The Use of Intraperitoneal Bupivacaine in Laparoscopic Roux-en-Y Gastric Bypass: a Double-blind, Randomized Controlled Trial

Single-Shot Regional Anesthesia for Bariatric Surgery: a Systematic Review and Network Meta-Analysis

PURPOSE

Laparoscopic bariatric surgeries can cause intense postoperative pain. Opioid medication can alleviate the pain but can have harmful side effects especially in patients with obstructive sleep apnea. To promote early recovery, enhanced recovery after surgery guideline advises minimizing opioid use and opting for alternative analgesics. This paper aims to investigate the effect of regional anesthesia techniques through a systematic review and network meta-analysis. Primary outcome is postoperative morphine equivalent consumption at 24 h.

METHODS

Search was conducted in the following databases: PubMed, CENTRAL, Scopus, and EMBASE, from the inception until 10 January 2023. The eligibility criteria were determined by PICOS, including postoperative opioid consumption, pain scores, time to ambulate, use of additional analgesics, and adverse events. The quality assessment was performed using the Risk of Bias 2 Tool, and the certainty of evidence was assessed using the GRADE approach. Funnel plots were used to evaluate publication bias.

RESULTS

We included 22 studies in quantitative synthesis. A review of 12 studies found that all techniques had a lower mean consumption of opioids compared to placebo or no intervention, with TAP block having the greatest reduction. The quality of evidence for postoperative pain, PONV, time to deambulate, and use of rescue analgesics, was rated as moderate, with TAP block being the most effective intervention. There was no publication bias in any outcome.

CONCLUSIONS

TAP block is superior to other regional anesthesia techniques in reducing opioid consumption, pain, PONV, and use of rescue analgesics in bariatric surgery. However, further research is needed.

Effect of Intraperitoneal Local Anesthetics in Laparoscopic Bariatric Surgery: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The effectiveness of intraperitoneal local anesthesia (IPLA) has been confirmed in other fields, but its use in bariatric surgery remains debatable. This study aimed to evaluate the analgesic effect of IPLA in bariatric surgery.

METHODS

PubMed, Web of Science, Embase, and the Cochrane Library were searched from inception to February 2022. All randomized controlled trials (RCTs) assessing IPLA's analgesic effect in bariatric surgery were included in this study. Pain-related indicators were the outcome.

RESULTS

Ten RCTs with 979 patients were included. Postoperative pain scores were significantly lower in IPLA group. Subgroup analysis demonstrated that IPLA was associated with lower pain scores in 6 h and at 24 h compared to the control group, without significant differences at 8, 12, and 48 h. Meanwhile, IPLA reduced the dose of opioids taken postoperatively. Additionally, there were no differences in adverse events between the two groups. As far as the number of postoperative analgesics used and hospital stays were concerned, our results did not show statistical differences between the two groups.

CONCLUSION

IPLA can reduce postoperative pain safely and effectively, particularly during the early postoperative stage.

Intraperitoneal Instillation of Local Anesthetic (IPILA) in Bariatric Surgery and the Effect on Post-operative Pain Scores: a Randomized Control Trial

BACKGROUND

Effective analgesia after bariatric procedures is vital as it can reduce post-operative opioid use. This leads to less nausea which may be associated with shorter post-operative length of stay (LOS). Understanding analgesic requirements in patients with obesity is important due to the varied physiology and increased number of comorbidities.

OBJECTIVES

The aim of this study was to evaluate the efficacy of intraperitoneal instillation of local anesthetic (IPILA) to reduce opioid requirements in patients undergoing laparoscopic bariatric surgery.

METHODS

A double-blinded randomized control trial was conducted to compare intraperitoneal instillation of ropivacaine to normal saline in 104 patients undergoing bariatric surgery. The primary endpoint was pain in recovery with secondary endpoints at 1, 2, 4, 6, 24, and 48 h post-operatively. Further endpoints were post-operative analgesic use and LOS. Safety endpoints included unexpected reoperation or readmission, complications, and mortality.

RESULTS

There were 54 patients in the placebo arm and 50 in the IPILA. Pain scores were significantly lower in the IPILA group both at rest (p = 0.04) and on movement (p = 0.02) in recovery with no difference seen at subsequent time points. Equally, IPILA was independently associated with reducing severe post-operative pain at rest and movement (adjusted odds ratio [aOR] 0.28, 95% CI 0.11-0.69, p = 0.007 and aOR 0.25, 95% CI 0.09-0.62, p = 0.004, respectively). There was no significant difference in LOS, opioid use, antiemetic use, morbidity, or mortality between the intervention and placebo groups.

CONCLUSION

The administration of ropivacaine intraperitoneally during laparoscopic bariatric surgery reduces post-operative pain in the recovery room but does not reduce opioid use nor LOS.

Efficacy of intraperitoneal bupivacaine in laparoscopic bariatric surgery

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In [patients undergoing bariatric surgery], is [intraperitoneal local bupivacaine during the operation ] associated with [ lower pain score and decrease in post operative pain medications]?

The search has been done and six randomized trial studies are considered to be appropriate to answer this question. The outcome assessed is the value of intraperitoneal bupivacaine in bariatric surgery in terms of effect on the pain score and post operative analgesia. We concluded that intraperitoneal bupivacaine causes improvement in both the pain score and post operative analgesia.

