A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy

Umbilical port versus epigastric port for gallbladder extraction in laparoscopic cholecystectomy: A systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND

After laparoscopic cholecystectomy, gallbladder can be extracted either from epigastric/subxiphoid port or umbilical port. We conducted systematic review of randomized controlled trials comparing the two.

METHODS

PRISMA-compliant systematic review and meta-analysis was conducted with pre-specified study protocol registered on PROSPERO (CRD42019128662). Multiple databases were searched from inception till 14 September 2019 using search terms "gallbladder", "specimen", "extraction', "extract", "cholecystectomy", "epigastric port", "subxiphoid port" "umbilical port". Outcomes assessed were postoperative pain (visual analog scale at 24 h postoperatively), port-site hernia, port-site infection, operative time and gallbladder retrieval time. Data were analyzed using random-effects models with risk ratios (RR) for dichotomous variables and mean difference (MD) for continuous variables.

RESULTS

Of 280 articles retrieved, 9 RCT's with 1036 participants were included. Quality of included studies was judged to be "moderate" to "low". There was no difference in postoperative pain at 24 h (p = 0.76), total operative time (p = 0.11), gallbladder retrieval time (p = 0.72) or surgical site infection (p = 0.93). Umbilical port retrieval was associated with significantly higher risk of port-site herniae (RR 2.68, 95%CI:1.06-6.80, p = 0.04). After sensitivity analysis, operative time was significantly shorter with epigastric retrieval (p = 0.0007). Trial sequential analysis showed that current studies were successful in achieving optimum information size for primary outcome.

CONCLUSIONS

There was no difference in postoperative pain and infections between umbilical and epigastric port retrieval. Umbilical port retrieval was associated with significantly higher risk of developing port-site hernia and could also be associated with longer operative time. Epigastric port may be favorable for gallbladder retrieval in multiport laparoscopic cholecystectomy.

Dezocine promotes T lymphocyte activation and inhibits tumor metastasis after surgery in a mouse model

Dezocine is an opioid analgesic with both μ-receptor agonist and antagonist activities. Administration of opioids influences the immune system through immune cells. Dendritic cells (DC) play crucial functions in inducing T cell response and mediating immune functions. DC surface displays several different opioid receptors whose expression is induced during DC maturation. We aimed to explore the effects of dezocine on DCs and T cells, as well as on tumor treatment. Mice were intraperitoneally administrated with increasing doses of dezocine (0.75, 1.25 and 2.0 mg/kg). Mouse bone marrow-derived dendritic cells (BMDCs) were then isolated from the bone marrow. The BMDC surface markers were evaluated by flow cytometry. T cell proliferation was assessed by the carboxyfluorescein succinimidyl ester assay. The number of mature DCs were increased by dezocine treatment in both human umbilical cord blood and mouse peripheral blood, suggesting that dezocine enhanced BMDC maturation. Dezocine-treated BMDCs promoted CD8+ T cell proliferation and cytotoxicity, while dezocine treatment inhibited tumor metastasis in mice. We therefore conclude that the administration of dezocine promotes BMDC maturation and inhibits tumor metastasis through elevating CD8+ T cell proliferation and cytotoxicity.

Effects of dezocine and sufentanyl for postoperative analgesia on activity of NK, CD4+ and CD8+ cells in patients with breast cancer

The effects of dezocine and sufentanyl on the activity of natural killer (NK), CD4⁺ and CD8⁺ cells in patients with breast cancer undergoing postoperative analgesia after radical mastectomy were compared. The clinical data of 76 female patients undergoing radical mastectomy in the Fudan University Shanghai Cancer Center from January 2015 to October 2017 were analyzed retrospectively. Forty-two patients treated with dezocine were group D and 34 patients with sufentanyl were group S. Visual analogue scale (VAS) was used to evaluate the analgesic effect at 3, 12, 24, 48 h after surgery. There was no significant difference in VAS score, NK cells, CD4⁺ cells, and CD8⁺ cell vitality at 3 h postoperatively between the two groups (P>0.05), and VAS score at 12, 24 and 48 h postoperatively in the S group was significantly lower than that in group D (P<0.05). The activity of NK cells and CD4⁺ cells at 3, 12, 24 and 48 h after surgery in group D was significantly higher than that in group S, and the difference was statistically significant (P<0.05). The activity of CD8⁺ cells at 3, 12, 24 and 48 h after surgery in group D was significantly lower than that in group S, and the difference was statistically significant (P<0.05). The analgesic effect of dezocine was slightly worse than that of sufentanyl, but it was more beneficial to the recovery of early postoperative immune function.

Procedure-Specific Pain Management (PROSPECT) - An update

Post-operative pain management protocols may be optimised by examining procedure-specific evidence and outcomes. This recognition led to the formation of the PROcedure-SPECific Pain ManagemenT (PROSPECT) collaboration of anaesthesiologists and surgeons. The aim of PROSPECT is to provide practical and evidence-based recommendations to prevent and treat post-operative pain after specific surgical procedures, thereby overcoming the limitations of generic, non-specific guidelines. Updates in the methodology of PROSPECT in 2017 have placed an increased emphasis on the clinical relevance of studies, including a focus on interventions in the context of multimodal analgesia strategies and consideration of risks and benefits of interventions in specific surgical settings. Evidence-based reviews of analgesic measures, including advice on surgical techniques and adjuvants after diverse surgical procedures, have been completed by the PROSPECT collaboration and are accessible on the website (www.postoppain.org) and published in the peer-reviewed literature. These reviews continue to identify significant gaps in clinically relevant research on post-operative analgesia and are possibly leading to a closing of some of these gaps.

