Efficacy of Intravenous Lidocaine During Endoscopic Submucosal Dissection for Gastric Neoplasm: A Randomized, Double-Blind, Controlled Study

Effect of intravenous lidocaine on outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: an updated systematic review and meta-analysis

BACKGROUND

Gastrointestinal endoscopic procedures (GEPs) are frequently employed for the diagnosis and treatment of various gastrointestinal ailments. While propofol sedation is widely used during these procedures, there is a concern regarding its potential negative effects. Intravenous (IV) lidocaine has been suggested as an add-on to propofol sedation for GEPs, but current evidence on its efficiency and safety is limited. This systematic review and meta-analysis aimed to assess the impact of IV lidocaine on outcomes in patients receiving propofol during GEPs.

METHODS

Electronic databases were screened for randomized controlled trials (RCTs), published up to 31 March 2023, investigating the effectiveness of intravenous lidocaine addition to propofol sedation during GEPs.

RESULTS

A total of 12 RCTs involving 712 patients that received IV lidocaine and propofol for GEF and 719 patients that received propofol were analyzed. Adding IV lidocaine to propofol sedation led to significant reduction in pain after the procedure (standardized mean difference (SMD) =  - 0.91, 95% confidence interval [CI]; - 1.51 to - 0.32), decreased propofol usage (SMD =  - 0.89; 95% CI, - 1.31 to - 0.48), lower recovery time (SMD =  - 0.95 min; 95% CI, - 1.48 to - 0.43), and decreased pain score (SMD =  - 0.91; 95% CI, - 1.51 to - 0.32). The overall rate of adverse events was markedly less in the lidocaine group than in the control group (RR = 0.74; 95% CI, 0.56 to 0.99).

CONCLUSION

Our results show that IV lidocaine improves patient outcomes by reducing post-procedural pain, decreasing propofol usage, shortening recovery time, and lowering pain scores. This study provides compelling evidence supporting the use of intravenous lidocaine as an adjunct to propofol sedation for gastrointestinal endoscopic procedures. However, further research is necessary to optimize the use of lidocaine and fully understand its long-term effects.

Effects of transcutaneous electrical acupoint stimulation (TEAS) on postoperative pain in patients undergoing gastric and esophageal ESD surgery: a study protocol for a prospective randomized controlled trial

BACKGROUND

Post-operative pain of endoscopic submucosal dissection (ESD) is always be overlooked and undertreated by endoscopists. However, the incidence of moderate to severe pain after ESD is as high as 44.9% to 62.8%, which can greatly affect the patient's recovery, reduce their satisfaction, and extend their hospital stay. Transcutaneous electrical acupoint stimulation (TEAS) have been shown to reduce postoperative pain and enhance gastrointestinal (GI) function recovery in patients undergoing abdomen surgery. However, there is no evidence regarding on the effect of TEAS on post-operative pain and complications in patients undergoing ESD. Therefore, we aim to investigate whether perioperative TEAS treatment is superior to the sham acupuncture in terms of post-ESD pain and GI function recovery.

METHODS

This study is a prospective, randomized controlled trail, which is single-blinded and in single center. A total of 120 patients undergoing elective gastric and esophageal ESD surgery in Beijing Friendship Hospital, Capital Medical University, will be involved in this study. These individuals will be stratified according to the type of ESD surgery (i.e. gastric or esophageal procedure) and be randomly divided into two groups. L14, PC6, ST36 and ST37 will be stimulated at the TEAS treatment group, and the control group will receive simulation at four sham acupoints. The primary outcome is post-EDS VAS score at the time of entering PACU, 10 min, 20 min, 30 min, 1 h, 2 h, 4 h, 6 h, 18 h, 24 h, 48 h after the surgery. The secondary outcomes include the anesthesia-associated parameters, sedation score, nausea and vomiting score, shivering score, recovery of gastrointestinal function, satisfaction of patients to anesthesia, incidence of postoperative complications, QLQ-C30 life quality scale, and the economic indicators.

DISCUSSION

The results of this study will confirm that continuous preventive application of TEAS can alleviate the postoperative pain among patients with gastric and esophageal ESD surgery and accelerate the recovery of post-ESD gastrointestinal function.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ID: ChiCTR2100052837, registered on November 6, 2021. http://www.chictr.org.cn/showproj.aspx?proj=135892 .

