Analgesic effect of intraperitoneal local anesthetic in surgery: an overview of systematic reviews

Efficacy and safety of intraperitoneal ropivacaine in pain management following laparoscopic digestive surgery: A systematic review and meta-analysis of RCTs

BACKGROUND

Managing postoperative pain effectively with an opioid-free regimen following laparoscopic surgery (LS) remains a significant challenge. Intraperitoneal instillation of ropivacaine has been explored for its potential to reduce acute postoperative pain, but its efficacy and safety are still under debate. This study aimed to evaluate the efficacy and safety of intraperitoneal instillation of ropivacaine for acute pain management following laparoscopic digestive surgery.

METHODS

We used PRISMA 2020 and a measurement tool to assess systematic reviews 2 guidelines to conduct this review. The random-effects model was adopted using Review Manager Version 5.4 for pooled estimates.

RESULTS

We retained 24 eligible RCTs involving 1705 patients (862 patients in the intraperitoneal instillation group and 843 patients in the control group). The intraperitoneal instillation group reduced total opioid consumption during the first 24 hours postoperatively (MD = -21.93 95% CI [-27.64, -16.23], P < .01), decreased pain scores at different time (4 hours, 8 hours, 12 hours and 24 hours), shorter the hospital stay (MD = -0.20 95% CI [-0.36, -0.05], P < .01), reduced the postoperative shoulder pain (MD = 0.18 95% CI [0.07, 0.44], P < .01), and decreased postoperative nausea and vomiting (MD = 0.47 95% CI [0.29, 0.77], P < .01).

CONCLUSION

Intraperitoneal instillation of ropivacaine appears to be an effective component of multimodal pain management strategies following laparoscopic digestive surgery, significantly reducing opioid consumption and improving postoperative recovery markers. Despite these promising results, additional high-quality trials are needed to confirm the efficacy and safety of this approach.

REGISTRATION

The registration number at PROSPERO was CRD42021279238.

Comparison of intraperitoneal and incisional lidocaine or ropivacaine irrigation for postoperative analgesia in dogs undergoing major abdominal surgeries

This study compared the postoperative analgesic efficacy of intraperitoneal and incisional lidocaine versus ropivacaine in dogs undergoing major abdominal surgeries. Dogs randomly received intraperitoneal lidocaine irrigation (4 mg kg-1, diluted to 5 ml kg-1, L group), ropivacaine (4 mg kg-1, diluted to 5 ml kg-1, R group) or 0.9% saline (5 ml kg-1, C group). Prior to skin closure, dogs received incisional lidocaine 2 mg kg-1 (group L), incisional ropivacaine 2 mg kg-1 (group R) or incisional saline 0.2 ml kg-1 (group C). Pain was assessed at different time points up to 24 hours after extubation, using the Short Form-Glasgow Composite Measure Pain Scale and VAS Scale. In group C, postoperative pain scores were significantly higher than in groups L and R from T0.5 to T6 (p < 0.05). In R group, postoperative pain scores were significantly lower than in groups L and C from T12 to T24 (p < 0.05). Rescue analgesia was administered to 5/11 dogs in L group, 1/10 dogs in R group and 8/10 dogs in C group. Groups L and R experienced a significantly lower postoperative pain during the first 6 hours after extubation, compared with group C. Ropivacaine provided lower postoperative pain scores than lidocaine and saline up to 24 hours after extubation. According to the obtained results, ropivacaine seemed to provide better and longer lasting postoperative analgesia compared with lidocaine. Therefore, intraperitoneal and incisional administration of ropivacaine in dogs undergoing major abdominal surgeries is recommended.

Perioperative opioid management for minimally invasive hysterectomy

Given the high volume of hysterectomies performed, the contribution of gynecologists to the opioid crisis is potentially significant. Following a hysterectomy, most patients are over-prescribed opioids, are vulnerable to developing new persistent opioid use, and can be the source of misuse, diversion, or accidental exposure. People who misuse opioids are at risk of an overdose related death, which is now one of the leading causes of death in the United States and is rising in other countries. It is the physician's responsibility to reduce opioid use by making impactful practice changes, such as 1) using pre-emptive opioid sparing strategies, 2) optimizing multimodal nonopioid pain management, 3) restricting postoperative opioid prescribing, and 4) educating patients on proper disposal of unused opioids. These changes can be implemented with an enhanced recovery after surgery protocol, shared decision-making, and patient education strategies related to opioids.

Efficacy and Safety of Intraperitoneal Local Anesthetics in Laparoscopic Appendectomy: A Systematic Review and Meta-Analysis

Intraperitoneal local anesthetics have been increasingly used nowadays. However, they are not routinely given in laparoscopic appendectomy and a lot of controversies are found about their administration in this procedure. The goal of this study is to review effectiveness and safety of intraperitoneal local anesthetics in laparoscopic appendectomy. We conducted a computer search of four authentic databases. We included randomized controlled trials (RCTs) which compared intraperitoneal local anesthetics versus control group in laparoscopic appendectomy. Data were extracted from eligible studies and pooled in a meta-analysis model using RevMan software. We evaluated post-operative pain in different periods and safety outcomes including postoperative nausea and vomiting (PONV) and shoulder pain. Furthermore, we assessed the length of hospital stay and postoperative opioid consumption within 24 hours. Seven RCTs were included with a total of 579 patients in this review. Our analysis indicated a significant difference in postoperative pain at different durations preferring intraperitoneal local anesthetics compared to control. Moreover, intraperitoneal local anesthetics were significantly linked to fewer patients experienced PONV and shoulder pain respectively (RR= 0.28, 95% CI [0.16, 0.50], p < 0.0001), (RR= 0.32, 95% CI [0.17, 0.58], p = 0.0002). We found less hospital stay duration in intraperitoneal local anesthetics group after removal of the heterogeneity (MD= -0.39, 95% CI [-0.63, -0.16], p = 0.001). Intraperitoneal local anesthetics were significantly linked to less postoperative opioid consumption (SMD = -0.60, 95% CI [-0.96, -0.24], p = 0.001). Intraperitoneal local anesthetics can be routinely used in laparoscopic appendectomy as it is associated with less postoperative pain and reduction in different adverse events postoperatively.

