Epidural analgesia in gastrointestinal surgery

Efficacy and feasibility of scheduled intravenous acetaminophen administration after pancreatoduodenectomy: a propensity score-matched study

PURPOSE

The efficiency and safety of routine intravenous administration of acetaminophen after highly invasive hepatobiliary pancreatic surgery remain unclear. In particular, there have been no studies focusing on pancreatoduodenectomy. The present study clarified its clinical utility for patients undergoing pancreatoduodenectomy.

METHODS

We retrospectively collected 179 patients who underwent open pancreatoduodenectomy from 2015 to 2020. The analgesic effects and adverse events in patients with scheduled intravenous administration of acetaminophen were evaluated using propensity score matching.

RESULTS

After 40 patients from each group were selected by propensity score matching, the postoperative liver function tests were not significantly different between the control and acetaminophen groups. No significant differences were found in the self-reported pain intensity score or postoperative nausea and vomiting; however, the rate of pentazocine use and the total number of additional analgesics were significantly lower in the acetaminophen group than in the control group (p = 0.003 and 0.002, respectively).

CONCLUSION

The scheduled intravenous administration of acetaminophen did not affect the postoperative liver function and had a good analgesic effect after pancreatoduodenectomy.

Analgesic Modalities in Patients Undergoing Open Pancreatoduodenectomy-A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review explored the efficacy of different analgesic modalities and the impact on perioperative outcome in patients undergoing pancreatoduodenectomy.

METHODS

A systematic literature search was performed on PubMed, Embase, Web of Science, Scopus, and Cochrane Library Database using the PRISMA framework. The primary outcome was pain scores on postoperative day one (POD1) and postoperative day two (POD2). The secondary outcomes included length of hospital stay (LOS) and specific procedure-related complications.

RESULTS

Five randomized controlled trials and ten retrospective cohort studies were included in the systematic review. Studies compared epidural analgesia (EA), patient-controlled analgesia (PCA), continuous wound infiltration (CWI), continuous bilateral thoracic paravertebral infusion (CTPVI), intrathecal morphine (ITM), and sublingual sufentanil. The pain scores on POD1 (p < 0.001) and POD2 (p = 0.05) were higher in the PCA group compared with the EA group. Pain scores were comparable between EA and CWI plus PCA or CTPVI on POD1 and POD2. Pain scores were comparable between EA and ITM on POD1. The procedure-related complications and length of hospital stay were not significantly different according to the type of analgesia.

CONCLUSIONS

EA provided lower pain scores compared with PCA on the first postoperative day after pancreatoduodenectomy; the length of hospital stay and procedure-related complications were similar between EA and PCA. CWI and CTPVI provided similar pain relief to EA.

Suppression of perioperative stress response in elective abdominal surgery: A randomized comparison between dexmedetomidine and epidural block

Background and Aims

Stress response after surgery induces local and systemic inflammation which may be detrimental if it goes unchecked. Blockade of afferent neurons or inhibition of hypothalamic function may mitigate the stress response.

Material and Methods

A total of 50 consenting adult ASA I/II patients undergoing elective abdominal surgery were randomized to receive either dexmedetomidine (Group D) or epidural bupivacaine (Group E) in addition to balanced general anesthesia. Laparoscopic surgery, contraindications to epidural administration, history of psychiatric disorders, obesity (BMI >30 kg/m2), on beta blockers or continuous steroid therapy for >5 days over last 1 year, and known case of endocrine abnormalities or malignancy were excluded. Serum cortisol, blood glucose, and blood urea were estimated. Hemodynamic parameters, total dose of dexmedetomidine, bupivacaine, emergence characteristics, and analgesic consumption over 24 h postoperatively were recorded. Statistical comparisons were done using Student's t-test, repeated measure analysis of variance followed by Dunnett's test, generalized linear model and Chi-square/Fisher's exact test. A P value <0.05 was considered significant.

Results

Serum cortisol levels were significantly lower in group E than group D 24 h after surgery (P = 0.029). Intraoperative and postoperative glucose level was lower in group E compared with group D. Time to request of first rescue analgesic was longer in group E than group D (P = 0.040). There was no significant difference between the number of doses of paracetamol required in the postoperative period (P = 0.198).

Conclusion

Epidural bupivacaine was more effective than intravenous dexmedetomidine for suppression of neuroendocrine and metabolic response to surgery. Dexmedetomidine provided better hemodynamic stability at the time of noxious stimuli and postoperatively.

Intrathecal Morphine and Effect on Opioid Consumption and Functional Recovery after Pancreaticoduodenectomy

BACKGROUND

Single-shot intrathecal morphine (ITM) is an effective strategy for postoperative analgesia, but there are limited data on its safety, efficacy, and relationship with functional recovery among patients undergoing pancreaticoduodenectomy.

STUDY DESIGN

This was a retrospective review of patients undergoing pancreaticoduodenectomy from 2014 to 2020 as identified by the institutional NSQIP Hepato-pancreato-biliary database. Patients were categorized by having received no spinal analgesia, ITM, or ITM with transversus abdominus plane block (ITM+TAP). The primary outcomes were average daily pain scores from postoperative days (POD) 0 to 3, total morphine equivalents (MEQ) consumed over POD 0 to 3, and average daily inpatient MEQ from POD 4 to discharge. Secondary outcomes included the incidence of opioid related complications, length of stay, and functional recovery.

RESULTS

A total of 233 patients with a median age of 67 years were included. Of these, 36.5% received no spinal analgesia, 49.3% received ITM, and 14.2% received ITM+TAP. Average pain scores in POD 0 to 3 were similar by mode of spinal analgesia (none [2.8], ITM [2.6], ITM+TAP [2.3]). Total MEQ consumed from POD 0 to 3 were lower for patients who received ITM (121 mg) and ITM+TAP (132 mg), compared with no spinal analgesia (232 mg) (p < 0.0001). Average daily MEQ consumption from POD 4 to discharge was lower for ITM (18 mg) and ITM+TAP (13.1 mg) cohorts compared with no spinal analgesia (32.9 mg) (p = 0.0016). Days to functional recovery and length of stay were significantly reduced for ITM and ITM+TAP compared with no spinal analgesia. These findings remained consistent through multivariate analysis, and there were no differences in opioid-related complications among cohorts.

CONCLUSIONS

ITM was associated with reduced early postoperative and total inpatient opioid utilization, days to functional recovery, and length of stay among patients undergoing pancreaticoduodenectomy. ITM is a safe and effective form of perioperative analgesia that may benefit patients undergoing pancreaticoduodenectomy.