Effect of Oral Clonidine on Shoulder Tip Pain and Hemodynamic Response After Laparoscopic Cholecystectomy: A Randomized Double Blind Study

Background

Shoulder tip pain is a common problem after laparoscopic cholecystectomy. There are a few clinical trial studies on the effect of clonidine on post laparoscopic shoulder pain (PLSP). This study aimed at evaluating the effect of oral clonidine on PLSP in semi-sitting position and post-operative hemodynamic response of patients undergoing LC surgery.

Methods

This randomized controlled clinical trial was conducted on 60 patients, who were candidates for elective laparoscopic cholecystectomy surgery under general anesthesia, and were randomly allocated to clonidine and placebo groups. Patients in the clonidine group received 0.2 mg oral, 90 minutes prior to induction. Patients in the placebo group received vitamin C tablets during the same time. Postoperative pain intensity was assessed, using a visual analog scale at the emergence from anesthesia, 4 and 8 hours after the operation by an anesthetist, who was blinded to the patient group. Mean arterial blood pressure and heart rate were recorded before clonidine administration and in post-operative period.

Results

The mean age was 36.85 ± 10.93 years and the mean Body Mass was 26.34 ± 3.46 kg/m². Two groups were not comparable with respect to occurrence of PLSP (P = 0.739). There was a significant difference in intensity of PLSP between the 2 groups at emergence from anesthesia (P = 0.012), 4 and 8 hours after the operation (P = 0.001) between 2 groups. The clonidine group showed a larger reduction of pain intensity at these phases. The result of independent t test indicated significant differences in the MABP value between the 2 groups at the time of emergence from anesthesia (P = 0.031). The clonidine group demonstrated a lower MABP level at this time.

Conclusions

Oral clonidine is not effective in preventing the PLSP. However, it alleviates PLSP intensity in the patient under LC procedure on the first post-operative hours.

The Effect of Nefopam Infusion during Laparascopic Cholecystectomy on Postoperative Pain

Background: While recovery from remifentanil is fast due to its rapid metabolism, it can induce hyperalgesia by activation of N-methyl-D-aspartic acid (NMDA) receptors. Therefore, administration of NMDA receptor antagonists such as ketamine is effective in relieving hyperalgesia caused by remifentanil. A previous study showed that nefopam administration before anesthesia combined with low-dose remifentanil reduced pain and analgesic consumption during the immediate postoperative period. We hypothesized that intraoperative infusion of nefopam during laparoscopic cholecystectomy would be as effective as ketamine in controlling pain during the acute postoperative period after sevoflurane and remifentanil based anesthesia. Methods: Sixty patients scheduled to undergo laparoscopic cholecystectomy were randomly divided into three groups. General anesthesia was maintained with sevoflurane and effect-site target concentration of remifentanil (4 ng/ml) in all patients. An intravenous bolus of nefopam (0.3 mg/kg) was given, followed by continuous infusion (65 µg/kg/h) in Group N (n=20). An intravenous bolus of ketamine (0.3 mg/kg) was administered, followed by continuous infusion (180 µg/kg/h) in Group K (n=20), and Group C received a bolus and subsequent infusion of normal saline equal to the infusion received by Group K (n=20). We compared postoperative Visual Analogue Scale (VAS) scores and analgesic requirements over the first 8 postoperative hours between groups. Results: The pain scores (VAS) and fentanyl requirements for 1 h after surgery were significantly lower in the nefopam and ketamine groups compared with the control group (p<0.05). There were no differences between the nefopam and ketamine groups. The three groups showed no differences in VAS scores and number of analgesic injections from 1 to 8 h after surgery. Conclusion: Intraoperative nefopam infusion during laparoscopic cholecystectomy reduced opioid requirements and pain scores (VAS) during the early postoperative period after remifentanil-based anesthesia.

Prospective survey to study factors which could influence same-day discharge after elective laparoscopic cholecystectomy in a tertiary care hospital of a developing country

All laparoscopic cholecystectomy (LC) patients in our hospital setting are admitted overnight. This article assesses the contribution of factors like postoperative nausea and vomiting (PONV), postoperative pain and surgical complications to overnight stay after elective LC. This 1-year observational study included patients having normal liver functions undergoing elective LC before 1400 h. The collected data included patient demographics, co-morbidities, PONV, pain scores, complications, surgical time, anesthesia technique, use of prophylactic antiemetics, analgesics, patient satisfaction and desire to have this surgery as day case or in-patient procedure. From 930 LC done per annum, 45.2 % (430/950) patients were included in this study. Prophylactic antiemetic was given in 91.6 %, intraoperative narcotics in 94.2 % patients and multimodal analgesia in 85.3 %. The mean pain score in the recovery and ward was maintained to <4. In the ward, 99.1 % patients were able to start oral fluids after 6 h and were started on oral non-steroidal anti-inflammatory drugs and paracetamol, and none required parental opioid. The PONV score of more than 2 was observed in only 3.2 % of patients in the ward requiring parenteral antiemetic. Surgical complications in the form of bleeding, visceral injury and bile duct leak were observed in 2 % of patients, which was treated intra-operatively. Satisfaction was observed in 99.3 % and desire to stay overnight in 87.4 % of patients. Factors like postoperative pain, PONV and surgical complications were well managed and were not associated with significant morbidity to justify routine overnight admission. However, majority of the patients desired to stay overnight, which could be improved by counseling and education.

Infrared image monitoring of local anesthetic poisoning in rats

BACKGROUND AND OBJECTIVES

To evaluate the thermographic predictive value of local anesthetic poisoning in rats that indicates the early recognition of thermal signs of intoxication and enable the immediate start of advanced life support.

METHODS

Wistar rats underwent intraperitoneal injection of saline and ropivacaine; they were allocated into pairs, and experiments performed at baseline and experimental times. For thermography, central and peripheral compartment were analyzed, checking the maximum and average differences of temperatures between groups. Thermographic and clinical observations were performed for each experiment, and the times in which the signs of intoxication occurred were recorded. In the thermal analysis, the thermograms corresponding to the times of interest were sought and relevant data sheets extracted for statistical analysis.

