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Dhondt LA, Vereen MS, van de Laar RLO, Stolker RJ, Dirckx M, van Beekhuizen HJ. Efficacy of locoregional analgesic techniques after laparotomy for gynecologic cancer: a systematic review. Int J Gynecol Cancer 2024; 34:1423-1430. [PMID: 39122447 DOI: 10.1136/ijgc-2024-005404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2024] Open
Abstract
OBJECTIVE To determine which locoregional techniques are effective in managing post-operative pain in major open oncologic gynecologic surgery in terms of pain scores and opioid consumption when epidural analgesia is not a feasible option. METHODS A systematic review of the literature, based on the Preferred Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, was conducted. The ROB-2 assessment was used to assess bias. The primary outcomes were opioid consumption and post-operative pain scores. Secondary outcomes included post-operative markers such as time to mobilization and bowel movement. RESULTS A total of nine studies (n=714) were included in the analysis. Eight studies had a low risk of bias. Five different forms of locoregional analgesia were described. Eight studies compared with placebo and one study compared rectus sheath block with epidural analgesia. Three of the five studies investigating transversus abdominis plane (TAP) blocks showed an improvement in pain scores and opioid consumption when compared with the placebo group. One study investigating rectus sheath blocks and another investigating paravertebral blocks demonstrated significantly less opioid consumption and improved pain scores at certain time points. The studies investigating continuous wound infiltration and superior hypogastric plexus block found no significant effect. No adverse effects of locoregional anesthesia were found. CONCLUSION Our study showed that TAP blocks, rectus sheath blocks, and paravertebral blocks may decrease opioid consumption and improve pain scores in patients undergoing open abdominal surgery for gynecologic cancer. Additionally, these techniques might serve as a viable alternative for patients with contraindications to epidural analgesia.
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Affiliation(s)
- Lieke A Dhondt
- Department of Gynecologic Oncology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Maya S Vereen
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Ralf L O van de Laar
- Department of Gynecologic Oncology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Robert-Jan Stolker
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Maaike Dirckx
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, Netherlands
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Taiym D, Cowan M, Nakamura B, Azad H, Strohl A, Barber E. Effect of continuous post-operative lidocaine infusion in an enhanced recovery program on opioid use following gynecologic oncology surgery. J Gynecol Oncol 2023; 34:e61. [PMID: 37232055 PMCID: PMC10482581 DOI: 10.3802/jgo.2023.34.e61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/16/2023] [Accepted: 04/16/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE To determine the effectiveness of implementing an Enhanced Recovery After Surgery (ERAS) program, including continuous intraoperative and postoperative intravenous (IV) lidocaine infusion, on perioperative opioid use. METHODS This was a single-institution retrospective pre- post- cohort study. Consecutive patients undergoing planned laparotomy for known or potential gynecologic malignancy were identified after implementation of an ERAS program and compared to a historical cohort. Opioid use was calculated as morphine milligram equivalents (MMEs). Cohorts were compared using bivariate tests. RESULTS A total of 215 patients were included in the final analysis, 101 patients received surgery before ERAS implementation and 114 received surgery after. A reduction in total opioid use was observed in ERAS patients compared with historical controls (MME 26.5 [9.6-60.8] versus 194.5 [123.8-266.8], p<0.001). Length of stay (LOS) was reduced by 25% in the ERAS cohort (median 3 days, range 2-26, versus 4 days, range 2-18; p<0.001). Within the ERAS cohort, 64.9% received IV lidocaine for the planned 48 hours, and 5.6% had the infusion discontinued early. Within the ERAS cohort, patients who received IV lidocaine infusion used less opioids compared to those who did not (median 16.9, range 5.6-55.1, versus 46.2, range 23.2-76.1; p<0.002). CONCLUSION An ERAS program including a continuous IV lidocaine infusion as the opioid-sparing analgesic strategy was noted to be safe and effective, leading to decreased opioid consumption and LOS compared with a historic cohort. Additionally, lidocaine infusion was noted to decrease opioid consumption even among patients already receiving other ERAS interventions.