Intravenous Lignocaine-Fentanyl Versus Epidural Ropivacaine-Fentanyl for Postoperative Analgesia After Major Abdominal Oncosurgery: A Pilot Prospective Randomised Study

OBJECTIVE

Epidural injection of local anaesthetics and intravenous opioid injection are two common analgesic strategies following major abdominal oncosurgery. However, epidural local anaesthetics may cause haemodynamic instability while opioid injection is associated with sedation and postoperative ileus. Intravenous lignocaine is also used for postoperative analgesia, and combined use of opioids plus lignocaine can reduce the doses and adverse effects of the individual drugs. This study therefore compared the analgesic efficacy of intravenous lignocaine-fentanyl (IV) to epidural ropivacaine-fentanyl (EPI) after major abdominal oncosurgery.

METHODS

Sixty patients were randomised to IV and EPI groups. Patients in the IV group received preoperative intravenous bolus injections of lignocaine 1.5 mg kg^-1 and fentanyl 0.5 μg kg^-1, intraoperative infusions of lignocaine 1 mg kg^-1 h^-1 and fentanyl 0.5 μg kg^-1 h^-1, and postoperative infusions of lignocaine 0.5 mg kg^-1 h^-1 and fentanyl 0.25 μg kg^-1 h^-1. In the EPI group, patients received a 6-ml epidural bolus injection of ropivacaine 0.2% plus fentanyl 2 μg mL^-1, intraoperative infusion of 5 mL·h^-1 fentanyl and postoperative ropivacaine 0.1% plus fentanyl 1 μg mL^-1 infusion at 5 mL h^-1. All patients also received postoperative patient-controlled IV fentanyl as rescue analgesia. Patient-controlled fentanyl consumption was documented as the primary outcome for postoperative analgesic efficacy. Results were compared by Mann-Whitney U-test and Student's t-test using Statistical Package for Social Science (SPSS) software.

RESULTS

Median (min-max) rescue fentanyl requirement in the first 24 h postsurgery was comparable between IV and EPI groups [780 (340-2520) μg vs. 820 (140-2260) μg; p=0.6], as was postoperative pain score (p>0.05). The incidence of intraoperative hypotension requiring bolus mephenteramine injection was significantly higher in the EPI group than the IV group (36% vs. 17%; p<0.001).

CONCLUSION

Intravenous lignocaine-fentanyl and epidural ropivacaine-fentanyl have comparable postoperative analgesic efficacies after major open abdominal oncosurgery.

Use and Outcomes of Epidural Analgesia in Upper Gastrointestinal Tract Cancer Resections

BACKGROUND

Epidural analgesia (EA) is an appealing adjunct for esophageal and gastric cancer patients. It remains unclear whether EA usage affects postoperative outcomes. There are no national data on the trends of EA utilization for these procedures. This study aims to use the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to study the utilization and outcomes of EA in open upper GI tract cancer resections.

MATERIALS AND METHODS

A retrospective review of NSQIP was performed for patients undergoing open elective esophagectomies and gastrectomies for nonmetastatic cancer between 2014 and 2017. An Armitage trend test was performed. The population was propensity matched and assessed.

RESULTS

There were 4802 esophagectomies performed. Twenty-nine percent of patients received EA. Of 2599 gastrectomies, 18% of patients received EA. The recent trends of EA use for esophagectomies (EA range [26.9%, 30.3%] P = 0.6535) and gastrectomies (EA [16.9%, 18.4%], P = 0.7797) remain stable. Propensity matching was performed, and the groups with and without EA were compared. For esophagectomies, EA was associated with blood transfusions (EA 14% versus No EA 10.8%, P = 0.0156). For gastrectomies, EA was associated with longer length of stay (LOS) (EA median [IQR] 8 [7,11] versus No EA 7 [6,11], P = 0.0002).

CONCLUSIONS

Despite the current opioid epidemic, the recent trends of EA for esophageal and gastric cancer patients remain stable. EA was associated with blood transfusions for esophagectomies and with a longer LOS for gastrectomies. Therefore, EA should be carefully considered, and its analgesic efficacy in this population should be investigated closely in future studies.

Combined epidural-general anaesthesia vs general anaesthesia in neonatal gastrointestinal surgery: A randomized controlled trial

BACKGROUND

Post-operative ileus is a frequent complication of gastrointestinal surgery under general anaesthesia. The aim of this study was to investigate whether combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery in neonates undergoing elective gastrointestinal surgery.

METHODS

A randomized controlled trial including 60 neonates who underwent gastrointestinal surgery at a university hospital was performed. Thirty neonates received combined epidural-general anaesthesia (CEGA), and 30 neonates received general anaesthesia (GA) alone. The primary outcome was the post-operative time to tolerance of full enteral nutrition. The secondary outcomes were the post-operative time defaecation, the duration of nasogastric drainage, and infections.

RESULTS

After excluding two neonates from the CEGA group, where repeated attempts at epidural catheterization were unsuccessful, a total of 58 patients completed the study (CEGA: 28; GA: 30). Full enteral nutrition was tolerated earlier in CEGA vs the GA group (4.0 vs 8.0 days; P = .0001). Time to defaecation was shorter in the CEGA group (3.5 vs 5.0 days; P = .0001). Duration of nasogastric drainage was similar between groups (7.0 vs 7.0 days; P = .9502). Fewer patients in the CEGA group experienced post-operative infection (35.7% vs 60.0%; P = .038).

CONCLUSION

Combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery and a lower infection risk after gastrointestinal surgery in neonates.

A Literature Review of Intrathecal Morphine Analgesia in Patients Undergoing Major Open Hepato-Pancreatic-Biliary (HPB) Surgery

CONTEXT

The optimal analgesic method for patients undergoing major open hepato-pancreatic-biliary surgery remains controversial. Continuous epidural infusion at the thoracic level remains the standard choice, however concerns have been raised due to associated complications. Single shot intrathecal morphine has emerged as a promising alternative offering similar analgesia with an enhanced safety profile.

EVIDENCE ACQUISITION

This review aimed to evaluate the literature comparing intrathecal morphine analgesia to other analgesic modalities following major open hepato-pancreatic-biliary surgery. The primary outcome was pain scores at rest and on movement 24 h after surgery. Secondary outcomes were postoperative opioid consumption within 72 postoperative hours, length of stay (LOS), intra-operative fluid administration and post-operative fluid administration within 72 postoperative hours, and overall systemic complication rate within 30 postoperative days.

RESULTS

Eleven trials matching the inclusion criteria were analysed. Intrathecal morphine resulted in equivalent or lower pain scores when contrasted to alternative techniques, but required higher amounts of postoperative opioid. Intrathecal morphine also offered reduced LOS and reduced fluid administration requirements to epidural analgesia, and there was no difference observed in major complication rate between analgesic modalities.

CONCLUSIONS

In summary the evidence suggests that intrathecal morphine may be a better first-line analgesic modality than epidural analgesia in the context of major open hepato-pancreatic-biliary surgery, but high-quality evidence supporting this is limited.