Intraperitoneal and incisional analgesia in small animals: simple, cost-effective techniques

The World Small Animal Veterinary Association Global Pain Council (WSAVA-GPC) has recently published its first "capsule review" by Monteiro et al. These are short articles that present a brief assessment of the scientific evidence and practical recommendations on important, and sometimes controversial, subjects in pain management. The capsules will be published regularly in the Journal of Small Animal Practice, the official journal of the WSAVA. This second article discusses the use of intraperitoneal and incisional analgesia in small animal practice, including their limitations and recommendations by the authors.

Ropivacaine regulates the expression and function of heme oxygenase-1

As a new generation of amide-type local anesthetics (LAs), ropivacaine has been widely used for pain management in clinical settings. Increasing evidence has shown that administration of ropivacaine causes cytotoxic effects and apoptosis. However, the underlying molecular mechanisms still need to be elucidated. In the current study, our results indicated that ropivacaine treatment caused a significant induction of heme oxygenase-1 (HO-1) at both the mRNA and protein levels in human SHSY5Y cells. Levels of HO-1 mRNA and protein peaked at 1 h and 18 h, respectively, in response to ropivacaine treatment. Additionally, ropivacaine treatment enhanced HO-1 activity in a dose-dependent manner. Interestingly, we found that ropivacaine treatment induced phosphorylation of p38. Blockage of p38 phosphorylation with its specific inhibitor SB203580 or by transfection with p38 siRNA restrained ropivacaine-stimulated HO-1 expression. Additionally, we found that ropivacaine treatment promoted nuclear translocation of Nrf2 and amplified ARE promoter activity. Silencing of Nrf2 abolished ropivacaine-induced HO-1 expression. Notably, we found that inhibition of HO-1 activity promoted ropivacaine-induced production of reactive oxygen species (ROS), deletion of reduced glutathione (GSH), and release of lactate dehydrogenase (LDH), suggesting that induction of HO-1 by ropivacaine acted as a compensatory survival response against ropivacaine.

Port Placement for Laparoscopic Colonic Resections - Video Vignette

Laparoscopic colonic resections often require manipulation and surgical action in all abdominal quadrants. Port placement, a fundamental part of a successful procedure, often varies widely among surgeons and is currently dictated by individual experience and preference. This variability may be suboptimal for the operation at hand, can be confusing for trainees and many times provide inadequate working posture for the surgeons, resulting in discomfort due to muscular fatigue in the hands, arms, shoulders and cervical spine. This article is protected by copyright. All rights reserved.

Managing Postoperative Pain After Minimally Invasive Gynecologic Surgery in the Era of the Opioid Epidemic

In this review, we examine the evidence behind nonopioid medication alternatives, peripheral nerve blocks, surgical techniques, and postoperative recovery protocols that can help minimize and effectively treat postoperative pain after minimally invasive gynecologic surgery (MIGS). Because of the depth and heterogeneity of the data, a narrative review was performed of reported interventions. A comprehensive review was performed of PubMed, Embase, and the Cochrane Database with a focus on randomized controlled trials. In the absence of literature specific to benign gynecology, similar specialty or procedural data were reviewed. A variety of nonopioid medications, surgical techniques, and postoperative recovery protocols have shown significant improvements in postoperative pain after gynecologic surgery. Nonopioid medication options that are beneficial include acetaminophen, nonsteroidal anti-inflammatories, and antiepileptics. Incision infiltration with local anesthesia also significantly reduces pain. Surgically, minimally invasive approaches, reducing the laparoscopic trocar size to <10 mm, and evacuating the pneumoperitoneum at the end of the case all have significant benefits. Lastly, enhanced recovery pathways show promise in reducing pain after MIGS. By using a multimodal approach, minimally invasive gynecologic surgeons can help to minimize and manage postoperative pain with less reliance on opioid pain medications.

Most systematic reviews of high methodological quality on psoriasis interventions are classified as high risk of bias using ROBIS tool

OBJECTIVES

No gold standard exists to assess methodological quality of systematic reviews (SRs). Although Assessing the Methodological Quality of Systematic Reviews (AMSTAR) is widely accepted for analyzing quality, the ROBIS instrument has recently been developed. This study aimed to compare the capacity of both instruments to capture the quality of SRs concerning psoriasis interventions.

STUDY DESIGN AND SETTING

Systematic literature searches were undertaken on relevant databases. For each review, methodological quality and bias risk were evaluated using the AMSTAR and ROBIS tools. Descriptive and principal component analyses were conducted to describe similarities and discrepancies between both assessment tools.

RESULTS

We classified 139 intervention SRs as displaying high/moderate/low methodological quality and as high/low risk of bias. A high risk of bias was detected for most SRs classified as displaying high or moderate methodological quality by AMSTAR. When comparing ROBIS result profiles, responses to domain 4 signaling questions showed the greatest differences between bias risk assessments, whereas domain 2 items showed the least.

CONCLUSION

When considering SRs published about psoriasis, methodological quality remains suboptimal, and the risk of bias is elevated, even for SRs exhibiting high methodological quality. Furthermore, the AMSTAR and ROBIS tools may be considered as complementary when conducting quality assessment of SRs.