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Affiliation(s)
- Deanna Taiym
- Northwestern University, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
| | - Matthew Cowan
- Albert Einstein College of Medicine, Division of Gynecologic Oncology, Montefiore Medical Center, Department of Obstetrics and Gynecology and Women's Health, Bronx, NY, USA
| | - Brad Nakamura
- Northwestern University, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
| | - Hooman Azad
- Department of Obstetrics and Gynecology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Anna Strohl
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cleveland, OH, USA
| | - Emma Barber
- Northwestern University, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
- Robert H Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
- Surgical Outcomes and Quality Improvement Center, Institute for Public Health in Medicine, Chicago, IL, USA.
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Moon AS, Andikyan V, Agarwal R, Stroever S, Misita D, Laibangyang A, Doo D, Chuang LT. Incisional infiltration versus transversus abdominis plane block of liposomal bupivacaine after midline vertical laparotomy for suspected gynecologic malignancy: a pilot study. Gynecol Oncol Rep 2023; 47:101203. [PMID: 37251783 PMCID: PMC10220396 DOI: 10.1016/j.gore.2023.101203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/09/2023] [Accepted: 05/13/2023] [Indexed: 05/31/2023] Open
Abstract
Background To evaluate whether incisional infiltration of liposomal bupivacaine would decrease opioid requirement and pain scores after midline vertical laparotomy for suspected or known gynecologic malignancy compared with transversus abdominis plane (TAP) block with liposomal bupivacaine. Methods A prospective, single blind randomized controlled trial compared incisional infiltration of liposomal bupivacaine plus 0.5% bupivacaine versus TAP block with liposomal bupivacaine plus 0.5% bupivacaine. In the incisional infiltration group, patients received 266 mg free base liposomal bupivacaine with 150 mg bupivacaine hydrochloride. In the TAP block group, 266 mg free base bupivacaine with 150 mg bupivacaine hydrochloride was administered bilaterally. The primary outcome was total opioid use during the first 48-hour postoperative period. Secondary outcomes included pain scores at rest and with exertion at 2, 6, 12, 24 and 48 h after surgery. Results Forty three patients were evaluated. After interim analysis, a three-fold higher sample size than originally calculated was required to detect a statistically significant difference. There was no clinical difference between the two arms in mean opioid requirement (morphine milligram equivalents) for the first 48 h after surgery (59.9 vs. 80.8, p = 0.13). There were no differences in pain scores at rest or with exertion between the two groups at pre-specified time intervals. Conclusion In this pilot study, incisional infiltration of liposomal bupivacaine and TAP block with liposomal bupivacaine demonstrated clinically similar opioid requirement after gynecologic laparotomy for suspected or known gynecologic cancer. Given the underpowered study, these findings cannot support the superiority of either modality after open gynecologic surgery.
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Affiliation(s)
- Ashley S. Moon
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Danbury/Norwalk Hospitals, Nuvance Health, 24 Hospital Avenue, Danbury, CT 06810, United States
| | - Vaagn Andikyan
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Danbury/Norwalk Hospitals, Nuvance Health, 24 Hospital Avenue, Danbury, CT 06810, United States
| | - Rakhee Agarwal
- Department of Research and Innovation, Danbury/Norwalk Hospitals, Nuvance Health, 24 Hospital Avenue, Danbury, CT 06810, United States
| | - Stephanie Stroever
- Department of Research and Innovation, Danbury/Norwalk Hospitals, Nuvance Health, 24 Hospital Avenue, Danbury, CT 06810, United States
| | - David Misita
- Department of Anesthesiology, Danbury/Norwalk Hospitals, Nuvance Health, 24 Hospital Avenue, Danbury, CT 06810, United States
| | - Anya Laibangyang
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Danbury/Norwalk Hospitals, Nuvance Health, 24 Hospital Avenue, Danbury, CT 06810, United States
| | - David Doo
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Danbury/Norwalk Hospitals, Nuvance Health, 24 Hospital Avenue, Danbury, CT 06810, United States
| | - Linus T. Chuang
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Danbury/Norwalk Hospitals, Nuvance Health, 24 Hospital Avenue, Danbury, CT 06810, United States
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Nelson G, Dowdy SC. Surgeon-administered transversus abdominis plane block in gynecologic surgery-is it time to tap out? Am J Obstet Gynecol 2023; 228:491-493. [PMID: 36967370 DOI: 10.1016/j.ajog.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/01/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, University of Calgary, Calgary, Alberta, Canada.
