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Schnabel A, Carstensen VA, Lohmöller K, Vilz TO, Willis MA, Weibel S, Freys SM, Pogatzki-Zahn EM. Perioperative pain management with regional analgesia techniques for visceral cancer surgery: A systematic review and meta-analysis. J Clin Anesth 2024; 95:111438. [PMID: 38484505 DOI: 10.1016/j.jclinane.2024.111438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 01/25/2024] [Accepted: 03/01/2024] [Indexed: 04/29/2024]
Abstract
STUDY OBJECTIVE Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear. DESIGN Systematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment. SETTING Postoperative pain treatment. PATIENTS Adult patients undergoing visceral cancer surgery. INTERVENTIONS Any kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques. MEASUREMENTS Primary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus. MAIN RESULTS 59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): -1.35 to -0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: -2.34 to -1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: -1.20 to -0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: -1.34 to -0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA. CONCLUSIONS Following visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery.
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Affiliation(s)
- Alexander Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Vivian A Carstensen
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Katharina Lohmöller
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Tim O Vilz
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Maria A Willis
- Department of General, Visceral, Thorax and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Stephan M Freys
- Department of Surgery, DIAKO Ev. Diakonie-Krankenhaus Bremen, Bremen, Germany
| | - Esther M Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany.
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Taiym D, Cowan M, Nakamura B, Azad H, Strohl A, Barber E. Effect of continuous post-operative lidocaine infusion in an enhanced recovery program on opioid use following gynecologic oncology surgery. J Gynecol Oncol 2023; 34:e61. [PMID: 37232055 PMCID: PMC10482581 DOI: 10.3802/jgo.2023.34.e61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/16/2023] [Accepted: 04/16/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE To determine the effectiveness of implementing an Enhanced Recovery After Surgery (ERAS) program, including continuous intraoperative and postoperative intravenous (IV) lidocaine infusion, on perioperative opioid use. METHODS This was a single-institution retrospective pre- post- cohort study. Consecutive patients undergoing planned laparotomy for known or potential gynecologic malignancy were identified after implementation of an ERAS program and compared to a historical cohort. Opioid use was calculated as morphine milligram equivalents (MMEs). Cohorts were compared using bivariate tests. RESULTS A total of 215 patients were included in the final analysis, 101 patients received surgery before ERAS implementation and 114 received surgery after. A reduction in total opioid use was observed in ERAS patients compared with historical controls (MME 26.5 [9.6-60.8] versus 194.5 [123.8-266.8], p<0.001). Length of stay (LOS) was reduced by 25% in the ERAS cohort (median 3 days, range 2-26, versus 4 days, range 2-18; p<0.001). Within the ERAS cohort, 64.9% received IV lidocaine for the planned 48 hours, and 5.6% had the infusion discontinued early. Within the ERAS cohort, patients who received IV lidocaine infusion used less opioids compared to those who did not (median 16.9, range 5.6-55.1, versus 46.2, range 23.2-76.1; p<0.002). CONCLUSION An ERAS program including a continuous IV lidocaine infusion as the opioid-sparing analgesic strategy was noted to be safe and effective, leading to decreased opioid consumption and LOS compared with a historic cohort. Additionally, lidocaine infusion was noted to decrease opioid consumption even among patients already receiving other ERAS interventions.
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Affiliation(s)
- Deanna Taiym
- Northwestern University, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
| | - Matthew Cowan
- Albert Einstein College of Medicine, Division of Gynecologic Oncology, Montefiore Medical Center, Department of Obstetrics and Gynecology and Women's Health, Bronx, NY, USA
| | - Brad Nakamura
- Northwestern University, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
| | - Hooman Azad
- Department of Obstetrics and Gynecology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Anna Strohl
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cleveland, OH, USA
| | - Emma Barber
- Northwestern University, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
- Robert H Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
- Surgical Outcomes and Quality Improvement Center, Institute for Public Health in Medicine, Chicago, IL, USA.
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Ketelaers SHJ, Dhondt L, van Ham N, Harms AS, Scholten HJ, Nieuwenhuijzen GAP, Rutten HJT, Burger JWA, Bloemen JG, Vogelaar FJ. A prospective cohort study to evaluate continuous wound infusion with local analgesics within an enhanced recovery protocol after colorectal cancer surgery. Colorectal Dis 2022; 24:1172-1183. [PMID: 35637573 DOI: 10.1111/codi.16201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/29/2022] [Accepted: 05/22/2022] [Indexed: 02/08/2023]
Abstract
AIM To reduce detrimental opioid-related side effects, minimising the postoperative opioid consumption is needed, especially in older patients. Continuous wound infusion (CWI) with local analgesics appears to be an effective opioid-sparing alternative. However, the added value of CWI to an enhanced recovery protocol after colorectal cancer (CRC) surgery is unclear. The aim of this study was to evaluate the outcomes of CWI after CRC surgery within a strictly adhered to enhanced recovery protocol. METHODS In this multicentre prospective observational cohort study, patients who underwent CRC surgery between May 2019 and January 2021 were included. Patients were treated with CWI as adjunct to multimodal pain management within an enhanced recovery protocol. Postoperative opioid consumption, pain scores and outcomes regarding functional recovery were evaluated. RESULTS A cohort of 130 consecutive patients were included, of whom 36.2% were ≥75 years. Postoperative opioids were consumed by 80 (61.5%) patients on postoperative day 0, and by 28 (21.5%), 27 (20.8%), and 18 (13.8%) patients on postoperative days 1, 2, and 3, respectively. Median pain scores were <4 on all days. The median time until first passage of stool was 1.0 (IQR: 1.0-2.0) day. Postoperative delirium occurred in 0.8%. Median length of hospital stay was 3.0 days (IQR: 2.0-5.0). CONCLUSION In patients treated with CWI, low amounts of postoperative opioid consumption, adequate postoperative pain control, and enhanced recovery were observed. CWI seems a beneficial opioid-sparing alternative and may further improve the outcomes of an enhanced recovery protocol after CRC surgery, which seems especially valuable for older patients.