Can intravenous lidocaine definitely attenuate propofol requirement and improve outcomes among colonoscopic patients under intravenous sedation?: A double-blinded, randomized controlled trial

BACKGROUND

Propofol-sparing effect of lidocaine has not been fully elucidated because propofol is usually mixed with many medications in anesthetic practice. Therefore, the study aimed to verify the additive effect of intravenous lidocaine to propofol without other sedative medications and control the depth of anesthesia using the bispectral index (BIS) during colonoscopy in a prospective, randomized, double-blinded controlled trial.

METHODS

Sixty-eight patients scheduled and undergoing colonoscopy were randomly allocated to receive intravenous lidocaine (1.5 mg/kg then 4 mg/kg/h) (Group L) or a similar volume of normal saline (Group C) with propofol administration guided by BIS monitoring. The primary outcome was total propofol requirements between group comparisons. The secondary outcomes included the number of hypoxemic periods, hemodynamic changes, duration in returning of BIS > 85, sedation scores, pain scores, postoperative opioid requirement, and patient satisfaction between group comparisons.

RESULTS

Intravenous lidocaine showed significantly reduced total propofol use (151.76 ± 50.78 mg vs 242.06 ± 50.86 mg, Group L vs Group C, respectively, P < .001). Duration in returning to BIS > 85, sedation scores, and patient satisfaction scores were significantly superior in Group L (P < .05). The number of hypoxemic episodes, changes of hemodynamic response, pain scores, and postoperative opioid requirement were similar in both groups. No adverse effects were detected in both groups.

CONCLUSION

Intravenous lidocaine produced a definitely effective reduced propofol requirement without other sedative agents and improved outcomes including patient satisfaction, duration in returning to BIS > 85, and sedation score during colonoscopy without adverse effects.

Comparing Different Anesthesia Methods on Anesthetic Effect and Postoperative Pain in Patients with Early Gastric Cancer during Endoscopic Submucosal Dissection

Endoscopic submucosal dissection (ESD) is a minimally invasive technique to completely peel the pathological mucosa from the submucosa under endoscopy, which has been often utilized to treat early gastric cancer. During the operation, anesthesia is required to reduce the discomfort due to the complexity, high risk, and longtime operation of ESD. In this study, we compared different anesthesia methods on anesthetic effect and postoperative pain in patients (≥65 years old) with early gastric cancer during ESD. For this purpose, 60 patients with early gastric cancer who were more than 65 years old were selected from January 2019 to December 2021, where 30 patients treated with simple intravenous general anesthesia were divided into the simple group and 30 patients treated with intravenous combined inhalation general anesthesia were regarded as the composite group. The hemodynamic index, wake-up time, postoperative pain intensity, operation time, and the incidence of adverse reactions were compared between the two groups. For the hemodynamic index before incision, after incision, and at the end of the operation, the mean arterial pressure (MAP) in the composite group was higher than that in the simple group (P < 0.05) and the heart rate (HR) was lower than that in the simple group (P < 0.05). After the ESD operation, the wake-up time and visual analogue scale (VAS) in the composite group were lower than those in the simple group (P < 0.05). In addition, the ESD operation time and incidence of adverse reactions in the composite group was significantly lower than that in the simple group (P < 0.05). These results showed that intravenous combined inhalation general anesthesia had a good anesthetic effect, stable hemodynamics during ESD operation, and slight postoperative pain.

Anesthesia for digestive tract endoscopy

PURPOSE OF REVIEW

Nonoperating room anesthesia for digestive tract endoscopy has its own specificities and requires practical training. Monitoring devices, anesthetic drugs, understanding of procedures and management of complications are critical aspects.

RECENT FINDINGS

New data are available regarding risk factors for intra- and postoperative complications (based on anesthesia registries), airway management, new anesthetic drugs, techniques of administration and management of advances in interventional endoscopy procedures.

SUMMARY

Digestive tract endoscopy is a common procedure that takes place outside the operating room most of the time and has become more and more complex due to advanced invasive procedures. Prior evaluation of the patient's comorbidities and a good understanding of the objectives and constraints of the endoscopic procedures are required. Assessing the risk of gastric content aspiration is critical for determining appropriate anesthetic protocols. The availability of adequate monitoring (capnographs adapted to spontaneous ventilation, bispectral index), devices for administration of anesthetic/sedative agents (target-controlled infusion) and oxygenation (high flow nasal oxygenation) guarantees the quality of sedation and patient' safety during endoscopic procedures. Knowledge of the specificities of each interventional endoscopic procedure (endoscopic retrograde cholangiopancreatography, submucosal dissection) allows preventing complications during anesthesia.

