Prospective, randomized study of ropivacaine wound infusion versus intrathecal morphine with intravenous fentanyl for analgesia in living donors for liver transplantation

Continuous Wound Irrigation and Intraoperative Methadone Decreases Opioid Use and Shortens Length of Stay After CRS/HIPEC

BACKGROUND

Epidural analgesia is resource and labor intense and may limit postoperative management options and delay discharge. This study compared postoperative outcomes after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) with epidural analgesia versus continuous wound infusion system (CWIS) with/without intraoperative methadone.

METHODS

A single-institution, retrospective chart review was performed including all patients undergoing open CRS/HIPEC from 2018 to 2021. Patient demographics, surgical characteristics, length of stay, and in-hospital analgesic use were reviewed. In-hospital opioid exposure in morphine milligram equivalents (MME) was calculated. Multivariate analysis (MVA) for mean total and daily opioid exposure was conducted.

RESULTS

A total of 157 patients were included. Fifty-three (34%) had epidural analgesia, 96 (61%) had CWIS, and 79 (50%) received methadone. Length of stay was significantly shorter with CWIS + methadone versus epidural (7 vs. 8 days, p < 0.01). MVA showed significantly lower mean total and daily opioid exposure with CWIS+methadone versus epidural (total: 252.8 ± 17.7 MME vs. 486.8 ± 86.6 MME; odds ratio [OR] 0.72, 95% confidence interval [CI] 0.52-0.98, p = 0.04; Daily: 32.8 ± 2.0 MME vs. 51.9 ± 5.7 MME, OR 0.72, 95% CI 0.52-0.99, p ≤ 0.05). The CWIS-only group (n = 17) had a significantly lower median oral opioid exposure versus epidural (135 MME vs. 7.5 MME, p < 0.001) and longer length of stay versus CWIS + methadone (9 vs. 7 days, p = 0.04), There were no CWIS or methadone-associated complications and one epidural abscess.

CONCLUSIONS

CWIS + methadone safely offers better pain control with less in-hospital opioid use, shorter length of stay, and decreased resource utilization compared with epidural analgesia in patients undergoing CRS-HIPEC.

Living liver donor pain management

PURPOSE OF REVIEW

Optimal pain control in living liver donors undergoing hepatectomy is strongly recommended considering their unique status as healthy individuals willingly undergoing surgery for the benefit of the recipient. This review aims to examine and evaluate different strategies aimed at ensuring effective postoperative pain management in living liver donors.

RECENT FINDINGS

Enhanced recovery after surgery (ERAS) protocols have proven effective in optimizing patient outcomes, including in living liver donor hepatectomy. By implementing these protocols, healthcare professionals can enhance postoperative pain control and accelerate recovery. Multimodal analgesia, which combines different techniques and agents, is crucial in pain management for living liver donors. Regional analgesia techniques, such as spinal anesthesia and various peripheral nerve blocks, have shown efficacy in reducing pain and facilitating early recovery. Systemic nonopioid analgesics, including acetaminophen, nonsteroidal anti-inflammatory drugs, ketamine, lidocaine, and dexmedetomidine act synergistically to alleviate pain and reduce inflammation. Minimizing the use of opioids is important to avoid adverse effects, and they should be reserved for rescue medication or breakthrough pain.

SUMMARY

Applying the principles of ERAS and multimodal analgesia to living liver donors can effectively control pain while promoting early recovery.

Multimodal intrathecal analgesia (MITA) with morphine for reducing postoperative opioid use and acute pain following hepato-pancreato-biliary surgery: A multicenter retrospective study

INTRODUCTION

The optimal analgesic modality for patients undergoing hepato-pancreato-biliary (HPB) surgery remains unknown. The analgesic effects of a multimodal intrathecal analgesia (MITA) technique of intrathecal morphine (ITM) in combination with clonidine and bupivacaine compared to ITM alone have not been investigated in these patients.

METHODS

We performed a multicenter retrospective study of patients undergoing complex HPB surgery who received ITM, bupivacaine, and clonidine (MITA group) or ITM-only (ITM group) as part of their perioperative analgesia strategy. The primary outcome was the unadjusted oral morphine equivalent daily dose (oMEDD) in milligrams on postoperative day 1. After adjusting for age, body mass index, hospital allocation, type of surgery, operation length, and intraoperative opioid use, postoperative oMEDD use was investigated using a bootstrapped quantile regression model. Other prespecified outcomes included postoperative pain scores, opioid-related adverse events, major complications, and length of hospital stay.

RESULTS

In total, 118 patients received MITA and 155 patients received ITM-only. The median (IQR) cumulative oMEDD use on postoperative day 1 was 20.5 mg (8.6:31.0) in the MITA group and 52.1 mg (18.0:107.0) in the ITM group (P < 0.001). There was a variation in the magnitude of the difference in oMEDD use between the groups for different quartiles. For the MITA group, on postoperative day 1, patients in the 25th percentile required 14.0 mg less oMEDD (95% CI: -25.9 to -2.2; P = 0.025), patients in the 50th percentile required 27.8 mg less oMEDD (95% CI: -49.7 to -6.0; P = 0.005), and patients in the 75th percentile required 38.7 mg less oMEDD (95% CI: -72.2 to -5.1; P = 0.041) compared to patients in the same percentile of the ITM group. Patients in the MITA group had significantly lower pain scores in the postoperative recovery unit and on postoperative days 1 to 3. The incidence of postoperative respiratory depression was low (<1.5%) and similar between groups. Patients in the MITA group had a significantly higher incidence of postoperative hypotension requiring vasopressor support. However, no significant differences were observed in major postoperative complications, or the length of hospital stay.

CONCLUSION

In patients undergoing complex HPB surgery, the use of MITA, consisting of ITM in combination with intrathecal clonidine and bupivacaine, was associated with reduced postoperative opioid use and resulted in superior postoperative analgesia without risk of respiratory depression when compared to patients who received ITM alone. A randomized prospective clinical trial investigating these two intrathecal analgesic techniques is justified.