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Affiliation(s)
| | - Lieke Dhondt
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| | - Nikki van Ham
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Ansgar S Harms
- Department of Anaesthesiology, VieCuri Medical Centre, Venlo, The Netherlands
| | - Harm J Scholten
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | | | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands.,GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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Daghmouri MA, Chaouch MA, Oueslati M, Rebai L, Oweira H. Regional techniques for pain management following laparoscopic elective colonic resection: A systematic review. Ann Med Surg (Lond) 2021; 72:103124. [PMID: 34925820 PMCID: PMC8648937 DOI: 10.1016/j.amsu.2021.103124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Pain management is an integral part of Enhanced Recovery After Surgery (ERAS) following laparoscopic colonic resection. A variety of regional and neuraxial techniques were proposed, but their efficacy is still controversial. This systematic review evaluates published evidence on analgesic techniques and their impact on postoperative analgesia and recovery for laparoscopic colonic surgery patients. Methods We conducted bibliographic research on May 10, 2021, through PubMed, Cochrane database, and Google scholar. We retained meta-analysis and randomized clinical trials. We graded the strength of clinical data and subsequent recommendations according to the Oxford Centre for Evidence-Based Medicine. Results Twelve studies were included. Thoracic epidural analgesia improved postoperative analgesia and bowel function following laparoscopic colectomy. However, it lengthens the hospital stay. Transversus abdominis plane block was as effective as thoracic epidural analgesia concerning pain control but with better postoperative recovery and lower length of hospital stay. Moreover, Lidocaine intravenous infusion improved postoperative pain management and recovery; Quadratus lumborum block provided similar postoperative analgesia and recovery. Finally, wound infiltration reduced postoperative pain without improving recovery of bowel function, and it could be proposed as an alternative to thoracic epidural analgesia. Conclusions Several analgesic techniques have been investigated. We found that abdominal wall blocks were as effective as thoracic epidural analgesia for pain management but with lower hospital stay and better recovery. We registered this review on PROSPERO (ID: CRD42021279228). First systematic review assessing the efficacy of analgesic techniques following laparoscopic elective colonic resection. Only colonic resection was evaluated contrary to other studies, including rectal surgery. High-quality studies (randomized controlled trials and meta-analyses) were assessed.
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Affiliation(s)
| | - Mohamed Ali Chaouch
- Department of Visceral Surgery, Fattouma Bourguiba Hospital, University of Monastir, Tunisia
| | - Maroua Oueslati
- Department of Anesthesia, Trauma Center of Ben Arrous, University of Manar, Tunisia
| | - Lotfi Rebai
- Department of Anesthesia, Trauma Center of Ben Arrous, University of Manar, Tunisia
| | - Hani Oweira
- Department of Surgery, Universitätsmedizin Mannheim, S, Heidelberg University, Mannheim, Germany
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Intravenous Local Anesthetic Compared with Intraperitoneal Local Anesthetic in Laparoscopic Colectomy: A Double-Blind Randomized Controlled Trial. Ann Surg 2021; 275:e30-e36. [PMID: 33630453 DOI: 10.1097/sla.0000000000004758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Controlling perioperative pain is essential to improving patient experience and satisfaction following surgery. Traditionally opioids have been frequently utilised for postoperative analgesia. Although they are effective at controlling pain, they are associated with adverse effects, including postoperative nausea, vomiting, ileus and long-term opioid dependency.Following laparoscopic colectomy, the use of intravenous or intraperitoneal infusions of lidocaine (IVL, IPL) are promising emerging analgesic options. Although both techniques are promising, there have been no direct, prospective randomized comparisons in patients undergoing laparoscopic colon resection. The purpose of this study was to compare IPL with IVL. METHODS Double blinded, randomized controlled trial of patients undergoing laparoscopic colonic resection. The two groups received equal doses of either IPL or IVL which commenced intra-operatively with a bolus followed by a continuous infusion for 3 days postoperatively. Patients were cared for through a standardized ERAS program. The primary outcome was total post-operative opioid consumption over the first three post-operative days. Patients were followed for 60 days. RESULTS Fifty-six patients were randomized in a 1:1 fashion to the IVL or IPL groups. Total opioid consumption over the first three post-operative days was significantly lower in the IPL group (70.9 mg vs 157.8 mg p < 0.05) and overall opioid consumption during the total length of stay was also significantly lower (80.3 mg vs 187.36 mg p < 0.05. Pain scores were significantly lower at two hours post-operatively in the IPL group, however, all other time points were not significant. There were no differences in complications between the two groups. CONCLUSION Perioperative use of IPL results in a significant reduction in opioid consumption following laparoscopic colon surgery when compared to IVL. This suggests that the peritoneal cavity/compartment is a strategic target for local anesthetic administration. Future ERAS recommendations should consider IPL as an important component of a multimodal pain strategy following colectomy.
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Haruethaivijitchock P, Ng JL, Taksavanitcha G, Theerawatanawong J, Rattananupong T, Lohsoonthorn V, Sahakitrungruang C. Postoperative analgesic efficacy of modified continuous transversus abdominis plane block in laparoscopic colorectal surgery: a triple-blind randomized controlled trial. Tech Coloproctol 2020; 24:1179-1187. [PMID: 32725352 DOI: 10.1007/s10151-020-02311-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 07/16/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The optimal opioid-sparing analgesic regimen following laparoscopic colorectal surgery (LCS) remains uncertain. We sought to determine the efficacy of low-dose bupivacaine infusion via surgeon-inserted modified continuous transversus abdominis plane (mcTAP) catheters after LCS. METHODS A parallel-group, placebo-controlled, randomized single-centre trial was conducted between April 2017 and February 2018. Block-of-four randomization and allocation concealment by sequentially-numbered, opaque sealed envelopes were used. Patients, surgeons and assessors were blinded. Fifty-two patients were randomized to receive either 0.2% bupivacaine or saline through mcTAP catheters. A 5 ml bolus followed by a 72 h infusion at 2 ml/h was started, with patient-controlled fentanyl analgesia and oral paracetamol given on demand. Primary outcomes were fentanyl consumptions in the first 24 h, second 24 h, and third 24 h following surgery. Secondary outcomes were pain numeric rating scores, recovery outcomes and complications. RESULTS Twenty-five patients in the bupivacaine group and 26 in the control group were analysed. Patients in the bupivacaine group required significantly less fentanyl overall (106.1 vs 484.5 mcg, p < 0.001) and at all time points (first 24 h: 61.0 vs 324.3 mcg, p < 0.001; second 24 h: 36.3 vs 119.0 mcg, p = 0.033; third 24 h: 8.8 vs 41.2, p = 0.030) when compared to placebo. Significantly lower pain scores at rest at 6 h (2.32 vs 4.0, p = 0.002), and 12 h (1.80 vs 3.08, p = 0.011) and on coughing at 6 h (4.56 vs 5.84, p = 0.019), 12 h (3.76 vs 4.96, p = 0.009), and 24 h (3.44 vs 4.24, p = 0.049) as well as significantly lower opioid-related complications such as nausea or vomiting (9 (36%) vs 1 (4%), p = 0.005) were observed in the bupivacaine group. There were no major block-related complications, and recovery outcomes were similar in both groups. CONCLUSIONS McTAP block reduces postoperative fentanyl consumption and pain scores after LCS, highlighting its role as a safe and useful opioid-sparing analgesia. REGISTRATION NUMBER TCTR20150831001 (Thai Clinical Trials Registry). Full trial protocol can be assessed at https://www.clinicaltrials.in.th/ .
