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Pandraklakis A, Haidopoulos D, Lappas T, Stamatakis E, Valsamidis D, Oikonomou MD, Loutradis D, Rodolakis A, Bisch SP, Nelson G, Thomakos N. Thoracic epidural analgesia as part of an enhanced recovery program in gynecologic oncology: a prospective cohort study. Int J Gynecol Cancer 2023; 33:1794-1799. [PMID: 37652530 DOI: 10.1136/ijgc-2023-004621] [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: 09/02/2023] Open
Abstract
OBJECTIVE To evaluate the safety and the effectiveness of thoracic epidural analgesia as part of the enhanced recovery after surgery (ERAS) multimodal analgesic protocol in patients with gynecologic oncology who have undergone laparotomy for suspected or confirmed malignancy. METHODS We conducted a prospective cohort study, following an enhanced recovery after surgery pathway, among patients who had undergone laparotomy for confirmed or suspected gynecological malignancy between January 2020 and September 2021. All patients who underwent laparotomy at the gynecologic oncology department for the aforementioned reason during that time were considered eligible. Patients (n=217) were divided into two groups: epidural (n=118) and non-epidural (n=99) group. Both groups were treated with the standard ERAS departmental analgesic protocol. The primary outcomes were length of hospital stay, complications, and readmission rates. RESULTS Data from 217 patients (epidural group, n=118 vs non-epidural group, n=99) with median age of 61 years (IQR 53-68) were analyzed. The most common type of cancer was of ovarian origin (85/217, 39.2%, p=0.055) and median (Aletti) surgical complexity score was 3 (p=0.42). No differences were observed in the patients' demographics, clinical, and surgical characteristics. Primarily, median length of stay was 4 days in both groups with statistically significant lower IQR in the epidural group (3-5 vs 4-5, p=0.021). Complication rates were more common in the non-epidural group (38/99, 38.3% vs 36/118, 30.5%, p<0.001) with similar rates of grade III (p=0.51) and IV (0%) complications and readmission rates (p=0.51) between the two groups. Secondarily, the epidural group showed lower pain scores (p<0.001) on the day of surgery and in the first post-operative day (p<0.001), higher mobilization rates on the day of surgery (94.1% vs 57.6%, p<0.001), faster removal of urinary catheter (p<0.001), shorter time to flatus (p<0.001), and less nausea on the day of surgery (p<0.001). CONCLUSION In this study we showed that thoracic epidural analgesia, when used as part of an ERAS protocol, is safe and offers more favorable pain relief along with a number of additional benefits, improving the peri-operative experience of patients with gynecologic cancer.
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Affiliation(s)
- Anastasios Pandraklakis
- Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, "Alexandra" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Haidopoulos
- Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, "Alexandra" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Lappas
- Department of Anesthesiology and Pain Management, "Alexandra" General Hospital, Athens, Greece
| | - Emmanouil Stamatakis
- Department of Anesthesiology and Pain Management, "Alexandra" General Hospital, Athens, Greece
| | - Dimitrios Valsamidis
- Department of Anesthesiology and Pain Management, "Alexandra" General Hospital, Athens, Greece
| | - Maria D Oikonomou
- The Fertility Centre, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Dimitrios Loutradis
- Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, "Alexandra" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Rodolakis
- Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, "Alexandra" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Steven P Bisch
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Nikolaos Thomakos
- Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, "Alexandra" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Catarci S, Zanfini BA, Capone E, Vassalli F, Frassanito L, Biancone M, Di Muro M, Fagotti A, Fanfani F, Scambia G, Draisci G. Blended (Combined Spinal and General) vs. General Anesthesia for Abdominal Hysterectomy: A Retrospective Study. J Clin Med 2023; 12:4775. [PMID: 37510890 PMCID: PMC10381710 DOI: 10.3390/jcm12144775] [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: 06/10/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Adequate pain management for abdominal hysterectomy is a key factor to decrease postoperative morbidity, hospital length of stay and chronic pain. General anesthesia is still the most widely used technique for abdominal hysterectomy. The aim of this study was to assess the efficacy and safety of blended anesthesia (spinal and general anesthesia) compared to balanced general anesthesia in patients undergoing hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis. METHODS We retrospectively collected data from adult ASA 1 to 3 patients scheduled for laparoscopic or mini-laparotomic hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis. Exclusion criteria were age below 18 years, ASA > 3, previous chronic use of analgesics, psychiatric disorders, laparotomic surgery with an incision above the belly button and surgery extended to the upper abdomen for the presence of cancer localizations (e.g., liver, spleen or diaphragm surgery). The cohort of patients was retrospectively divided into three groups according to the anesthetic management: general anesthesia and spinal with morphine and local anesthetic (Group 1), general anesthesia and spinal with morphine (Group 2) and general anesthesia without spinal (Group 3). RESULTS NRS was lower in the spinal anesthesia groups (Groups 1 and 2) than in the general anesthesia group (Group 3) for every time point but at 48 h. The addition of local anesthetics conferred a small but significant NRS decrease (p = 0.009). A higher percentage of patients in Group 3 received intraoperative sufentanil (52.2 ± 18 mcg in Group 3 vs. Group 1 31.8 ± 16.2 mcg, Group 2 44.1 ± 15.6, p < 0.001) and additional techniques for postoperative pain control (11.4% in Group 3 vs. 2.1% in Group 1 and 0.8% in Group 2, p < 0.001). Intraoperative hypotension (MAP < 65 mmHg) lasting more than 5 min was more frequent in patients receiving spinal anesthesia, especially with local anesthetics (Group 1 25.8%, Group 2 14.6%, Group 3 11.6%, p < 0.001), with the resulting increased need for vasopressors. Recovery-room discharge criteria were met earlier in the spinal anesthesia groups than in the general anesthesia group (Group 1 102 ± 44 min, Group 2 91.9 ± 46.5 min, Group 3 126 ± 90.7 min, p < 0.05). No differences were noted in postoperative mobilization or duration of ileus. CONCLUSIONS Intrathecal administration of morphine with or without local anesthetic as a component of blended anesthesia is effective in improving postoperative pain control following laparoscopic or mini-laparotomic hysterectomy, in reducing intraoperative opioid consumption, in decreasing postoperative rescue analgesics consumption and the need for any additional analgesic technique. We recommend managing postoperative pain with a strategy tailored to the patient's physical status and the type of surgery, preventing and treating side effects of pain treatments.