Comparison of the analgesic effect of intrathecal morphine between laparoscopic and open living donor hepatectomy: Propensity score matching analysis

Laparoscopic donor hepatectomy is being increasingly adopted in transplant programs due to its numerous advantages. However, the role of intrathecal morphine (ITM) in laparoscopic donor hepatectomy has not been thoroughly investigated. This study aimed to compare the analgesic effects and safety of ITM between laparoscopic and open donor hepatectomy. This retrospective study included 742 donors who underwent hepatectomy with ITM between April 2007 and June 2019. Among them, 168 and 574 donors underwent laparoscopic hepatectomy (LH) and open hepatectomy (OH), respectively. Propensity score matching yielded two comparable groups of 168 donors each. The primary endpoint was the incidence of moderate-to-severe pain (maximum numerical rating scale [NRS] pain score ≥ 4) within 24 postoperative hours. The LH group had a significantly lower incidence of moderate-to-severe pain within 24 postoperative hours than the OH group (16.1% vs 64.3%, P < .001). Moreover, the cumulative rescue intravenous opioids (in morphine-equivalent dose) on postoperative day (POD) 1 was lower in the LH group than in the OH group (3.3 [0-8.3] mg vs 10 [3.3-17.3] mg; P < .001). There were no significant between-group differences in the incidence of respiratory depression (2.4% vs 0.6%; P = .371) and prescriptions for pruritus (14.3% vs 15.5%; P = .878). However, the prescriptions for postoperative nausea and vomiting (PONV) was significantly higher in the LH group than in the OH group (64.9% vs 41.7%; P < .001). The predictors of antiemetic agent prescription included the use of laparoscopic procedure (adjusted odds ratio [OR], 2.05; 95% confidence interval [CI], 1.11-3.79; P = .021) and female sex (adjusted OR, 5.63; 95% CI, 3.19-9.92; P < .001). Preoperative ITM administration resulted in a significantly lower incidence of moderate-to-severe pain within 24 postoperative hours after laparoscopic donor hepatectomy than after open donor hepatectomy.

Comparison of two doses of intrathecal morphine in laparoscopic donor hepatectomy: A randomized double-blinded non-inferiority trial

BACKGROUND

Intrathecal morphine (ITM) injection is an effective postoperative analgesic strategy in open or laparoscopic donor hepatectomy; however, the optimal dose has not been determined. In this trial, we compared the post-operative analgesic effects of two doses (300 vs. 400 μg) of ITM injections.

METHODS

In this prospective randomized non-inferiority trial, 56 donors were divided into either the 300 μg or 400 μg ITM group (n = 28, each). The primary outcome was the resting pain score at 24 h postoperatively. Pain scores, cumulative opioid consumption, and side effects (postoperative nausea and vomiting [PONV]) were compared up to 48 h postoperatively.

RESULTS

Fifty-five donors participated in the entire study. The mean resting pain scores at 24 h after surgery were 1.7 ± 1.6 and 1.7 ± 1.1 in the ITM 300 and ITM 400 groups, respectively (mean difference, 0 [95% CI, -.8 to .7], p = .978). The upper limit of the 95% CI was lower than the prespecified non-inferiority margin (δ = 1), indicating that non-inferiority had been established. The incidence of PONV was lower in the ITM 300 group than in the ITM 400 group at 18 (p = .035) and 24 h postoperatively (p = .015). There were no significant differences in the resting and coughing pain scores and cumulative opioid consumption at any time point.

CONCLUSION

For laparoscopic donor hepatectomy, preoperative ITM 300 μg exhibited non-inferior postoperative analgesic effects compared to ITM 400 μg, with a lower incidence of PONV.

Anxiety, pain intensity, and decision regret of living liver donors during postoperative period

AIM

The aim of this study was to explore and examine the relationship between anxiety, acute pain intensity, and decision regret of living liver donors in the postoperative stage.

METHODS

This is a prospective correlational study. Data were collected consecutively for one year (from September 2017 to September 2018) at a medical center in northern Taiwan. Information about anxiety and acute pain intensity was collected preoperatively and on postoperative day (POD) 3 and POD 7. Satisfaction with pain management and decision regret was inquired about on POD 7.

RESULTS

Data of 57 consecutive living liver donors (56.1 % male, mean age 34.12 ± 9.92 years) were analyzed. Living liver donors experienced moderate anxiety and acute pain levels in the postoperative period. The mean score of decision regret was 12.63 (range 0-60), indicating a low level of regret. The acute pain intensity decreased significantly between POD 3 and POD 7 (p < .001); however, the anxiety level slightly increased (p = .031). Older and married living liver donors had higher anxiety levels. The satisfaction level of pain management was negatively correlated with the POD 7 acute pain intensity (r = -0.26, p = .049) and decision regret (r = -0.37, p = .005), but it was positively correlated with POD 7 anxiety (r = 0.38, p = .004).

CONCLUSIONS

The postoperative period was hard for living liver donors as they would experience moderate acute pain and anxiety. Although the decision regret was low, the satisfaction level of pain management would negatively affect it. Therefore, the effectiveness of pain management and anxiety management should be continually ensured in the postoperative period.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.

METHODS

A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.

RESULTS

A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.

CONCLUSIONS

These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.

Efficacy of a local anesthetic gel infusion kit for pain relief after minimally invasive colorectal surgery: an open-label, randomized clinical trial

Continuous wound infusion with local anesthesia is an effective method for reducing postoperative pain after laparoscopic colorectal surgery. However, most subcutaneous local anesthesia is delivered through continuous injection, which can be inconvenient for patients. This study compared the effectiveness of postoperative pain relief from the application of a local poloxamer 407-based ropivacaine hydrogel (Gel) to the incision site with continuous infusion-type ropivacaine administration (On-Q) in patients undergoing laparoscopic colorectal surgery. This prospective, randomized, non-inferiority study included 61 patients who underwent laparoscopic colorectal surgery with an incision length of 3-6 cm. All 61 patients were randomly assigned to the Gel group (poloxamer 407-based 0.75% ropivacaine, 22.5 mg) or the On-Q group (0.2% ropivacaine, 4 mg/hour for two days). Postoperative analgesia was induced in all patients with intravenous patient-controlled analgesia (IV-PCA). The outcome measures, which were assessed for 72 h after surgery, included the total amount of fentanyl consumed via IV-PCA (primary endpoint), and the amount of rescue analgesia (pethidine) and postoperative pain intensity assessed using a numeric rating scale (NRS) [secondary endpoints]. The Gel was administered to 31 patients and On-Q was used for 30 patients. There was no significant difference in the total usage of fentanyl between the two groups (Gel group, 1623.98 mcg; On-Q group, 1595.12 mcg; P = 0.806). There was also no significant difference in the frequency of analgesic rescue medication use (P = 0.213) or NRS scores (postoperative 6 h, P = 0.860; 24 h, P = 0.333; 48 h, P = 0.168; and 72 h, P = 0.655) between the two groups. The Gel, which continuously delivers a local anesthetic to operative sites, can thus be considered an effective device for analgesia and pain relief for midline incisions in laparoscopic colorectal surgery.