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Use of intraperitoneal bupivacaine, during bariatric procedures, improves post operative pain score.

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There is decrease in the post operative analgesia when intraperitoneal bupivacaine is used in the bariatric operations.

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Different ways can be used to apply intraperitoneal bupivacaine in the bariatric surgery field.

Transversus Abdominis Plane Block Versus Intraperitoneal Local Anesthetics in Bariatric Surgery: A Systematic Review and Network Meta-analysis

BACKGROUND

Transversus abdominis plane (TAP) block and intraperitoneal local anesthetics (IPLA) are widely investigated techniques that potentially improve analgesia after bariatric surgery. The analgesic efficacy of TAP block has been shown in previous studies, but the performance of TAP block can be difficult in patients with obesity. We performed a systematic review and meta-analysis to compare the analgesic efficacy of TAP block and IPLA. An alternative technique is useful in clinical setting when TAP block is not feasible.

METHODS

We searched PubMed, Embase, and CENTRAL from inception until August 2020 for randomized controlled trials comparing both techniques. The primary outcome was cumulative morphine consumption at 24 h. Secondary pain-related outcomes included pain score at rest and on movement at 2, 6, 12, and 24 h; postoperative nausea and vomiting; and length of hospital stay.

RESULTS

We included 23 studies with a total of 2,178 patients. TAP block is superior to control in reducing opioid consumption at 24 h, improving pain scores at all the time points and postoperative nausea and vomiting. The cumulative opioid consumption at 24 h for IPLA is less than control, while the indirect comparison between IPLA with PSI and control showed a significant reduction in pain scores at rest, at 2 h, and on movement at 12 h, and 24 h postoperatively.

CONCLUSIONS

Transversus abdominis plane block is effective for reducing pain intensity and has superior opioid-sparing effect compared to control. Current evidence is insufficient to show an equivalent analgesic benefit of IPLA to TAP block.

Biodegradable polymer-nanoclay composites as intestinal sleeve implants installed in digestive tract for obesity and type 2 diabetes treatment

Obesity and type 2 diabetes have become serious health problems in 21st century. Development of non-invasive treatment to treat obesity and type-2 diabetes is still unmet needs. For targeting on this, one of the promising treatments is to implant an intestine sleeve in the gastrointestinal tract for limitation of food absorption. In this context, biodegradable polymer intestine sleeve was composed of polycaprolactone (PCL), poly-DL-lactic acid (PDLLA) and disk-shape nano-clay (Laponite®), and fabricated as an implantable device. Here, Laponite® as a rheological additive to improve the compatibility of PCL and PDLLA, and the polymers/clay composites were also evaluated by scanning electron microscopy SEM analysis and mechanical measurements. The mass ratio 90/10/1 of PCL/PDLLA/Laponite® composite was selected for fabrication of intestine sleeve, because of the highest toughness and flexibility, which are tensile strength of 91.9 N/mm² and tensile strain of 448% at the failure point. The prepared intestine sleeve was implanted and deployed at the duodenum in type2 diabetic rats, providing significant benefits in control of the body weight and blood glucose, while compared with the non-implanted type 2 diabetic rats. More importantly, the food intake records and histopathological section reports presented that the implanted rats still have normal appetites and no noticeable acute symptoms of inflammation in the end of the test. These appreciable performances suggested the implantation of biocompatible polymer composites has a highly potential treatment for obesity and type 2 diabetes.

Effect of intraperitoneal bupivacaine on postoperative pain in laparoscopic bariatric surgeries

BACKGROUND

Postoperative pain has many adverse effects and, if not properly controlled, it may lead to a wide range of complications. Opioids, as frequently used drugs for pain control, have some serious respiratory and gastrointestinal complications, especially in obese patients.

OBJECTIVES

In this study, we planned to evaluate the effect of intraperitoneal bupivacaine lavage on postoperative pain in laparoscopic bariatric surgeries.

SETTING

The study was conducted in Firoozgar Hospital (affiliated to Iran University of Medical Sciences), Tehran, Iran.

METHODS

In this clinical trial, 106 patients scheduled for laparoscopic bariatric surgery, randomly assigned to receive either intraperitoneal lavage with 50 mL of .2% bupivacaine or the same volume of normal saline during the operation. One-gram intravenous paracetamol was infused for all patients at the end of surgery, and all patients received intravenous paracetamol infusion for 1 day after surgery. Pain level, assessed by visual analog scale, was recorded at 1, 4, 8, and 24 hours after surgery. Total additive analgesics administered during the first day after surgery was also recorded.

RESULTS

The pain score during the first 24 hours after surgery decreased significantly in both groups, but comparing the groups showed that pain level at 1, 4, 8, and 24 hours after surgery in the bupivacaine group was significantly lower than the normal saline group (P < .05). Also, opioid consumption during 24 hours was significantly lower in the bupivacaine group (P < .001).

CONCLUSIONS

Intraperitoneal lavage with bupivacaine is an effective approach to control postoperative pain in obese patients undergoing laparoscopic bariatric surgery.