Incidence and Risk Factors of Coagulation Profile Derangement After Liver Surgery: Implications for the Use of Epidural Analgesia-A Retrospective Cohort Study

BACKGROUND

Hepatic surgery is a major abdominal surgery. Epidural analgesia may decrease the incidence of postoperative morbidities. Hemostatic disorders frequently occur after hepatic resection. Insertion or withdrawal (whether accidental or not) of an epidural catheter during coagulopathic state may cause an epidural hematoma. The aim of the study is to determine the incidence of coagulopathy after hepatectomy, interfering with epidural catheter removal, and to identify the risk factors related to coagulopathy.

METHODS

We performed a retrospective review of a prospective, multicenter, observational database including patients over 18 years old with a history of liver resection. Main collected data were the following: age, preexisting cirrhosis, Child-Pugh class, preoperative and postoperative coagulation profiles, extent of liver resection, blood loss, blood products transfused during surgery. International normalized ratio (INR) ≥1.5 and/or platelet count <80,000/mm defined coagulopathy according to the neuraxial anesthesia guidelines. A logistic regression analysis was performed to assess the association between selected factors and a coagulopathic state after hepatic resection.

RESULTS

One thousand three hundred seventy-one patients were assessed. Seven hundred fifty-nine patients had data available about postoperative coagulopathy, which was observed in 53.5% [95% confidence interval, 50.0-57.1]. Maximum derangement in INR occurred on the first postoperative day, and platelet count reached a trough peak on postoperative days 2 and 3. In the multivariable analysis, preexisting hepatic cirrhosis (odds ratio [OR] = 2.49 [1.38-4.51]; P = .003), preoperative INR ≥1.3 (OR = 2.39 [1.10-5.17]; P = .027), preoperative platelet count <150 G/L (OR = 3.03 [1.77-5.20]; P = .004), major hepatectomy (OR = 2.96 [2.07-4.23]; P < .001), and estimated intraoperative blood loss ≥1000 mL (OR = 1.85 [1.08-3.18]; P = .025) were associated with postoperative coagulopathy.

CONCLUSIONS

Coagulopathy is frequent (53.5% [95% confidence interval, 50.0-57.1]) after liver resection. Epidural analgesia seems safe in patients undergoing minor hepatic resection without preexisting hepatic cirrhosis, showing a normal preoperative INR and platelet count.

Post-Pancreaticoduodenectomy Outcomes and Epidural Analgesia: A 5-year Single-Institution Experience

BACKGROUND

Optimal pain control post pancreaticoduodenectomy is a challenge. Epidural analgesia (EDA) is used increasingly, despite inherent risks and unclear effects on outcomes.

METHODS

All pancreaticoduodenectomies (PDs) performed from January 2013 through December 2017 were included. Clinical parameters were obtained from a retrospective review of a prospective clinical database, the American College of Surgeons NSQIP prospective institutional database, and medical record review. Chi-square, Fisher's exact test, and independent-samples t-tests were used for univariable analyses. Multivariable regression was performed.

RESULTS

Six hundred and seventy-one consecutive PDs from a single institution were included (429 EDA, 242 non-EDA). On univariable analysis, EDA patients experienced significantly less wound disruption (0.2% vs 2.1%), unplanned intubation (3.0% vs 7.9%), pulmonary embolism (0.5% vs 2.5%), mechanical ventilation longer than 48 hours (2.1% vs 7.9%), septic shock (2.6% vs 5.8%), and lower pain scores. On multivariable regression (accounting for baseline group differences (ie sex, hypertension, preoperative transfusion, laboratory results, approach, and pancreatic duct size), EDA was associated with less superficial wound infections (odds ratio [OR] 0.34; 95% CI 0.14 to 0.83; p = 0.017), unplanned intubations (OR 0.36; 95% CI 0.14 to 0.88; p = 0.024), mechanical ventilation longer than 48 hours (OR 0.22; 95% CI 0.08 to 0.62; p = 0.004), and septic shock (OR 0.39; 95% CI 0.15 to 1.00; p = 0.050). Epidural analgesia improved pain scores post-PD days 1 to 3 (p < 0.001). No differences were seen in cardiac or renal complications; pancreatic fistula (B+C) or delayed gastric emptying, 30-/90-day mortality, length of stay, readmission, discharge destination, or unplanned reoperation.

CONCLUSIONS

Based on the largest single-institution series published to date, our data support the use of EDA for optimization of pain control. More importantly, our data document that EDA improved infectious and pulmonary complications significantly.

Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review

Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.

Comparison of the effects of patient-controlled epidural and intravenous analgesia on postoperative bowel function after laparoscopic gastrectomy: a prospective randomized study

BACKGROUND

Although laparoscopic surgery significantly reduces surgical trauma compared to open surgery, postoperative ileus is a frequent and significant complication after abdominal surgery. Unlike laparoscopic colorectal surgery, the effects of epidural analgesia on postoperative recovery after laparoscopic gastrectomy are not well established. We compared the effects of epidural analgesia to those of conventional intravenous (IV) analgesia on the recovery of bowel function after laparoscopic gastrectomy.

METHOD

Eighty-six patients undergoing laparoscopic gastrectomy randomly received either patient-controlled epidural analgesia with ropivacaine and fentanyl (Epi PCA group) or patient-controlled IV analgesia with fentanyl (IV PCA group), beginning immediately before incision and continuing for 48 h thereafter. The primary endpoint was recovery of bowel function, evaluated by the time to first flatus. The balance of the autonomic nervous system, pain scores, duration of postoperative hospital stay, and complications were assessed.

RESULTS

The time to first flatus was shorter in the epidural PCA group compared with the IV PCA group (61.3 ± 11.1 vs. 70.0 ± 12.3 h, P = 0.001). Low-frequency/high-frequency power ratios during surgery were significantly higher in the IV PCA group, compared with baseline and those in the epidural PCA group. The epidural PCA group had lower pain scores during the first 1 h postoperatively and required less analgesics during the first 6 h postoperatively.

CONCLUSIONS

Compared with IV PCA, epidural PCA facilitated postoperative recovery of bowel function after laparoscopic gastrectomy without increasing the length of hospital stay or PCA-related complications. This beneficial effect of epidural analgesia might be attributed to attenuation of sympathetic hyperactivation, improved analgesia, and reduced opioid use.