Comparison of postoperative analgesic effects of posterior quadratus lumborum block and intrathecal morphine in laparoscopic donor hepatectomy: a prospective randomized non-inferiority clinical trial

Background

Posterior quadratus lumborum block (QLB) and intrathecal morphine are accepted analgesic strategies in laparoscopic liver resection, but their effects have not been compared after laparoscopic donor hepatectomy. This study was planned to perform this comparison.

Methods

Fifty-six donors were randomized to receive bilateral posterior (QLB2, 20 mL of 0.375% ropivacaine on each side, 150 mg total) or preoperative injection of 0.4 mg morphine sulfate intrathecally. Primary outcome was resting pain score at 24 hour postsurgery. Secondary outcomes included cumulative opioid consumption and recovery parameters. Serial plasma ropivacaine concentrations were measured in QLB group. Only the outcome assessor was properly blinded.

Results

Mean resting pain score at 24-hour postsurgery was 4.19±1.66 in QLB group (n=27) and 3.07±1.41 in intrathecal morphine group (n=27, p=0.04). Mean difference (QLB group-intrathecal morphine group) was 1.11 (95% CI 0.27 to 1.95), and the upper limit of CI was higher than prespecified non-inferiority margin (δ=1), indicating an inferior effect of QLB. Cumulative opioid consumption was significantly higher in QLB group at 24 hours and 48 hours postsurgery. QLB group exhibited lower incidence of postoperative pruritus at all time points, and there were no differences in other recovery outcomes. All measured ropivacaine concentrations were below the threshold for systemic toxicity (4.3 µg/mL).

Conclusions

Bilateral posterior QLB elicited higher resting pain scores at 24-hour after laparoscopic donor hepatectomy than intrathecal morphine and did not meet the definition of non-inferiority.

Trial registration number

KCT0005360.

Perioperative management of living donor liver transplantation: Part 2 - Donors

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation method has become a widely practiced and established transplantation option for adult patients suffering with end-stage liver disease, and it has successfully helped address the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplantation Anesthesiologists jointly reviewed published studies on the perioperative management of adult live liver donors undergoing donor hemi-hepatectomy. The goal of the review is to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live donors. We featured the current status, donor selection process, outcomes and complications, surgical procedure, anesthetic management, Enhanced Recovery After Surgery protocols, avoidance of blood transfusion, and considerations for emergency donation. Recent surgical advances, including laparoscopic donor hemi-hepatectomy and robotic laparoscopic donor surgery, are also addressed.

Comparison of Analgesic Efficacy of Erector Spinae Plane Block and Posterior Quadratus Lumborum Block in Laparoscopic Liver Resection: A Randomized Controlled Trial

Purpose

Ultrasound-guided fascial plane blocks, including the erector spinae plane (ESP) and quadratus lumborum (QL) blocks, provide effective postoperative abdominal analgesia. However, there is limited evidence on the analgesic efficacy of ESP and QL blocks after liver surgery. Therefore, we aimed to compare the cumulative opioid consumption between the ESP and QL blocks in patients with hepatocellular carcinoma undergoing laparoscopic liver resection.

Patients and Methods

Eighty-eight patients scheduled to undergo laparoscopic liver resection were randomized to receive bilateral single injection of ESP block at T8 (ESP group) or bilateral single injection of posterior QL block (QL group; 20 mL of 0.375% ropivacaine for each side, ie, total 150 mg of ropivacaine), in addition to intravenous (IV) fentanyl patient-controlled analgesia and multimodal analgesia. The primary outcome was cumulative opioid consumption over the first 24 h, expressed as IV morphine equivalents. Secondary outcomes included serial plasma ropivacaine concentrations, pain scores, time to first flatus, and Quality of Recovery-15 scores.

Results

Eighty-five patients were analyzed (ESP group, n = 42; QL group, n = 43). Cumulative 24-h opioid consumption was similar between the ESP and QL groups (41.4 ± 22.6 mg vs 44.2 ± 20.0 mg, mean difference (QL-ESP), 2.8 mg, 95% confidence interval, −6.4 to 12 mg, p > 0.99). There were no significant differences in resting pain scores at 24, 48 and 72 h postoperatively or recovery outcomes. The peak plasma ropivacaine concentration 30 min after injection was significantly higher in the ESP group (1.5 ± 0.3 µg/mL) than in the QL group (1.3 ± 0.5 µg/mL, p = 0.035); however, both were lower than the arterial threshold value of systemic toxicity (4.3 µg/mL).

Conclusion

ESP and QL blocks provided similar postoperative analgesia in patients undergoing laparoscopic liver resection.

Randomized trial of poloxamer 407-based ropivacaine hydrogel after thoracoscopic pulmonary resection

BACKGROUND

We conducted a comparative study to evaluate the efficacy of poloxamer 407-based ropivacaine hydrogel at the wound site (Gel) and continuous thoracic paravertebral block (On-Q) for postoperative pain following thoracoscopic pulmonary resection.

METHODS

This prospective, randomized, noninferiority study included 89 patients randomized into the two groups; Gel (poloxamer 407-based 0.75% ropivacaine, 22.5 mg) and On-Q (0.2% ropivacaine, 4 mg/hour for 48 hours). The primary outcome measure was total fentanyl consumption and secondary outcome measures were the need for rescue analgesia and pain intensity using the numeric rating scale (NRS).

RESULTS

There was no significant difference in total fentanyl consumption between the Gel group and the On-Q group (1504.29 ± 315.72 mcg vs 1560.32 ± 274.81 mcg, p = 0.374). Pain intensity using the NRS between the Gel group and the On-Q group demonstrated no statistical differences (6 hours: 3.56 vs 3.55, p = 0.958; 24 hours: 3.21 vs 3.00, p = 0.250; 48 hours: 2.75 vs 2.49, p = 0.233; and 72 hours: 2.39 vs 2.33, p = 0.811), and there was no significant difference in the frequency of analgesic rescue medication use (3.70 vs 3.33, p = 0.417).