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN
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Opioid-sparing anesthesia and patient-reported outcomes after open gynecologic surgery: a historical cohort study. Can J Anaesth 2022; 69:1477-1492. [PMID: 36224506 DOI: 10.1007/s12630-022-02336-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/13/2022] [Accepted: 05/30/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE Dexmedetomidine and ketamine may be administered intraoperatively as continuous infusions to provide opioid-sparing anesthesia. Recent evidence has yielded controversial results regarding the impact of opioid-free anesthesia on postoperative complications, and there is a gap in knowledge regarding patient-reported outcomes (PROs). This study aimed to determine the impact of opioid-sparing anesthesia and opioid-based anesthesia on PROs among gynecologic patients within an enhanced recovery after surgery (ERAS) program. METHODS We formed a single-center historical cohort from patients enrolled in another study who underwent open gynecologic surgery on an ERAS program from November 2014 to December 2020 (n = 2,095). We identified two cohorts based on the type of balanced anesthesia administered: 1) opioid-sparing anesthesia defined as the continuous infusion of dexmedetomidine and ketamine (adjuvants) during surgery or 2) opioid-based anesthesia (no adjuvants). We measured the quality of postoperative recovery using the MD Anderson Symptom Inventory (MDASI), a 29-item validated tool that was administered preoperatively, daily while admitted, and weekly after discharge until week 6. The primary outcome was interference with walking. We matched both cohorts and used a multilevel linear mixed-effect model to evaluate the effect of opioid-sparing anesthesia on the primary outcome. RESULTS In total, 498 patients were eligible (159 in the opioid-sparing anesthesia cohort and 339 in the opioid-based anesthesia cohort), of whom 149 matched pairs were included in the final analysis. Longitudinal assessment showed no significant or clinically important difference in interference with walking (P = 0.99), general activity (P = 0.99), or other PROs between cohorts. Median [interquartile range (IQR)] intraoperative opioid administration (expressed as morphine milligram equivalents [MME]) among matched patients in the opioid-sparing anesthesia cohort was 30 [25-55] mg vs 58 [8-70] mg in the opioid-based anesthesia cohort (P < 0.01). Patients in the opioid-sparing anesthesia cohort had a lower opioid consumption in the postanesthesia care unit than those in the opioid-based anesthesia cohort (MME, 3 [0-10] mg vs 5 [0-15] mg; P < 0.01), but there was no significant difference between cohorts in total postoperative opioid consumption (MME, 23 [0-94] mg vs 35 [13-95] mg P = 0.053). CONCLUSIONS In this single-center historical cohort study, opioid-sparing anesthesia had no significant or clinically important effects on interference with walking or other PROs in patients undergoing gynecologic surgery compared with opioid-based anesthesia. Opioid-sparing anesthesia was associated with less short-term opioid consumption than opioid-based anesthesia.
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Jiang H, Ma Q, Dong J, Ye X. The effect of liposomal bupivacaine for surgical wound infiltration: A meta‐analysis of randomised controlled trials. Int Wound J 2022; 20:1591-1608. [PMID: 36345868 PMCID: PMC10088822 DOI: 10.1111/iwj.14015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022] Open
Abstract
Liposomal bupivacaine (LB) has consistently been considered a potential analgesic for surgical wound infiltration. However, the evidence of its analgesic effectiveness remains unclear. In this meta-analysis, we attempted to identify the potential clinical role of LB wound infiltration in different surgical procedures. Randomised controlled trials (RCTs) comparing LB with non-liposomal local anaesthetics and placebos were retrieved from six electronic databases. The primary outcome was cumulative morphine equivalent consumption within 24, 48, and 72 hours after surgery. Approximately 2659 patients from 22 studies were included in the meta-analysis. Compared to the control, LB-wound infiltration did not reduce the postoperative morphine consumption at 24 hours (weighted mean difference [WMD], -0.60 mg; 97.5% confidence interval [CI], -2.78 to 1.59 mg; P = 0.54), 48 hours (WMD, -1.00 mg; 97.5% CI, -3.23 to 1.24; P = 0.32) or 72 hours (WMD, 0.50 mg; 97.5% CI, -0.67 to 1.67; P = 0.33). Similarly, secondary outcome analysis did not reveal any additional benefits of LB in any other pain-related outcomes. LB was not associated with any adverse effects. Overall, LB does not appear to improve the postoperative analgesic, rehabilitation, or safety outcomes. Current evidence does not support the routine use of LB for wound infiltration following surgical procedures.
