1
|
Ju H, Shen K, Li J, Feng Y. Total postoperative opioid dose is an independent risk factor for prolonged postoperative ileus after laparoscopic colorectal surgery: a case-control study. Korean J Anesthesiol 2024; 77:133-138. [PMID: 37096402 PMCID: PMC10834719 DOI: 10.4097/kja.22792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/20/2023] [Accepted: 04/24/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Prolonged postoperative ileus (PPOI) is a major complication of colorectal surgery. Increased opioid consumption has been proposed to increase the risk of PPOI. This study aimed to test the hypothesis that an increased total postoperative opioid dose (TPOD) is associated with the increased incidence of PPOI. METHODS For this matched case-control study, patients who underwent elective laparoscopic colorectal procedures at the Peking University People's Hospital between January 2018 and June 2020 were retrospectively reviewed. Patients with PPOI were assigned to the ileus group, while patients without PPOI (control group) were matched at a 1:1 ratio to the ileus group according to age, American Society of Anesthesiologists physical status score, and type of surgical procedure. The primary outcome was the TPOD between the ileus and control groups. The secondary outcome was risk factors of PPOI. RESULTS A total of 267 participants were included in the final analysis. No differences in baseline or operative factors were found between the two groups. The TPOD, intravenous sufentanil dose on postoperative day 1 (POD1), and the use of patient-controlled analgesia with basal infusion were associated with PPOI (P < 0.05). Multivariate logistic regression analysis revealed that an increased TPOD was an independent risk factor for developing PPOI after laparoscopic colorectal procedures (Odd ratio: 1.67, 95% CI [1.03, 2.71], P = 0.04). CONCLUSIONS The TPOD is an independent risk factor for PPOI after laparoscopic colorectal surgery. We need to explore new strategies of postoperative analgesia to reduce the dosage of TPOD.
Collapse
Affiliation(s)
- Hui Ju
- Department of Anesthesiology, Peking University People’s Hospital, Beijing, China
| | - Kai Shen
- Department of Gastroenterologic Surgery, Peking University People’s Hospital, Beijing, China
| | - Jiaxin Li
- Department of Anesthesiology, Peking University People’s Hospital, Beijing, China
| | - Yi Feng
- Department of Anesthesiology, Peking University People’s Hospital, Beijing, China
| |
Collapse
|
2
|
Chevrollier GS, Klinger AL, Green HJ, Gastanaduy MM, Johnston WF, Vargas HD, Kann BR, Whitlow CB, Paruch JL. Liposomal Bupivacaine Transversus Abdominis Plane Blocks in Laparoscopic Colorectal Resections: A Single-Institution Randomized Controlled Trial. Dis Colon Rectum 2023; 66:322-330. [PMID: 35849756 DOI: 10.1097/dcr.0000000000002346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Transversus abdominis plane blocks improve postoperative pain after colon and rectal resections, but the benefits of liposomal bupivacaine use for these blocks have not been clearly demonstrated. OBJECTIVE This study aimed to determine whether using liposomal bupivacaine in transversus abdominis plane blocks improves postoperative pain and reduces opioid use after colorectal surgery compared to standard bupivacaine. DESIGN This study was a single-blinded, single-institution, prospective randomized controlled trial comparing liposomal bupivacaine to standard bupivacaine in transversus abdominis plane blocks in patients undergoing elective colon and rectal resections. SETTINGS This study was conducted at a single-institution academic medical center with 6 staff colorectal surgeons and 2 colorectal surgery fellows. PATIENTS Ninety-six patients aged 18 to 85 years were assessed for eligibility; 76 were included and randomly assigned to 2 groups of 38 patients. INTERVENTIONS Patients in the experimental group received liposomal bupivacaine transversus abdominis plane blocks, whereas the