CONCLUSIONS

We confirm the noninferiority of Gel compared with On-Q for acute postoperative pain following thoracoscopic pulmonary resection. Considering a technical simplicity and low systemic toxicity of the local injection of Gel, this analgesic modality may be worthy of further research and is thus considered to have potential as a viable alternative to On-Q for regional analgesia.

Bilateral continuous erector spinae plane block using a programmed intermittent bolus regimen versus intrathecal morphine for postoperative analgesia in living donor laparoscopic hepatectomy: A randomized controlled trial

STUDY OBJECTIVE

To determine if continuous bilateral erector spinae plane (ESP) blocks would improve the postoperative analgesia in the first 48 h after laparoscopic donor hepatectomy, compared to intrathecal morphine (ITM).

DESIGN

Prospective, randomized controlled trial.

SETTING

A single tertiary care center from October 2019 and September 2020.

PATIENTS

A total of 60 donors scheduled to undergo elective laparoscopic right hepatectomy.

INTERVENTIONS

Sixty donors were randomized to receive either bilateral continuous T8 ESP blocks with a programmed intermittent bolus regimen of 10 mL 0.2% ropivacaine every 3 h for 48 h (n = 30) or 400 μg ITM (n = 30), in addition to IV fentanyl PCA and multimodal analgesia.

MEASUREMENTS

The primary outcome was cumulative opioid consumption over the first 48 h, expressed as IV morphine equivalents. Secondary outcomes included pain scores, Quality of Recovery-15 scores, ambulation within 24 h, time to first flatus, and opioid-related adverse drug events over 72 h.

MAIN RESULTS

Fifty-nine donors were analyzed. Cumulative 48-h opioid consumption was similar between the ITM and ESP groups (29.8 ± 18.2 vs. 35.1 ± 21.9 mg, mean difference (ESP-ITM) (95% CI), 5.3 (-11.5 to 22) mg; p > 0.99). Resting pain scores at 48 and 72 h postoperatively were significantly lower in the ESP group (0 [0-2] vs. 3 [1.5-3], and 0 [0-2] vs. 3 [1-3] respectively, both p<0.001) (Goldaracena and Barbas, 2019; Ko et al., 2009; Choi et al., 2007 [1-3]) respectively, both p < 0.001). The ESP group had significantly lower incidences of postoperative nausea, vomiting, and pruritus at all timepoints. There were no differences in recovery outcomes.

CONCLUSIONS

Continuous ESP blocks did not reduce cumulative 48-h opioid consumption compared to 400 μg ITM after laparoscopic donor hepatectomy, but it was associated with a significantly reduced risk of postoperative nausea, vomiting and pruritus.

CLINICAL TRIAL NUMBER AND REGISTRY URL

Clinical Trial Registry of Korea; https://cris.nih.go.kr/cris/index.jsp and identifier: KCT0004313; date of registration: October 15, 2019; principal investigator's name: Justin Sangwook Ko.

Ropivacaine continuous wound infusion after mastectomy with immediate autologous breast reconstruction: A retrospective observational study

Continuous wound infusion usually provides postoperative analgesia as a multimodal analgesia with systemic opioid use. When continuous wound infusion of local anesthetics (LA) supports successful postoperative analgesia without systemic opioid use, the side effects of opioid can be reduced. Nevertheless, continuous wound infusion after mastectomy with immediate autologous breast reconstruction leads to concerns about wound healing. This study evaluated analgesic effects and wound healing conditions of continuous wound infusion of LA compared with opioid-based, intravenous patient-controlled analgesia (IV PCA) in mastectomy with immediate autologous breast reconstruction.This retrospective observational study included females, aged between 33 and 67 years, who underwent mastectomy with immediate autologous breast reconstruction. Sixty-five patients were enrolled. The eligible patients were placed into 2 groups for managing postoperative pain, one used continuous wound infusion with 0.5% ropivacaine (ON-Q, n = 32) and the other used a fentanyl-based IV PCA (IV PCA, n = 33). Using the electronic medical record system, the postoperative recovery profiles were examined over 5 days using a visual analogue scale (VAS), incidence of postoperative nausea and vomiting (PONV), incidence of sleep disturbance, frequency of rescue analgesic use, analgesia-related adverse events, length of hospital stay, and degree of patient satisfaction. The condition of the surgical wound was observed for 1 year after surgery.The primary endpoint was the intensity of pain at 6 hours after surgery. The VAS was comparable between the groups (P > .05). Although recovery profiles and the degree of patient satisfaction were similar between the groups, the incidence of PONV was significantly lower in the ON-Q group than in the IV PCA group on the day of surgery and postoperative day 1. No patients had severe wound complications. The satisfaction score of analgesia in the ON-Q group was comparable with that of the patients in the IV PCA group.This study demonstrates that single use of continuous wound infusion showed comparable analgesia with fentanyl-based IV PCA in patients who underwent mastectomy with immediate autologous breast reconstruction. Furthermore, the continuous infusion of LA directly on the surgical site did not significantly affect wound healing.

Analgesic efficacy of intrathecal morphine and bupivacaine during the early postoperative period in patients who underwent robotic-assisted laparoscopic prostatectomy: a prospective randomized controlled study

Background

The present study was performed to investigate the analgesic efficacy of intrathecal morphine and bupivacaine (ITMB) in terms of treating early postoperative pain in adult patients who underwent robotic-assisted laparoscopic prostatectomy (RALP).

Methods

Fifty patients were prospectively enrolled and randomly classified into the non-ITMB (n = 25) and ITMB (n = 25) groups. The ITMB therapeutic regimen consisted of 0.2 mg morphine and 7.5 mg bupivacaine (total 1.7 mL). All patients were routinely administered the intravenous patient-controlled analgesia and appropriately treated with rescue intravenous (IV) opioid drugs, based on the discretion of the attending physicians who were blinded to the group assignments. Cumulative IV opioid consumption and the numeric rating scale (NRS) score were assessed at 1, 6, and 24 h postoperatively, and opioid-related complications were measured during the day after surgery.