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Affiliation(s)
- Stefano Catarci
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Bruno Antonio Zanfini
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Emanuele Capone
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Francesco Vassalli
- Department of Critical Care and Perinatal Medicine, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Luciano Frassanito
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Matteo Biancone
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Mariangela Di Muro
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Anna Fagotti
- Department of Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Francesco Fanfani
- Department of Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Giovanni Scambia
- Department of Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
| | - Gaetano Draisci
- Department of Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, IRCCS Fondazione Policlinico A. Gemelli, 00168 Rome, Italy
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Ma Y, Zhang R, Cao X, Zhang L, Bao S, Ren J, Ma W. Effects of intraoperative esketamine addition on gastrointestinal function after benign gynaecological laparoscopic surgery: a double-blind, randomized controlled study. BMC Anesthesiol 2023; 23:220. [PMID: 37353773 PMCID: PMC10288755 DOI: 10.1186/s12871-023-02184-z] [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] [Received: 01/11/2023] [Accepted: 06/17/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Gastrointestinal hypokinesis can occur transiently after benign gynecologic surgery. Opioids cause the side effect of postoperative gastrointestinal hypokinesis, but an opioid-sparing anaesthetic protocol based on esketamine reduces intraoperative opioid consumption. Therefore, this study hypothesised that an opioid-sparing anaesthetic protocol based on esketamine would shorten the gastrointestinal function recovery time after benign gynaecological laparoscopic surgery. METHODS This was a prospective randomized controlled double-blind study conducted in a single centre. All patients scheduled for elective benign laparoscopic gynaecological surgery at Xing'an Meng People's Hospital, Inner Mongolia Autonomous Region, from November 2021 to April 2022 were consecutively enrolled and randomly divided into the opioid-sparing anaesthesia group (Group OS) and the conventional anaesthesia group (Group C). Postoperative first exhaust time, feeding time and postoperative nausea and/or vomiting (PONV) were analyzed in both groups. RESULTS A total of 71 patients were enrolled in this study, including 35 in Group OS and 36 in Group C. The general condition, operative time, type of surgery, intraoperative bleeding, intraoperative fluid volume and intraoperative urine volume were not statistically different between the two groups. Compared with Group C, significantly shorter first postoperative flatus time (11 [8, 14] h vs. 14 [11, 18], p = 0.003) and anaesthesia resuscitation time (7 [6, 9] h vs. 9 [7, 11] h, p = 0.013)were observed in the OS group. The incidence of PONV in Group OS was significantly lower compared with Group C (11.4% vs. 41.7%, p = 0.007). CONCLUSION The esketamine-based opioid-sparing anaesthetic protocol can shorten the postoperative first flatus time after benign laparoscopic surgery in gynaecology, and reduce the incidence of PONV. In addition, the application of esketamine may reduce the postoperative opioid dose requirement of patients. TRIAL REGISTRATION This study was registered with the China Clinical Trials Registry (registration number: ChiCTR2100052528, 30/10/2021).
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Affiliation(s)
- Yuhua Ma
- Department of Anesthesiology, Xing'an Meng People's Hospital, Inner Mongolia Autonomous Region, Xing'an Meng, Inner Mongolia, 137400, China
| | - Ran Zhang
- Department of Anesthesiology, Peking University People's Hospital, Beijing, 100044, China.