control group received standard bupivacaine blocks. MAIN OUTCOME MEASURES The primary outcome was maximum pain score on postoperative day 2. Secondary outcomes included daily maximum and average pain scores in the 3 days after surgery, as well as daily morphine milligram equivalent use and length of hospital stay. RESULTS Patients receiving liposomal bupivacaine blocks had lower maximum pain scores on the day of surgery (mean, 6.5 vs 7.7; p = 0.008). No other difference was found between groups with respect to maximum or average pain scores at any time point postoperatively, nor was there any difference in morphine milligram equivalents used or length of stay (median, 3.1 d). LIMITATIONS This was a single-institution study with only patients blinded to group assignment. CONCLUSIONS Liposomal bupivacaine use in transversus abdominis plane blocks for patients undergoing laparoscopic colorectal resections does not seem to improve postoperative pain, nor does it reduce narcotic use or decrease length of stay. Given its cost, use of liposomal bupivacaine in transversus abdominis plane blocks is not justified for colon and rectal resections. See Video Abstract at http://links.lww.com/DCR/B979 . CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov . Identifier: NCT04781075. BLOQUEOS TAP DE BUPIVACANA LIPOSOMAL EN RESECCIONES COLORRECTALES LAPAROSCPICAS UN ENSAYO CONTROLADO ALEATORIO DE UNA SOLA INSTITUCIN ANTECEDENTES:Los bloqueos del plano transverso del abdomen, mejoran el dolor posoperatorio después de las resecciones de colon y recto, pero los beneficios del uso de bupivacaína liposomal para estos bloqueos, no se han demostrado claramente.OBJETIVO:Investigar la eficacia de la inyección con tejido adiposo autólogo recién recolectado en fístulas anales criptoglandulares complejas.DISEÑO:Ensayo controlado, aleatorio, prospectivo, simple ciego, de una sola institución, que compara la bupivacaína liposomal con la bupivacaína estándar en bloqueos del plano transverso del abdomen, en pacientes sometidos a resecciones electivas de colon y recto. Identificador de ClinicalTrials.gov : NCT04781075.ENTORNO CLINICO:Centro médico académico de una sola institución con seis cirujanos de plantilla y becarios de cirugía colorrectal.PACIENTES:Se evaluó la elegibilidad de 96 pacientes de 18 a 85 años; 76 fueron incluidos y aleatorizados en dos grupos de 38 pacientes.INTERVENCIONES:Los pacientes del grupo experimental recibieron bloqueos del plano transverso del abdomen con bupivacaína liposomal, mientras que el grupo de control recibió bloqueos de bupivacaína estándar.PRINCIPALES MEDIDAS DE VALORACION:El resultado primario fue la puntuación máxima de dolor en el segundo día posoperatorio. Los resultados secundarios incluyeron las puntuaciones máximas y medias diarias de dolor en los 3 días posteriores a la cirugía, así como el uso diario equivalente en miligramos de morfina y la duración de la estancia hospitalaria.RESULTADOS:Los pacientes que recibieron bloqueos de bupivacaína liposomal, tuvieron puntuaciones máximas de dolor más bajas, el día de la cirugía (media 6,5 frente a 7,7, p = 0,008). No hubo ninguna otra diferencia entre los grupos con respecto a las puntuaciones de dolor máximas o promedio en cualquier momento después de la operación, ni hubo ninguna diferencia en los equivalentes de miligramos de morfina utilizados o la duración de la estancia (mediana de 3,1 días).LIMITACIONES:Estudio de una sola institución con cegamiento de un solo paciente.CONCLUSIONES:El uso de bupivacaína liposomal en bloqueos del plano transverso del abdomen, para pacientes sometidos a resecciones colorrectales laparoscópicas, no parece mejorar el dolor posoperatorio, ni reduce el uso de narcóticos ni la duración de la estancia hospitalaria. Dado su costo, el uso de bupivacaína liposomal en bloqueos TAP no está justificado para resecciones de colon y recto. Consulte Video Resumen en http://links.lww.com/DCR/B797 . Traducción Dr. Fidel Ruiz Healy.