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Affiliation(s)
- P Haruethaivijitchock
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - J L Ng
- Department of Colorectal Surgery, Singapore General Hospital, Singapore, Singapore
| | - G Taksavanitcha
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - J Theerawatanawong
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - T Rattananupong
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - V Lohsoonthorn
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - C Sahakitrungruang
- Colorectal Surgery Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand.
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Paladini G, Di Carlo S, Musella G, Petrucci E, Scimia P, Ambrosoli A, Cofini V, Fusco P. Continuous Wound Infiltration of Local Anesthetics in Postoperative Pain Management: Safety, Efficacy and Current Perspectives. J Pain Res 2020; 13:285-294. [PMID: 32099452 PMCID: PMC6999584 DOI: 10.2147/jpr.s211234] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/14/2020] [Indexed: 12/18/2022] Open
Abstract
Local infiltration and continuous infusion of surgical wound with anesthetics are parts of multimodal analgesia for postoperative pain control. The techniques, given the simplicity of execution that does not increase the timing of the intervention and does not require additional technical skills, are applied in several kinds of surgeries. The continuous wound infiltration can be used for days and a variety of continuous delivery methods can be chosen, including patient-controlled analgesia, continuous infusion or intermittent bolus. The purpose of this narrative review is to analyze the literature, in particular by researching the safety, efficacy and current perspectives of continuous wound infiltration for postoperative pain management in different surgical settings. We have identified 203 articles and 95 of these have been taken into consideration: 17 for the lower limb surgery; 7 for the upper limb surgery, 51 for the laparotomy/laparoscopic surgery of the abdominopelvic area, 13 studies regarding breast surgery and 7 for cardiothoracic surgery. The analysis of these studies reveals that the technique has a variable effectiveness based on the type of structure involved: it is better in structures rich in subcutaneous and connective tissue, while the effectiveness is limited in anatomic districts with a greater variability of innervation. However, regardless the heterogeneity of results, a general reduction in pain intensity and in opioid consumption has been observed with continuous wound infiltration: it is an excellent analgesic technique that can be included in the multimodal treatment of postoperative pain or represents a valid alternative when other options are contraindicated.
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Affiliation(s)
- Giuseppe Paladini
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Stefano Di Carlo
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti, Chieti, Italy
| | - Giuseppe Musella
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Emiliano Petrucci
- Department of Anesthesia and Intensive Care, San Salvatore Academic Hospital of L'Aquila, L'Aquila, Italy
| | - Paolo Scimia
- Department of Anesthesia and Intensive Care, ASUR Marche AV5, San Benedetto Del Tronto, Italy
| | - Andrea Ambrosoli
- Department of Anesthesia, Perioperative Medicine and Intensive Care Therapy, Filippo Del Ponte Women and Children's Hospital, ASST Sette Laghi, Varese, Italy
| | - Vincenza Cofini
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Pierfrancesco Fusco
- Department of Anesthesia and Intensive Care, San Salvatore Academic Hospital of L'Aquila, L'Aquila, Italy
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Thangavel AR, Sethi S, Gupta V. Comparison of Continuous Wound Infusion versus Continuous Epidural Infusion in Upper Abdominal Surgery: Noninferiority Randomized Controlled Trial. Anesth Essays Res 2019; 13:676-682. [PMID: 32009714 PMCID: PMC6937894 DOI: 10.4103/aer.aer_133_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 11/12/2019] [Accepted: 11/20/2019] [Indexed: 12/19/2022] Open
Abstract
Context: Wound catheter offers a less invasive alternative for postoperative analgesia in the abdominal surgery. Methods: We conducted a single-center, prospective, open-label noninferiority randomized controlled trial. A total of 40 patients who consented to this trial, undergoing upper abdominal surgery via an upper midline incision, were randomized into two groups. In the continuous wound infusion (CWI) group, the wound catheter was placed in the subcutaneous plane of the surgical incision; the continuous epidural infusion (CEI) group received thoracic epidural with a catheter placed. After the surgery, both the groups received 0.2% ropivacaine infusion at 10 mL/h following a 10 mL bolus for 48 h postsurgery. Postoperatively, the pain scores were noted at multiple time points, along with a record of morphine consumption and adverse effects. Results: There was no significant difference in pain scores both at rest and on movement between the two groups at all the time points assessed. The mean difference in numerical rating scale score 24 h postsurgery at rest (0.1, 95% confidence interval [CI] = −0.45, 0.65) and on movement (0.05, 95% CI = −0.73, 0.83), with 95% CI in both the groups, was within the noninferiority limit. Morphine consumption was less in the CEI group, though not significant. The time to appearance of bowel movement, time to ambulate, and length of hospital stay were significantly lower in the CWI group. The incidence of hypotension requiring intervention was higher in the CEI group. Conclusion: Hence, analgesia provided by continuous wound catheter infusion is not inferior to CEI with better preservation of hemodynamics and faster recovery.
