Pharmacological Methods of Postoperative Pain Management After Laparoscopic Cholecystectomy: A Review of Meta-analyses

Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

Preoperative Bilateral External Oblique Intercostal Plus Rectus Sheath Block for Postoperative Pain Management Following Laparoscopic Cholecystectomy: A Noninferior Double-Blind Placebo-Controlled Trial

OBJECTIVES

The transversus abdominis plane (TAP) block has proven efficacy and is an important component of multimodal analgesia in laparoscopic cholecystectomy (LC). The external oblique intercostal (EOI) block can provide a dermatomal sensory blockade of T6 to T10 using an anterior axillary line injection. The bilateral rectus sheath (RS) block can significantly reduce early postoperative pain caused by umbilical or periumbilical incisions. The current study aimed to compare the analgesic efficacies of ultrasound-guided subcostal TAP (UG-TAP) combined with the RS block and ultrasound-guided EOI (UG-EOI) combined with the RS block for LC.

METHODS

Patients were randomly assigned to TAP or EOI group. Patients in TAP group received UG-TAP combined with an RS block. Patients in EOI group received UG-EOI combined with an RS block. The primary outcome was postoperative 24-hour sufentanil consumption.

RESULTS

A total of 49 patients were included in the final analysis. The postoperative 24-hour sufentanil consumption in the EOI group was significantly lower than that in the TAP group (9.79±10.22 vs. 18.67±12.58 µg; P [noninferiority] <0.01; noninferiority confirmed). Fewer patients in the EOI versus TAP group had a numerical rating score of >3 during motion. Furthermore, the mean postoperative 48-hour sufentanil consumption was lower in the EOI versus TAP group (11.54±11.70 vs. 23.04±17.10 µg; P =0.01). The mean postoperative 24-hour Quality of Recovery-15 score was higher in the EOI versus TAP group (135.21±4.40 vs. 131.91±5.11; P =0.02).

DISCUSSION

These findings suggest that UG-EOI combined with an RS block was superior to UG-TAP combined with an RS block for postoperative pain management in patients undergoing LC.

Analgesic benefits of pre-operative versus postoperative transversus abdominis plane block for laparoscopic cholecystectomy: a frequentist network meta-analysis of randomized controlled trials

BACKGROUND

Transversus abdominis plane (TAP) block has been utilized to alleviate pain following laparoscopic cholecystectomy (LC). However, the optimal timing of administration remains uncertain. This study aimed to compare the efficacy of pre-operative and postoperative TAP blocks as analgesic options after LC.

METHODS

A frequentist network meta-analysis of randomized controlled trials (RCTs) was conducted. We systematically searched PubMed (via the National Library of Medicine), EMBASE, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science up to March 2023. The study included RCTs that enrolled adult patients (≥ 18 years) who underwent LC and received either pre-operative or postoperative TAP blocks. The primary outcome assessed was 24-hour postoperative morphine consumption (mg). Additionally, pain rest scores within 3 hours, 12 hours, and 24 hours, as well as postoperative nausea and vomiting (PONV), were considered as pre-specified secondary outcomes.

RESULTS

A total of 34 trials with 2317 patients were included in the analysis. Postoperative TAP block demonstrated superiority over the pre-operative TAP block in reducing opioid consumption (MD 2.02, 95% CI 0.87 to 3.18, I2 98.6%, p < 0.001). However, with regards to postoperative pain, neither pre-operative nor postoperative TAP blocks exhibited superiority over each other at any of the assessed time points. The postoperative TAP block consistently ranked as the best intervention using SUCRA analysis. Moreover, the postoperative TAP block led to the most significant reduction in PONV.

CONCLUSIONS

The findings suggest that the postoperative TAP block may be slightly more effective in reducing 24-hour postoperative opioid consumption and PONV when compared to the pre-operative TAP block.

TRIAL REGISTRATION

PROSPERO, CRD42023396880 .

Efficacy of intraoperative intravenous lidocaine infusion on postoperative opioid consumption after laparoscopic cholecystectomy: a randomized controlled trial

PURPOSE

We designed this study to evaluate the impact of intraoperative intravenous lidocaine infusion on postoperative opioid consumption after laparoscopic cholecystectomy.

METHODS

In total, 98 patients scheduled for elective laparoscopic cholecystectomy were included and randomized. In the experimental group, intravenous lidocaine (bolus 1.5 mg/kg and continuous infusion 2 mg/kg/h) was administered intraoperatively additionally to the standard analgesia, whereas the control group received a matching placebo. Blinding existed at the level of both the patient and the investigator.

RESULTS

Our study failed to confirm any benefit in opioid consumption, during the postoperative period. Lidocaine resulted to reduced intraoperative systolic, diastolic, and mean arterial pressure. Lidocaine administration did not change postoperative pain scores or the incidence of shoulder pain, at any time endpoint. Moreover, we did not identify any difference in terms of postoperative sedation levels and nausea rates.

CONCLUSION

Overall, lidocaine did not have any effect on postoperative analgesia after laparoscopic cholecystectomy.

Determining a Method to Minimize Pain After Laparoscopic Cholecystectomy Surgery

BACKGROUND

Although many studies have investigated control of postoperative pain, inadequacy of treatment still remains. In this study, we aimed to identify a method with the capacity to minimize abdominal and right shoulder pain after laparoscopic cholecystectomy.