Efficacy and safety of multimodal analgesic techniques for preventing chronic postsurgery pain under different surgical categories: a meta-analysis

The purpose of this meta-analysis was to compare the efficacy and safety of regional anesthesia to manage chronic postsurgery pain. A systematic search of PubMed, EmBase, and the Cochrane Central Register of Controlled Trials was performed to identify randomized controlled trials that focused on chronic pain frequency, analgesic consumption, and adverse effects under different surgical categories. We collected 21 trials assessing 1,980 patients for our meta-analysis. The summary of relative risks (RRs) and standard mean differences (SMDs) were calculated to measure the treatment effect of regional anesthesia. Results indicated that regional anesthesia significantly reduced the frequency of postsurgery pain (RR, 0.69; 95% confidence interval [CI], 0.56–0.85; p < 0.001). The results showed significant differences in overall patient satisfaction between applications with and without regional anesthesia (SMD, 1.95; 95%CI, 0.83–3.06; p = 0.001); however in other results, there were no significant differences between the two groups. Subgroup analysis suggested that regional anesthesia treatment might differ according to country. In conclusion, our study indicated that regional anesthesia was effective and safe in reducing the frequency of postsurgery pain and improved overall patient satisfaction; however, studies on the long-term efficacy and safety of regional anesthesia are still required to further confirm these findings.

Effect of epidural compared to patient-controlled intravenous analgesia on outcomes for patients undergoing liver resection for neoplastic disease

BACKGROUND

Epidural analgesia is routinely used for postoperative pain control following abdominal surgeries, yet data regarding the safety and efficacy of epidural analgesia is controversial.

METHODS

Pain-related and clinical perioperative data were extracted and correlated with baseline clinicopathologic data and method of analgesia (epidural vs. intravenous patient-controlled analgesia) in patients who underwent hepatectomy from 2012 to 2014. Chronic pain was defined by specific narcotic requirements preoperatively.

RESULTS

Eighty-seven patients underwent hepatectomy with 60% having epidurals placed for postoperative pain control. Epidural patients underwent more major hepatectomies and open resections. Comparison of pain scores between both groups demonstrated no significant difference (all P > .05). A significantly lower proportion of TEA patients required additional IV pain medications than those with IVPCA (P < 0.001). There was no major effect of epidural analgesia on time to ambulation or complications (all P > 0.05). After adjusting for perioperative factors, and surgical extent and approach, no significant differences in fluids administered or length of stay were detected.

CONCLUSIONS

Overall postoperative outcomes were not significantly different based on method of analgesia after adjusting for type and extent of hepatic resection. Though patients with epidurals underwent more extensive operations they required less additional IV pain medications than IVPCA patients.

Role of epidural and patient-controlled analgesia in site-specific laparoscopic colorectal surgery

Background and Objectives:

Limited data are available comparing epidural and patient-controlled analgesia in site-specific colorectal surgery. The aim of this study was to evaluate 2 modes of analgesia in patients undergoing laparoscopic right colectomy (RC) and low anterior resection (LAR).

Methods:

Prospectively collected data on 433 patients undergoing laparoscopic or laparoscopic-assisted colon surgery at a single institution were retrospectively reviewed from March 2004 to February 2009. Patients were divided into groups undergoing RC (n = 175) and LAR (n = 258). These groups were evaluated by use of analgesia: epidural analgesia, “patient-controlled analgesia” alone, and a combination of both. Demographic and perioperative outcomes were compared.

Results:

Epidural analgesia was associated with a faster return of bowel function, by 1 day (P < .001), in patients who underwent LAR but not in the RC group. Delayed return of bowel function was associated with increased operative time in the LAR group (P = .05), patients with diabetes who underwent RC (P = .037), and patients after RC with combined analgesia (P = .011). Mean visual analogue scale pain scores were significantly lower with epidural analgesia compared with patient-controlled analgesia in both LAR and RC groups (P < .001).

Conclusion:

Epidural analgesia was associated with a faster return of bowel function in the laparoscopic LAR group but not the RC group. Epidural analgesia was superior to patient-controlled analgesia in controlling postoperative pain but was inadequate in 28% of patients and needed the addition of patient-controlled analgesia.

Addition of clonidine to bupivacaine in transversus abdominis plane block prolongs postoperative analgesia after cesarean section

Background and Aims:

The aim was to compare duration of postoperative analgesia with addition of clonidine to bupivacaine in bilateral transversus abdominis plane (TAP) block after lower segment cesarean section (LSCS).

Material and Methods:

One hundred American Society of Anesthesiologists (ASA) grade I and II pregnant patients undergoing LSCS under spinal anesthesia were randomly divided to receive either 20 ml bupivacaine 0.25% (Group B; n = 50) or 20 ml bupivacaine+1ug/kg clonidine bilaterally (Group BC; n = 50) in TAP block in a double-blind fashion. The total duration of analgesia, patient satisfaction score, total requirement of analgesics in the first 24 h, and the side effects of clonidine such as sedation, dryness of mouth, hypotension, and bradycardia were observed. P < 0.05 was taken as significant.

Results:

In 99 patients analyzed, TAP block failed in five patients. Duration of analgesia was significantly longer in Group BC (17.8 ± 3.7 h) compared to Group B (7.3 ± 1.2 h; P < 0.01). Mean consumption of diclofenac was 150 mg and 65.4 mg in Groups B and BC (P < 0.01), respectively. All patients in Group BC were extremely satisfied (P < 0.01) while those in Group B were satisfied. Thirteen patients (28%) in Group BC were sedated but arousable (P = 0.01) compared to none in Group B. In Group BC, 19 patients complained of dry mouth compared to 13 in Group B (P = 0.121). None of the patients experienced hypotension or bradycardia.

Conclusion:

Addition of clonidine 1 μg/kg to 20 ml bupivacaine 0.25% in TAP block bilaterally for cesarean section significantly increases the duration of postoperative analgesia, decreases postoperative analgesic requirement, and increases maternal comfort compared to 20 ml of bupivacaine 0.25% alone.

Pain control for laparoscopic colectomy: an analysis of the incidence and utility of epidural analgesia compared to conventional analgesia

PURPOSE

The aim of this study was to compare short-term outcomes between epidural analgesia and conventional intravenous analgesia for patients undergoing laparoscopic colectomy. This paper uses a large national database to add a current perspective on trends in analgesia and the outcomes associated with two analgesia options. Our evidence augments the opinions of recent randomized controlled trials.

METHODS

The University HealthSystem Consortium, an alliance of more than 300 academic and affiliate institutions, was reviewed for the time period of October 2008 through September 2014. International Classification of Disease 9th Clinical Modification codes for laparoscopic colectomy and epidural catheter placement were used.

RESULTS

A total of 29,429 patients met our criteria and underwent laparoscopic colectomy during the study period. One hundred and ten (0.374%) patients had an epidural catheter placed for analgesia. Baseline patient demographics were similar for the epidural and conventional analgesia groups. Total charges were significantly higher in the epidural group ($52,998 vs. $39,277; p < 0.001). Median length of stay was longer in the epidural group (6 vs. 5 days; p < 0.001). There was no statistical difference between the epidural and conventional analgesia groups in death (0 vs. 0.03%; p = 0.999), urinary tract infection (0 vs. 0.1%; p = 0.999), ileus (11.8 vs. 13.6%; p = 0.582), or readmission rate (9.1 vs. 9.3%; p = 0.942).