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Affiliation(s)
- Hua Jiang
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
| | - Qiong Ma
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
| | - Jing Dong
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
| | - Xin Ye
- Hospital of Chengdu University of Traditional Chinese Medicine Chengdu China
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Trad ATA, Tamhane P, Weaver AL, Baker MV, Visscher SL, Borah BJ, Kalogera E, Gebhart JB, Trabuco EC. Impact of enhanced recovery implementation in women undergoing abdominal sacrocolpopexy. Int J Gynaecol Obstet 2022; 159:727-734. [PMID: 35598156 DOI: 10.1002/ijgo.14279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/30/2022] [Accepted: 05/17/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the effect of Enhanced Recovery After Surgery (ERAS) with and without liposomal bupivacaine (LB) on opioid use, hospital length of stay (LOS), costs, and morbidity of women undergoing sacrocolpopexy. METHODS Retrospective cohort of women who underwent abdominal sacrocolpopexy between April 1, 2009 and November 30, 2017. Costs for relevant healthcare services were determined by assigning 2017 charges multiplied by 2017 Medicare Cost Report's cost to charge ratios. Outcomes were compared among periods with multivariable regression models adjusted for age, American Society of Anesthesiologists score, and concurrent hysterectomy and posterior repair. RESULTS Patients were subdivided into pre-ERAS (G1, n = 128), post-ERAS (G2, n = 83), and post-ERAS plus LB (G3, n = 91). The proportion of patients needing opioids during postoperative days 0-2 was significantly less for G3 (75.8%) compared with G1 (97.7%) and G2 (92.8%); P < 0.001). The median morphine equivalent units (MEU) with interquartile ranges, mean LOS, and adjusted mean standardized costs were significantly lower in G3 compared with the other two groups (35 [20-75] vs. 67 [31-109], and 60 [30-122] MEUs; 1.8 vs. 2.3 vs. 2.9 days; and $2391, $2975, and $3844, for G3, G2, and G1, respectively; P < 0.001). CONCLUSION Implementation of an ERAS pathway led to significant decreases in opioid use, LOS, and costs. Supplementation with LB further improved these measures.
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Affiliation(s)
| | - Prajakta Tamhane
- Department of Family Medicine, Reid Health, Richmond, Indiana, USA
| | - Amy L Weaver
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary V Baker
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sue L Visscher
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bijan J Borah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Miami Cancer Institute, Miami, Florida, USA
| | - John B Gebhart
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Emanuel C Trabuco
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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8
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Otremba B, Dinges HC, Schubert AK, Zink W, Steinfeldt T, Wulf H, Wiesmann T. [Liposomal bupivacaine-No breakthrough in postoperative pain management]. Anaesthesist 2022; 71:556-564. [PMID: 35469071 DOI: 10.1007/s00101-022-01118-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 11/29/2022]
Abstract
One of the main limitations concerning the use of local anesthetics is due to their restricted duration of action. In recent years, liposomal formulations with prolonged release kinetics have been developed to extend the pharmacological duration of action of the 1‑stage peripheral regional anesthesia (single-shot procedure) and thus bring about a longer duration of action. The focus here is particularly on achieving postoperative freedom from pain for at least 24 h (or even better 48 h) and thus early mobilization of patients using on-demand medication causing (at most) minor local sensory blockade without causing motor impairments (at least that is the ideal). Therefore, methods of utilizing slow-release drugs as seen in liposomal carrier systems have experienced increasing scientific attention in the last few years. A common modern pharmacological example with a theoretically significantly longer duration of action is liposomal bupivacaine, an amide local anesthetic. Due to a multivesicular liposome structure, the retarded release of the active component bupivacaine HCl leads to a theoretical pharmacological effectiveness of up to 72 h. Previous studies consistently showed a safety profile comparable to conventional bupivacaine