Results

Demographic findings were comparable between patients who did and did not receive ITMB. The intraoperative dose of remifentanil was lower in the ITMB group than in the non-ITMB group. Pain scores (i.e., NRS) at rest and during coughing as well as cumulative IV opioid consumption were significantly lower in patients who received ITMB than in those who did not in the post-anesthesia care unit (PACU; i.e., at 1 h after surgery) and the ward (i.e., at 6 and 24 h after surgery). ITMB was significantly associated with postoperative NRS scores of ≤ 3 at rest and during coughing in the PACU (i.e., at 1 h after surgery) before and after adjusting for cumulative IV opioid consumption. In the ward (i.e., at 6 and 24 h after surgery), ITMB was associated with postoperative NRS scores of ≤ 3 at rest and during coughing before adjusting for cumulative IV opioid consumption but not after. No significant differences in complications were observed, such as post-dural puncture headache, respiratory depression, nausea, vomiting, pruritus, or neurologic sequelae, during or after surgery.

Conclusion

A single spinal injection of morphine and bupivacaine provided proper early postoperative analgesia and decreased additional requirements for IV opioids in patients who underwent RALP.

Trial registration: Clinical Research Information Service, Republic of Korea; approval number: KCT0004350 on October 17, 2019. https://cris.nih.go.kr/cris/en/search/search_result_st01.jsp?seq=15637

Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations

Background and objectives

Effective pain control improves postoperative rehabilitation and enhances recovery. The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after open liver resection using Procedure-Specific Postoperative Pain Management (PROSPECT) methodology.

Strategy and selection criteria

Randomized controlled trials (RCTs) published in the English language from January 2010 to October 2019 assessing pain after liver resection using analgesic, anesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane databases.

Results

Of 121 eligible studies identified, 31 RCTs and 3 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain relief were non-steroidal anti-inflammatory drugs, continuous thoracic epidural analgesia, and subcostal transversus abdominis plane (TAP) blocks. Limited procedure-specific evidence was found for intravenous dexmedetomidine, intravenous magnesium, intrathecal morphine, quadratus lumborum blocks, paravertebral nerve blocks, continuous local anesthetic wound infiltration and postoperative interpleural local anesthesia. No evidence was found for intravenous lidocaine, ketamine, dexamethasone and gabapentinoids.

Conclusions

Based on the results of this review, we suggest an analgesic strategy for open liver resection, including acetaminophen and non-steroidal anti-inflammatory drugs, combined with thoracic epidural analgesia or bilateral oblique subcostal TAP blocks. Systemic opioids should be considered as rescue analgesics. Further high-quality RCTs are needed to confirm and clarify the efficacy of the recommended analgesic regimen in the context of an enhanced recovery program.

Comparison of the effects of intravenous propofol and inhalational desflurane on the quality of early recovery after hand-assisted laparoscopic donor nephrectomy: a prospective, randomised controlled trial

OBJECTIVES

We compared early recovery outcomes between living kidney donors who received total intravenous (IV) propofol versus inhalational desflurane during hand-assisted laparoscopic nephrectomy.

DESIGN

A single-centre, prospective randomised controlled trial.

SETTING

University hospital.

PARTICIPANTS

Study participants were enrolled between October 2019 and February 2020. A total of 80 living donors were randomly assigned to an intravenous propofol group (n=40) or a desflurane group (n=40).

INTERVENTION

Propofol group received intravenous propofol and desflurane group received desflurane, as a maintenance anaesthetic.

PRIMARY AND SECONDARY OUTCOME MEASURES

The quality of postoperative functional recovery was primarily assessed using the Korean version of the Quality of Recovery-40 (QoR-40K) questionnaire on postoperative day 1. Secondarily, ambulation, pain score, rescue analgesics, complications and total hospital stay were assessed postoperatively.

RESULTS

Our study population included 35 males and 45 females. The mean age was 46±13 years. The global QoR-40K score (161 (154-173) vs 152 (136-161) points, respectively, p=0.001) and all five subdimension scores (physical comfort, 49 (45-53) vs 45 (42-48) points, respectively, p=0.003; emotional state, 39 (37-41) vs 37 (33-41) points, respectively, p=0.005; psychological support, 30 (26-34) vs 28 (26-32) points, respectively, p=0.04; physical independence, 16 (11-18) vs 12 (8-14) points, respectively, p=0.004; and pain, 31 (28-33) vs 29 (25-31) points, respectively, p=0.021) were significantly higher in the intravenous propofol group than the desflurane group. The early ambulation success rate and numbers of early and total steps were higher, but the incidence of nausea/vomiting was lower, in the intravenous propofol group than the desflurane group. The total hospital stay after surgery was shorter in the intravenous propofol group than the desflurane group.

CONCLUSIONS

Intravenous propofol may enhance the quality of postoperative recovery in comparison to desflurane in living kidney donors.

TRIAL REGISTRATION NUMBER

KCT0004365.

Surgeon-Placed Continuous Wound Infusion Pain Catheters Markedly Decrease Narcotic Use and Improve Outcomes After Pancreatic Tumor Resection

BACKGROUND

Pancreatectomy results in significant postoperative pain and typically requires opioid analgesia for adequate pain control. Local anesthetics may decrease postoperative pain and opioid requirements but can be limited by onset of action, duration of effect, and inability to titrate dosing after administration. This can be overcome by surgeon placement of tunneled peri-incisional catheters with continuous wound infusion (CWI).

METHODS

This retrospective cohort study analyzed patients undergoing open pancreatic tumor resection. All the patients received patient-controlled analgesia (PCA), enabling an objective comparison of opioid requirements, and underwent the same recovery pathway. The patients received CWI (n = 45), PCA alone (n = 11), or epidural analgesia (EA) (n = 9). The primary outcome was total opioid use in terms of intravenous morphine milligram equivalents (MMEs) and patient-reported pain scores on a numeric rating scale (NRS) of 0 to 10.

RESULTS

No differences in baseline patient or tumor characteristics were observed. In both the uni- and multivariate analyses, CWI was associated with lower opioid use than PCA (MME, 83 vs 207 mg; p = 0.004) or EA (MME, 83 vs 156 mg; p < 0.001) without having a negative impact on pain scores. Furthermore, CWI was associated with a greater percentage of time that patients experienced optimal pain control (NRS, ≤ 4: 63% vs 50%; p = 0.033) and a shorter time to PCA independence (4.0 vs 4.9 days; p = 0.004) than PCA alone. In addition, CWI was associated with earlier ambulation [EA vs CWI: odds ratio (OR), 0.05; p = 0.021], improved spirometry performance (CWI vs PCA: regression coefficient (coef), 267; p = 0.013), and earlier urinary catheter removal (EA vs CWI: coef, 1.30; p = 0.013). The findings showed no differences in time to return of bowel function, antiemetic use, or hospital length of stay.