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Affiliation(s)
- Arun Raja Thangavel
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sameer Sethi
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Wei S, Yu-Han Z, Wei-Wei J, Hai Y. The effects of intravenous lidocaine on wound pain and gastrointestinal function recovery after laparoscopic colorectal surgery. Int Wound J 2019; 17:351-362. [PMID: 31837112 DOI: 10.1111/iwj.13279] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 11/24/2019] [Indexed: 02/05/2023] Open
Abstract
To evaluate the efficacy of intravenous lidocaine in relieving postoperative pain and promoting rehabilitation in laparoscopic colorectal surgery, we conducted this meta-analysis. The systematic search strategy was performed on PubMed, EMBASE, Chinese databases, and Cochrane Library before September 2019. As a result, 10 randomised clinical trials were included in this meta-analysis (n = 527 patients). Intravenous lidocaine significantly reduced pain scores at 2, 4, 12, 24, and 48 hours on movement and 2, 4, and 12 hours on resting-state and reduced opioid requirement in first 24 hours postoperatively (weighted mean difference [WMD] = -5.02 [-9.34, -0.70]; P = .02). It also decreased the first flatus time (WMD: -10.15 [-11.20, -9.10]; P < .00001), first defecation time (WMD: -10.27 [-17.62, -2.92]; P = .006), length of hospital stay (WMD: -1.05 [-1.89, -0.21]; P = .01), and reduced the incidence of postoperative nausea and vomiting (risk ratio: 0.53 [0.30, 0.93]; P = .03) when compared with control group. However, it had no effect on pain scores at 24 and 48 hours at rest, the normal dietary time, and the level of serum C-reactive protein. In summary, perioperative intravenous lidocaine could alleviate acute pain, reduce postoperative analgesic requirements, and accelerate recovery of gastrointestinal function in patients undergoing laparoscopic colorectal surgery.
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Affiliation(s)
- Shi Wei
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhang Yu-Han
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Wei-Wei
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Hai
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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10
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Evidence-based recommendations for blinding in surgical trials. Langenbecks Arch Surg 2019; 404:273-284. [DOI: 10.1007/s00423-019-01761-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/05/2019] [Indexed: 12/15/2022]
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Preperitoneal or Subcutaneous Wound Catheters as Alternative for Epidural Analgesia in Abdominal Surgery. Ann Surg 2019; 269:252-260. [DOI: 10.1097/sla.0000000000002817] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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12
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Huang YY, Suthananthan AE, Hunt V, Hruby J, Koek S, Rowcroft A, Beh H, Jayasundera M. The role of intraperitoneal ropivacaine in laparoscopic appendicectomy: a prospective, double-blinded randomized control Australian study. ANZ J Surg 2019; 89:101-105. [DOI: 10.1111/ans.15049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 12/11/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Yang Y. Huang
- Department of General Surgery; Armadale-Kelmscott Memorial Hospital; Armadale Western Australia Australia
| | - Arul E. Suthananthan
- Department of General Surgery; Armadale-Kelmscott Memorial Hospital; Armadale Western Australia Australia
| | - Victoria Hunt
- Department of General Surgery; Armadale-Kelmscott Memorial Hospital; Armadale Western Australia Australia
| | - Jan Hruby
- Department of General Surgery; Armadale-Kelmscott Memorial Hospital; Armadale Western Australia Australia
| | - Sharnice Koek
- Department of General Surgery; Armadale-Kelmscott Memorial Hospital; Armadale Western Australia Australia
| | - Alistair Rowcroft
- Department of General Surgery; Armadale-Kelmscott Memorial Hospital; Armadale Western Australia Australia
| | - Han Beh
- Department of General Surgery; Armadale-Kelmscott Memorial Hospital; Armadale Western Australia Australia
| | - Mohan Jayasundera
- Department of General Surgery; Armadale-Kelmscott Memorial Hospital; Armadale Western Australia Australia
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Comparison of the postoperative effect between epidural anesthesia and continuous wound infiltration on patients with open surgeries: A meta-analysis. J Clin Anesth 2018; 51:20-31. [PMID: 30064083 DOI: 10.1016/j.jclinane.2018.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/02/2018] [Accepted: 07/24/2018] [Indexed: 11/23/2022]
Abstract
PURPOSE The study aimed to compare the effect of epidural anesthesia (EA) and continuous wound infiltration (CWI) on surgical patients. METHODS The literature retrieval was conducted in relevant databases from their inception to June 2018 with the predefined searching strategy and selection criteria. Then, the Cochrane Collaboration's tool was used to assess the quality of included studies. In addition, odds ratio (OR) and standardized mean difference (SMD) with its corresponding 95% confidence interval (CI) were used as a measure of effect size for evaluating outcomes indicators. RESULTS Totally, sixteen RCTs were included. The incidence of hypotension in EA group was significantly higher than CWI group (OR = 3.7398; 95% CI: 1.0632 to 13.1555). In addition, EA provided better pain relief than CWI on rest at 72 h (SMD = -0.6037; 95% CI: -1.0767 to -0.1308) after surgery. Additionally, there were no significant differences in pain score on rest and mobilization at 2 h, 12 h, 24 h and 48 h. Moreover, the subgroup analysis showed that pain scores in EA group was significantly reduced at 2 h on rest and 12 h on mobilization than CWI group after liver resection surgery, as well as at 72 h on rest after colorectal surgery. CONCLUSION CWI is superior to EA with a lower incidence of complications for use in surgery, and EA may provide better pain control than CWI on pain relief after surgery.
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Beaussier M, Parc Y, Guechot J, Cachanado M, Rousseau A, Lescot T. Ropivacaine preperitoneal wound infusion for pain relief and prevention of incisional hyperalgesia after laparoscopic colorectal surgery: a randomized, triple-arm, double-blind controlled evaluation vs intravenous lidocaine infusion, the CATCH study. Colorectal Dis 2018; 20:509-519. [PMID: 29352518 DOI: 10.1111/codi.14021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/20/2017] [Indexed: 02/08/2023]
Abstract
AIM The abdominal incision for specimen extraction could trigger postoperative pain after laparoscopic colorectal resections (LCRs). Continuous wound infusion (CWI) of ropivacaine may be a valuable option for postoperative analgesia. This study was undertaken to evaluate the potential benefits of ropivacaine CWI on pain relief, metabolic stress reaction, prevention of wound hyperalgesia and residual incisional pain after LCR. A subgroup with intravenous lidocaine infusion (IVL) was added to discriminate between the peripheral and systemic effects of local anaesthetic infusions. METHOD Patients were randomly allocated to three subgroups: CWI (0.2% ropivacaine 10 ml/h for 48 h); IVL (lidocaine 1.5% at 4 ml/h for 48 h); control group. RESULTS In all, 95 patients were randomized (86 patients analysed). Postoperative pain intensity did not differ significantly between groups. Within the first 24 h after surgery, morphine requirement was significantly lower in the CWI group compared with the IVL group, but there was no significant difference compared with the control group (P = 0.02 and P = 0.15, respectively). The area of hyperalgesia did not differ significantly between subgroups, nor did the hyperalgesia ratio which was 1.2 cm (0.0-6.7) vs 1.9 cm (0.4-4.0) vs 2.0 cm (0.5-7.0) in the CWI, IVL and control groups respectively (P = 0.35). The number of patients reporting residual incisional pain after 3 months (3/26 vs 4/23 vs 4/23 in the CWI, IVL and control groups respectively) did not differ significantly between the groups, nor did their metabolic stress reactions. CONCLUSION Ropivacaine CWI at the site of the abdominal incision did not provide any significant benefit either on analgesia or on the prevention of wound hyperalgesia after LCR.