Intravenous Lidocaine Infusion Reduce Post-operative Pain and Length of Hospital in Elderly Patients Undergoing Surgery: Meta-analysis of Randomized Controlled Trials

Objective. It is debated wheter intravenous (IV) lidocaine improves post-operative pain and has other potential benefits in elderly patients. This systematic review and meta-analysis aimed to estimate the effect of perioperative continuous IV lidocaine in elderly patients undergoing surgery. Method. PubMed/Medline, Web of Science, Embase, and CENTRAL databases (through OVID SP) were searched independently until October 10, 2020 by two authors. We included all randomized controlled trials that compared the effect of continuous IV lidocaine and any placebo or no treatment in elderly patients after surgery. Primary outcomes were length of hospital stay and post-operative pain score. Results. Eighteen studies (988 patients) were included. Meta-analysis suggested that IV lidocaine reduced the post-operative pain scores 2 hours (standardized mean difference [SMD]: −1.58, 95% confidence interval [CI]: −2.03 to −1.13), 4 hours (SMD:−1.20, 95% CI: −2.02 to −.39), 8 hours (SMD:−.82, 95% CI: −1.51 to −.13), 12 hours (SMD:−.66, 95% CI: −1.28 to −.04), and 24 hours (SMD:−.42, 95% CI: −.72 to −.12) post-operatively. Moreover, those patients given IV lidocaine had a shorter length of hospital stay (MD: −.24, 95% CI: −.71 to −.23) and required fewer opioid drugs (SMD: −.31, 95% CI: −.31 to −.01). Conclusion. The evidence suggested that IV lidocaine significantly reduced post-operative pain intensity and opioid consumption and shortened the length of hospital stay in elderly patients. IV lidocaine decreased the incidence of post-operative nausea while it could not reduce the incidence of post-operative vomiting and accelerate the recovery of gastrointestinal function.

Impact of intravenous and topical lidocaine on clinical outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: a meta-analysis of randomised controlled trials

BACKGROUND

The efficacy of i.v. or topical lidocaine as an anaesthesia adjunct in improving clinical outcomes in patients receiving gastrointestinal endoscopic procedures under propofol sedation remains unclear.

METHODS

Electronic databases (MEDLINE, EMBASE, and Cochrane Library) were searched for RCTs comparing the clinical outcomes with or without lidocaine application (i.v. or topical) in patients receiving propofol for gastrointestinal endoscopic procedures from inception to 29 March 2021. The primary outcome was propofol dosage, while secondary outcomes included procedure time, recovery time, adverse events (e.g. oxygen desaturation), post-procedural pain, and levels of endoscopist and patient satisfaction.

RESULTS

Twelve trials (1707 patients) published between 2011 and 2020 demonstrated that addition of i.v. (n=7) or topical (n=5) lidocaine to propofol sedation decreased the level of post-procedural pain (standardised mean difference [SMD]=-0.47, 95% confidence interval [CI]: -0.8 to -0.14), risks of gag events (risk ratio [RR]=0.51, 95% CI: 0.35-0.75), and involuntary movement (RR=0.4, 95% CI: 0.16-0.96). Subgroup analysis demonstrated that only i.v. lidocaine reduced propofol dosage required for gastrointestinal endoscopic procedures (SMD=-0.83, 95% CI: -1.19 to -0.47), increased endoscopist satisfaction (SMD=0.75, 95% CI: 0.21-1.29), and shortened the recovery time (SMD=-0.83, 95% CI: -1.45 to -0.21). Intravenous or topical lidocaine did not affect the incidence of oxygen desaturation (RR=0.72, 95% CI: 0.41-1.24) or arterial hypotension (RR=0.6, 95% CI: 0.22-1.65) and procedure time (SMD=0.21, 95% CI: -0.09 to 0.51).

CONCLUSION

This meta-analysis demonstrated that i.v. or topical lidocaine appears safe to use and may be of benefit for improving propofol sedation in patients undergoing gastrointestinal endoscopic procedures. Further large-scale trials are warranted to support our findings.

Efficacy and safety of supplemental intravenous lidocaine for sedation in gastrointestinal endoscopic procedures: systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Some studies have shown that intravenous (IV) lidocaine reduces the dose requirement of propofol in GI endoscopic procedures. We conducted this study to evaluate the efficacy and safety of the combination of IV lidocaine and propofol compared with propofol alone in GI endoscopic procedures.