CONCLUSION

Compared to conventional analgesic techniques, epidural analgesia does not reduce the rate of postoperative ileus, and it is associated with increased cost and increased length of stay. Based on our data, routine use of epidural analgesia for laparoscopic colectomy cannot be justified.

Impact of epidural analgesia on quality of life and pain in advanced cancer patients

Patients with advanced cancer often experience chronic postoperative pain and poor quality of life. The objective of this study was to determine if epidural self-controlled analgesia reduced the incidence of chronic pain and improved the quality of life when compared with intravenous self-controlled analgesia. A total of 50 patients diagnosed with advanced cancer who received analgesia treatment were randomly divided into two groups, epidural self-controlled analgesia group (EA group, n = 26) and intravenous self-controlled analgesia group (IA group, n = 24). Visual analog scale (VAS) and Karnofsky score were used to assess the pain and the quality of life, respectively. A multifunction monitor was used to continuously record the physical signs of patients after treatment. The physical signs, such as heart failure, respiration, pulse, blood pressure, and oxygen saturation, in the two groups were better after analgesia treatment. Meanwhile, the respiration and oxygen saturation in the EA group were significantly improved compared with that of the IA group (p < .05). The VAS in the EA group was significantly lower than that in the IA group (p < .05), and the Karnofsky score in the EA group was significantly higher than that in the IA group (p < .05). Moreover, patients treated with EA felt more satisfied and experienced fewer complications than those with IA (p < .05). The epidural self-controlled analgesia may greatly improve the quality of life and relieve the pain in patients with advanced cancer.

Peri-operative epidural may not be the preferred form of analgesia in select patients undergoing pancreaticoduodenectomy

BACKGROUND AND OBJECTIVES

Epidural analgesia has become the preferred method of pain management for major abdominal surgery. However, the superior form of analgesia for pancreaticoduodenecomy (PD), with regard to non-analgesic outcomes, has been debated. In this study, we compare outcomes of epidural and intravenous analgesia for PD and identify pre-operative factors leading to early epidural discontinuation.

METHODS

A retrospective review was performed on 163 patients undergoing PD between 2007 and 2011. We performed regression analyses to measure the predictive success of two groups of analgesia on morbidity and mortality and to identify predictors of epidural failure.

RESULTS

Intravenous analgesia alone was given to 14 (9%) patients and 149 patients (91%) received epidural analgesia alone or in conjunction with intravenous analgesia. Morbidity and mortality were not significantly different between the two groups. Early epidural discontinuation was necessary in 22 patients (15%). Those older than 72 and with a BMI < 20 (n = 5) had their epidural discontinued in 80% of cases compared to 12% not meeting these criteria. However, early epidural discontinuation was not associated with increased morbidity and mortality.

CONCLUSION

Epidural analgesia may be contraindicated in elderly, underweight patients undergoing PD given their increased risk of epidural-induced hypotension or malfunction.

Magnesium Can Decrease Postoperative Physiological Ileus and Postoperative Pain in Major non Laparoscopic Gastrointestinal Surgeries: A Randomized Controlled Trial

BACKGROUND

Magnesium is an antagonist of (N-methyl D-Aspartate) NMDA receptor and its related canals, and may affect perceived pain.

OBJECTIVES

The aim of this study was to evaluate the impact of intravenous magnesium on the hemodynamic parameters, analgesic consumption and ileus.

PATIENTS AND METHODS

A randomized, double blind, placebo controlled study was performed. Thirty two patients of ASA I or II, scheduled for major gastrointestinal (GI) surgery, were divided into magnesium and control groups. Magnesium group received a bolus of 40 mg/kg of magnesium sulphate, followed by a continuous perfusion of 10 mg/kg/h for the intraoperative hours. Postoperative analgesia was ensured by Morphine patient-controlled analgesia (PCA). The patients were evaluated by Intraoperative hemodynamic parameters, the postoperative pain by numeral rating scale (NRS), and the total dose of intraoperative and postoperative analgesic consumption. Postoperative hemodynamic, respiratory parameters, physiological gastrointestinal obstruction (ileus), and side effects were also recorded.

RESULTS

The study included 14 males and 18 females. Age range of patients was 17 to 55 years old. The average age in the magnesium group was 41.33 ± 10.06 years and45.13 ± 11.74 years in control group. Mean arterial pressure (MAP) of magnesium group decreased during the operation but increased in control group (P < 0.001), and systemic vascular resistance (SVR) of magnesium group decreased during the operation also (P < 0.02) but increased in control group. Postoperative cumulative Morphine consumption in magnesium group, was significantly in lower level (P = 0.026). For NRS, severe pain was significantly lower, in magnesium group, at all intervals of postoperative evaluations, but moderate and mild pain were not lower significantly. Duration of postoperative ileus was 2.3 ± 0.5 days in magnesium group, and 4.2 ± 0.6 days in control group (P = 0.01).

CONCLUSIONS

Intravenous magnesium reduces postoperative ileus, postoperative severe pain and intra/post operative analgesic requirements in patients after major GI surgery. No side effects of magnesium in these doses were seen, so it seems to be beneficial along with routine general anesthesia in major GI surgeries.

Role of thoracic epidural block in improving post-operative outcome for septic patients: a preliminary report

BACKGROUND AND OBJECTIVES

Sepsis is considered a relative contraindication for epidural blockade. Recent evidence indicates that thoracic epidural blockade may be of benefit during sepsis by improving gut perfusion. This study was planned to evaluate whether combining thoracic epidural blockade with general anaesthesia could decrease the post-operative mortality and morbidity in patients with sepsis due to perforation peritonitis.

METHODS

This randomised non-blinded study included consenting adult patients of the American Society of Anesthesiologists grade II-III, undergoing emergency laparotomy for small intestinal perforation peritonitis. Severity of illness was evaluated using Mannheim Peritonitis Index, Acute Physiology and Chronic Health Evaluation III score and clinical indicators of systemic inflammatory response syndrome. Patients were randomised into two groups depending on the anaesthetic technique [general anaesthesia combined with thoracic epidural block (group GT) and general anaesthesia (group GA), n = 33 each. The thoracic block was extended from T5 to T10 using 0.125% bupivacaine in aliquots of 2-3 ml, with 50 μg fentanyl. Post-operatively, patients were followed for occurrence of any major morbidity till discharge from hospital, and 30-day mortality. 'Major morbidity' included development of organ failure. Post-operative markers for gut motility and perfusion, that is, time to passage of flatus, stools, resumption of oral feeds and occurrence of anastomotic leak were also observed. Sample size was calculated at power of 80% and α error of 0.05, aiming to detect a decrease of 50% in the incidence of post-operative major morbidity or mortality.