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Affiliation(s)
- M Beaussier
- Department of Anaesthesiology and Critical Care Medicine, St-Antoine University Hospital, Assistance Publique - Hôpitaux de Paris, Sorbonne Universités, Paris, France
| | - Y Parc
- Department of Digestive Surgery, St-Antoine University Hospital, Assistance Publique - Hôpitaux de Paris, Sorbonne Universités, Paris, France
| | - J Guechot
- Department of Biology, St-Antoine University Hospital, Assistance Publique - Hôpitaux de Paris, Sorbonne Universités, Paris, France
| | - M Cachanado
- Unité de Recherche Clinique de l'Est Parisien (URC-Est), Paris, France
| | - A Rousseau
- Unité de Recherche Clinique de l'Est Parisien (URC-Est), Paris, France
| | - T Lescot
- Department of Anaesthesiology and Critical Care Medicine, St-Antoine University Hospital, Assistance Publique - Hôpitaux de Paris, Sorbonne Universités, Paris, France
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MacFater WS, Xia W, Barazanchi A, Su’a B, Svirskis D, Hill AG. Intravenous Local Anaesthetic Compared with Intraperitoneal Local Anaesthetic in Abdominal Surgery: A Systematic Review. World J Surg 2018; 42:3112-3119. [DOI: 10.1007/s00268-018-4623-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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16
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Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines. Anesthesiol Clin 2017; 35:e115-e143. [PMID: 28526156 DOI: 10.1016/j.anclin.2017.01.018] [Citation(s) in RCA: 235] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.
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17
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MacFater WS, Rahiri JL, Lauti M, Su'a B, Hill AG. Intravenous lignocaine in colorectal surgery: a systematic review. ANZ J Surg 2017; 87:879-885. [PMID: 28677829 DOI: 10.1111/ans.14084] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Colorectal surgery leads to morbidity during recovery including pain and fatigue. Intravenous (IV) lignocaine (IVL) has both analgesic and anti-inflammatory effects that may improve post-operative pain and recovery. The aim of this review is to compare the effectiveness of IVL to other perioperative analgesia regimens for reducing pain and opioid consumption following colorectal surgery. METHODS Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, a literature search was conducted to identify randomized clinical trials that compared IVL with IV placebo or epidural anaesthesia in open or laparoscopic colorectal surgery. The primary outcomes were opioid requirements and pain scores assessed by visual analogue score. Data were entered into pre-designed electronic spreadsheets. RESULTS The literature search identified 2707 studies. A total of nine randomized clinical trials met the inclusion criteria. Five studies investigated IVL compared with IV placebo and four studies investigated IVL compared with epidural anaesthesia. Two out of the five studies comparing IVL and placebo showed statistically significant reductions in opioid consumption with IVL. There was a variable degree of improvement in pain scores when IVL was compared with epidural. Two studies showed a significant difference, with lower opioid consumption and pain scores in the epidural group. Laparoscopic and open procedures could not be compared between the IVL and placebo group. CONCLUSION IVL has shown limited benefit towards reducing early pain and morphine consumption when compared with placebo in colorectal surgery. However, IVL did not show any significant reduction in pain or opioid consumption when compared with epidural. Further research investigating IVL combined with intraperitoneal local anaesthetic is warranted.
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Affiliation(s)
- Wiremu S MacFater
- Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Jamie-Lee Rahiri
- Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Melanie Lauti
- Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Bruce Su'a
- Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Andrew G Hill
- Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand
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Blencowe NS, Cook JA, Pinkney T, Rogers C, Reeves BC, Blazeby JM. Delivering successful randomized controlled trials in surgery: Methods to optimize collaboration and study design. Clin Trials 2017; 14:211-218. [DOI: 10.1177/1740774516687272] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Randomized controlled trials in surgery are notoriously difficult to design and conduct due to numerous methodological and cultural challenges. Over the last 5 years, several UK-based surgical trial-related initiatives have been funded to address these issues. These include the development of Surgical Trials Centers and Surgical Specialty Leads (individual surgeons responsible for championing randomized controlled trials in their specialist fields), both funded by the Royal College of Surgeons of England; networks of research-active surgeons in training; and investment in methodological research relating to surgical randomized controlled trials (to address issues such as recruitment, blinding, and the selection and standardization of interventions). This article discusses these initiatives more in detail and provides exemplar cases to illustrate how the methodological challenges have been tackled. The initiatives have surpassed expectations, resulting in a renaissance in surgical research throughout the United Kingdom, such that the number of patients entering surgical randomized controlled trials has doubled.
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Affiliation(s)
- Natalie S Blencowe
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jonathan A Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Thomas Pinkney
- Academic Department of Surgery, School of Cancer Sciences, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, UK
| | - Chris Rogers
- Clinical Trials Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Division of Surgery, Head & Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Lee SH, Sim WS, Kim GE, Kim HC, Jun JH, Lee JY, Shin BS, Yoo H, Jung SH, Kim J, Lee SH, Yo DK, Na YR. Randomized trial of subfascial infusion of ropivacaine for early recovery in laparoscopic colorectal cancer surgery. Korean J Anesthesiol 2016; 69:604-613. [PMID: 27924202 PMCID: PMC5133233 DOI: 10.4097/kjae.2016.69.6.604] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/06/2016] [Accepted: 08/16/2016] [Indexed: 01/06/2023] Open
Abstract
Background There is a need for investigating the analgesic method as part of early recovery after surgery tailored for laparoscopic colorectal cancer (LCRC) surgery. In this randomized trial, we aimed to investigate the analgesic efficacy of an inverse ‘v’ shaped bilateral, subfascial ropivacaine continuous infusion in LCRC surgery. Methods Forty two patients undergoing elective LCRC surgery were randomly allocated to one of two groups to receive either 0.5% ropivacaine continuous infusion at the subfascial plane (n = 20, R group) or fentanyl intravenous patient controlled analgesia (IV PCA) (n = 22, F group) for postoperative 72 hours. The primary endpoint was the visual analogue scores (VAS) when coughing at postoperative 24 hours. Secondary end points were the VAS at 1, 6, 48, and 72 hours, time to first flatus, time to first rescue meperidine requirement, rescue meperidine consumption, length of hospital stay, postoperative nausea and vomiting, sedation, hypotension, dizziness, headache, and wound complications. Results The VAS at rest and when coughing were similar between the groups throughout the study. The time to first gas passage and time to first rescue meperidine at ward were significantly shorter in the R group compared to the F group (P = 0.010). Rescue meperidine was administered less in the R group; however, without statistical significance. Other study parameters were not different between the groups. Conclusions Ropivacaine continuous infusion with an inverse ‘v ’ shaped bilateral, subfascial catheter placement showed significantly enhanced bowel recovery and analgesic efficacy was not different from IV PCA in LCRC surgery.