METHODS

We reviewed several databases from inception to October 13, 2020, to identify randomized controlled trials (RCTs) that compared the role of IV propofol and lidocaine with IV propofol plus placebo for sedation in endoscopic procedures. Our outcomes of interest were the differences in total dose of propofol administered, procedure time, and intraoperative adverse events. For categorical variables, we calculated pooled risk ratios with 95% confidence intervals (CI); for continuous variables, we calculated standardized mean difference (SMD) with 95% CI. Data were analyzed using a random effect model. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework to ascertain the quality of evidence.

RESULTS

We included 5 randomized controlled trials with 318 patients. We found that the total dose of propofol administered was significantly lower in the lidocaine group than the control group (SMD, -0.76; 95% CI, -1.09 to -0.42). We found no significant difference in procedure time (SMD, 0.16; 95% CI, -0.26 to 0.57) or adverse events (risk ratio, 0.60; 95% CI, 0.35-1.03) between the groups. There was moderate to substantial heterogeneity in the data. Quality of evidence based on the GRADE framework ranged from low to moderate.

CONCLUSIONS

Moderate quality of evidence suggests that IV lidocaine decreases the dose of propofol administered for GI endoscopic procedures.

Effect of intravenous lidocaine on short-term pain after hysteroscopy: a randomized clinical trial

Background

The role of intravenous lidocaine infusion in endoscopic surgery has been previously evaluated for pain relief and recovery. Recently, it has been shown to reduce postoperative pain and opioid in patients undergoing endoscopic submucosal dissection. Similar to endoscopic submucosal dissection, operative hysteroscopy is also an endoscopic surgical procedure within natural lumens. The present study was a randomized clinical trial in which we evaluated whether intravenous lidocaine infusion would reduce postoperative pain in patients undergoing hysteroscopic surgery.

Objective

To evaluate whether intravenous lidocaine infusion could reduce postoperative pain in patients undergoing operative hysteroscopy.

Methods

Eighty-five patients scheduled to undergo elective hysteroscopy were randomized to receive either an intravenous bolus of lidocaine 1.5 mg.kg^-1 over 3 minutes, followed by continuous infusion at a rate of 2 mg.kg^-1. h^-1 during surgery, or 0.9% normal saline solution at the same rate. The primary outcome was to evaluate postoperative pain by Visual Analog Scale (VAS). Secondary outcomes included remifentanil and propofol consumption.

Results

In the lidocaine group, the VAS was significantly lower at 0.5 hour (p = 0.008) and 4 hours (p = 0.020). Patients in the lidocaine group required less remifentanil than patients in the control group (p < 0.001). However, there was no difference between the two groups in the propofol consumption. The incidence of throat pain was significantly lower in the lidocaine group (p = 0.019). No adverse events associated with lidocaine infusion were discovered.

Conclusion

Intravenous lidocaine infusion as an adjuvant reduces short-term postoperative pain in patients undergoing operative hysteroscopy.

Impact of BMI on Complications of Gastric Endoscopic Submucosal Dissection

BACKGROUND

Gastric endoscopic submucosal dissection (ESD) has a high rate of complications. However, it is unclear whether BMI affects ESD complications. We aimed to investigate the impact of BMI on ESD complications.

METHODS

A total of 7,263 patients who underwent gastric ESD were classified into 3 groups according to the Asia-Pacific classification of BMI: normal (BMI <23 kg/m2, n = 2,466), overweight (BMI 23-24.9 kg/m2, n = 2,117), and obese (BMI ≥25 kg/m2, n = 2,680). Adjusted logistic regression analyses were conducted to assess the association between BMI and ESD complications.

RESULTS

Compared to the normal group, a lower incidence of perforation and a higher incidence of pneumonia and leukocytosis were found in the overweight and obese groups, and intra-ESD desaturation and hypertension were more frequent in the obese group. After adjustment for confounders, the risk of perforation significantly decreased in the overweight (odds ratio [OR] = 0.24, 95% confidence interval [CI]: 0.17-0.33) and obese (OR = 0.12, 95% CI: 0.08-0.18) groups compared to that in the normal group. Meanwhile, the risk of pneumonia significantly increased in the overweight (OR = 11.04, 95% CI: 6.31-19.31) and obese (OR = 10.71, 95% CI: 6.14-18.66) groups compared to the normal group. During sedation, the obese group had a significantly increased risk of desaturation (OR = 2.81, 95% CI: 1.18-6.69) and hypertension (OR = 1.35, 95% CI: 1.11-1.63) compared to the normal group.