RESULTS

Basal and experimental: the display of the thermal images at times was possible. It was possible to calculate the heat transfer rate in all cases. At baseline it was possible to see the physiology of microcirculation, characterized by thermal distribution in the craniocaudal direction. It was possible to visualize the pathophysiological changes or thermal dysautonomias caused by intoxication before clinical signs occur, characterized by areas of hyper-radiation, translating autonomic nervous system pathophysiological disorders. In animals poisoned by ropivacaine, there was no statistically significant difference in heat transfer rate at the experimental time.

CONCLUSIONS

The maximum temperature, medium temperature, and heat transfer rate were different from the statistical point of view between groups at the experimental time, thus confirming the systemic thermographic predictive value.

Novel management of postoperative pain using only oral analgesics after LADG

PURPOSE

Managing postoperative pain is important to ensure a good quality of life and fast recovery after surgery. We examined the feasibility of peroral management for the postoperative pain after laparoscopic-assisted distal gastrectomy (LADG).

METHODS

Between June 2012 and September 2013, we enrolled 34 patients prospectively to receive peroral tramadol/acetaminophen combination tablets, celecoxib and prochlorperazine maleate after LADG through postoperative day 3 (ORAL group). The postoperative pain was assessed using a visual analogue scale. Postoperative outcomes related to the analgesic methods were compared with those of patients who used epidural anesthesia between January 2010 and December 2011 (EPI group).

RESULTS

The ORAL group pain scale scores on postoperative days 1-3 were 3.96, 3.06 and 2.40, respectively. The frequency of additional analgesic use in the ORAL group was significantly lower than in the EPI group (P = 0.006). The rate of urethral catheter reinsertion was 20.6 % in the EPI group (P = 0.054). A multivariate analysis revealed that only epidural anesthesia was a significant risk factor for the need for additional medication four times or more for breakthrough pain (P = 0.048).

CONCLUSION

Postoperative pain management using oral analgesics after LADG is feasible and safe, and is an ideal pain treatment associated with few adverse events while providing pain relief not inferior to epidural anesthesia.

Comparison of intra-peritoneal bupivacaine and intravenous paracetamol for postoperative pain relief after laparoscopic cholecystectomy

Background:

Nonsteroidal anti-inflammatory drugs used for postoperative analgesia have considerable adverse effects, with paracetamol having a different mechanism of action, superior side effect profile and availability in intravenous (IV) form, this study was conducted to compare intra-peritoneal bupivacaine with IV paracetamol for postoperative analgesia following laparoscopic cholecystectomy.

Aim:

The aim was to compare the efficacy of intra-peritoneal administration of bupivacaine 0.5% and IV acetaminophen for postoperative analgesia in patients undergoing laparoscopic cholecystectomy.

Settings and Design:

Randomized, prospective trial.

Materials and Methods:

A total of 60 patients of American Society of Anesthesiologists physical Status I and II scheduled for laparoscopic cholecystectomy were enrolled for this study. Group I received 2 mg/kg of 0.5% bupivacaine as local intra-peritoneal application and Group II patients received IV 1 g paracetamol 6^th hourly. Postoperatively, the patients were assessed for pain utilizing Visual Analog Scale (VAS), Visual Rating Prince Henry Scale (VRS), shoulder pain. The total number of patients requiring rescue analgesia and any side-effects were noted.

Statistical Analysis:

Data analysis was performed using Students unpaired t-test. SPSS version 11.5 was used.

Results:

The VAS was significantly higher in Group I compared with Group II at 8^th, 12^th and 24^th postoperative hour. At 1^st and 4^th postoperative hours, VAS was comparable between the two groups. Although the VRS was higher in Group I compared with Group II at 12^th and 24^th postoperative hour; the difference was statistically significant only at 24^th postoperative hour. None of the patients in either of the groups had shoulder pain up to 8 h postoperative. The total number of patients requiring analgesics was higher in Group II than Group I at 1^st postoperative hour.

Conclusion:

Although local anesthetic infiltration and intra-peritoneal administration of 0.5% bupivacaine decreases the severity of incisional, visceral and shoulder pain in the early postoperative period, IV paracetamol provides sustained pain relief for 24 postoperative hours after elective laparoscopic cholecystectomy.

A Double-Blinded Randomized Trial to Compare the Effectiveness of Minimally Invasive Procedures Using Patient-Reported Outcomes

BACKGROUND

The Institute of Medicine has included the comparison of minimally invasive surgical techniques in its research agenda. This study seeks to evaluate a model for the comparison of minimally invasive procedures using patient-reported outcomes.

STUDY DESIGN

A double-blinded randomized controlled trial (NCT01489436) was conducted. Baseline data were obtained, standardized anesthesia was induced, and patients were randomized to single-port (SP) or 4-port (FP) laparoscopic cholecystectomy. Perioperative care was standardized. The outcomes were pain (Visual Analog Scale) on postoperative day 1 (primary) and quality of life (Patient-Reported Outcomes Measures Information System and Linear Analog Self-Assessment), serum cytokines, and heart rate variability (secondary). Analysis was intention to treat. Using identical occlusive dressings, patients and the outcomes assessor remained blinded until postoperative day 2.

RESULTS

Fifty-five patients were randomized to each arm. There was no difference in demographics. Visual Analog Scale pain score on postoperative day 1 was significantly different from baseline in each group (SP: 1.6 ± 1.9 to 4.2 ± 2.4 vs FP: 1.8 ± 2.3 to 4.2 ± 2.2), but not different from each other (p = 0.83). Patients in the FP arm reported significantly less fatigue on postoperative day 7 than patients in the SP group (3.1 ± 2.1 vs 4.2 ± 2.2; p = 0.009). Fewer patients in the FP group required postoperative oral narcotics before discharge (40% vs 60%; p = 0.056). Cytokines levels and heart rate variability were similar between arms. In patients followed for >1 year, no difference in umbilical hernia rates was noted.