| | - Xue Cao
- Department of Anesthesiology, Xing'an Meng People's Hospital, Inner Mongolia Autonomous Region, Xing'an Meng, Inner Mongolia, 137400, China
| | - Lin Zhang
- Department of Anesthesiology, Xing'an Meng People's Hospital, Inner Mongolia Autonomous Region, Xing'an Meng, Inner Mongolia, 137400, China
| | - Suozhu Bao
- Department of Anesthesiology, Xing'an Meng People's Hospital, Inner Mongolia Autonomous Region, Xing'an Meng, Inner Mongolia, 137400, China
| | - Jie Ren
- Department of Anesthesiology, Xing'an Meng People's Hospital, Inner Mongolia Autonomous Region, Xing'an Meng, Inner Mongolia, 137400, China
| | - Weiwei Ma
- Department of Anesthesiology, Xing'an Meng People's Hospital, Inner Mongolia Autonomous Region, Xing'an Meng, Inner Mongolia, 137400, China
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Durmusoğlu F, Attar E. Enhanced Recovery Pathways in Gynecology. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2020.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Fatih Durmusoğlu
- Department of Obstetrics and Gynecology, Medipol University Medical School, Istanbul, Turkey
| | - Erkut Attar
- Department of Obstetrics and Gynecology, Yeditepe University Medical School, Istanbul, Turkey
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Ackroyd SA, Hernandez E, Roberts ME, Chu C, Rubin S, Mantia-Smaldone G, Houck K. Postoperative complications of epidural analgesia at hysterectomy for gynecologic malignancies: an analysis of the National Surgical Quality Improvement Program. Int J Gynecol Cancer 2020; 30:1203-1209. [DOI: 10.1136/ijgc-2020-001339] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/28/2020] [Accepted: 04/30/2020] [Indexed: 11/04/2022] Open
Abstract
ObjectiveThe aim of this study was to identify the rate of 30-day postoperative complications after the use of epidural in women undergoing hysterectomy for gynecologic malignancy. Secondary outcome was the impact of epidural on hospital length of stay.MethodsA retrospective cohort study was conducted using the American College of Surgeons’ National Surgical Quality Improvement Program database. This large dataset includes perioperative risk factors and 30-day post-operative outcomes from more than 680 hospitals. Women who underwent abdominal hysterectomy for a gynecologic malignancy from January 2014 to December 2017 were included. Adult patients (18 years or older) who underwent abdominal hysterectomy were identified using common procedure terminology and international classification of diseases codes. Only laparotomy cases were included, and minimally invasive cases (laparoscopy, transvaginal) were excluded due to the small prevalence of epidural cases in this cohort. All patients received general anesthesia. If patients were noted to have “epidural anesthesia” they were included in the epidural cohort and those receiving other adjuvant techniques (regional blocks or spinal anesthesia) were excluded. The primary outcome of interest was the 30-day occurrence of a pulmonary embolism, deep-vein thrombosis, pneumonia, and urinary tract infection. Those who received epidural analgesia were matched in a 1:1 ratio with a similar group of patients who did not receive epidural analgesia using a calculated propensity score to control for confounding factors.ResultsA total of 2035 (13.8%) patients undergoing abdominal hysterectomy for a gynecologic malignancy received epidural analgesia. 1:1 propensity-matched samples included 2035 patients in both epidural and no-epidural groups. Patient characteristics between groups were similar. Overall 30-day complication rates were higher in the epidural group (75.9% vs 62.0%, P<0.01). Specific complications that were higher in the epidural group included: blood transfusion (28.9% vs 22.8%); wound disruption (2.0% vs 1.1%); surgical site infection (10.1% vs 7.2%); and delay in return of bowel function (12.3% vs 9.3%) (all P<0.05). Hospital length of stay was significantly longer in the epidural group as compared with the no-epidural group (5.69 days vs 4.79 days, P<0.01) and readmissions were higher in the epidural group (10.5% vs 9.7%, P<0.01), but there was no difference in 30-day mortality between the groups (P=0.62).DiscussionThe rate of 30-day complications and length of stay among women undergoing an abdominal hysterectomy for gynecologic malignancy was higher for those who received epidural analgesia, but there was no difference in 30-day mortality. Although epidural analgesia can provide a number of benefits when used for postoperative pain control, the possible association with increased 30-day morbidity and length of stay needs to be considered.
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Glaser GE, Kalogera E, Kumar A, Yi J, Destephano C, Ubl D, Glasgow A, Habermann E, Dowdy SC. Outcomes and patient perspectives following implementation of tiered opioid prescription guidelines in gynecologic surgery. Gynecol Oncol 2020; 157:476-481. [DOI: 10.1016/j.ygyno.2020.02.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/12/2020] [Accepted: 02/16/2020] [Indexed: 01/05/2023]
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Moulder JK, Boone JD, Buehler JM, Louie M. Opioid Use in the Postoperative Arena: Global Reduction in Opioids After Surgery Through Enhanced Recovery and Gynecologic Surgery. Clin Obstet Gynecol 2019; 62:67-86. [PMID: 30407228 DOI: 10.1097/grf.0000000000000410] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Enhanced recovery programs aim to reduce surgical stress to improve the patient perioperative experience. Through a combination of multimodal analgesia and maintaining a physiological state, postoperative recovery is improved. Many analgesic adjuncts are available that improve postoperative pain control and limit opioid analgesia requirements. Adjuncts are often used in combination, but different interventions may be incorporated for patient-specific and procedure-specific needs. Postoperative pain control can be optimized by continuing nonopioid adjuncts, and prescribing opioid analgesia to address breakthrough pain. Prescribing practices should balance optimizing pain relief, minimizing the risk of chronic pain, while limiting the potential for opioid misuse.