HCl. Liposomal bupivacaine has been approved by the U.S. Food and Drug Administration (FDA) under the trade name Exparel© (Pacira Pharmaceuticals, Parsippany, NJ, USA) since 2011; however, its use is currently limited to local wound infiltration, transverse abdominis plane (TAP) blocks, and interscalene nerve blocks of the brachial plexus. In 2020, the European Medicines Agency (EMA) also approved the use of liposomal bupivacaine for blockade of the brachial plexus or the femoral nerve and as a field block or for wound infiltration to treat postoperative pain. So far, studies on the clinical effectiveness of liposomal bupivacaine have been very heterogeneous and there have been no conclusive meta-analyses with sufficient rigor or significance. Recent systematic reviews and meta-analyses, combining the results of clinical studies regarding the analgesic efficiency of liposomal bupivacaine in different fields of application, consistently refuted any benefit of clinical relevance provided by the liposomal formulation. There is currently sufficient evidence to now end the ongoing debate around liposomal bupivacaine. The aim of this work is to give the reader a current, evidence-based overview of this substance.
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Affiliation(s)
- Berit Otremba
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland.
| | - Hanns-Christian Dinges
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland
| | - Ann-Kristin Schubert
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland
| | - Wolfgang Zink
- Klinik für Anästhesiologie, Operative Intensiv- und Notfallmedizin, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Deutschland
| | - Thorsten Steinfeldt
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland.,Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Berufsgenossenschaftliche Unfallklinik, Frankfurt am Main, Deutschland
| | - Hinnerk Wulf
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland
| | - Thomas Wiesmann
- Klinik für Anästhesie und Intensivtherapie Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35033, Marburg, Deutschland.,Klinik für Anästhesiologie und operative Intensivmedizin, Diakoneo Diakonie-Klinikum Schwäbisch Hall, Schwäbisch Hall, Deutschland
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Transversus Abdominis Plane Block Versus Local Wound Infiltration for Postoperative Pain After Laparoscopic Colorectal Cancer Resection: a Randomized, Double-Blinded Study. J Gastrointest Surg 2022; 26:425-432. [PMID: 34505222 DOI: 10.1007/s11605-021-05121-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 08/10/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite the extensive administration of the enhanced recovery after surgery (ERAS) program, postoperative pain remains a major concern for patients. Transversus abdominis plane (TAP) block and local wound infiltration (LWI) are two techniques that have been widely applied in abdominal surgery. However, these two techniques have rarely been compared in terms of their analgesic effects on patients that undergo laparoscopic colorectal surgery with the ERAS program. METHODS A randomized, double-blinded study was conducted in this study. Briefly, 174 patients that underwent colorectal surgery with the ERAS program were randomly allocated to TAP block treatment (TAP group) or local wound infiltration (LWI group). All patients were assessed for their pain scores at rest and in motion at 6, 24, 48, and 72 h after surgery. The administration frequency of bolus for PCIA and the use amount of rescue analgesics (parecoxib) were recorded. Finally, the patients were monitored with follow-up surveys on their postoperative function recovery, complications, lengths of stay, treatment cost, and satisfaction. RESULTS In terms of the pain scores at rest and in motion, the two groups revealed no significant difference throughout the study sessions, and no difference was found in the administration frequency of bolus and the use amount of parecoxib. Moreover, the two groups demonstrated similar results in their postoperative recovery, and no significant differences were found in terms of postoperative complications. CONCLUSIONS Compared with local wound infiltration, transversus abdominis plane block is not significantly advantageous for postoperative pain control and recovery in patients undergoing laparoscopic colorectal surgery with the ERAS program. However, local wound infiltration might be preferred since it is available with less technical difficulties.