Collapse
Affiliation(s)
| | - Aaron L Klinger
- Department of Surgery, Section of Colon and Rectal Surgery, Louisiana State School of Medicine, New Orleans, Louisiana
| | - Heather J Green
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Mariella M Gastanaduy
- Center for Outcomes and Health Services Research, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - W Forrest Johnston
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Herschel D Vargas
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Brian R Kann
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Charles B Whitlow
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Jennifer L Paruch
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| |
Collapse
|
3
|
Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews. J Clin Med 2022; 11:jcm11195628. [PMID: 36233497 PMCID: PMC9572852 DOI: 10.3390/jcm11195628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022] Open
Abstract
The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.
Collapse
|
4
|
Chintalapudi N, Agarwalla A, Bortman J, Lu J, Basmajian HG, Amin NH, Liu JN. Liposomal Bupivacaine Associated with Cost Savings during Postoperative Pain Management in Fragility Intertrochanteric Hip Fractures. Clin Orthop Surg 2022; 14:162-168. [PMID: 35685981 PMCID: PMC9152892 DOI: 10.4055/cios21024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Intertrochanteric hip fractures are among the most common and most expensive diagnoses in the Medicare population. Liposomal bupivacaine is a novel preparation of a commonly used analgesic agent that, when used intraoperatively, decreases narcotic requirements and hospital length of stay and increases the likelihood of discharge to home. The purpose of this investigation was to determine whether there was an economic benefit to utilizing intraoperative liposomal bupivacaine in patients with fragility intertrochanteric hip fractures in comparison to a group of patients who did not receive liposomal bupivacaine. METHODS This is a retrospective observational study performed at two academic medical centers. Fifty-six patients with intertrochanteric hip fractures treated with cephalomedullary nail implant who received standard hip fracture pain management protocol were compared to a cohort of 46 patients with intertrochanteric hip fractures who received additional intraoperative injections of liposomal bupivacaine. All other standards of care were identical. A cost analysis was completed including the cost of liposomal bupivacaine, operating room costs, and discharge destination. Statistical significance was set at p < 0.05. RESULTS Although the length of hospital stay was similar between the two groups (3.2 days vs. 3.8 days, p = 0.08), patients receiving intraoperative liposomal bupivacaine had a lower likelihood of discharge to a skilled nursing facility (84.8% vs. 96.4%, p = 0.002) and a longer operative time (73.4 minutes vs 67.2 minutes, p = 0.004). The cost-benefit analysis indicated that for an investment of $334.18 in the administration of 266 mg of liposomal bupivacaine, there was a relative saving of $1,323.21 compared to the control group. The benefit-cost ratio was 3.95, indicating a $3.95 benefit for each $1 spent in liposomal bupivacaine. CONCLUSIONS Despite the increased initial cost, intraoperative use of liposomal bupivacaine was found to be a cost-effective intervention due to the higher likelihood of discharge to home during the postoperative management of patients with intertrochanteric hip fractures.
Collapse
Affiliation(s)
| | - Avinesh Agarwalla
- Department of Orthopedic Surgery, Westchester Medical Center, Westchester, NY, USA
| | | | - Joana Lu
- Department of Orthopaedic Surgery, Pomona Valley Hospital Medical Center, Pomona Valley, CA, USA
| | - Hrayr G. Basmajian
- Department of Orthopaedic Surgery, Pomona Valley Hospital Medical Center, Pomona Valley, CA, USA
| | - Nirav H. Amin
- Department of Orthopaedic Surgery, Pomona Valley Hospital Medical Center, Pomona Valley, CA, USA
| | - Joseph N. Liu
- Department of Orthopedic Surgery, Loma Linda Medical Center, Loma Linda, CA, USA
| |
Collapse
|
5
|