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Affiliation(s)
| | | | - Jason M Buehler
- Anesthesiology, University of Tennessee Medical Center Knoxville, Graduate School of Medicine, Knoxville, Tennessee
| | - Michelle Louie
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
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Omar AM. Postoperative continuous transversus abdominis plane block vs continuous wound infusion of levobupivacaine in females undergoing open gynecologic procedures. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Schwartz AR, Lim S, Broadwater G, Cobb L, Valea F, Marosky Thacker J, Habib A, Havrilesky L. Reduction in opioid use and postoperative pain scores after elective laparotomy with implementation of enhanced recovery after surgery protocol on a gynecologic oncology service. Int J Gynecol Cancer 2019; 29:935-943. [DOI: 10.1136/ijgc-2018-000131] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/26/2019] [Accepted: 03/04/2019] [Indexed: 01/31/2023] Open
Abstract
ObjectiveEnhanced Recovery After Surgery (ERAS) protocols are designed to mitigate the physiologic stress response created by surgery, to decrease the time to resumption of daily activities, and to improve overall recovery. This study aims to investigate postoperative recovery outcomes following gynecologic surgery before and after implementation of an ERAS protocol.MethodsA retrospective chart review was performed of patients undergoing elective laparotomy at a major academic center following implementation of an ERAS protocol (11/4/2014–7/27/2016) with comparison to a historical cohort (6/23/2013–9/30/2014). The primary outcome was length of hospital stay. Secondary outcomes included surgical variables, time to recovery of baseline function, opioid usage, pain scores, and complication rates. Statistical analyses were performed using Wilcoxon rank sum, Fisher’s exact, and chi squared tests.ResultsOne hundred and thirty-three women on the ERAS protocol who underwent elective laparotomy were compared with 121 historical controls. There was no difference in length of stay between cohorts (median 4 days; P = 0.71). ERAS participants had lower intraoperative (45 vs 75 oral morphine equivalents; P < 0.0001) and postoperative (45 vs 154 oral morphine equivalents; P < 0.0001) opioid use. ERAS patients reported lower maximum pain scores in the post-anesthesia care unit (three vs six; P < 0.0001) and on postoperative day 1 (four vs six; P = 0.002). There was no statistically significant difference in complication or readmission rates.ConclusionsERAS protocol implementation was associated with decreased intraoperative and postoperative opioid use and improved pain scores without significant changes in length of stay or complication rates.
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Huepenbecker SP, Cusworth SE, Kuroki LM, Lu P, Samen CD, Woolfolk C, Deterding R, Wan L, Helsten DL, Bottros M, Mutch DG, Powell MA, Massad LS, Thaker PH. Continuous epidural infusion in gynecologic oncology patients undergoing exploratory laparotomy: The new standard for decreased postoperative pain and opioid use. Gynecol Oncol 2019; 153:356-361. [DOI: 10.1016/j.ygyno.2019.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/12/2019] [Accepted: 02/19/2019] [Indexed: 02/07/2023]
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Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 2019; 29:651-668. [PMID: 30877144 DOI: 10.1136/ijgc-2019-000356] [Citation(s) in RCA: 380] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery. METHODS A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jamie Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
| | - Chelsia Gillis
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Elias
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena Wijk
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jeffrey Huang
- Department of Anesthesiology, Oak Hill Hospital, Brooksville, Florida, USA
| | - Jonas Nygren
- Departments of Surgery and Clinical Sciences, Ersta Hospital and Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Grant MC, Gibbons MM, Ko CY, Wick EC, Cannesson M, Scott MJ, Wu CL. Evidence review conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery: focus on anesthesiology for gynecologic surgery. Reg Anesth Pain Med 2019; 44:rapm-2018-100071. [PMID: 30737316 DOI: 10.1136/rapm-2018-100071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/11/2018] [Accepted: 12/27/2018] [Indexed: 12/27/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols for gynecologic (GYN) surgery are increasingly being reported and may be associated with superior outcomes, reduced length of hospital stay, and cost savings. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery, which is a nationwide initiative to disseminate best practices in perioperative care to more than 750 hospitals across five major surgical service lines in a 5-year period. The program is designed to identify evidence-based process measures shown to prevent healthcare-associated conditions and hasten recovery after surgery, integrate those into a comprehensive service line-based pathway, and assist hospitals in program implementation. In conjunction with this effort, we have conducted an evidence review of the various anesthesia components which may influence outcomes and facilitate recovery after GYN surgery. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for preoperative (carbohydrate loading/fasting, multimodal preanesthetic medications), intraoperative (standardized intraoperative pathway, regional anesthesia, protective ventilation strategies, fluid minimization) and postoperative (multimodal analgesia) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for ERAS for GYN surgery.