RESULTS

Patients in the two groups were similar with respect to demographic profile and severity of sepsis. The number of patients with major morbidity or 30-day mortality were statistically similar between the two groups (group GT, 0/33; group GA 4/33; P = 0.114). A significantly shorter time to pass stools and resume oral feeds in group GT (4 ± 2 vs. 3 ± 1 days) (P = 0.006 and 0.012, respectively) and lesser incidence of anastomotic leak (0/33 vs. 4/33; P = 0.114) showed earlier recovery of gut motility and perfusion in that group.

CONCLUSION

Use of intra-operative segmental thoracic epidural blockade performed in addition to general anaesthesia suggested some benefit in improving post-operative mortality or major morbidity, but the trend was not significant, perhaps due to the small sample size. There was, however, a significantly earlier return of bowel motility and earlier discharge from hospital.

The effect of fluid overload in the presence of an epidural on the strength of colonic anastomoses

BACKGROUND

Despite the beneficial effects of epidurals in intra-abdominal surgery, the incidence of anastomotic leak remains controversial when used. Moreover, studies have also shown that fluid overload may be deleterious to anastomoses. The purpose of this paper is to evaluate the effects of varying intraoperative fluid protocols, in the presence of an epidural, on the burst pressure strength of colonic anastomoses.

METHODS

An epidural was installed in 18 rabbits, divided into three groups. Group 1 received 30 mL/kg/h Ringer's lactate, Group 2 received 100 mL/kg/h Ringer's lactate, and Group 3 received 30 mL/kg/h Pentaspan. Two colo-colonic anastomoses were performed per rabbit. On postoperative day 7 the anastomoses were resected and their burst pressures measured as a surrogate for anastomotic leak.

RESULTS

When comparing the average burst pressures of all three groups, there was a significant difference (P = 0.04). The anastomoses in the 100 mL/kg/h Ringer's lactate group were shown to be the weakest, with 64% of the anastomoses having burst under 120 mm Hg. The rabbits hydrated with Pentaspan had the highest strength, with no anastomoses bursting under 120 mm Hg. This translated into significant burst pressure differences (P = 0.02) between Group 2 and Group 3.

CONCLUSION

These results suggest that fluid overload with a crystalloid, in the presence of an epidural, may be deleterious to the healing of colonic anastomoses, creating a higher risk of anastomotic leak. Intraoperative resuscitation should thus focus on goal-directed euvolemia with appropriate amounts of colloids and/or crystalloids to prevent the risk of weakening anastomoses, especially in patients with epidurals.

Feasibility study of analgesia via epidural versus continuous wound infusion after laparoscopic colorectal resection

Background

With the adoption of enhanced recovery and emerging new modalities of analgesia after laparoscopic colorectal resection (LCR), the role of epidural analgesia has been questioned. This pilot trial assessed the feasibility of a randomized controlled trial (RCT) comparing epidural analgesia and use of a local anaesthetic wound infusion catheter (WIC) following LCR.

Methods

Between April 2010 and May 2011, patients undergoing elective LCR in two centres were randomized to analgesia via epidural or WIC. Sham procedures were used to blind surgeons, patients and outcome assessors. The primary outcome was the feasibility of a large RCT, and all outcomes for a definitive trial were tested. The success of blinding was assessed using a mixed-methods approach.

Results

Forty-five patients were eligible, of whom 34 were randomized (mean(s.d.) age 70(11·8) years). Patients were followed up per-protocol; there were no deaths, and five patients had a total of six complications. Challenges with capturing pain data were identified and resolved. Mean(s.d.) pain scores on the day of discharge were 1·9(3·1) in the epidural group and 0·7(0·7) in the WIC group. Median length of stay was 4 (range 2–35, interquartile range 3–5) days. Mean use of additional analgesia (intravenous morphine equivalents) was 12 mg in the WIC arm and 9 mg in the epidural arm. Patient blinding was successful in both arms. Qualitative interviews suggested that patients found participation in the trial acceptable and that they would consider participating in a future trial.

Conclusion

A blinded RCT investigating the role of epidural and WIC administration for postoperative analgesia following LCR is feasible. Rigorous standard operating procedures for data collection are required.

Anesthesia and perioperative management of colorectal surgical patients - A clinical review (Part 1)

Colorectal surgery is commonly performed for colorectal cancer and other pathology such as diverticular and inflammatory bowel disease. Despite significant advances, such as laparoscopic techniques and multidisciplinary recovery programs, morbidity and mortality remain high and vary among surgical centers. The use of scoring systems and assessment of functional capacity may help in identifying high-risk patients and predicting complications. An understanding of perioperative factors affecting colon blood flow and oxygenation, suppression of stress response, optimal fluid therapy, and multimodal pain management are essential. These fundamental principles are more important than any specific choice of anesthetic agents. Anesthesiologists can significantly contribute to enhance recovery and improve the quality of perioperative care.

[Perioperative protection of the gastrointestinal tract]

The gastrointestinal tract is a complex organ system. Dysfunctions of this organ system may evoke a variety of consequences for the entire organism and influence the inflammatory response in particular. In perioperative medicine, nutrition, prokinetics, peridural anesthesia, catecholamines and volume therapy can be applied in order to improve the gastrointestinal functional or at least to avoid further aggravation. Early enteral nutrition is especially important in the reduction of postsurgical ileus and infectious complications. Also, prokinetics and thoracic peridural anesthesia favorably affect postsurgical ileus. Norepinephrine, if necessary in combination with dobutamine, seems to have fewer negative effects on splanchnic perfusion than epinephrine. The data on volume therapy remain controversial but fluid balance has to be calculated very carefully also considering enteral loss of fluids. Thus, in order to treat and avoid gastrointestinal problems after surgery and to prevent negative effects for the complete organism, multimodal concepts with regard to detail are required.

Pain scores are not predictive of pain medication utilization

Objective. To compare Visual Analogue Scale (VAS) scores with overall postoperative pain medication requirements including cumulative dose and patterns of medication utilization and to determine whether VAS scores predict pain medication utilization. Methods. VAS scores and pain medication data were collected from participants in a randomized trial of the utility of phenazopyridine for improved pain control following gynecologic surgery. Results. The mean age of the 219 participants was 54 (range19 to 94). We did not detect any association between VAS and pain medication utilization for patient-controlled anesthesia (PCA) or RN administered (intravenous or oral) medications. We also did not detect any association between the number of VAS scores recorded and mean pain scores. Conclusion. Postoperative VAS scores do not predict pain medication use in catheterized women inpatients following gynecologic surgery. Increased pain severity, as reflected by higher VAS scores, is not associated with an increase in pain assessment. Our findings suggest that VAS scores are of limited utility for optimal pain control. Alternative or complimentary methods may improve pain management.