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Affiliation(s)
- Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo-Seog Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Go Eun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Division of Colorectal Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Hyun Jun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University of College of Medicine, Seoul, Korea
| | - Jin Young Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung-Seop Shin
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heejin Yoo
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Seoul, Korea
| | - Sin-Ho Jung
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Seoul, Korea
| | - Joungyoun Kim
- Department of Information Statistics, Chungbuk National University, Cheongju, Korea
| | - Seung Hyeon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Deok Kyu Yo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yu Ri Na
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Burnell P, Coates R, Dixon S, Grant L, Gray M, Griffiths B, Jones M, Madhavan A, McCallum I, McClean R, Naru K, Newton L, O'Loughlin P, Shaban F, Sukha A, Somnath S, Shumon S, Harji D. Protocol for a multicentre, prospective, observational cohort study of variation in practice in perioperative analgesic strategies in elective laparoscopic colorectal surgery: the LapCoGesic Study. BMJ Open 2016; 6:e008810. [PMID: 27601484 PMCID: PMC5020879 DOI: 10.1136/bmjopen-2015-008810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Laparoscopic surgery combined with enhanced recovery programmes has become the gold standard in the elective management of colorectal disease. However, there is no consensus with regard to the optimal perioperative analgesic regime in this cohort of patients, with a number of options available, including thoracic epidural spinal analgesia, patient-controlled analgesia, subcutaneous and/or intraperitoneal local anaesthetics, local anaesthetic wound infiltration catheters and transversus abdominis plane blocks. This study aims to explore any differences in analgesic strategies employed across the North East of England and to assess whether any variation in practice has an impact on clinical outcomes. METHODS AND ANALYSIS All North East Colorectal units will be recruited for participation by the Northern Surgical Trainees Research Association (NoSTRA). Data will be collected over a consecutive 2-month period. Outcome measures will include postoperative pain score, postoperative opioid analgesic use and side effects, length of stay, 30-day complication rates, 30-day reoperative rates and 30-day readmission rates. ETHICS AND DISSEMINATION Ethical approval for this study has been granted by the National Research Ethics Service. The protocol will be disseminated through NoSTRA. Individual unit data will be presented at local meetings. Overall collective data will be published in peer-reviewed journals and presented at relevant surgical meetings.
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Affiliation(s)
- Phillippa Burnell
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Rachael Coates
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Steven Dixon
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Lucy Grant
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Matthew Gray
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Ben Griffiths
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Mike Jones
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Anantha Madhavan
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Iain McCallum
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Ross McClean
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Karen Naru
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Lydia Newton
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Paul O'Loughlin
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Fadlo Shaban
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Anisha Sukha
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Sameer Somnath
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Syed Shumon
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
| | - Deena Harji
- Department of Academic Surgery, University of Newcastle, Newcastle upon Tyne, UK
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21
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Role of Epidural Analgesia within an ERAS Program after Laparoscopic Colorectal Surgery: A Review and Meta-Analysis of Randomised Controlled Studies. Surg Res Pract 2016; 2016:7543684. [PMID: 27642630 PMCID: PMC5013204 DOI: 10.1155/2016/7543684] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/29/2016] [Indexed: 12/29/2022] Open
Abstract
Introduction. Epidural analgesia has been a cornerstone of any ERAS program for open colorectal surgery. With the improvements in anesthetic and analgesic techniques as well as the introduction of the laparoscopy for colorectal resection, the role of epidural analgesia has been questioned. The aim of the review was to assess through a meta-analysis the impact of epidural analgesia compared to other analgesic techniques for colorectal laparoscopic surgery within an ERAS program. Methods. Literature research was performed on PubMed, Embase, and the Cochrane Library. All randomised clinical trials that reported data on hospital stay, postoperative complications, and readmissions rates within an ERAS program with and without an epidural analgesia after a colorectal laparoscopic resection were included. Results. Five randomised clinical trials were selected and a total of 168 patients submitted to epidural analgesia were compared to 163 patients treated by an alternative analgesic technique. Pooled data show a longer hospital stay in the epidural group with a mean difference of 1.07 (95% CI 0.06-2.08) without any significant differences in postoperative complications and readmissions rates. Conclusion. Epidural analgesia does not seem to offer any additional clinical benefits to patients undergoing laparoscopic colorectal surgery within an ERAS program.
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22
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Foster JD, Ewings P, Falk S, Cooper EJ, Roach H, West NP, Williams-Yesson BA, Hanna GB, Francis NK. Surgical timing after chemoradiotherapy for rectal cancer, analysis of technique (STARRCAT): results of a feasibility multi-centre randomized controlled trial. Tech Coloproctol 2016; 20:683-93. [PMID: 27510524 DOI: 10.1007/s10151-016-1514-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 05/10/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal time of rectal resection after long-course chemoradiotherapy (CRT) remains unclear. A feasibility study was undertaken for a multi-centre randomized controlled trial evaluating the impact of the interval after chemoradiotherapy on the technical complexity of surgery. METHODS Patients with rectal cancer were randomized to either a 6- or 12-week interval between CRT and surgery between June 2012 and May 2014 (ISRCTN registration number: 88843062). For blinded technical complexity assessment, the Observational Clinical Human Reliability Analysis technique was used to quantify technical errors enacted within video recordings of operations. Other measured outcomes included resection completeness, specimen quality, radiological down-staging, tumour cell density down-staging and surgeon-reported technical complexity. RESULTS Thirty-one patients were enrolled: 15 were randomized to 6 and 16-12 weeks across 7 centres. Fewer eligible patients were identified than had been predicted. Of 23 patients who underwent resection, mean 12.3 errors were observed per case at 6 weeks vs. 10.7 at 12 weeks (p = 0.401). Other measured outcomes were similar between groups. CONCLUSIONS The feasibility of measurement of operative performance of rectal cancer surgery as an endpoint was confirmed in this exploratory study. Recruitment of sufficient numbers of patients represented a challenge, and a proportion of patients did not proceed to resection surgery. These results suggest that interval after CRT may not substantially impact upon surgical technical performance.