CONCLUSIONS

Early postoperative quality of life data captured differences in fatigue, indicating improved recovery after FP within a controlled trial. Physiologic measures were similar, suggesting that the differences between SP and FP are minimal.

Effects of peritoneal ropivacaine nebulization for pain control after laparoscopic gynecologic surgery

STUDY OBJECTIVE

To evaluate the effects of peritoneal cold nebulization of ropivacaine on pain control after gynecologic laparoscopy.

DESIGN

Evidence obtained from a properly designed, randomized, double-blind, placebo-controlled trial (Canadian Task Force classification I).

SETTING

Tertiary care center.

PATIENTS

One hundred thirty-five women with American Society of Anesthesiologists disease classified as ASA I-III who were scheduled to undergo operative laparoscopy.

INTERVENTION

Patients were randomized to receive either nebulization of 30 mg ropivacaine before surgery (preoperative group), nebulization of 30 mg ropivacaine after surgery (postoperative group), instillation of 100 mg ropivacaine before surgery (instillation group), or instillation of saline solution (control group). Nebulization was performed using the Aeroneb Pro device.

MEASUREMENT AND MAIN RESULTS

Pain scores, morphine consumption, and ambulation time were collected in the post-anesthesia care unit and at 4, 6, and 24 hours postoperatively. One hundred eighteen patients completed the study. Patients in the preoperative group reported lower pain Numeric Ranking Scale values compared with those in the control group (net difference 2 points; 95% confidence interval [CI], 0.3-3.1 at 4 hours, 1-3 at 6 hours, and 0.7-3 at 24 hours; p = .01) Patients in the preoperative group consumed significantly less morphine than did those in the control group (net difference 7 mg; 95% CI, 0.7-13; p = .02). More patients who received nebulization walked without assistance within 12 hours after awakening than did those in the instillation and control groups (net difference 15%; 95% CI, 6%-24%; p = .001).

CONCLUSIONS

Cold nebulization of ropivacaine before surgery reduced postoperative pain and morphine consumption and was associated with earlier walking without assistance.

Pharmacological interventions for prevention or treatment of postoperative pain in people undergoing laparoscopic cholecystectomy

BACKGROUND

While laparoscopic cholecystectomy is generally considered less painful than open surgery, pain is one of the important reasons for delayed discharge after day-surgery and overnight stay following laparoscopic cholecystectomy. The safety and effectiveness of different pharmacological interventions such as non-steroidal anti-inflammatory drugs, opioids, and anticonvulsant analgesics in people undergoing laparoscopic cholecystectomy is unknown.

OBJECTIVES

To assess the benefits and harms of different analgesics in people undergoing laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization International Clinical Trials Registry Platform portal (WHO ICTRP) to March 2013 to identify randomised clinical trials of relevance to this review.

SELECTION CRITERIA

We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different pharmacological interventions with no intervention or inactive controls for outcomes related to benefit in this review. We considered comparative non-randomised studies with regards to treatment-related harms. We also considered trials that compared one class of drug with another class of drug for this review.

DATA COLLECTION AND ANALYSIS

Two review authors collected the data independently. We analysed the data with both fixed-effect and random-effects models using Review Manager 5 analysis. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included 25 trials with 2505 participants randomised to the different pharmacological agents and inactive controls. All the trials were at unclear risk of bias. Most trials included only low anaesthetic risk people undergoing elective laparoscopic cholecystectomy. Participants were allowed to take additional analgesics as required in 24 of the trials. The pharmacological interventions in all the included trials were aimed at preventing pain after laparoscopic cholecystectomy. There were considerable differences in the pharmacological agents used and the methods of administration. The estimated effects of the intervention on the proportion of participants who were discharged as day-surgery, the length of hospital stay, or the time taken to return to work were imprecise in all the comparisons in which these outcomes were reported (very low quality evidence). There was no mortality in any of the groups in the two trials that reported mortality (183 participants, very low quality evidence). Differences in serious morbidity outcomes between the groups were imprecise across all the comparisons (very low quality evidence). None of the trials reported patient quality of life or time taken to return to normal activity. The pain at 4 to 8 hours was generally reduced by about 1 to 2 cm on the visual analogue scale of 1 to 10 cm in the comparisons involving the different pharmacological agents and inactive controls (low or very low quality evidence). The pain at 9 to 24 hours was generally reduced by about 0.5 cm (a modest reduction) on the visual analogue scale of 1 to 10 cm in the comparisons involving the different pharmacological agents and inactive controls (low or very low quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of very low quality that different pharmacological agents including non-steroidal anti-inflammatory drugs, opioid analgesics, and anticonvulsant analgesics reduce pain scores in people at low anaesthetic risk undergoing elective laparoscopic cholecystectomy. However, the decision to use these drugs has to weigh the clinically small reduction in pain against uncertain evidence of serious adverse events associated with many of these agents. Further randomised clinical trials of low risk of systematic and random errors are necessary. Such trials should include important clinical outcomes such as quality of life and time to return to work in their assessment.

Post-Laparoscopic Cholecystectomy Pain: Effects of Preincisional Infiltration and Intraperitoneal Levobupivacaine 0.25% on Pain Control-a Randomized Prospective Double-Blinded Placebo-Controlled Trial

OBJECTIVE

The aim of this study was to compare the postoperative analgesic efficacy of preincisional and intraperitoneal levobupivacaine or normal saline in patients undergoing laparoscopic cholecystectomy.