Copperthwaite A, Sahebally SM, Raza ZM, Devane L, McCawley N, Kearney D, Burke J, McNamara D. A meta-analysis of laparoscopic versus ultrasound-guided transversus abdominis plane block in laparoscopic colorectal surgery. Ir J Med Sci 2022; 192:795-803. [PMID: 35499808 DOI: 10.1007/s11845-022-03017-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/22/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND Enhanced recovery programmes in laparoscopic colorectal surgery (LCS) employ combined approaches to achieve postoperative analgesia. Transversus abdominis plane (TAP) block is a locoregional anaesthetic technique that may reduce postoperative pain. AIMS To perform a systematic review and meta-analysis to compare the effectiveness of laparoscopic- versus ultrasound-guided TAP block in LCS. METHODS Databases were searched for relevant articles from inception until March 2022. All randomised controlled trials (RCTs) that compared laparoscopic (LTB) versus ultrasound-guided (UTB) TAP blocks in LCS were included. The primary outcome was narcotic consumption at 24 h postoperatively, whilst secondary outcomes included pain scores at 24 h postoperatively, operative time, postoperative nausea and vomiting (PONV) and complication rates. Random effects models were used to calculate pooled effect size estimates. RESULTS Three RCTs were included capturing 219 patients. Studies were clinically heterogenous. On random effects analysis, LTB was associated with significantly lower narcotic consumption (SMD - 0.30 mg, 95% CI = - 0.57 to - 0.03, p = 0.03) and pain scores (SMD - 0.29, 95% CI = - 0.56 to - 0.03, p = 0.03) at 24 h. However, there were no differences in operative time (SMD - 0.09 min, 95% CI = - 0.40 to 0.22, p = 0.56), PONV (OR = 0.97, 95% CI = 0.36 to 2.65, p = 0.96) or complication (OR = 1.30, 95% CI = 0.64 to 2.64, p = 0.47) rates. CONCLUSIONS LTB is associated with significantly less narcotic usage and pain at 24 h postoperatively but similar PONV, operative time and complication rates, compared to UTB. However, the data were inconsistent, and our findings require further investigation. LTB obviates the need for ultrasound devices whilst also decreasing procedure logistical complexity.
Collapse
Affiliation(s)
- Amy Copperthwaite
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland.
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland.
- Department of Otolaryngology, Sligo University Hospital, Sligo, Ireland.
| | - Shaheel Mohammad Sahebally
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - Zeeshan Muhammad Raza
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - Liam Devane
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - Niamh McCawley
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - David Kearney
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - John Burke
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - Deborah McNamara
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| |
Collapse
|
6
|
Ardon A, Hernandez N. The Use of Peripheral Nerve Blockade in Laparoscopic and Robotic Surgery: Is There a Benefit? Curr Pain Headache Rep 2022; 26:25-31. [PMID: 35076876 DOI: 10.1007/s11916-022-01002-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to synthesize recent literature investigating the use of regional anesthesia for minimally invasive surgery. RECENT FINDINGS Recent studies investigating the use of newer peripheral nerve blocks such as erector spinae plane (ESP) and quadratus lumborum (QL) block are very limited. Evidence supporting the use of peripheral nerve blockade in laparoscopic or robotic surgery is very limited and of low-moderate quality. While transverse abdominal plane (TAP) block may decrease opioid and pain scores after laparoscopic cholecystectomy, bariatric surgery, and colorectal surgery, the benefit of the block in the presence of multimodal analgesia remains to be clarified. Unilateral paravertebral block may be beneficial for percutaneous nephrolithotomy. ESP and rectus sheath blockade may enhance analgesia in laparoscopic surgery, but the magnitude of this benefit may not be clinically relevant. Limited evidence supports the use of QL block in laparoscopic urologic surgery. There is insufficient recent evidence to support the use of TAP or QL block for laparoscopic gynecologic surgery.
