Prospective, randomized controlled trial on use of ropivacaine after robotic thyroid surgery: Effects on postoperative pain

Ropivacaine Local Infiltration for Pain Control After Thyroidectomy: A Systematic Review and Meta-Analysis

Objective

To evaluate the analgesic role of ropivacaine local infiltration in patients undergoing thyroidectomy.

Data Sources

PubMed, Google Scholar, CENTRAL, Scopus, and Web of Science.

Review Methods

A systematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs). Our specific endpoints include pain severity, total opioid analgesia consumption, patient satisfaction, length of hospital stay, postanesthesia care unit (PACU) length of stay, surgery duration, and the incidence of postoperative nausea and vomiting (PONV). Using Stata, we pooled dichotomous outcomes and continuous outcomes using risk ratio (RR) and standardized mean difference (SMD) or mean difference (MD), respectively, with a 95% confidence interval (CI).

Results

Eight RCTs and 633 patients were included. Ropivacaine significantly decreased pain after 1 to 2 hours postoperatively (SMD: -1.40, 95% CI [-2.30, -0.51]). However, there was no difference between both groups after 4 hours (P = .11), 6 to 8 hours (P = .05), 16 to 18 hours (P = .10), and 24 hours (P = .37). Also, ropivacaine significantly decreased analgesia consumption (SMD: -0.75, 95% CI [-1.30, -0.20]), with no effect on surgery duration (P = .59), length of hospital stays (P = .32), patient satisfaction score (P = .25), and PACU length of stay (P = .25). Finally, there was no difference between both groups regarding the incidence of PONV (RR: 1.01, 95% CI [0.70, 1.45]).

Conclusion

Ropivacaine local infiltration after thyroidectomy significantly decreased pain for up to 1 to 2 hours and analgesia consumption compared to control, but with uncertain evidence. However, ropivacaine had no effect on pain from 4 to 24 hours, surgery duration, length of PACU stay, length of hospital stay, and patient satisfaction.

Comparison of the Postoperative Outcomes of the Mini-Flap Bilateral Axillo-Breast Approach (BABA) and Conventional BABA Robot-Assisted Thyroidectomy

The bilateral axillo-breast approach (BABA) for robot-assisted thyroidectomy has some advantages over other minimally invasive thyroidectomies. However, some people do not consider this as a minimally invasive thyroidectomy because of the wider surgical skin flap. Thus, we devised mini-flap BABA robot-assisted thyroidectomy and analyzed the postoperative outcomes. The clinical records of 44 patients undergoing BABA robot-assisted thyroidectomy using a conventional flap or mini-flap were evaluated retrospectively. There were no significant group differences in clinicopathological characteristics. The operating and flap making times were shorter in the mini-flap group (206.18 ± 31.09 vs. 178.90 ± 34.43 min, p = 0.009; 38.85 ± 2.73 vs. 32.21 ± 8.62 min, p = 0.003, respectively). The total drainage amount was smaller in the mini-flap group (196.57 ± 81.40 vs. 150.74 ± 40.80 mL, p = 0.027). The numeric rating scale score and number of analgesics were lower at 2 h postoperatively in the mini-flap group (5.52 ± 0.87 vs. 4.57 ± 1.31, p = 0.006; 0.95 ± 0.22 vs. 0.65 ± 0.49, p = 0.012, respectively). There was no significant group difference in immediate oncological outcomes (p = 1.000). Mini-flap BABA robot-assisted thyroidectomy minimized the surgical flap and improved surgical outcomes. Therefore, it is a form of minimally invasive thyroidectomy. However, long-term follow-up of oncological outcomes is needed.

Drugs used in regional block analgesia for thyroidectomy: A network meta-analysis of randomized controlled trials

BACKGROUND

Postoperative pain has become one of the major obstacles to postoperative recovery and can lead to increasing demand for opioids. So far, a wide variety of drugs is used for regional block anesthesia, but which one is the best remains unclear. Thus, this study aims to obtain the best drug for thyroid surgery regional block based on their efficacy and side effects through Bayesian network meta-analysis.

METHODS

Systemically searched MEDLINE, CENTRAL, Embase, and web of science on July 3, 2021 to obtain randomized controlled trials (RCTs) focusing on adults who underwent open thyroidectomy and regional blocks, and took opioids requirement, and the postoperative pain level as outcomes. The "Gemtc" package of R-4.1.1 was used for Bayesian network meta-analysis based on extracted data.

RESULTS

We retrieved 398 articles, and finally included 31 RCTs, which included a total of 2221 patients. Patients received levobupivacaine had the lowest requirement rate for opioids and lowest pain score at T6 and T12. Non-steroidal anti-inflammatory drugs show significant superiority neither in the opioids requirement nor the pain score. Clonidine has a better potential to act as a qualified anesthetic adjuvant compared to adrenaline. The ranking results of the subgroup analysis were consistent with the integrated analysis.

CONCLUSION

Levobupivacaine has a relatively greater advantage in reducing opioids requirement and decreasing the pain score of patients, and bilateral superficial cervical plexus blockade and pre thyroidectomy intervention have more advantages than local wound infiltration and post thyroidectomy intervention in alleviating patients' pain.

Preoperative flap-site injection with ropivacaine and epinephrine in BABA robotic and endoscopic thyroidectomy safely reduces postoperative pain: A CONSORT-compliant double-blinded randomized controlled study (PAIN-BREKOR trial)

BACKGROUND

Clinical trials on bilateral axillo-breast approach (BABA) thyroidectomy show that levobupivacaine and ropivacaine significantly reduce postoperative pain, but they focused on BABA robotic thyroidectomy only and did not identify specific sites of significant pain relief. Our objective was to assess the pain reduction at various sites and safety of ropivacaine-epinephrine flap injection in BABA thyroidectomy.

METHODS

This prospective double-blinded randomized controlled trial was conducted in compliance with the revised CONSORT statement (ClinicalTrials.gov registration no. NCT02112370). Patients were randomized into the ropivacaine-epinephrine arm or control (normal saline) arm.

RESULTS

From January 2014 to May 2016, 148 patients participated. The primary endpoint was site-specific pain, as measured by numeric rating scale 12 hours after surgery. The ropivacaine-epinephrine group exhibited significantly less swallowing difficulty (P = .008), anterior neck pain (P = .016), and right (P = .019) and left (P = .035) chest pain. Secondary endpoints were systolic (P = .402), diastolic (P = .827) blood pressure, and pulse rate (P = .397) after injection before incision and during surgery. The vital signs of the groups just after injection did not differ. During surgery, the ropivacaine-epinephrine patients had higher pulse rates (99 ± 13.3 vs 88 ± 16.1, P < .001) but within normal range. There were no adverse events such as postoperative nausea and vomiting. There was no significant difference in pain scores in either patient group between patients who underwent robotic or endoscopic interventions.

CONCLUSION

BABA flap-site injection with ropivacaine and epinephrine mix before incision effectively and safely reduced postoperative pain. Future studies should focus on tailoring ropivacaine and epinephrine dosage for individuals.