METHODS

Sixty patients who participated in the study were randomly divided into 3 groups. Group 1 received intraperitoneal levobupivacaine (0.25% 40 mL) immediately after the pneumoperitoneum. Group 2 received periportal levobupivacaine (0.25% 5 mL in each trochar incision area) before incision and intraperitoneal levobupivacaine (0.25% 40 mL) immediately after the pneumoperitoneum. Group 3 received for periportal and intraperitoneal instillation of normal saline. The visual analog scale (VAS) at 0, 1, 2, 4, 8, 12 and 24 hours for both shoulder and abdominal pain were recorded. Analgesia requirements and incidence of nausea and vomiting were also recorded.

RESULTS

There were no difference between the groups for demographic data. The pain scores were lower in Groups 1 and 2 than Group 3 (control) during rest, cough and movement (p<0.05). Rescue analgesic treatment was significantly lower in patients of Group 2 (15%) as compared with that of Groups 1 (35%) and 3 (90%) (p<0.05). The incidence of shoulder pain was significantly lower in Group 2 (25%) and Group 1 (20%) than in any of the control group patients (p<0.05).

CONCLUSION

The results indicated that 0.25% levobupivacaine was effective in preventing pain and the need for postoperative analgesic when intraperitoneal instillation or preincisional local infiltration in combination with intraperitoneal instillation. However, levobupivacaine for preincisional local infiltration in combination with intraperitoneal instillation is the better choice because of its higher efficacy.

Evidence-based postoperative pain management after laparoscopic colorectal surgery

AIM

The aim of this systematic review was to evaluate the available literature on the management of pain after laparoscopic colorectal surgery.

METHOD

Randomized studies, published in English between January 1995 and July 2011, assessing analgesic and anaesthetic interventions in adults undergoing laparoscopic colorectal surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. The efficacy and adverse effects of the analgesic techniques was assessed. The recommendations were based on procedure-specific evidence from a systematic review and supplementary transferable evidence from other relevant procedures.

RESULTS

Of the 170 randomized studies identified, 12 studies were included. Overall, all approaches including ketorolac, methylprednisolone, intraperitoneal instillation of ropivacaine, intravenous lidocaine infusion, intrathecal morphine and epidural analgesia improved pain relief, reduced opioid requirements and improved bowel function. However, there were significant differences in the study designs and the variables evaluated, precluding quantitative analysis. The L'Abbé plots of the data from the epidural analgesia studies included in this review indicate that the pain scores in the nonepidural groups, although higher than those in the epidural groups, were within an acceptable level (i.e. < 4/10).

CONCLUSION

Infiltration of surgical incisions with local anaesthetic at the end of surgery, systemic steroids, conventional nonsteroidal anti-inflammatory drugs or cyclooxygenase-2-selective inhibitors in combination with paracetamol with opioid used as rescue are recommended. Intravenous lidocaine infusion is recommended, but not as the first line of therapy. However, neuraxial blocks (i.e. epidural analgesia and spinal morphine) are not necessary based on high risk:benefit ratio.

Intraperitoneal nebulization of ropivacaine for pain control after laparoscopic cholecystectomy: a double-blind, randomized, placebo-controlled trial

BACKGROUND

Intraperitoneal local anaesthetic nebulization is a relatively novel approach to pain management after laparoscopic surgery. This randomized, double-blind, placebo-controlled trial evaluated the effects of intraperitoneal ropivacaine nebulization on pain control after laparoscopic cholecystectomy.

METHODS

Patients undergoing laparoscopic cholecystectomy were randomized to receive intraperitoneal nebulization of ropivacaine 1% (3 ml) before surgical dissection and normal saline 3 ml at the end of surgery (preoperative nebulization group); intraperitoneal nebulization of normal saline 3 ml before surgical dissection and ropivacaine 1% (3 ml) at the end of surgery (postoperative nebulization group); or intraperitoneal nebulization of normal saline 3 ml before surgical dissection and at the end of surgery (placebo group). Intraperitoneal nebulization of ropivacaine or saline was performed using the Aeroneb Pro(®) device. Anaesthetic and surgical techniques were standardized. The degree of pain on deep breath or movement, incidence of shoulder pain, morphine consumption, and postoperative nausea and vomiting were collected in the post-anaesthesia care unit and at 6, 24, and 48 h after surgery.

RESULTS

Compared with placebo, ropivacaine nebulization significantly reduced postoperative pain (-33%; Cohen's d 0.64), referred shoulder pain (absolute reduction -98%), morphine requirements (-41% to -56% Cohen's d 1.16), and time to unassisted walking (up to -44% Cohen's d 0.9) (P<0.01). There were no differences in pain scores between ropivacaine nebulization groups.

CONCLUSIONS

Ropivacaine nebulization before or after surgery reduced postoperative pain and referred shoulder pain after laparoscopic cholecystectomy. Furthermore, ropivacaine nebulization reduced morphine requirements and allowed earlier mobility.

Randomized clinical trial of single-port, minilaparoscopic and conventional laparoscopic cholecystectomy

Background

This three-armed randomized clinical trial, with blinding of patients and outcome assessors, tested the hypothesis that single-port (SP) and/or minilaparoscopic (ML) cholecystectomy are superior to conventional laparoscopic (CL) cholecystectomy.

Methods

Patients eligible for elective laparoscopic cholecystectomy were randomized to SP, ML or CL procedures. The primary outcome was pain measured on a visual analogue scale twice daily during the blinded period. Secondary outcomes included duration of operation, technical performance score, complications, quality of life, cosmesis and patient satisfaction. Postoperative follow-up lasted 1 year.