CONCLUSIONS

After open pancreatic tumor resection, CWI is safe and associated with decreased opioid requirements and improved functional outcomes without a negative impact on pain scores, supporting its potential for preferred use over PCA or EA alone.

Intrathecal morphine is associated with reduction in postoperative opioid requirements and improvement in postoperative analgesia in patients undergoing open liver resection

Background

Our study aimed to test the hypothesis that the addition of intrathecal morphine (ITM) results in reduced postoperative opioid use and enhanced postoperative analgesia in patients undergoing open liver resection using a standardized enhanced recovery after surgery (ERAS) protocol with multimodal analgesia.

Methods

A retrospective analysis of 216 adult patients undergoing open liver resection between June 2010 and July 2017 at a university teaching hospital was conducted. The primary outcome was the cumulative oral morphine equivalent daily dose (oMEDD) on postoperative day (POD) 1. Secondary outcomes included postoperative pain scores, opioid related complications, and length of hospital stay. We also performed a cost analysis evaluating the economic benefits of ITM.

Results

One hundred twenty-five patients received ITM (ITM group) and 91 patients received usual care (UC group). Patient characteristics were similar between the groups. The primary outcome - cumulative oMEDD on POD1 - was significantly reduced in the ITM group. Postoperative pain scores up to 24 h post-surgery were significantly reduced in the ITM group. There was no statistically significant difference in complications or hospital stay between the two study groups. Total hospital costs were significantly higher in the ITM group.

Conclusion

In patients undergoing open liver resection, ITM in addition to conventional multimodal analgesic strategies reduced postoperative opioid requirements and improved analgesia for 24 h after surgery, without any statistically significant differences in opioid-related complications, and length of hospital stay. Hospital costs were significantly higher in patients receiving ITM, reflective of a longer mandatory stay in intensive care.

Trial registration

Registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) under ACTRN12620000001998.

Delayed remnant kidney function recovery is less observed in living donors who receive an analgesic, intrathecal morphine block in laparoscopic nephrectomy for kidney transplantation: a propensity score-matched analysis

BACKGROUND

This study analyzed remnant kidney function recovery in living donors after laparoscopic nephrectomy to establish a risk stratification model for delayed recovery and further investigated clinically modifiable factors.

PATIENTS AND METHODS

This retrospective study included 366 adult living donors who underwent elective donation surgery between January 2017 and November 2019 at our hospital. ITMB was included as an analgesic component in the living donor strategy for early postoperative pain relief from November 2018 to November 2019 (n = 116). Kidney function was quantified based on the estimated glomerular filtration rate (eGFR), and delayed functional recovery of remnant kidney was defined as eGFR < 60 mL/min/1.73 m² on postoperative day (POD) 1 (n = 240).

RESULTS

Multivariable analyses revealed that lower risk for development of eGFR < 60 mL/min/1.73 m² on POD 1 was associated with ITMB, female sex, younger age, and higher amount of hourly fluid infusion (area under the receiver operating characteristic curve = 0.783; 95% confidence interval = 0.734-0.832; p < 0.001). Propensity score (PS)-matching analyses showed that prevalence rates of eGFR < 60 mL/min/1.73 m² on PODs 1 and 7 were higher in the non-ITMB group than in the ITMB group. ITMB adjusted for PS was significantly associated with lower risk for development of eGFR < 60 mL/min/1.73 m² on POD 1 in PS-matched living donors. No living donors exhibited severe remnant kidney dysfunction and/or required renal replacement therapy at POD 7.

CONCLUSIONS

We found an association between the analgesic impact of ITMB and better functional recovery of remnant kidney in living kidney donors. In addition, we propose a stratification model that predicts delayed functional recovery of remnant kidney in living donors: male sex, older age, non-ITMB, and lower hourly fluid infusion rate.

A Comparison of Intrathecal and Intravenous Morphine for Analgesia After Hepatectomy: A Randomized Controlled Trial

BACKGROUND

Effective analgesia is essential for patient recovery after liver resection. This study aimed to evaluate the effects of the addition of preoperative intrathecal morphine to multimodal intravenous analgesia in patients undergoing liver resection.

METHODS

In this single-blind randomized controlled trial, patients undergoing liver resection were randomly assigned to the patient-controlled analgesia with (ITM-IV) or without (IV) preoperative intrathecal morphine groups. All patients received acetaminophen and dexketoprofen. The primary outcome was pain severity at rest over three postoperative days, assessed using the numerical rating scale (NRS).

RESULTS

The study included 36 patients (18 in each group). The mean maximum daily NRS scores over the first three postoperative days in the ITM-IV and IV groups were 1.3, 1.1, and 0.3 and 1.6, 1.1, and 0.7, respectively (p = 0.580). No differences were observed in pain severity while coughing, with corresponding scores of 2.8, 2.1, and 1.1, respectively, in the ITM-IV group and 2.3, 2.2, and 1.5, respectively, in the IV group (p = 0.963). Proportions of patients reporting clinically significant pain at rest and while coughing were 11.1% and 44.4%, respectively, in the ITM-IV group, and 16.7% and 44.4%, respectively, in the IV group (both p > 0.999). Cumulative morphine doses in the ITM-IV and IV groups were 26 mg and 17 mg, respectively (p = 0.257). Both groups also showed similar time to mobilization (p = 0.791) and solid food intake (p = 0.743), sedation grade (p = 0.584), and morbidity (p = 0.402).

CONCLUSIONS

Preoperative intrathecal morphine administration provides no benefits to multimodal analgesia in patients undergoing liver resection.

TRIAL REGISTRATION NUMBER

Clinicaltrial.gov Identifier: NCT03620916.

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.

Bilateral single-injection erector spinae plane block versus intrathecal morphine for postoperative analgesia in living donor laparoscopic hepatectomy: a randomized non-inferiority trial

BACKGROUND

Intrathecal morphine (ITM) provides effective postoperative analgesia in living donor hepatectomy but has significant adverse effects. Studies support the efficacy of erector spinae plane (ESP) blocks in laparoscopic abdominal surgery; we therefore hypothesized that they would provide non-inferior postoperative analgesia compared with ITM and reduce postoperative nausea/vomiting and pruritus. We conducted a randomized, controlled, non-inferiority trial to compare the analgesic efficacy of ITM and bilateral single-injection ESP blocks in laparoscopic donor hepatectomy.