Collapse
Affiliation(s)
- Alberto Ardon
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
| | - Nadia Hernandez
- Department of Anesthesiology and Perioperative Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| |
Collapse
|
7
|
Villadiego L, Baker BW. Improving Pain Management After Cesarean Birth Using Transversus Abdominis Plane Block With Liposomal Bupivacaine as Part of a Multimodal Regimen. Nurs Womens Health 2021; 25:357-365. [PMID: 34480867 DOI: 10.1016/j.nwh.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/22/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022]
Abstract
As educators, advocates, and champions for women's health, nurses play pivotal roles throughout a woman's pregnancy and childbirth journey. Most women experience postsurgical pain after cesarean birth and are prescribed opioids. Caution around opioid use warrants opioid-reducing strategies, particularly because exposure to opioids exacerbates risk for developing persistent postsurgical opioid use. Multimodal approaches can help address this concern. Regional anesthesia using transversus abdominis plane blocks with aqueous formulations of local anesthetics can reduce opioid consumption and pain but has a short duration of action. Liposomal formulation of bupivacaine prolongs its release, overcoming this obstacle. Transversus abdominis plane blocks with liposomal bupivacaine can reduce opioid use and pain after cesarean birth, improving recovery. These findings represent numerous implications for nursing practice to improve postcesarean pain management.
Collapse
|
8
|
Byrnes KG, Sahebally SM, Burke JP. Effect of liposomal bupivacaine on opioid requirements and length of stay in colorectal enhanced recovery pathways: A systematic review and network meta-analysis. Colorectal Dis 2021; 23:603-613. [PMID: 32966662 DOI: 10.1111/codi.15377] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/23/2020] [Accepted: 09/08/2020] [Indexed: 12/15/2022]
Abstract
AIM Reducing postoperative opioid consumption is a key aim of enhanced recovery after colorectal surgery protocols. Potential solutions include anaesthetic techniques such as local infiltration of anaesthetic agents or transversus abdominis plane (TAP) blocks. This study aimed to assess the efficacy of liposomal bupivacaine (LB) for colorectal resections, across a variety of anaesthetic techniques. METHODS PubMed, Scopus and Embase databases were searched for relevant studies assessing LB, administered by any anaesthetic technique. The primary outcome was postoperative morphine consumed (milligrams) and the secondary outcome was length of stay (days). A Bayesian network meta-analysis comparing LB versus non-LB analgesia was performed alongside meta-regression for different surgical approaches. RESULTS Twelve trials were included, with a total of 2512 patients. LB-based wound infiltration was most likely to reduce length of stay followed by TAP block with LB (sum under the cumulative ranking [SUCRA] 85.55 and 70.26, respectively). TAP block with LB was most likely to reduce morphine requirements, followed by wound infiltration with LB (SUCRA 83.94 and 75.73, respectively). Compared to standard analgesia, LB-based wound infiltration reduced morphine usage (mean difference 36.64 mg, 95% credibility interval 15.64-59.20) and length of stay (mean difference 1.79 days, 95% credibility interval 0.59-3.81). On meta-regression, the findings held for minimally invasive surgery only. CONCLUSION Although LB-based interventions were associated with reduced postoperative morphine requirements and length of stay in this network meta-analysis, the confidence in these estimates was graded as very low. Further well-executed trials are required before LB can be recommended as a first-line agent.
Collapse
|
9
|
Cata JP, Fournier K, Corrales G, Owusu-Agyemang P, Soliz J, Bravo M, Wilks J, Van Meter A, Hernandez M, Gottumukkala V. The Impact of Thoracic Epidural Analgesia Versus Four Quadrant Transversus Abdominis Plane Block on Quality of Recovery After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Surgery: A Single-Center, Noninferiority, Randomized, Controlled Trial. Ann Surg Oncol 2021; 28:5297-5310. [PMID: 33534044 DOI: 10.1245/s10434-021-09622-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/06/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recovery after CRS-HIPEC influenced by several factors, including pain and opioid consumption. We hypothesized that 4Q-TAP blocks provide not inferior quality of recovery compared with TEA after CRS-HIPEC. We conducted a randomized, controlled trial to determine whether 4-quadrant transversus abdominis plane (4Q-TAP) block analgesia was noninferior to thoracic epidural (TEA) among patients who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS HIPEC). METHODS Patients 18 years or older who underwent a CRS-HIPEC surgery were randomly assigned to have either TEA or 4Q-TAP blocks. The primary outcome of this study was the change in quality of recovery 2 days after surgery. Secondary outcomes included quality of recovery on Days 1, 3, 5, 7, 10, and 30 postoperatively, opioid consumption, pain intensity, length of stay, and postoperative complications. Analyses were performed on a per-protocol basis. RESULTS Sixty-eight patients were included in the analysis. The difference between 4Q-TAP and TEA in the mean QoR-15 change from surgery at postoperative Days 1, 2, and 3 was 0.80 (P = 0.004), -4.5 (P = 0.134), and 3.4 (P = 0.003), respectively. All differences through postoperative day 30 were significantly within the noninferiority boundary of -10 except at postoperative Day 2 (P = 0.134). Length of stay, opioid-related adverse events, and frequency and grade of complications were not significantly different between TEA and 4Q-TAP patients. CONCLUSIONS Despite the significantly higher use of opioids after CRS-HIPEC in patients with 4Q-TAP blocks, their short-term quality of recovery was not inferior to those treated with TEA. Patients undergoing CRS-HIPEC can be effectively managed with 4Q-TAP blocks.
