesia and perioperative patient conditioning with omega-3 fatty acids (n3FA), glucose control (GC) and on-demand fluid therapy, respectively, showed beneficial effects. In the MOFA- study these components were used together in patients undergoing colon or liver surgery. We hypothesized that the use of a perioperative MOFA program improves intestine function represented as time to the first postoperative bowel movement in adult patients compared to standard ERAS.

Methods

After BfArM and IRB approval 100 patients were enrolled in this prospective randomized controlled trial. All patients received ERAS therapy (control). In addition, the MOFA group received 0.2 g/kg fish oil (Omegaven®), preoperatively, followed by a 48 h continuous infusion of 0.2 g/kg/d n3FA; and GC was kept below < 8 mmol/L. Pre- and postoperatively energy drinks were administered.

Results

As compared to control group the MOFA concept resulted in an earlier onset of flatulence by 14 h (46.6 ± 25.7, 32.0 ± 17.9, p = 0.030, hours, control vs. MOFA, respectively). Effects on onset of bowel movement were not observed (74.5 ± 30.4, 66.4 ± 29.2, p = 0.163, hours, control vs. MOFA, respectively). The disease severity (SAPS II score; p = 0.720) as well as deployment of resources (TISS 28 score, p = 0.709) did not differ between groups. No statistic significant difference between MOFA and control group regarding inflammation, impairment of coagulation, length of hospital stay or incidence of postoperative surgical complications were observed.

Conclusions

The MOFA concept did not result in an improvement of intestine function or faster recovery after elective colon or liver surgery compared to standard ERAS therapy. Omega-3 fatty acids showed no impairment of coagulation or improved resolution of inflammation. Further trials in a larger patient collective are needed to investigate potential beneficial effects of omega-3 fatty acids in abdominal surgery.

Trial registration

This trial was prospectively registered at the European Union Clinical Trials Register (EuDraCT 2005–004814-33, date: 10-05-2005, https://www.clinicaltrialsregister.eu/ctr-search/search?query=2005-004814-33+).

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0823-6) contains supplementary material, which is available to authorized users.

REGIONAL ANAESTHESIA IN THORACIC AND ABDOMINAL SURGERY

Surgical procedure causes tissue damage which activates systemic inflammatory response and leads to changes in endocrine and metabolic system. Anaesthesia and pain can further disrupt immune performance. Regional anaesthesia causes afferent nerve blockade and in this way mediates immune protection. Thoracic epidural analgesia is the cornerstone of pain relief in thoracic and abdominal surgery. Alternatively thoracic paravertebral block can be used with less side effects and good analgesic properties. Drugs that interfere with blood coagulation obstruct the use of central regional blocks. Surgery has also changed recently from open to minimally invasive. Also pain treatment for this procedures has changed to less aggressive, systemic or locoregional techniques. It was shown that transversus abdominis plane block and epidural analgesia have the same effect on postoperative pain, but transversus abdominis plane block was better regarding hemodynamic stability and hospital stay. Multimodal approach combining regional and systemic analgesia is currently the most appropriate perioperative pain management strategy. More studies should be done to give recommendations.

Risk of bias judgements and strength of conclusions in meta-evidence from the Cochrane Colorectal Cancer Group

BACKGROUND

The Cochrane Collaboration records risk of bias (ROB) judgements on the original studies it analyses. The aim of this review is to perform an audit of all literature produced by the Cochrane Colorectal Cancer Group (CCCG), focusing on whether intervention type has any relationship with ROB and the ability of a review to inform clinical practice.

METHODS

The most recent version of every CCCG review from January 2000 to the end of July 2018 was included. Conclusions were categorized as informing clinical practice (I) or not (N). Both I and N categories were divided into firm (F) or tempered (T) based on the definitiveness of their language. ROB judgements were aggregated. Reviews were classed as Medical (M), Surgical (S), Medical & Surgical (MS) or Other (O) based on their intervention, with O reviews then excluded. Data were analyzed in SPSS.

RESULTS

Ninety-five reviews were included, covering 1892 studies. Sixty-two percent (n = 59/95) informed clinical practice (I). Thirty-eight percent (n = 36/95) did not inform clinical practice (N). Of the N group, 53% (n = 19/36) were completely equivocal (firm) while 47% (n = 17/36) were moderately so (tempered). In the I group, 46% (n = 27/59) gave a conclusion that was firm and 54% (n = 32/59) were tempered. Seven thousand five hundred sixty-four cases of bias were assessed. Risk of bias was low in 43%, high in 20% and unclear in 37%. A review that regarded a medical intervention alone was significantly more likely to be comprised of studies with a low risk of bias than a review that included a surgical intervention (p < 0.001).

CONCLUSION

The Cochrane Colorectal Cancer Group finds the risk of bias to be low in less than half of its judgements. A review that included a surgical intervention was less likely to display low risk of bias. Risk of bias was associated with whether a review informed clinical practice, but intervention type was not. Readers of colorectal literature should be cautious when considering original and meta-evidence in this field, particularly where a surgical intervention is assessed.