[Nonanalgesic effects of thoracic epidural anesthesia]

Thoracic epidural anesthesia, which has been performed since the 1950s, has progressed from being one analgesic technique among others to its present status as the technique of choice for managing pain after major abdominal and thoracic surgery. In addition to providing effective analgesia, the epidural infusion of local anesthetic agents produces a sympathetic block that offers advantages over other types of pain control, particularly with respect to the cardiovascular, respiratory, and gastrointestinal systems. Thoracic epidural anesthesia provides dynamic pain relief, allowing the patient to resume activity early. It also permits early extubation and is associated with fewer postoperative pulmonary complications, shorter duration of paralytic ileus, and a better response to the stress of anesthesia and surgery. However, meta-analyses have not yet demonstrated that postoperative outcomes are improved. This review describes the nonanalgesic effects of thoracic epidural anesthesia.

Epidural analgesia in open resection of colorectal cancer: is there a clinical benefit? a retrospective study on 1,470 patients

BACKGROUND

Epidural analgesia (EA) is effective for postoperative pain relief and results in an earlier recovery from postoperative paralytic ileus. This study evaluated the influence of epidural analgesia on the postoperative 30-day mortality and morbidity after open colorectal cancer resection.

METHODS

A retrospective observational study was performed at a single, tertiary hospital. All patients with an open colorectal cancer surgery between 1991 and 2008 were identified from the hospital database.

RESULTS

Of the 1,470 patients included in the study, 838 (57.0%) received an EA. Mortality was lower after EA (1.5% vs. 5.7%, p < 0.001). Risk of pneumonia was reduced after EA (odds ratio (OR), 0.45; 95% confidence interval (CI), 0.28-0.74; p = 0.001), but not the risk of anastomotic leakage (OR, 1.18; 95% CI, 0.76-1.81; p = 0.465) or surgical site infections (OR, 1.09; 95% CI, 0.74-1.60; p = 0.663). A subgroup analysis of 427 patients operated on after 2002 (reflecting improved perioperative management) yielded similar results. However, no significant reduction in mortality was observed in the subgroup analysis.

CONCLUSION

For patients with open colorectal cancer surgery, the application of EA leads to a reduction in pneumonia. Although this is only a retrospective study, it strongly supports the use of EA.

Postoperative ileus: strategies for reduction

Postoperative Ileus (POI) is a frequent, frustrating occurrence for patients and surgeons after abdominal surgery. Despite significant research investigating how to reduce this multi-factorial phenomenon, a single strategy has not been shown to reduce POI's significant effects on length of stay (LOS) and hospital costs. Perhaps the most significant cause of POI is the use of narcotics for analgesia. Strategies that target inflammation and pain reduction such as NSAID use, epidural analgesia, and laparoscopic techniques will reduce POI but are accompanied by a simultaneous reduction in opioid use. Pharmacologic means of stimulating gut motility have not shown a positive effect, and the routine use of nasogastric tubes only increases morbidity. Recent multi-site phase III trials with alvimopan, a peripherally acting mu-antagonist, have shown significant reductions in POI and LOS by 12 and 16 hours, respectively, by blunting the effects of narcotics on gut motility while sparing centrally mediated analgesia. Use of alvimopan, along with a multi-modal postoperative treatment plan involving early ambulation, feeding, and avoiding nasogastric tubes, will likely be the crux of POI treatment and prevention.

[Continuous infusion of local anesthetic at the site of the abdominal surgical wound for postoperative analgesia: a systematic review]

OBJECTIVES

We present a systematic review of clinical trials to evaluate the efficacy of infusing local anesthetic through a catheter placed in the abdominal surgical wound.

METHODS

The Jadad (Oxford) scoring system was used to select trials. The variables considered in relation to each trial selected were as follows: type of intervention and incision; type, dose, and concentration of local anesthetic; site where the catheter was placed; rescue analgesia required; opioid use; and incidence of adverse events.

RESULTS

Fifteen clinical trials with a mean Jadad score of 4.6 were selected. The 1139 patients enrolled in the trials were grouped according to catheter placement: subfascial (6 trials), subcutaneous (8 trials), and both (1 trial). Six additional unpublished trials registered at ClinicalTrials.gov were also located.

CONCLUSIONS

Surgical wound analgesia is a safe technique whose effectiveness has been observed in cesarean sections and hysterectomies performed with Pfannenstiel incisions. Outcomes for other types of surgery are inconsistent. There is a lack of studies of the optimal site for catheter placement as well as of adequate anesthetic concentration and volume.

Standard perioperative management in gastrointestinal surgery

Introduction

The outcome of patients who are scheduled for gastrointestinal surgery is influenced by various factors, the most important being the age and comorbidities of the patient, the complexity of the surgical procedure and the management of postoperative recovery. To improve patient outcome, close cooperation between surgeons and anaesthesiologists (joint risk assessment) is critical. This cooperation has become increasingly important because more and more patients are being referred to surgery at an advanced age and with multiple comorbidities and because surgical procedures and multimodal treatment modalities are becoming more and more complex.

Objective

The aim of this review is to provide clinicians with practical recommendations for day-to-day decision-making from a joint surgical and anaesthesiological point of view. The discussion centres on gastrointestinal surgery specifically.

Enhanced recovery program in laparoscopic colectomy for cancer

INTRODUCTION

Both laparoscopic colectomy and application of enhanced recovery program (ERP) in open colectomy have been demonstrated to enable early recovery and to shorten hospital stay. This study evaluated the impact of ERP on results of laparoscopic colectomy and comparison was made with the outcomes of patients prior to the application of ERP.

METHODS

An ERP was implemented in the authors' center in December 2006. Short-term outcomes of consecutive 84 patients who underwent laparoscopic colonic cancer resection 23 months before (control group) and 96 patients who were operated within 13 months; after application of ERP (ERP group) were compared.

RESULTS

Between the ERP and control groups, there was no statistical difference in patient characteristics, pathology, operating time, blood loss, conversion rate or complications. Compared to the control group, patients in the ERP group had earlier passage of flatus [2 (range: 1-5) versus 2 (range: 1-4) days after operation respectively; p = 0.03)] and a lower incidence of prolonged post-operative ileus (6% versus 0 respectively; p = 0.02). There was no difference in the hospital stay between the two groups [4 (range: 2-34) days in control group and 4 (range: 2-23) days in ERP group; p = 0.4)]. The re-admission rate was also similar (7% in control group and 5% in ERP group; p = 0.59).

CONCLUSIONS

In laparoscopic colectomy for cancer, application of ERP was associated with no increase in complication rate but significant improvement of gastrointestinal function. ERP further hastened patient recovery but resulted in no difference in hospital stay.