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Sandhu HK, Miller CC, Tanaka A, Estrera AL, Charlton-Ouw KM. Effectiveness of Standard Local Anesthetic Bupivacaine and Liposomal Bupivacaine for Postoperative Pain Control in Patients Undergoing Truncal Incisions: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e210753. [PMID: 33724391 PMCID: PMC7967071 DOI: 10.1001/jamanetworkopen.2021.0753] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Liposomal bupivacaine for pain relief is purported to last 3 days compared with 8 hours with standard bupivacaine. However, its effectiveness is unknown in truncal incisions for cardiothoracic or vascular operations. OBJECTIVE To compare the effectiveness of single-administration standard bupivacaine vs liposomal bupivacaine in patients undergoing truncal incisions. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial enrolled patients undergoing sternotomy, thoracotomy, minithoracotomy, and laparotomy from a single cardiovascular surgery department in an academic medical center between November 2012 and June 2018. The study was powered to detect a Cohen effect size of 0.35 with a power of greater than 80%. Data analysis was performed from July to December 2018. INTERVENTION Patients were randomized to standard bupivacaine or liposomal bupivacaine. MAIN OUTCOMES AND MEASURES Pain was assessed over 3 postoperative days by the Numeric Rating Scale (NRS). Adjunctive opioids were converted to morphine equivalents units (MEU). NRS scores were compared using Wilcoxon rank-sum (3-day area under the curve) and 2-way nonparametric mixed models (daily scale score) to assess time-by-group interaction. Secondary outcomes included cumulative opioid consumption. RESULTS A total of 280 patients were analyzed, with 140 in each group (single-administration standard bupivacaine vs liposomal bupivacaine). Mean (SD) age was 60.2 (14.4) years, and 101 of 280 patients (36%) were women. Irrespective of treatment assignment, pain decreased by a mean of approximately 1 point per day over 3 days (β = -0.87; SE = 0.11; mixed model regression P < .001). Incision type was associated with pain with patients undergoing thoracotomy (including minithoracotomy) reporting highest median (interquartile range [IQR]) pain scores on postoperative days 1 (liposomal vs standard bupivacaine, 6 [4-8] vs 5 [3-7]; P = .049, Wilcoxon rank-sum) and 2 (liposomal vs standard bupivacaine, 5 [4-7] vs 4 [2-6]; P = .003, Wilcoxon rank-sum) but not day 3 (liposomal vs standard bupivacaine, 3 [2-6] vs 3 [1-5]; P = .10, Wilcoxon rank-sum), irrespective of treatment group. Median (IQR) 3-day cumulative NRS was 12.0 (8.0-16.5) for bupivacaine and 13.5 (9.0-17.0) for liposomal bupivacaine (P = .15, Wilcoxon rank-sum) Furthermore, use of opioids was greater following liposomal bupivacaine compared with standard bupivacaine (median [IQR], 41.5 [21.3-73.8] MEU vs 33.0 [17.8-62.5] MEU; P = .03, Wilcoxon rank-sum). On multivariable analysis, no interaction by incision type was observed for mean pain scores or opioid use. CONCLUSIONS AND RELEVANCE In this randomized clinical trial involving truncal incisions for cardiovascular procedures, liposomal bupivacaine did not provide improved pain control and did not reduce adjunctive opioid use compared with conventional bupivacaine formulation over 3 postoperative days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02111746.
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Affiliation(s)
- Harleen K. Sandhu
- McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Charles C. Miller
- McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Akiko Tanaka
- McGovern Medical School at the University of Texas Health Science Center at Houston
- Memorial Hermann Hospital, Texas Medical Center, Houston
| | - Anthony L. Estrera
- McGovern Medical School at the University of Texas Health Science Center at Houston
- Memorial Hermann Hospital, Texas Medical Center, Houston
| | - Kristofer M. Charlton-Ouw
- McGovern Medical School at the University of Texas Health Science Center at Houston
- HCA Houston Healthcare, Gulf Coast Division, Houston, Texas
- Department of Clinical Sciences, University of Houston College of Medicine, Houston, Texas
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