Results

A total of 105 patients were randomized, 35 in each group. One conversion from a SP to a CL technique was necessary in a patient with chronic cholecystitis. Pain intensity was similar in the three groups, both during the blinded period (day 0 to 3; P = 0·865) and over the whole 7-day evaluation period (P = 0·911). The presence of clinically relevant between-group differences was ruled out (95 per cent confidence interval + 1·0 to − 0·5 for difference in pain scores between SP and CL groups, and − 0·8 to + 0·6 between ML and CL groups). Operating time was significantly longer for SP and ML than for CL cholecystectomy (P = 0·001). Postoperative complications included injury to the diaphragm (1), choledocholithiasis (1), wound infection (5) and hernia (1), all after SP cholecystectomy (P = 0·001). Twelve-month follow-up was complete in 99 patients (94·3 per cent). Cosmesis as rated by patients was significantly better at 6 months after SP and ML procedures (P = 0·043), but no difference was observed at 12 months (P = 0·229).

Conclusion

SP and ML cholecystectomy had no advantage over the CL approach in terms of postoperative outcome. Registration number: DRKS00000302 (German Registry of Clinical Trials).

Epidural technique for postoperative pain: gold standard no more?

Epidural analgesia is a well-established technique that has commonly been regarded as the gold standard in postoperative pain management. However, newer, evidence-based outcome data show that the benefits of epidural analgesia are not as significant as previously believed. There are some benefits in a decrease in the incidence of cardiovascular and pulmonary complications, but these benefits are probably limited to high-risk patients undergoing major abdominal or thoracic surgery who receive thoracic epidural analgesia with local anaesthetic drugs only. There is increasing evidence that less invasive regional analgesic techniques are as effective as epidural analgesia. These include paravertebral block for thoracotomy, femoral block for total hip and knee arthroplasty, wound catheter infusions for cesarean delivery, and local infiltration analgesia techniques for lower limb joint arthroplasty. Wound infiltration techniques and their modifications are simple and safe alternatives for a variety of other surgical procedures. Although pain relief associated with epidural analgesia can be outstanding, clinicians expect more from this invasive, high-cost, labour-intensive technique. The number of indications for the use of epidural analgesia seems to be decreasing for a variety of reasons. The decision about whether to continue using epidural techniques should be guided by regular institutional audits and careful risk-benefit assessment rather than by tradition. For routine postoperative analgesia, epidural analgesia may no longer be considered the gold standard.

Novel strategy for the control of postoperative pain: long-lasting effect of an implanted analgesic hydrogel in a rat model of postoperative pain

BACKGROUND

The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) is the most common nonopioid analgesic currently used for postoperative pain management. We tested the sustained analgesic effect of ketoprofen emanating from a biodegradable gelatin hydrogel in a rat model of postoperative pain.

METHODS

A sheet of analgesic-infiltrated hydrogel was inserted below the plantaris muscle at the end of surgery. Mechanical thresholds were measured by use of von Frey filaments before and 2 weeks after the operation. The effect of ketoprofen on the postoperative pain was also assessed immunohistochemically by assessing microglial activation in the spinal cord with anti-OX-42 and phosphorylated p38 mitogen-activated protein kinase antibodies.

RESULTS

Implantation of ketoprofen-infiltrated gelatin hydrogel exerted a sustained analgesic effect for 1 week after the operation. Preemptive analgesia with zaltoprofen, another NSAID, produced an additive analgesic effect in conjunction with the ketoprofen-infiltrated hydrogel. Microglial activation was attenuated by the treatment with ketoprofen-infiltrated hydrogel on day 3 after the incision.

CONCLUSIONS

These results demonstrate that ketoprofen was effective in reducing mechanical hypersensitivity for 1 week in a rat model of postoperative pain and that the implantation of NSAID-infiltrated gelatin hydrogel may serve as a useful analgesic method for the long-term relief of patients after surgery.

Esmolol versus ketamine-remifentanil combination for early postoperative analgesia after laparoscopic cholecystectomy: a randomized controlled trial

PURPOSE

Controversy surrounds the optimal technique to moderate pain after laparoscopic cholecystectomy (LC). Opioid analgesics, sympatholytic drugs, and adjuvants, such as ketamine, have all been used. We compared esmolol with a combination of remifentanil plus ketamine in patients undergoing LC to determine the impact of these drugs on morphine requirements and pain control.

METHODS

Sixty American Society of Anesthesiologists physical status I-II patients undergoing LC and anesthetized with sevoflurane were randomized to one of two groups. Group E patients received a bolus of esmolol 0.5 mg·kg(-1) iv at induction followed by an infusion of 5-15 μg·kg(-1)·min(-1), and Group R-K patients received a bolus of ketamine 0.5 mg·kg(-1) iv and remifentanil 0.5 μg·kg(-1) iv at induction followed by a remifentanil infusion titrated over a range of 0.1-0.5 μg·kg(-1)·min(-1). All patients received paracetamol, dexketoprofen, and levobupivacaine via infiltration of laparoscopic port sites. After surgery, a predetermined bolus of morphine was administered according to a verbal numerical rating scale (VNRS) for pain intensity. The primary outcome of interest was postoperative morphine requirement.

RESULTS

Median consumption of morphine was higher in Group R-K than in Group E (5 mg [4-6] vs 0 mg [0-2], respectively; P < 0.001). In the postanesthesia care unit, patients in Group R-K had higher pain scores than patients in Group E (difference in maximum VNRS, -11; 95% confidence interval (CI), -19 to -3). The concentration of sevoflurane to maintain a bispectral index~40 was higher in Group E than in Group R-K (between-group difference 0.3%; 95% CI, 0.15 to 0.40). The incidence of postoperative nausea and vomiting was similar between the two groups.

CONCLUSION

Intraoperative esmolol infusion reduces morphine requirements and provides more effective analgesia compared with a combination of remifentanil-ketamine given by infusion in patients undergoing LC.