Collapse
Affiliation(s)
- Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 409, Houston, TX, 77005, USA. .,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA.
| | - Keith Fournier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - German Corrales
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 409, Houston, TX, 77005, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Pascal Owusu-Agyemang
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 409, Houston, TX, 77005, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Joseph Soliz
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 409, Houston, TX, 77005, USA
| | - Mauro Bravo
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 409, Houston, TX, 77005, USA.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Jonathan Wilks
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 409, Houston, TX, 77005, USA
| | - Antoinette Van Meter
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 409, Houston, TX, 77005, USA
| | - Mike Hernandez
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vijay Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 409, Houston, TX, 77005, USA.,Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | | |
Collapse
|
10
|
Sommer NP, Schneider R, Wehner S, Kalff JC, Vilz TO. State-of-the-art colorectal disease: postoperative ileus. Int J Colorectal Dis 2021; 36:2017-2025. [PMID: 33977334 PMCID: PMC8346406 DOI: 10.1007/s00384-021-03939-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Postoperative Ileus (POI) remains an important complication for patients after abdominal surgery with an incidence of 10-27% representing an everyday issue for abdominal surgeons. It accounts for patients' discomfort, increased morbidity, prolonged hospital stays, and a high economic burden. This review outlines the current understanding of POI pathophysiology and focuses on preventive treatments that have proven to be effective or at least show promising effects. METHODS Pathophysiology and recommendations for POI treatment are summarized on the basis of a selective literature review. RESULTS While a lot of therapies have been researched over the past decades, many of them failed to prove successful in meta-analyses. To date, there is no evidence-based treatment once POI has manifested. In the era of enhanced recovery after surgery or fast track regimes, a few approaches show a beneficial effect in preventing POI: multimodal, opioid-sparing analgesia with placement of epidural catheters or transverse abdominis plane block; μ-opioid-receptor antagonists; and goal-directed fluid therapy and in general the use of minimally invasive surgery. CONCLUSION The results of different studies are often contradictory, as a concise definition of POI and reliable surrogate endpoints are still absent. These will be needed to advance POI research and provide clinicians with consistent data to improve the treatment strategies.