Impact of an enhanced recovery programme in colorectal surgery

Surgery is undergoing revolutionary change as a result of newer approaches to pain control, the introduction of techniques that reduce the post-operative stress response, and the use of minimally invasive operations, such as laparoscopic surgery. As demand for hospital beds continues to escalate, it is paramount that patients recover from surgery quickly and safely; the use of evidence-based interventions to hasten recovery within an enhanced recovery programme (ERP) can play a vital role in achieving this, as well as reducing costs by shortening hospital stay. This article outlines the principles and key elements of an ERP, and discusses how it can help to achieve an improved and safe recovery and shorter hospital stay for patients, thereby reducing the cost to the NHS of inpatient treatment and recovery. The literature surrounding the development of 'enhanced recovery' (also called 'fast-track') surgery is reviewed to determine whether it is appropriate for patients undergoing elective colorectal surgery.

Randomized clinical trial of laxatives and oral nutritional supplements within an enhanced recovery after surgery protocol following liver resection

BACKGROUND

Routine laxatives may expedite gastrointestinal recovery and early tolerance of food within an enhanced recovery after surgery (ERAS) programme. Combined with carbohydrate loading and oral nutritional supplements (ONS), it may further enhance recovery of gastrointestinal function and promote earlier overall recovery.

METHODS

Seventy-four patients undergoing liver resection were randomized in a two-by-two factorial design to receive either postoperative magnesium hydroxide as a laxative, preoperative carbohydrate loading and postoperative ONS, their combination or a control group. Patients were managed within an ERAS programme of care. The primary outcome measure was time to first passage of stool. Secondary outcome measures were gastric emptying, postoperative oral calorie intake, time to functional recovery and length of hospital stay.

RESULTS

Sixty-eight patients completed the trial. The laxative group had a significantly reduced time to passage of stool: median (interquartile range) 4 (3-5) versus 5 (4-6) days (P = 0.034). The ONS group showed a trend towards a shorter time to passage of stool (P = 0.076) but there was no evidence of interaction in patients randomized to the combination regimen. Median length of hospital stay was 6 (4-7) days. There were no differences in secondary outcomes between groups.

CONCLUSION

Within an ERAS protocol for patients undergoing liver resection, routine postoperative laxatives result in an earlier first passage of stool but the overall rate of recovery is unaltered.

Pathogenesis and management of postoperative ileus

Postoperative ileus (POI) is a predictable delay in gastrointestinal (GI) motility that occurs after abdominal surgery. Probable mechanisms include disruption of the sympathetic/parasympathetic pathways to the GI tract, inflammatory changes mediated over multiple pathways, and the use of opioids for the management of postoperative pain. Pharmacologic treatment of postoperative ileus continues to be problematic as most agents are unreliable and unsubstantiated with robust clinical trials. The selective opioid antagonist alvimopan has shown promise in reducing POI, but needs more rigorous investigation. Clinician interventions proven to be of benefit include laparoscopy, thoracic epidural anesthesia, avoidance of opioids, and early feeding. Early ambulation may also contribute to early resolution of POI; however, routine nasogastric decompression plays no role and may increase complications. Multimodal care plans remain the mainstay of treatment for POI.

Anaesthesia for acute intestinal obstruction associated with cerebral arteriovenous malformation in a child

This case report describes the perioperative management of a child presenting with acute intestinal obstruction secondary to bowel malrotation after a recent intracranial haemorrhage associated with an intracranial arteriovenous malformation. We discuss the anaesthesia planning for this case, where the 'optimal' management strategies for the two conditions present are potentially conflicting. Issues include rapid sequence induction in the presence of a ruptured arteriovenous malformation, maintenance of cerebral perfusion pressure in the face of bowel ischaemia, and the use of epidural anaesthesia in a child with recent intracranial haemorrhage. Written consent was obtained from the patient and parents to publish this case.

Epidural ropivacaine concentrations for intraoperative analgesia during major upper abdominal surgery: a prospective, randomized, double-blinded, placebo-controlled study

BACKGROUND

The postoperative beneficial effects of thoracic epidural analgesia (TEA) within various clinical pathways are well documented. However, intraoperative data are lacking on the effect of different epidurally administered concentrations of local anesthetics on inhaled anesthetic, fluid and vasopressor requirement, and hemodynamic changes. We performed this study among patients undergoing major upper abdominal surgery under combined TEA and general anesthesia.

METHODS

Forty-five patients undergoing major upper abdominal surgery were randomly assigned to one of three treatment groups receiving intraoperative TEA with either 10 mL of 0.5% (Group 1) or 0.2% (Group 2) ropivacaine (both with 0.5 microg/mL sufentanil supplement), or 10 mL saline (Group 3) every 60 min. Anesthesia was maintained with desflurane in nitrous oxide (60%) initiated at an age-adapted 1 minimum alveolar concentration (MAC) until incision. Desflurane administration was then titrated to maintain an anesthetic level between 50 and 55, as assessed by continuous Bispectral Index monitoring and the common clinical signs (PRST score). Lack of intraoperative analgesia, as defined by an increase in pulse rate, sweating, and tearing (PRST) score >2 or an increase of mean arterial blood pressure (MAP) >20% of baseline, was treated by readjusting the end-tidal concentration of desflurane toward 1 MAC, and above this level by additional rescue i.v. remifentanil infusion. Hypotension, as defined as a decrease in MAP >20% of baseline, was treated by reducing the end-tidal desflurane concentration to a Bispectral Index level of 50-55 and below that with crystalloid or norepinephrine infusion, depending on central venous pressure.

RESULTS

End-tidal desflurane concentration could be significantly reduced in Group 1 to 0.7 +/- 0.1 MAC (P < 0.001) and to 0.8 +/- 0.1 MAC (P < 0.001) in Group 2, but not in Group 3. Significant hypotension occurred within 20 min in all patients of Groups 1 and 2 (MAP from 80 +/- 10 to 56 +/- 5) (Group 1), 78 +/- 18 to 58 +/- 7 mm Hg (Group 2), P < 0.01, whereas MAP remained unchanged in Group 3 (74 +/- 12 to 83 +/- 15 mm Hg, P = 0.42). Heart rate did not change significantly over time within any of the groups. Furthermore, groups did not differ significantly regarding i.v. fluid and norepinephrine requirement. Patients in Group 3 received more remifentanil throughout the surgical procedure (7.2 +/- 4.9 mg x kg(-1) x h(-1)) when compared with Group 2 (1.6 +/- 2.2 mg x kg(-1) x h(-1)), P < 0.01. Remifentanil infusion among patients receiving ropivacaine 0.5% was not necessary at any time.

CONCLUSION

Epidural administration of 0.5% ropivacaine leads to a more pronounced sparing effect on desflurane concentration for an adequate anesthetic depth when compared with a 0.2% concentration of ropivacaine at comparable levels of vasopressor support and i.v. fluid requirement.