METHODS

Fifty-four donors were randomized to receive bilateral ESP blocks with 20 mL 0.5% ropivacaine (n=27) or 400 µg ITM (n=27). Primary outcome was resting pain score 24 hours postoperatively measured on an 11-point numeric rating scale. The prespecified non-inferiority limit was 1. Incidences of postoperative nausea/vomiting and pruritus were assessed.

RESULTS

The mean treatment difference (ESP-ITM) in the primary outcome was 1.2 (95% CI 0.7 to 1.8). The 95% CI upper limit exceeded the non-inferiority limit. Opioid consumption and all other pain measurements were similar between groups up to 72 hours postoperatively. The ESP group had significantly lower incidences of postoperative vomiting (p=0.002) and pruritus (p<0.001).

CONCLUSIONS

Bilateral single-injection ESP blocks resulted in higher resting pain scores 24 hours postoperatively compared with ITM and thus did not meet the study definition of non-inferiority. However, the pain intensity with ESP blocks was mild (mean pain scores <3/10) and associated with reduced incidence of postoperative vomiting and pruritus. It warrants further investigation as an analgesic option after laparoscopic living donor hepatectomy.

TRIAL REGISTRATION NUMBER

KCT0003191.

Wound analgesia in a patient with hemophilia in a highly traumatic operation

AIM

The aim of the study was to describe the use of the wound analgesia method in a patient with hemophilia in the case of a clinical case.

MATERIALS AND METHODS

A patient with severe hemophilia A underwent postoperative analgesia after total knee replacement (within the first 48 hours) with an extended infusion of local anesthetic (ropivacaine) into the wound.

RESULTS

During the first 8 hours, the patient received 20 mg of morphine (with the aid of a device for patient-controlled analgesia), the pain level ranged from 7 to 4 points. Further, there was a sufficient effect (NRS - 2 points), from anesthesia only with ropivacaine, using a system for anesthetizing surgical wounds. Complications and side effects were not noted.

CONCLUSION

The clinical case demonstrates an effective and safe method of prolonged analgesia in patients with hemophilia. Considering encouraging data, further study of wound analgesia in this category of patients is necessary.

Most effective pain-control procedure for open liver surgery: a network meta-analysis

BACKGROUND

To determine the most effective pain-control procedure for open liver surgery through a network meta-analysis and provide a best developing direction in this field.

METHODS

PubMed, Embase and Cochrane Library database were searched for randomized controlled trials up to 1 July 2016. We extracted data on post-operative pain score at the 4th-8th hour and 24th hour from studies that compared various pain-control strategies. Network meta-analysis was conducted in Aggregate Data Drug Information System software by evaluating the parametric pain score at rest and on movement. Cumulative probability value was utilized to rank the procedures under examination. The inconsistency would also be tested by node-splitting models.

RESULTS

Twelve articles containing 661 patients were included. Intrathecal analgesia plus intravenous analgesia played the most effective role in pain controlling at post-operative 4-8 h (both at rest and on movement, P = 0.49 and P = 0.62, respectively) and at post-operative 24 h (both at rest and on movement, P = 0.46 and P = 0.29, respectively). Node-splitting models test revealed that no significant inconsistency existed in this research.

CONCLUSIONS

Intrathecal analgesia plus intravenous analgesia revealed the most effective clinical pain-control value for open liver surgery. More importantly, we believed that creating a better comprehensive and systematic combined pain-control procedure should be considered as the developing direction in this field.

Comparison of intrathecal morphine and surgical-site infusion of ropivacaine as adjuncts to intravenous patient-controlled analgesia in living-donor kidney transplant recipients

INTRODUCTION

This prospective observational study compared the postoperative analgesic effectiveness of intrathecal morphine (ITM) and surgical-site infusion (SSI) of ropivacaine as adjuncts to intravenous (IV) patient-controlled analgesia (PCA) (fentanyl) in living-donor kidney transplant recipients.

METHODS

Patients undergoing living-donor kidney transplantation who received ITM or SSI in addition to IV PCA were included. Rescue analgesia was achieved with IV meperidine as required. The primary outcome, measured using the Numeric Pain Rating Scale (NRS), was pain at rest and when coughing. Patients were assessed for 48 hours after surgery.

RESULTS

A total of 53 patients (32 ITM, 21 SSI) were included in the study. The ITM group showed significantly lower NRS scores, at rest and when coughing, for up to 12 and eight hours. NRS scores were comparable between the groups at other times. The ITM group had significantly less postoperative systemic opioid requirement in the first 24 hours, but there was no significant difference between the systemic opioid consumption of the groups on postoperative Day 2. In the ITM group, 3 (9.4%) patients presented with bradypnoea and 1 (3.1%) with excessive sedation in the first 12 postoperative hours. More patients in the ITM group developed pruritus requiring treatment during the first 24 hours. There were no differences between the groups in other outcomes (e.g. nausea/vomiting, change in pulmonary or kidney functions).

CONCLUSION

Compared with SSI, ITM reduced immediate postoperative pain and IV opioid consumption on postoperative Day 1 after living-donor kidney transplantation, but at the cost of increased pruritus and respiratory depression.

The improved quality of postoperative analgesia after intrathecal morphine does not result in improved recovery and quality of life in the first 6 months after orthopedic surgery: a randomized controlled pilot study

Objective

In orthopedic surgery, it is well known that the use of intrathecal morphine (ITM) leads to an improved quality of postoperative analgesia. Little is known how this improved analgesia affects the long-term course after surgery.

Study design

A randomized, double-blind trial.

Setting

Academic medical center.

Subjects

Forty-nine patients undergoing total hip or knee replacement surgery in spinal anesthesia.

Methods

Patients were randomly assigned to receive either 0.1 mg (n=16) or 0.2 mg (n=16) morphine sulfate intrathecally or physiological saline (n=17) added to 3 mL 0.5% isobaric bupivacaine for spinal anesthesia. As a function of the quality of the short-term postoperative analgesia, the effect on recovery and quality of life was evaluated at various time points up to 26 weeks after surgery.

Results

In both ITM groups, the additionally required postoperative systemic morphine dose was significantly reduced compared with the placebo group (P=0.004). One week after operation, patients with ITM reported significantly less pain at rest (P=0.01) compared to the placebo group. At discharge, in comparison with the 0.1 mg ITM and placebo group, the 0.2 mg ITM group showed a higher degree of impairment regarding pain, stiffness, and physical function of the respective joint (P=0.02). Over the further follow-up period of 6 months after surgery, recovery and the quality of life did not differ significantly between the three study groups (P>0.2).