Collapse
Affiliation(s)
- Nils P. Sommer
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | | | - Sven Wehner
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | - Jörg C. Kalff
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | - Tim O. Vilz
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| |
Collapse
|
11
|
Zhu Y, Xiao T, Qu S, Chen Z, Du Z, Wang J. Transversus Abdominis Plane Block With Liposomal Bupivacaine vs. Regular Anesthetics for Pain Control After Surgery: A Systematic Review and Meta-Analysis. Front Surg 2020; 7:596653. [PMID: 33251245 PMCID: PMC7674642 DOI: 10.3389/fsurg.2020.596653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/05/2020] [Indexed: 12/29/2022] Open
Abstract
Background: Transverse abdominal plane (TAP) blocks are used to provide pain relief after abdominopelvic surgeries. The role of liposomal bupivacaine (LB) for TAP blocks is unclear. Therefore, this study aimed to synthesize evidence on the efficacy of LB vs. regular anesthetics in improving outcomes of TAP block. Methods: PubMed, Science Direct, Embase, Springer, and CENTRAL databases were searched up to July 24, 2020. Studies comparing LB with any regular anesthetic for TAP block for any surgical procedure and reporting total analgesic consumption (TAC) or pain scores were included. Results: Seven studies including five randomized controlled trials (RCTs) were reviewed. LB was compared with regular bupivacaine (RB) in all studies. A descriptive analysis was conducted for TAC due to heterogeneity in data presentation. There were variations in the outcomes of studies reporting TAC. Meta-analysis of pain scores indicated statistically significant reduction of pain with the use of LB at 12 h (MD: -0.89 95% CI: -1.44, -0.34 I2 = 0% p = 0.01), 24 h (MD: -0.64 95% CI: -1.21, -0.06 I2 = 0% p = 0.03), 48 h (MD: -0.40 95% CI: -0.77, 0.04 I2 = 0% p = 0.03) but not at 72 h (MD: -0.37 95% CI: -1.31, 0.56 I2 = 57% p = 0.43). Pooled analysis indicated no difference in the duration of hospital stay between LB and RB (MD: -0.18 95% CI: -0.49, 0.14 I2 = 61% p = 0.27). LB significantly reduced the number of days to first ambulation postsurgery (MD: -0.28 95% CI: -0.50, -0.06 I2 = 0% p = 0.01). Conclusions: Current evidence on the role of LB for providing prolonged analgesia with TAP blocks is unclear. Conflicting results have been reported for TAC. LB may result in a small reduction in pain scores up to 48 h but not at 72 h. Further, high-quality homogenous RCTs are needed to establish high-quality evidence.
Collapse
Affiliation(s)
| | | | - Shuangquan Qu
- Department of Anesthesiology, Hunan Children's Hospital, Changsha, China
| | | | | | | |
Collapse
|
12
|
Chapman BC, Shepherd B, Moore R, Stanley DJ, Nelson EC. Dual adjunct therapy with dexamethasone and dexmedetomidine in transversus abdominis plane blocks reduces postoperative opioid use in colorectal surgery. Am J Surg 2020; 222:198-202. [PMID: 33012502 DOI: 10.1016/j.amjsurg.2020.09.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 09/12/2020] [Accepted: 09/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The objective of this study is to determine if the addition of dexmedetomidine to dexamethasone in transversus abdominis plane (TAP) blocks lowers postoperative opioid use following colorectal surgery. METHODS Retrospective review of patients undergoing minimally invasive colorectal surgery and perioperative TAP block with either 1) local anesthetic and dexamethasone or 2) local anesthetic, dexamethasone, and dexmedetomidine. Post-operative opioid use was converted to morphine milligram equivalents (MME). RESULTS 55 patients were identified: 38 (69%) receiving dexamethasone only and 17 (31%) receiving dexamethasone and dexmedetomidine. The dexamethasone and dexmedetomidine group had significantly lower median MME use at 12-h (2 vs. 13 mg), 24-h (4 vs. 28 mg), 36-h (8 vs. 38 mg), and 48-h (17 vs. 53 mg) (all p < 0.05). There was no difference at 72-h. CONCLUSION Perioperative TAP blocks with dexamethasone and dexmedetomidine following colorectal surgery results in significantly less postoperative opioid use up to 48 h after surgery.
Collapse
Affiliation(s)
- Brandon C Chapman
- University of Tennessee College of Medicine Chattanooga, Department of Surgery, Chattanooga, TN, USA.
| | - Brian Shepherd
- University of Tennessee College of Medicine Chattanooga, Department of Anesthesiology, Chattanooga, TN, USA
| | - Richard Moore
- University of Tennessee College of Medicine Chattanooga, Department of Surgery, Chattanooga, TN, USA
| | - Daniel J Stanley
- University of Tennessee College of Medicine Chattanooga, Department of Surgery, Chattanooga, TN, USA
| | - Eric C Nelson
- University of Tennessee College of Medicine Chattanooga, Department of Surgery, Chattanooga, TN, USA
| |
Collapse
|