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Affiliation(s)
- Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Melinda M Gibbons
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Clifford Y Ko
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Anesthesiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christopher L Wu
- Anesthesiology, Hospital for Special Surgery, New York City, New York, USA
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Lemoine A, Lambaudie E, Bonnet F, Leblanc E, Alfonsi P. [Perioperative care of epithelial ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. ACTA ACUST UNITED AC 2019; 47:187-196. [PMID: 30686730 DOI: 10.1016/j.gofs.2018.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Indexed: 01/28/2023]
Abstract
The following recommendations cover the perioperative management of ovarian, Fallopian tube and primary peritoneal cancers. Five questions related to pre-habilitation and enhanced recovery after surgery were evaluated. The conclusions and recommendations are based on an analysis of the level of evidence available in the literature. These recommendations are part of the overall recommendations for improving the management of ovarian, fallopian or primary peritoneal cancer, made with the support of INCa (Institut National du Cancer). The main preoperative measures are screening for nutritional deficiencies (Grade B) and for anaemia (GradeC) in patients with ovarian cancer. It is not possible to make recommendations on the correction of malnutrition and/or anemia or on the contribution of pre-operative immuno-nutrition due to the absence of data in ovarian cancer, tube cancer or primary peritoneum cancer. For the same reasons, no recommendation can be made on the value of preoperative digestive preparation in ovarian, fallopian tube or primary peritoneum cancer. During surgery, goal-directed fluid therapy for patients with advanced ovarian cancer is recommended (Grade B). A single dose infusion of tranexamic acid is recommended for patients with ovarian, fallopian tube or primary peritoneal cancer (GradeC). For postoperative analgesia, epidural analgesia is recommended for patients undergoing cyto-reduction surgery by laparotomy (Grade B). In the absence of epidural analgesia, patient controlled analgesia with morphine without continuous infusion (Grade B) is recommended. No recommendation can be given regarding intravenous administration of lidocaine and/or ketamine during surgery, or, regarding peri-operatively prescription of gabapentin or pregabalin. In the absence of studies on the impact of different non-opiate analgesic combinations for ovarian cancer surgery, no recommendations can be made. Early oral feeding is recommended, including in cases of digestive resection (Grade B). The implementation of enhanced recovery programs, including early mobilization, is recommended (GradeC).
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Affiliation(s)
- A Lemoine
- Service d'anesthésie, hôpital Tenon, médecine Sorbonne université, 75020 Paris, France.
| | - E Lambaudie
- Inserm, département de chirurgie oncologique, institut Paoli Calmettes, Aix-Marseille université, CNRS, 13000 Marseille, France
| | - F Bonnet
- Service d'anesthésie, hôpital Tenon, médecine Sorbonne université, 75020 Paris, France
| | - E Leblanc
- Département de chirurgie oncologique, centre Oscar Lambret, 59000 Lille, France
| | - P Alfonsi
- Service d'anesthésie, université Paris Descartes, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France
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Smith HJ, Leath CA, Straughn JM. Enhanced Recovery After Surgery in Surgical Specialties. Surg Clin North Am 2018; 98:1275-1285. [DOI: 10.1016/j.suc.2018.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines. Anesthesiol Clin 2017; 35:e115-e143. [PMID: 28526156 DOI: 10.1016/j.anclin.2017.01.018] [Citation(s) in RCA: 240] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.
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Dowdy SC, Nelson G. Enhanced recovery in gynecologic oncology – A sea change in perioperative management. Gynecol Oncol 2017. [DOI: 10.1016/j.ygyno.2017.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Enhanced Recovery After Surgery for Advanced Ovarian Cancer: A Systematic Review of Interventions Trialed. Int J Gynecol Cancer 2017; 27:1274-1282. [DOI: 10.1097/igc.0000000000000981] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
ObjectivesWe sought to summarize the evidence for interventions aiming at enhanced recovery after surgery (ERAS) in ovarian cancer through a systematic review.MethodsWe searched MEDLINE, EMBASE, and The Cochrane Library for studies testing ERAS interventions in patients undergoing surgery for ovarian cancer. Study selection and data extraction were done independently by 2 reviewers with disagreements resolved by discussion with a senior, third reviewer.ResultsWe identified 25 studies including 1648 participants with ovarian cancer. Nine observational studies addressed ERAS protocols. Four of them were prospective, and 3 included historical controls. The other 16 studies reported single interventions, for example, early feeding, omission of pelvic drains, early orogastric tube removal, Doppler-guided fluid management, and patient-controlled epidural analgesia. Early feeding protocols were tested in 7 of the 12 randomized trials. Early feeding appeared to be safe and was associated with significantly faster recovery of bowel function.ConclusionsFew studies have specifically studied ERAS interventions in ovarian cancer. All studies on protocols including multiple interventions were susceptible to bias. Early feeding is the intervention that is best supported by randomized trials. Application of evidence for ERAS derived from nonovarian cancer is challenged by the differences not only in the scope of surgery but also in ovarian cancer patients’ comorbidities. Postoperative morbidity is particularly high in these patients because of their poor nutritional status, perioperative fluids shifts, and long operating times. These patients may also show excessive response to surgical stress. Innovative, randomized trials are needed to reliably determine the feasibility, safety, and effectiveness of specific ERAS interventions in ovarian cancer.