MATERIALS AND METHODS

A total of 684 subjects, 77% (n=527) female and 23% (n=157) male, were included in this study. A T-drain was prescribed for patients requiring bile duct exploration and patients with acute cholecystitis were excluded from the study. Subjects were classified into groups as follows: Group 1: control group without drain and intraperitoneal analgesics; Group 2: a drain was placed but no intraperitoneal analgesic was applied; Group 3: no drain was placed and intraperitoneal subhepatic bupivacaine was applied; and Group 4: drain was placed and intraperitoneal subhepatic bupivacaine was applied. Parietal pain and visceral pain were evaluated with visual analog scale (VAS).

RESULTS

A drain was present in 51.9% (n=355) of the cases. A statistically significant difference was found between the preoperative pulse rate measurements of the cases according to the groups ( P =0.009; <0.01). Subhepatic bupivacaine was administered in 50.1% (n=355) of the cases. A statistically significant difference was found between the second, fourth, sixth, 12th, and 24th hour VAS scores of the cases according to the groups [2 h VAS scores (mean±SD): Group 1: 3.58±1.07, Group 2: 3.86±1.12, Group 3: 1.20±0.67, and Group 4: 1.50±1.21 ( P <0.001)]; [4 h VAS scores (mean±SD): Group 1: 2.55±1.26, Group 2: 2.87±1.14, Group 3: 1.66±1.06, and Group 4: 2.02±1.23 ( P <0.001)]; [6 h VAS scores (mean±SD): Group 1: 2.50±0.91, Group 2: 2.53±1.14, Group 3: 1.66±1.06, and Group 4: 2.02±1.23 ( P <0.001)]; [12 h VAS scores (mean±SD): Group 1: 3.24±1.2, Group 2: 3.49±1.14, Group 3: 2.83±0.98, and Group 4 : 2.99±1.36 ( P <0.001)]; and [24 h VAS scores (mean±SD): Group 1: 3.75±0.99, Group 2: 4.01±0.91, Group 3: 3.61±1.34, and Group 4: 4.01±1.08 ( P <0.001)].

CONCLUSION

Bupivacaine spraying reduces postoperative abdominal pain, while drain placement minimizes shoulder pain by reducing CO 2 remaining under the diaphragm.

Comparative Study of Dezocine and Ketorolac Tromethamine in Patient-Controlled Intravenous Analgesia of Laparoscopic Cholecystectomy

Purpose

This study aimed to observe the application value of dezocine and ketorolac tromethamine in patient-controlled intravenous analgesia (PCIA) of patients undergoing laparoscopic cholecystectomy (LC).

Methods

A total of 154 patients who underwent LC surgery in our hospital and received PCIA after surgery from September 2020 to September 2021 were selected, they were divided into group A (n = 77) and group B (n = 77). Group A was given dezocine and group B was given ketorolac tromethamine. The analgesia, sedation, comfort, and adverse reactions of the two groups were closely observed at 4, 8, 12, and 24 h after surgery.

Results

At 4, 8, 12, and 24 h after surgery, the visual analog scale scores in group B were lower than those in group A (P &lt; 0.05). At 4, 8, 12, and 24 h after surgery, the Ramsay scores in group B were higher than those in group A (P &lt; 0.05). At 4, 8, 12, and 24 h after surgery, there was no significant difference in Bruggrmann comfort scale scores between the two groups (P &gt; 0.05). There was no significant difference in the incidence of adverse reactions between the two groups (P &gt; 0.05).

Conclusion

Both dezocine and ketorolac tromethamine have high clinical application value in patients who underwent LC surgery and received PCIA, with higher patient comfort and fewer adverse reactions. But compared with dezocine, ketorolac tromethamine can achieve better sedative and analgesic effects, which is worthy of clinical promotion.

A. Bilateral versus unilateral erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: a randomized controlled study

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the common surgical intervention for benign biliary diseases. Postoperative pain after LC remains as an important problem, with two components: somatic and visceral. Trocar entry incisions lead to somatic pain, while peritoneal distension with diaphragm irritation leads to visceral pain. Following its description by Forero et al., the erector spinae plane (ESP) block acquired considerable popularity among clinicians. This led to the use of ESP block for postoperative pain management for various operations.

MATERIALS AND METHODS

This study was conducted between January and June 2019. Patients aged between 18 and 65 years with an American Society of Anesthesiologists (ASA) physical status I.ÇôII, scheduled for elective laparoscopic cholecystectomy were included in the study. All the patients received bilateral or unilateral ESP block at the T8 level preoperatively according to their groups.

RESULTS

There was no significant difference between the groups in terms NRS scores either at rest or while coughing at any time interval except for postoperative 6^th hour (p = 0.023). Morphine consumption was similar between the groups but was significantly lower in group B at 12 and 24 hours (p = 0.044 and p = 0.022, respectively). Twelve patients in group A and three patients in group B had shoulder pain and this difference was statistically significant (p = 0.011).

DISCUSSION

In conclusion, bilateral ESP block provided more effective analgesia than unilateral ESP block in patients undergoing elective LC. Bilateral ESP block reduced the amount of opioid consumption and the incidence of postoperative shoulder pain.