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Affiliation(s)
- J D Foster
- Department of Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK.,Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - P Ewings
- Southwest Research Design Service, Taunton and Somerset NHS Trust, Taunton, UK
| | - S Falk
- University Hospitals Bristol, Upper Maudlin Street, Bristol, UK
| | - E J Cooper
- Department of Pathology, Yeovil District Hospital, Higher Kingston, Yeovil, UK
| | - H Roach
- University Hospitals Bristol, Upper Maudlin Street, Bristol, UK
| | - N P West
- Leeds Institute of Cancer and Pathology, School of Medicine, St James's University Hospital, University of Leeds, Leeds, UK
| | - B A Williams-Yesson
- Department of Research and Development, St Mary's Hospital, Imperial College, London, UK
| | - G B Hanna
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - N K Francis
- Department of Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK. .,Faculty of Science, University of Bath, Wessex House 3.22, Bath, BA2 7AY, UK.
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Mungroop TH, Veelo DP, Busch OR, van Dieren S, van Gulik TM, Karsten TM, de Castro SM, Godfried MB, Thiel B, Hollmann MW, Lirk P, Besselink MG. Continuous wound infiltration versus epidural analgesia after hepato-pancreato-biliary surgery (POP-UP): a randomised controlled, open-label, non-inferiority trial. Lancet Gastroenterol Hepatol 2016; 1:105-113. [PMID: 28404067 DOI: 10.1016/s2468-1253(16)30012-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Epidural analgesia is the international standard for pain treatment in abdominal surgery. Although some studies have advocated continuous wound infiltration with local anaesthetics, robust evidence is lacking, especially on patient-reported outcome measures. We aimed to determine the effectiveness of continuous wound infiltration in hepato-pancreato-biliary surgery. METHODS In this randomised controlled, open label, non-inferiority trial (POP-UP), we enrolled adult patients undergoing hepato-pancreato-biliary surgery by subcostal or midline laparotomy in two Dutch hospitals. Patients were centrally randomised (1:1) to receive either pain treatment with continuous wound infiltration using bupivacaine plus patient-controlled analgesia with morphine or to receive (patient-controlled) epidural analgesia with bupivacaine and sufentanil. All patients were treated within an enhanced recovery setting. Randomisation was stratified by centre and type of incision. The primary outcome was the mean Overall Benefit of Analgesic Score (OBAS) from day 1-5, a validated composite endpoint of pain scores, opioid side-effects, and patient satisfaction (range 0 [best] to 28 [worst]). Analysis was per-protocol. The non-inferiority limit of the mean difference was + 3·0. This trial is registered with the Netherlands Trial Registry, number NTR4948. FINDINGS Between Jan 20, 2015, and Sept 16, 2015, we randomly assigned 105 eligible patients: 53 to receive continuous wound infiltration and 52 to receive epidural analgesia. One patient in the continuous wound infiltration group discontinued treatment, as did five in the epidural analgesia group; of these five patients, preoperative placement failed in three (these patients were treated with continuous wound infiltration instead), one patient refused an epidural, and data for the primary endpoint was lost for one. Thus, 55 patients were included in the continuous wound infiltration group and 47 in the epidural analgesia group for the per-protocol analyses. Mean OBAS was 3·8 (SD 2·4) in the continuous wound infiltration group versus 4·4 (2·2) in the epidural group (mean difference -0·62, 95% CI -1·54 to 0·30). Because the upper bound of the one-sided 95% CI did not exceed +3·0, non-inferiority was shown. Four (7%) patients in the continuous wound infiltration group and five (11%) of those in the epidural group had an adverse event. One patient in the continuous wound infiltration group had a serious adverse event (temporary hypotension and arrhythmia after bolus injection); no serious adverse events were noted in the epidural group. INTERPRETATION These data suggest that continuous wound infiltration is non-inferior to epidural analgesia in hepato-pancreato-biliary surgery within an enhanced recovery setting. Further large-scale trials are required to make a definitive assessment of non-inferiority. FUNDING Academic Medical Centre, Amsterdam, Netherlands.
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Affiliation(s)
- Timothy H Mungroop
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands; Department of Anaesthesiology, Academic Medical Centre, Amsterdam, Netherlands
| | - Denise P Veelo
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, Netherlands
| | - Olivier R Busch
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - Susan van Dieren
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands; Department of Anaesthesiology, Academic Medical Centre, Amsterdam, Netherlands
| | | | - Tom M Karsten
- Department of Surgery, OLVG Oost, Amsterdam, Netherlands
| | | | - Marc B Godfried
- Department of Anaesthesiology, OLVG Oost, Amsterdam, Netherlands
| | - Bram Thiel
- Department of Anaesthesiology, OLVG Oost, Amsterdam, Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, Netherlands
| | - Philipp Lirk
- Department of Anaesthesiology, Academic Medical Centre, Amsterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands.
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Feldheiser A, Aziz O, Baldini G, Cox BPBW, Fearon KCH, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytrebø LM, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60:289-334. [PMID: 26514824 PMCID: PMC5061107 DOI: 10.1111/aas.12651] [Citation(s) in RCA: 364] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/23/2015] [Accepted: 09/25/2015] [Indexed: 12/17/2022]
Abstract
Background The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Methods Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. Results This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. Conclusions Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.
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Affiliation(s)
- A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - O. Aziz
- St. Mark's Hospital Harrow Middlesex UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - B. P. B. W. Cox
- Department of Anesthesiology and Pain Therapy University Hospital Maastricht (azM) Maastricht The Netherlands
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - R. H. Kennedy
- St. Mark's Hospital/Imperial College Harrow, Middlesex/London UK
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - D. N. Lobo
- Gastrointestinal Surgery National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK
| | - T. Miller
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - F. F. Radtke
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - T. Ruiz Garces
- Anestesiologa y Reanimacin Hospital Clinico Lozano Blesa Universidad de Zaragoza Zaragoza Spain
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal Quebec Canada
| | - M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Surrey UK
| | - J. K. Thacker
- Department of Surgery Duke University Medical Center Durham North Carolina USA
| | - L. M. Ytrebø
- Department of Anaesthesiology University Hospital of North Norway Tromso Norway
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
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25
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Abstract
Anesthesiologists play a pivotal role in facilitating recovery of patients undergoing colorectal surgery, as many Enhanced Recovery After Surgery (ERAS) elements are under their direct control. Successful implementation of ERAS programs requires that anesthesiologists become more involved in perioperative care and more aware of the impact of anesthetic techniques on surgical outcomes and recovery. Key to achieving success is strict adherence to the principle of aggregation of marginal gains. This article reviews anesthetic and analgesic care of patients undergoing elective colorectal surgery in the context of an ERAS program, and also discusses anesthesia considerations for emergency colorectal surgery.