CONCLUSIONS

High BMI was significantly associated with ESD complications. More caution is needed in cases of obese patients undergoing ESD.

The influence of voltage-gated sodium channels on human gastrointestinal nociception

BACKGROUND

Abdominal pain is a frequent and persistent problem in the most common gastrointestinal disorders, including irritable bowel syndrome and inflammatory bowel disease. Pain adversely impacts quality of life, incurs significant healthcare expenditures, and remains a challenging issue to manage with few safe therapeutic options currently available. It is imperative that new methods are developed for identifying and treating this symptom. A variety of peripherally active neuroendocrine signaling elements have the capability to influence gastrointestinal pain perception. A large and growing body of evidence suggests that voltage-gated sodium channels (VGSCs) play a critical role in the development and modulation of nociceptive signaling associated with the gut. Several VGSC isoforms demonstrate significant promise as potential targets for improved diagnosis and treatment of gut-based disorders associated with hyper- and hyposensitivity to abdominal pain.

PURPOSE

In this article, we critically review key investigations that have evaluated the potential role that VGSCs play in visceral nociception and discuss recent advances related to this topic. Specifically, we discuss the following: (a) what is known about the structure and basic function of VGSCs, (b) the role that each VGSC plays in gut nociception, particularly as it relates to human physiology, and (c) potential diagnostic and therapeutic uses of VGSCs to manage disorders associated with chronic abdominal pain.

Impact of postoperative analgesia with dezocine plus ropivacaine versus fentanyl plus ropivacaine on stress response and immune function in patients with gastric cancer

AIM

To investigate the effect of postoperative analgesia with dezocine combined with ropivacaine and fentanyl combined with ropivacaine on stress response and immune function in patients with gastric cancer.

METHODS

Eighty-eight patients with gastric cancer who underwent surgery from November 2016 to October 2017 at Tongji Hospital were randomly divided into an observation group and a control group, with 44 cases in each group. The patients in the observation group were given dexrazoxane 30 mg + 0.75% ropivacaine 20 mL + 100 mL 0.9% sodium chloride injection for analgesia; the control group was given fentanyl 8 μg + 0.75% ropivacaine 20 mL + 100 mL 0.9% sodium chloride injection. The analgesic effects at 4, 12, 24, and 48 h after operation were compared between the two groups. Serum levels of interleukin (IL)-6, IL-2, tumor necrosis factor α (TNF-α), monocyte chemotactic protein-1 (MCP-1), and high mobility group box-1 (HMGB-1), plasma levels of endothelin (ET) and AngⅡ, and the levels of CD3⁺, CD4⁺, CD8⁺ T cells, and natural killer cells (NK) in immune cells were compared in the two groups before and after surgery. Adverse reactions within 48 h after surgery such as dizziness, nausea, and respiratory depression were recorded.

RESULTS

Visual acuity scores in the observation group at 4, 12, 24, and 48 h after operation were significantly lower than those in the control group (t = 4.636, 4.399, 7.084, 11.022, P < 0.05). Serum levels of IL-6, TNF-α, MCP-1, and HMGB-1 in the observation group at 24 and 48 h after operation were significantly lower than those in the control group, and the levels of IL-2 in the observation group were significantly higher than those in the control group (t_{24 h} = 14.544, 18.041, 17.154, 14.143, 15.797, t_{48 h} = 17.016, 18.838, 9.389, 17.821, 19.497, P < 0.05). Plasma levels of ET and Ang Ⅱ in the observation group at 24 and 48 h after operation were significantly lower than those in the control group (t_{24 h} = 3.900, 2.784, t_{48 h} = 2.816, 2.122, P < 0.05). The levels of CD3⁺, CD4⁺ T cells, and NK cells in immune cells in the observation group at 24 h after operation were significantly higher than those in the control group (t = 5.767, 2.716, 2.978, P < 0.05). There was no significant difference in CD8+ T cells between the two groups before and after operation (t = 0.316, P > 0.05). Within 48 h after operation, the incidence of adverse reactions in the observation group was significantly lower than that in the control group (11.36% vs 29.55%, χ² = 4.469, P < 0.05).

CONCLUSION

Postoperative analgesia with dezocine plus ropivacaine is effective in patients with gastric cancer, which can reduce stress response and inflammatory cytokines and improve immune function.