[Wound infiltration with local anesthetics for postoperative analgesia. Results of a national survey about its practice in France]

BACKGROUND AND OBJECTIVE

Local wound infiltration is a component of multimodal postoperative (p.o.) analgesia. Its implementation in current clinical practice remains unknown. Pain and Regional Anesthesia Committee of the French Anaesthesia and Intensive Care Society (Sfar) aimed to appraise its practice.

METHOD

Postal sample survey based on representative sample of national activity were sent to heads of anaesthesiology departments. The questionnaires included 36 items on single-shot and continuous wound infiltrations (CWI) with considerations about modality of administration, drugs and development limitations. Results in mean [CI95 %].

RESULTS

Response rate was 32 % (n=120). Sample was in accordance with national representation of health institutions. Local infiltration was included in 85 % [79-91] of the p.o. analgesia protocols. Regardless of the surgery, single-shot wound infiltration and CWI were used in more than 50 % of the patients by respectively 58 % [49-67] and 18 % [11-25] of the responders. However, a significant part of the surgeons remained reluctant to CWI. Lack of information and fear of septic complications were the most reported barriers. Peritoneal instillation after laparoscopy was rarely performed, in contrast with intra-articular infiltration after knee arthroscopy, performed systematically or very frequently by 60 % [50-70] of the responders.

CONCLUSION

The practice of local wound infiltration for p.o. analgesia seems presently well established, especially for single-shot injections. CWI is less commonly performed. Several surgical reluctances remain to be overcome. Better information about effectiveness and safety are likely to still improve their practices.

Oral premedication with pregabalin or clonidine for hemodynamic stability during laryngoscopy and laparoscopic cholecystectomy: A comparative evaluation

BACKGROUND

Hemodynamic responses of laryngoscopy and laparoscopy should be attenuated by the appropriate premedication, smooth induction, and rapid intubation. The present study evaluated the clinical efficacy of oral premedication with pregabalin or clonidine for hemodynamic stability during laryngoscopy and laparoscopic cholecystectomy.

METHODS

A total of 180 healthy adult consented patients aged 35 to 52 years with American Society of Anesthesiologist (ASA) physical status I and II of both gender, who met the inclusion criteria for elective laparoscopic cholecystectomy, were randomized to receive placebo Group I, pregabalin (150 mg) Group II, or clonidine (200 μg) Group III, given 75 to 90 minutes before surgery as oral premedication. All groups were compared for preoperative sedation and anxiety level along with changes of heart rate and mean arterial pressure prior to premedication, before induction, after laryngoscopy, pneumoperitoneum, release of carbon dioxide, and extubation. Intraoperative analgesic drug requirement and any postoperative complications were also recorded.

RESULTS

Pregabalin and clonidine proved to have sedative and anxiolytic effects as oral premedicants and decreased the need of intraoperative analgesic drug requirement. Clonidine was superior to pregabalin for attenuation of the hemodynamic responses to laryngoscopy and laparoscopy, but it increased the incidence of intra-and postoperative bradycardia. No significant differences in the parameters of recovery were observed between the groups. None of the premedicated patient has suffered from any postoperative side effects.

CONCLUSION

Oral premedication with pregabalin 150 mg or clonidine 200 μg causes sedation and anxiolysis with hemodynamic stability during laryngoscopy and laparoscopic cholecystectomy, without prolongation of recovery time and side effects.

Intraperitoneal ropivacaine nebulization for pain management after laparoscopic cholecystectomy: a comparison with intraperitoneal instillation

BACKGROUND

Studies evaluating intraperitoneal local anesthetic instillation for pain relief after laparoscopic procedures have reported conflicting results. In this randomized, double-blind study we assessed the effects of intraperitoneal local anesthetic nebulization on pain relief after laparoscopic cholecystectomy.

METHODS

Patients undergoing elective laparoscopic cholecystectomy were randomly assigned to receive either instillation of ropivacaine 0.5%, 20 mL after induction of the pneumoperitoneum, or nebulization of ropivacaine 1%, 3 mL before and after surgery. Anesthetic and surgical techniques were standardized. Degree of pain at rest and on deep breathing, incidence of shoulder pain, morphine consumption, unassisted walking time, and postoperative nausea and vomiting were evaluated at 6, 24, and 48 hours after surgery.

RESULTS

Of the 60 patients included, 3 exclusions occurred for conversion to open surgery. There were no differences between groups in pain scores or in morphine consumption. No patients in the nebulization group presented significant shoulder pain in comparison with 83% of patients in the instillation group (absolute risk reduction -83, 95% CI -97 to -70, P<0.001). Nineteen (70%) patients receiving nebulization walked without assistance within 12 hours after surgery in comparison with 14 (47%) patients receiving instillation (absolute risk reduction -24, 95% CI -48 to 1, P=0.04). One (3%) patient in the instillation group vomited in comparison with 6 (22%) patients in the nebulization group (absolute risk reduction -19%, 95% CI -36 to -2, P=0.03).

CONCLUSIONS

Intraperitoneal ropivacaine nebulization was associated with reduced shoulder pain and unassisted walking time but with an increased incidence of postoperative vomiting after laparoscopic cholecystectomy.