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Effects of Patient-Controlled Epidural Analgesia and Patient-Controlled Intravenous Analgesia on Analgesia in Patients Undergoing Spinal Fusion Surgery. Am J Ther 2017; 23:e1806-e1812. [PMID: 26510183 DOI: 10.1097/mjt.0000000000000338] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We compared the outcomes of patient-controlled epidural analgesia (PCEA) and patient-controlled intravenous analgesia (PCIA) in analgesia after spinal fusion surgery. A total of 120 patients who underwent spinal fusion surgeries between April 2013 and April 2015 at Shaanxi Provincial People's Hospital were selected for this study based on defined inclusion criteria. All patients were randomly divided into 2 groups before surgery: PCEA group (n = 65) and PCIA group (n = 55). Visual analog scales (VAS) were used to evaluate the degree of pain. Besides, the active and passive activities of patients during 1- to 3-day recovery period after surgery were recorded. Verbal rating scales were used to measure pain levels after surgery and after surgery. Adverse effects of PCEA and PCIA were monitored, which included nausea, vomiting, pruritus, drowsiness, respiratory depression, and headache. Our results showed no statistically significant differences between PCEA and PCIA in sex ratio, age, height, weight, American Society of Anesthesiologists level, surgery time, number of fusion section, surgery methods, and duration of anesthesia (all P > 0.05). The PCEA group was associated with significantly lower VAS scores, compared with the PCIA group, at 3, 6, 12, 24, and 48-hour postsurgery (all P < 0.05) when surgery-associated pain is expected to be intense. Also, compared with the PCIA group, the PCEA group showed higher frequency of recovery activities on first and second day postsurgery (all P < 0.05). The overall patient satisfaction level of analgesia in the PCEA group was significantly higher than in the PCIA group (P < 0.05). Moreover, the incidence of hypopiesia and skin itching in the PCIA group was higher than in the PCEA group (all P < 0.05). Finally, drowsiness and headache were markedly lower in the PCIA group after surgery, compared with the PCEA group, and this difference was statistically significant (all P < 0.05). Our results provide strong evidence that PCEA exhibits significantly greater efficacy than PCIA for pain management after spinal fusion surgery, with lower VAS scores, higher frequency of recovery activities, and overall higher satisfaction level.
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Oh TK, Lim MC, Lee Y, Yun JY, Yeon S, Park SY. Improved Postoperative Pain Control for Cytoreductive Surgery in Women With Ovarian Cancer Using Patient-Controlled Epidural Analgesia. Int J Gynecol Cancer 2016; 26:588-93. [PMID: 26825838 PMCID: PMC4767108 DOI: 10.1097/igc.0000000000000644] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Many studies have compared different methods of postoperative pain management in abdominal laparotomy patients; however, the conclusions have been inconsistent and controversial. This study aimed to compare the pain scores and complications of patients who underwent cytoreductive surgery for ovarian cancer and used either patient-controlled epidural analgesia (PCEA) or patient-controlled intravenous analgesia (PCA) for postoperative pain management. We hypothesized that PCEA would be superior to PCA for postoperative pain management in ovarian cancer surgery. MATERIALS AND METHODS The medical records of women who underwent ovarian cancer surgery in 2014 were reviewed retrospectively. Pain scores for postoperative days (PODs) 0 to 5 days and the incidence of complications were examined and compared in patients who received PCEA and PCA. Means were compared using an independent sample t test or Wilcoxon rank sum test, and proportions were compared using Fisher exact test or a χ(2) test at each time point. A mixed-effects model was applied to determine correlations among repeated measurements. A P value less than 0.05 was considered significant. RESULTS Of the 105 study patients, 38 received PCEA and 67 received PCA. Pain scores were significantly lower in the PCEA group than the PCA group at POD 0 (2.47 ± 1.75 vs 4.39 ± 1.17; P < 0.001), 1 (2.65 ± 1.02 vs 3.32 ± 1.09; P < 0.001), and 3 (2.17 ± 1.13 vs 2.79 ± 1.08; P = 0.011), and tended to be lower in the PCEA group at PODs 2, 4, and 5. Patient-controlled epidural analgesia provided significantly better pain relief as analyzed by a mixed-effect model. Complications were not significantly different between both groups. There was no significant difference in pain relief between both groups at PODs 4 and 5. CONCLUSIONS Patient-controlled epidural analgesia was more effective for postoperative pain management compared with PCA from POD 0 to POD 3 in patients with ovarian cancer who underwent cytoreductive surgery, without increasing the morbidity.
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Affiliation(s)
- Tak Kyu Oh
- *Department of Anesthesiology and Pain Medicine, †Center for Uterine Cancer, and ‡Gynecologic Cancer Branch, Research Institute and Hospital, National Cancer Center, Gyeonggi-do; §Department of Nursing, Sorabol College, Gyeongju-Si, Gyeongsangbuk-do; and ∥Biometric Research Branch, Research Institute and Hospital, National Cancer Center, Gyeonggi-do, Republic of Korea
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Abstract
IMPORTANCE Enhanced recovery programs (ERPs) are considered standard of care across a variety of surgical disciplines, but ERPs have not been widely adopted in gynecology. OBJECTIVE The aim of this study was to describe ERP principles and the role of ERPs in gynecology and gynecologic oncology. EVIDENCE ACQUISITION Comprehensive literature search was performed using MEDLINE, the Cochrane Collaboration Database, and PubMed. RESULTS Meta-analyses of a substantial number of randomized controlled trials have shown that implementation of ERP protocols is associated with decreased length of hospital stay, a decrease in rates of postoperative complication, decreased morbidity, and cost savings while preserving patient satisfaction and quality of life. CONCLUSIONS AND RELEVANCE High-quality evidence exists for improved outcomes among patients in ERPs. Enhanced recovery programs save resources and costs across the health care system. As quality metrics and bundled payments increase in health care, ERPs will have increasing prominence.