Regional analgesia techniques for pain management in patients admitted to the intensive care unit

Controlling pain should be a priority in the clinical practice of intensive care units (ICUs). Monomodal analgesic approaches, such as the administration of opioids, are widely employed; however, the widespread use of opioids has catastrophic consequences, given their multiple side effects and the development of dependence. Regional analgesia (RA), with single or continuous dosing using neuraxial and peripheral catheters, can play an important role in multimodal analgesia for management of pain in critical care patients. RA provides superior pain control, as compared to systemic treatments, and is associated with a lower rate of side effects. Nevertheless, RA remains underused in ICUs. Many critically ill, post-surgical or traumatically injured patients would benefit from these techniques. For these reasons, we aim to establish a set of potential indications integrating the use of RA in analgesia protocols routinely used in ICUs. We performed a review of literature sources with contrasted evidence levels to present RA techniques and their potential applications in ICU patients.

Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass

BACKGROUND

General anaesthesia combined with epidural analgesia may have a beneficial effect on clinical outcomes. However, use of epidural analgesia for cardiac surgery is controversial due to a theoretical increased risk of epidural haematoma associated with systemic heparinization. This review was published in 2013, and it was updated in 2019.

OBJECTIVES

To determine the impact of perioperative epidural analgesia in adults undergoing cardiac surgery, with or without cardiopulmonary bypass, on perioperative mortality and cardiac, pulmonary, or neurological morbidity.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase in November 2018, and two trial registers up to February 2019, together with references and relevant conference abstracts.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) including adults undergoing any type of cardiac surgery under general anaesthesia and comparing epidural analgesia versus another modality of postoperative pain treatment. The primary outcome was mortality.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

We included 69 trials with 4860 participants: 2404 given epidural analgesia and 2456 receiving comparators (systemic analgesia, peripheral nerve block, intrapleural analgesia, or wound infiltration). The mean (or median) age of participants varied between 43.5 years and 74.6 years. Surgeries performed were coronary artery bypass grafting or valvular procedures and surgeries for congenital heart disease. We judged that no trials were at low risk of bias for all domains, and that all trials were at unclear/high risk of bias for blinding of participants and personnel taking care of study participants.Epidural analgesia versus systemic analgesiaTrials show there may be no difference in mortality at 0 to 30 days (risk difference (RD) 0.00, 95% confidence interval (CI) -0.01 to 0.01; 38 trials with 3418 participants; low-quality evidence), and there may be a reduction in myocardial infarction at 0 to 30 days (RD -0.01, 95% CI -0.02 to 0.00; 26 trials with 2713 participants; low-quality evidence). Epidural analgesia may reduce the risk of 0 to 30 days respiratory depression (RD -0.03, 95% CI -0.05 to -0.01; 21 trials with 1736 participants; low-quality evidence). There is probably little or no difference in risk of pneumonia at 0 to 30 days (RD -0.03, 95% CI -0.07 to 0.01; 10 trials with 1107 participants; moderate-quality evidence), and epidural analgesia probably reduces the risk of atrial fibrillation or atrial flutter at 0 to 2 weeks (RD -0.06, 95% CI -0.10 to -0.01; 18 trials with 2431 participants; moderate-quality evidence). There may be no difference in cerebrovascular accidents at 0 to 30 days (RD -0.00, 95% CI -0.01 to 0.01; 18 trials with 2232 participants; very low-quality evidence), and none of the included trials reported any epidural haematoma events at 0 to 30 days (53 trials with 3982 participants; low-quality evidence). Epidural analgesia probably reduces the duration of tracheal intubation by the equivalent of 2.4 hours (standardized mean difference (SMD) -0.78, 95% CI -1.01 to -0.55; 40 trials with 3353 participants; moderate-quality evidence). Epidural analgesia reduces pain at rest and on movement up to 72 hours after surgery. At six to eight hours, researchers noted a reduction in pain, equivalent to a reduction of 1 point on a 0 to 10 pain scale (SMD -1.35, 95% CI -1.98 to -0.72; 10 trials with 502 participants; moderate-quality evidence). Epidural analgesia may increase risk of hypotension (RD 0.21, 95% CI 0.09 to 0.33; 17 trials with 870 participants; low-quality evidence) but may make little or no difference in the need for infusion of inotropics or vasopressors (RD 0.00, 95% CI -0.06 to 0.07; 23 trials with 1821 participants; low-quality evidence).Epidural analgesia versus other comparatorsFewer studies compared epidural analgesia versus peripheral nerve blocks (four studies), intrapleural analgesia (one study), and wound infiltration (one study). Investigators provided no data for pulmonary complications, atrial fibrillation or flutter, or for any of the comparisons. When reported, other outcomes for these comparisons (mortality, myocardial infarction, neurological complications, duration of tracheal intubation, pain, and haemodynamic support) were uncertain due to the small numbers of trials and participants.

AUTHORS' CONCLUSIONS

Compared with systemic analgesia, epidural analgesia may reduce the risk of myocardial infarction, respiratory depression, and atrial fibrillation/atrial flutter, as well as the duration of tracheal intubation and pain, in adults undergoing cardiac surgery. There may be little or no difference in mortality, pneumonia, and epidural haematoma, and effects on cerebrovascular accident are uncertain. Evidence is insufficient to show the effects of epidural analgesia compared with peripheral nerve blocks, intrapleural analgesia, or wound infiltration.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

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.