Influence of preemptive analgesia on pulmonary function and complications for laparoscopic cholecystectomy

Pain and diaphragmatic dysfunction are the major reasons for postoperative pulmonary complications after upper abdominal surgery. Preoperative administration of analgesics helps to reduce and prevent pain. The objective of this study was first to research the rate of pulmonary complications for laparoscopic cholecystectomy (LC) and then analyze the influence of preemptive analgesia on pulmonary functions and complications. Seventy patients scheduled for elective LC were included in our double-blind, randomized, placebo-controlled, prospective study. Randomly, 35 patients received 1 g etofenamate (group 1) and 35 patients 0.9% saline (group 2) intramuscularly 1 h before surgery. All patients underwent physical examination, chest radiography, lung function tests, and pulse oxygen saturation measurements 2 h before surgery and postoperatively on day 2. Atelectasis was graded as micro, focal, segmental, or lobar. With preemptive analgesia, the need for postoperative analgesia decreased significantly in group 1. In both groups mean spirometric values were reduced significantly after the operation, but the difference and proportional change according to preoperative recordings were found to be similar [29.5 vs. 31.3% reduction in forced vital capacity (FVC) and 32.9 vs. 33.5% reduction in forced expiratory volume in 1 s (FEV(1)) for groups 1 and 2, respectively]. There was an insignificant drop in oxygen saturation rates for both groups. The overall incidence of atelectasia was similar for group 1 and 2 (30.2 vs. 29.2%). Although the degree of atelectesia was found to be more severe in the placebo group, the difference was not statistically significant. We concluded that although preemptive analgesia decreased the need for postoperative analgesia, this had no effect on pulmonary functions and pulmonary complications.

Repeated intraperitoneal instillation of levobupivacaine for the management of pain after laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis. Postoperative pain, however, can prolong hospital stay and lead to increased morbidity. In the context of a multimodal approach to analgesia, intraperitoneal local anesthetic administration optimizes analgesia and facilitates early postoperative recovery, and it may be associated with a decreased risk of side effects.

METHODS

A total of 71 patients was randomized to receive either intraperitoneal analgesic (IPA group) or not (controls). At the completion of cholecystectomy, 10 mL of levobupivacaine 0.5% were infused intraperitoneally in the IPA group and 8 h postoperatively, whereas in the controls, 10 mL of 0.9% NaCl were administered in the corresponding points of time. Differences in pain scores between groups were the primary endpoints. Opioid consumption and adverse effects were the secondary endpoints.

RESULTS

The 2 groups were homogenous in respect to age, sex, body mass index (BMI), and duration of operation. No conversion, complication, or mortality was recorded. The IPA group had a lesser visual analog scale score at rest and at movement compared with controls at all points of time measured. Moreover, fentanyl consumption in the recovery room was significantly greater in the control group, and the consumption of meperidine and the percentage of the patients that requested rescue analgesia in the ward was significantly greater in the control group. Local analgesic intraperitoneal injection as well as parecoxib for postoperative analgesia had no significant adverse effects.

CONCLUSION

Our study showed that 2 separate doses of intraperitoneally administered levobupivacaine significantly decreased postoperative pain and the need for opioids compared with placebo. This technique is simple, safe, and without adverse effects.

A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia

BACKGROUND

Thoracotomy induces severe postoperative pain and impairment of pulmonary function, and therefore regional analgesia has been intensively studied in this procedure. Thoracic epidural analgesia is commonly considered the "gold standard" in this setting; however, evaluation of the evidence is needed to assess the comparative benefits of alternative techniques, guide clinical practice and identify areas requiring further research.

METHODS

In this systematic review of randomized trials we evaluated thoracic epidural, paravertebral, intrathecal, intercostal, and interpleural analgesic techniques, compared to each other and to systemic opioid analgesia, in adult thoracotomy. Postoperative pain, analgesic use, and complications were analyzed.

RESULTS

Continuous paravertebral block was as effective as thoracic epidural analgesia with local anesthetic (LA) but was associated with a reduced incidence of hypotension. Paravertebral block reduced the incidence of pulmonary complications compared with systemic analgesia, whereas thoracic epidural analgesia did not. Thoracic epidural analgesia was superior to intrathecal and intercostal techniques, although these were superior to systemic analgesia; interpleural analgesia was inadequate.

CONCLUSIONS

Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral block with LA can be recommended. Where these techniques are not possible, or are contraindicated, intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of analgesia, which requires the use of supplementary systemic analgesia. Quantitative meta-analyses were limited by heterogeneity in study design, and subject numbers were small. Further well designed studies are required to investigate the optimum components of the epidural solution and to rigorously evaluate the risks/benefits of continuous infusion paravertebral and intercostal techniques compared with thoracic epidural analgesia.

Effect of paracetamol and coxib with or without dexamethasone after laparoscopic cholecystectomy

BACKGROUND

Pain after laparoscopic cholecystectomy (LCC) is multifactorial. Effective post-operative pain control is necessary in LCC performed as day-case surgery. We studied the efficacy of paracetamol or valdecoxib with or without dexamethasone after LCC.

METHODS

One hundred sixty patients were randomized to four groups of 40 patients. Groups 1 and 3 received parecoxib 40 mg intravenously (IV) during surgery and valdecoxib 40 mg x 1 per os (PO) for 7 post-operative days. Groups 2 and 4 received paracetamol 1 g x 4 IV during surgery and 1 g x 4 PO for 7 days. In addition, Groups 3 and 4 were given dexamethasone 10 mg IV intra-operatively. Propofol and remifentanil were used during surgery. The patients were given oxycodone 0.05 mg/kg IV in phase 1 post-anaesthesia care unit (PACU 1) or 0.15 mg/kg PO in phase 2 post-anaesthesia care unit (PACU 2) as needed to keep visual analogue scale <3/10. The patients were supplied with the study drugs for 7 post-operative days.

RESULTS

Pain intensity, nausea and the need of oxycodone in phase 1 PACU were similar in all groups. Dexamethasone reduced the need of oral oxycodone in phase 2 PACU (7.0 +/- 1.0 mg vs. 9.1 +/- 1.0 mg, P<0.05). Pain intensity was similar in all groups at home. More patients in the parecoxib/valdecoxib groups needed rescue medication on the 1st post-operative day (P<0.001) than paracetamol-treated patients.

CONCLUSION

Paracetamol was as effective as parecoxib/valdecoxib for pain after LCC. Dexamethasone decreased the need of oxycodone in phase 2 PACU. The effect of dexamethasone was similar in paracetamol and parecoxib/valdecoxib patients.