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Kalogera E, Dowdy SC. Enhanced Recovery Pathway in Gynecologic Surgery. Obstet Gynecol Clin North Am 2016; 43:551-73. [DOI: 10.1016/j.ogc.2016.04.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part II. Gynecol Oncol 2016; 140:323-32. [PMID: 26757238 PMCID: PMC6038804 DOI: 10.1016/j.ygyno.2015.12.019] [Citation(s) in RCA: 274] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/14/2015] [Accepted: 12/21/2015] [Indexed: 12/15/2022]
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Moslemi F, Rasooli S, Baybordi A, Golzari SE. A Comparison of Patient Controlled Epidural Analgesia With Intravenous Patient Controlled Analgesia for Postoperative Pain Management After Major Gynecologic Oncologic Surgeries: A Randomized Controlled Clinical Trial. Anesth Pain Med 2015; 5:e29540. [PMID: 26587406 PMCID: PMC4644303 DOI: 10.5812/aapm.29540] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/27/2015] [Accepted: 07/05/2015] [Indexed: 01/14/2023] Open
Abstract
Background: Postoperative pain after major open gynecologic surgeries requires appropriate pain management. Objectives: This study aimed at comparing perioperative patient controlled epidural analgesia (PCEA) and patient controlled intravenous analgesia (PCA) after gynecologic oncology surgeries. Patients and Methods: In this clinical trial study, 90 patients with American society of anesthesiologists (ASA) class I or II scheduled for gynecologic oncologic surgeries were randomly allocated to two groups (45 patients each group) to receive: patient-controlled epidural analgesia with bupivacaine and fentanyl (PCEA group), or patient controlled intravenous analgesia (IV PCA group) with fentanyl, pethidine and ondansetron. Postoperative pain was assessed over 48 hours using the visual analog scale (VAS). The frequency of rescue analgesia was recorded. Occurrence of any concomitant events such as nausea, vomiting, ileus, purities, sedation and respiratory complications were recorded postoperatively. Results: There were no statistically significant differences in demographic data including; age, weight, ASA physical status, duration of surgery, intraoperative bleeding, and the amount of blood transfusion (P > 0.05), between the two studied groups. Severity of postoperative pain was not significantly different between the two groups (P > 0.05); however, after first patient mobilization, pain was significantly lower in the epidural group than the IV group (P < 0.001). There was no significant difference between the two groups regarding the incidence of complications such as nausea, vomiting, purities or ileus (P > 0.05). Nevertheless, the incidence and severity of sedation was significantly higher in the IV group (P < 0.001). Respiratory depression was higher in the IV group than the epidural group; this difference, however, was not significant (P = 0.11). In the epidural group, only 10 patients (22.2%) had mild and transient lower extremities parenthesis. Conclusions: Both intravenous and epidural analgesic techniques with combination of analgesics provide proper postoperative pain control after major gynecologic cancer surgeries without any significant complications. Regarding lower sedative and respiratory depressant effects of epidural analgesia, it seems that this method is a safer technique for postoperative pain relief in these patients.
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Affiliation(s)
- Farnaz Moslemi
- Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sousan Rasooli
- Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Baybordi
- Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad E.J. Golzari
- Drug Applied Research Center, Tabriz Univesity of Medical Sciences, Tabriz, Iran
- Corresponding author: Samad E.J. Golzari, Tabriz University of Medical Sciences, Tabriz, Iran. Tel: +98-9141151894, Fax: +98-4135566449, E-mail:
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Honerlaw KR, Rumble ME, Rose SL, Coe CL, Costanzo ES. Biopsychosocial predictors of pain among women recovering from surgery for endometrial cancer. Gynecol Oncol 2015; 140:301-6. [PMID: 26363211 DOI: 10.1016/j.ygyno.2015.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/02/2015] [Accepted: 09/06/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study investigated post-surgical changes in pain among endometrial cancer patients, as well as the extent to which emotional distress and inflammatory and regulatory cytokine levels were associated with pain. METHODS Women (N=71) who underwent surgery for endometrial cancer completed questionnaires assessing pain intensity and interference, depression, and anxiety at 1week, 4weeks, and 16weeks post-surgery. Participants also provided a blood sample for the analysis of a panel of 7 cytokines at the same time points. RESULTS Participants showed significant declines in pain intensity and pain interference from 1week to 4weeks post-surgery, after which pain remained stable. After adjusting for time since surgery, surgery type, adjuvant therapy, disease stage, age, and BMI, mixed-effects linear regression models indicated that greater depression and anxiety were associated with both greater pain intensity and interference. Higher levels of circulating IL-6 were also correlated with greater pain intensity, but not interference. Fixed-effects linear regression models indicated that temporal variation in depression, anxiety, and IL-6 within individual patients was associated with corresponding changes in pain. Pain symptoms were maximal when anxiety, depression, and IL-6 were highest. No other cytokines were associated with changes in pain. CONCLUSION These findings indicate that depression, anxiety, and IL-6 may exacerbate pain during the recovery period following surgery for a gynecologic malignancy. Targeting these psychological processes and the proinflammatory cytokine IL-6 in women with more severe and persistent pain may help to reduce suffering and improve post-surgical recovery.
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Affiliation(s)
- Kelsey R Honerlaw
- Department of Psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Meredith E Rumble
- Department of Psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Stephen L Rose
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States; Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, United States
| | - Christopher L Coe
- Department of Psychology, University of Wisconsin-Madison, Madison, WI, United States
| | - Erin S Costanzo
- Department of Psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States; Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, United States.