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Affiliation(s)
- Gabriele Baldini
- Department of Anesthesia, Montreal General Hospital, McGill University Health Centre, 1650 Avenue Cedar, Montreal, Quebec H3G 1A4, Canada.
| | - William J Fawcett
- Royal Surrey County Hospital, Postgraduate School, University of Surrey, Guildford GU2 7XX, UK
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McIsaac D, Cole E, McCartney C. Impact of including regional anaesthesia in enhanced recovery protocols: a scoping review. Br J Anaesth 2015; 115 Suppl 2:ii46-56. [DOI: 10.1093/bja/aev376] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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27
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Comparison of pain relief between patient-controlled epidural analgesia and patient-controlled intravenous analgesia for patients undergoing spinal fusion surgeries. Arch Orthop Trauma Surg 2015; 135:1247-55. [PMID: 26119710 DOI: 10.1007/s00402-015-2263-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Indexed: 10/23/2022]
Abstract
INTRODUCTION This meta-analysis aimed to compare the postoperative analgesic effects of patient-controlled epidural analgesia (PCEA) and patient-controlled intravenous analgesia (PCIA) for patients undergoing spinal fusion surgeries. METHOD Relevant articles were identified using computerized and manual search strategies. Statistical analyses were undertaken by the CMA 2.0 statistical software. RESULTS Nine cohort studies with a total of 436 patients undergoing spinal fusion surgeries were incorporated in the present meta-analysis. There were significant differences between the PCEA and PCIA groups in the visual analogue scale score of patients undergoing spinal fusion [standardized mean difference = 0.27, 95 % confidence interval (95 % CI) = 0.070-0.470, P = 0.008]. However, no obvious difference was observed in the rate of side effects between the PCIA and PCEA groups (side effects: odds ratio = 0.957, 95 % CI = 0.536-1.708, P = 0.882). CONCLUSION Our findings suggested that PCEA may be more effective in relieving pain than PCIA for patients undergoing spinal fusion surgeries.
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Barr J, Boulind C, Foster JD, Ewings P, Reid J, Jenkins JT, Williams-Yesson B, Francis NK. Impact of analgesic modality on stress response following laparoscopic colorectal surgery: a post-hoc analysis of a randomised controlled trial. Tech Coloproctol 2015; 19:231-9. [PMID: 25715786 DOI: 10.1007/s10151-015-1270-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 01/27/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Epidural analgesia is perceived to modulate the stress response after open surgery. This study aimed to explore the feasibility and impact of measuring the stress response attenuation by post-operative analgesic modalities following laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) protocol. METHODS Data were collected as part of a double-blinded randomised controlled pilot trial at two UK sites. Patients undergoing elective laparoscopic colorectal resection were randomised to receive either thoracic epidural analgesia (TEA) or continuous local anaesthetic infusion to the extraction site via wound infusion catheter (WIC) post-operatively. The aim of this study was to measure the stress response to the analgesic modality by measuring peripheral venous blood samples analysed for serum concentrations of insulin, cortisol, epinephrine and interleukin-6 at induction of anaesthesia, at 3, 6, 12 and 24 h after the start of operation. Secondary endpoints included mean pain score in the first 48 h, length of hospital stay, post-operative complications and 30-day re-admission rates. RESULTS There was a difference between the TEA and WIC groups that varies across time. In the TEA group, there was significant but transient reduced level of serum epinephrine and a higher level of insulin at 3 and 6 h. In the WIC, there was a significant reduction of interleukin-6 values, especially at 12 h. There was no significant difference observed in the other endpoints. CONCLUSIONS There is a significant transient attenuating effect of TEA on stress response following laparoscopic colorectal surgery and within ERAS as expressed by serum epinephrine and insulin levels. Continuous wound infusion with local anaesthetic, however, attenuates cytokine response as expressed by interleukin-6.
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Affiliation(s)
- J Barr
- Yeovil District Hospital Foundation, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK
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29
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Abstract
This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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30
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Ventham NT, Hughes M, O'Neill S, Johns N, Brady RR, Wigmore SJ. Systematic review and meta-analysis of continuous local anaesthetic wound infiltration versus epidural analgesia for postoperative pain following abdominal surgery. Br J Surg 2013; 100:1280-9. [PMID: 24244968 DOI: 10.1002/bjs.9204] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Local anaesthetic wound infiltration techniques reduce opiate requirements and pain scores. Wound catheters have been introduced to increase the duration of action of local anaesthetic by continuous infusion. The aim was to compare these infiltration techniques with the current standard of epidural analgesia. METHODS A meta-analysis of randomized clinical trials (RCTs) evaluating wound infiltration versus epidural analgesia in abdominal surgery was performed. The primary outcome was pain score at rest after 24 h on a numerical rating scale. Secondary outcomes were pain scores at rest at 48 h, and on movement at 24 and 48 h, with subgroup analysis according to incision type and administration regimen(continuous versus bolus), opiate requirements, nausea and vomiting, urinary retention, catheter-related complications and treatment failure. RESULTS Nine RCTs with a total of 505 patients were included. No differences in pain scores at rest 24 h after surgery were detected between epidural and wound infiltration. There were no significant differences in pain score at rest after 48 h, or on movement at 24 or 48 h after surgery. Epidural analgesia demonstrated a non-significant a trend towards reduced pain scores on movement and reduced opiate requirements. There was a reduced incidence of urinary retention in the wound catheter group. CONCLUSION Within a heterogeneous group of RCTs, use of local anaesthetic wound infiltration was associated with pain scores comparable to those obtained with epidural analgesia. Further procedure-specific RCTs including broader measures of recovery are recommended to compare the overall efficacy of epidural and wound infiltration analgesic techniques.
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