Conclusion

Morphine (0.1 mg) as adjunct to 0.5% bupivacaine for spinal anesthesia is effective to produce a pronounced postoperative analgesia with a beneficial analgesic effect up to 1 week after surgery. With this study design, the different quality of postoperative analgesia had no effect on quality of life and recovery in patients over the 6-month follow-up period. In the medium term, ITM may induce hyperalgesic effects.

Epidural Versus Paravertebral Nerve Block for Postoperative Analgesia in Patients Undergoing Open Liver Resection: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVES

Although many studies have found no difference between thoracic epidural block and unilateral thoracic paravertebral block after thoracotomy, no previous studies have compared epidural block with bilateral thoracic paravertebral block (bTPVB) in patients undergoing open liver resection. We aimed to investigate whether there was a significant analgesic advantage of thoracic epidural over bTPVB after liver resection.

METHODS

This randomized, prospective, open-label study included adult patients undergoing elective open liver resection. Patients were randomized to receive either thoracic epidural block or bTPVB, through which ropivacaine (0.2%) was infused for 3 days. The primary outcome was pain Verbal Rating Scale (VRS) score (0-10) at rest and with postoperative incentive spirometry. Secondary outcomes included VRS at rest, inspired volumes during incentive spirometry, patient-controlled analgesia hydromorphone utilization, measures of hemodynamic stability, and postoperative bowel function.

RESULTS

Eighty patients completed the study and received thoracic epidural block (n = 41) or bTPVBs (n = 39). No catheter-related complications were noted. The primary outcome, pain (VRS) with incentive spirometry, was significantly lower in the epidural group (epidural vs bTPVB, mean [SD]) (4.5 [2.7] vs 5.4 [2.7] at 24 hours postoperatively, and 3.2 [2.1] vs 4.6 [2.4] at 48 hours postoperatively). Maximal inspired volumes at 24 hours postoperatively (917 [379] vs 1042 [468] mL) and cumulative utilization of patient-controlled analgesia hydromorphone during the first 48 hours postoperatively (10.7 [7.9] vs 13.6 [8.5] mg) were not significantly different between groups. Decrease in mean arterial pressure from baseline at 24 hours postoperatively was greater for the epidural group (-12.6 [15.8] vs -3.8 [16.2]; P = 0.016).

CONCLUSIONS

This study suggests that there is a modest analgesic advantage of thoracic epidural over bTPVBs for patients after open liver resection.

Endogenous opiates and behavior: 2014

This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 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 (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants). This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 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 (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants).

The efficacy of continuous subcostal transversus abdominis plane block for analgesia after living liver donation: a retrospective study

PURPOSE

Postoperative pain management for living liver donors has become a major concern as a result of the increasing number of living liver donations. Transversus abdominis plane (TAP) block has been known to provide effective analgesia for abdominal surgery. The aim of this study was to evaluate the efficacy of ultrasound-guided continuous subcostal TAP block as a part of a multimodal analgesic regimen in comparison with conventional intravenous (IV) fentanyl-based analgesia in living liver donors.

METHODS

Thirty-two donors were retrospectively classified into either the continuous subcostal TAP block group (TAP group) or the IV fentanyl-based analgesia group (control group). TAP group donors received bilateral continuous subcostal TAP infusion of 0.125 % levobupivacaine at 6 ml/h. Control group donors did not receive any neural blockade.

RESULTS

Cumulative fentanyl consumption was significantly lower in the TAP group for 48 h (P < 0.01) as compared to the control group. Further, the donors in the TAP group had significantly lower incidence of nausea and vomiting during 24-48 h postoperatively (P < 0.01) and fewer delays in the initiation of oral intake than those in the control group (P = 0.02).

CONCLUSIONS

In conclusion, continuous subcostal TAP block provided an effective opioid-sparing analgesia for living liver donors.

Analgesia after liver transplantation

This article addresses postoperative analgesia in patients with end-stage liver disease who have undergone liver transplantation (LT). Postoperative analgesia determines how patients perceive LT. Although important, this topic is underrepresented in the current literature. With an increased frequency of fast tracking in LT, efficient intra- and postoperative analgesia are undergoing changes. We herein review the current literature, compare the benefits and disadvantages of the therapeutic options, and make recommendations based on the current literature and clinical experience.

Comparison of pain relief between patient-controlled epidural analgesia and patient-controlled intravenous analgesia for patients undergoing spinal fusion surgeries

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.

Multidisciplinary rehabilitation can impact on health-related quality of life outcome in radical cystectomy: secondary reported outcome of a randomized controlled trial

Purpose

Health related quality of life (HRQoL) is an important outcome in cancer care, although it is not well reported in surgical uro-oncology. Radical cystectomy (RC) with lymph-node dissection is the standard treatment of muscle-invasive bladder cancer and high-risk noninvasive bladder cancer. A wide range of impairments are reported postsurgery. The aims were to evaluate whether a standardized pre- and postoperative physical exercise program and enhanced mobilization can impact on HRQoL and inpatient satisfaction in RC, as defined by the European Organisation for Research and Treatment of Cancer (EORTC).

Materials and methods

Patients were randomized to fast-track RC and intervention (n_I=50) or fast-track standard treatment (n_S=57). HRQoL and inpatient satisfaction was measured using valid questionnaires: EORTC Quality of Life Questionnaire Core 30 (QLQ-C30) combined with the disease-specific EORTC BLS24 (baseline), and EORTC BLM30 (follow-up), and IN-PATSAT32 inpatient-satisfaction survey at discharge. Efficacy was defined as the differences in HRQoL-scores between treatment groups at the 4-month follow-up.

Results

The intervention group significantly improved HRQoL scores in dyspnea (P≤0.05), constipation (P<0.02), and abdominal flatulence (P≤0.05) compared to the standard group. In contrast, the standard group reported significantly reduced symptoms in sleeping pattern (P≤0.04) and clinically relevant differences in role function, body function, and fatigue. The intervention did not compromise inpatient satisfaction.

Conclusion

We found no overall impact on global HRQoL due to a physical rehabilitation program. However, pre- and postoperative physical rehabilitation can significantly and positively impact on HRQoL aspects related to bowel management and respiratory function (dyspnea) without compromising inpatient satisfaction. These results highlight the role of multimodal rehabilitation, including physical exercises in fast-track RC.