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Wang N, Wang J, Zhang R, Wang F, Wang R. The effects of anaesthetics on postoperative physiological reactions: a meta-analysis. Clin Exp Pharmacol Physiol 2015; 42:1127-34. [PMID: 26016612 DOI: 10.1111/1440-1681.12430] [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: 12/29/2014] [Revised: 05/19/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
Abstract
This study aimed to systematically investigate the effects of different anaesthetics on postoperative physiological reactions compared with placebo. The literature search was conducted using three databases: PubMed, EMBASE, and the Cochrane Library. Studies published from January 1990 to January 2015 were screened. The language was restricted to English. Heterogeneity was analyzed by the Q test and I(2) statistic. A fixed-effect model was used for homogenous data and a random-effects model for heterogeneous data. The odds ratio (OR) and 95% confidence interval (CI) were calculated to monitor the incidences of overall adverse events, arterial blood pressure, and cardiac abnormalities. Sensitivity analysis was performed to estimate the strength of the meta-analysis, and publication bias was analyzed using Egger's test. A total of 24 articles were included in this meta-analysis. There were 1,810 and 1,806 cases in the anaesthetic group and the placebo group, respectively. The incidence of overall adverse events was significantly lower in the anaesthetic group compared with the placebo group (OR = 0.57; 95% CI, 0.38-0.84). No publication bias was observed, and no inverse estimates were calculated using sensitivity analysis. There was no significant difference for the incidence of arterial blood pressure (OR = 4.62; 95% CI, 0.90-23.70) and cardiac abnormalities (OR = 1.18; 95% CI, 0.53-2.63) between the two groups. Although the incidence of overall adverse events was decreased in the anaesthetic group, it is impossible to determine whether the use of anaesthetics during surgical operation has a protective effect on postoperative physiological reactions.
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Affiliation(s)
- Na Wang
- Department of Anaesthesiology, First Hospital of Jilin University, Changchun, China
| | - Jinguo Wang
- Department of Urology, First Hospital of Jilin University, Changchun, China
| | - Rui Zhang
- Department of Colorectal Surgery, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Fei Wang
- Department of Anaesthesia, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Rui Wang
- Department of Information Engineering, Jilin Business and Technology College, Changchun, China
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Abstract
Studies on enhanced recovery after gynecological surgery are limited but seem to report outcome benefits similar to those reported after colorectal surgery. Regional anesthesia is recommended in enhanced recovery protocols. Effective regional anesthetic techniques in gynecologic surgery include spinal anesthesia, epidural analgesia, transversus abdominis plane blocks, local anesthetic wound infusions and intraperitoneal instillation catheters. Non-opioid analgesics including pregabalin, gabapentin, NSAIDs, COX-2 inhibitors, and paracetamol reduce opioid consumption after surgery. This population is at high risk for PONV, thus, a multimodal anti-emetic strategy must be employed, including strategies to reduce the baseline risk of PONV in conjunction with combination antiemetic therapy.
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Affiliation(s)
- Jeanette R Bauchat
- Northwestern University, Feinberg School of Medicine, 250 East Huron Street, F5-704, Chicago, IL 60611, USA
| | - Ashraf S Habib
- Duke University Medical Center, Box 3094, Durham, NC 27710, USA.
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Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol 2014; 135:586-94. [DOI: 10.1016/j.ygyno.2014.10.006] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/03/2014] [Accepted: 10/05/2014] [Indexed: 12/20/2022]
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Courtney-Brooks M, Tanner Kurtz KC, Pelkofski EB, Nakayama J, Duska LR. Continuous epidural infusion anesthesia and analgesia in gynecologic oncology patients: less pain, more gain? Gynecol Oncol 2014; 136:77-81. [PMID: 25449564 DOI: 10.1016/j.ygyno.2014.10.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 10/17/2014] [Accepted: 10/17/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE There is a lack of consistent data regarding gynecologic oncology (GO) patients and the use of neuraxial anesthesia for post-operative pain management. Our objective was to compare the use of continuous epidural infusion (CEI) as part of post-operative pain management to more traditional management schemes. METHODS GO patients undergoing laparotomy from July 1st, 2011 through July 31st, 2012 were identified. Patient demographic data and peri-operative details were abstracted from the medical record. The primary outcome was a mean patient visual analog pain score. Secondary outcomes included length of stay, post-operative urinary tract infection (UTI) and venous thromboembolic (VTE) events. RESULTS There were 237 laparotomies during the study time period. Fifty-six women had CEI for post-operative pain management and 181 did not. Patients with CEI had lower pain scores on POD #0 (3.8 vs 5.3, p < 0.01), #1 (2.6 vs 4.0, p < 0.01) and #2 (2.5 vs 3.5, p < 0.01) compared to women without CEI. There was no difference in the length of stay between those with and without CEI (103 vs 94 h, p = 0.32). Women with CEI did have a longer length of urinary catheterization (56 vs 26 h, p = 0.01) but not an increased rate of UTI (5.5% vs 1.8%, p = 0.24). There was a higher rate of post-operative VTE events among women with CEI (8.9% vs 1.7%, p = 0.02). CONCLUSIONS In this small series, GO patients undergoing laparotomy had improved post-operative pain control when their analgesia regimen included CEI. However, the higher rate of VTE events among CEI users is concerning and merits further investigation.
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Affiliation(s)
- Madeleine Courtney-Brooks
- Thornton Gynecology Oncology Service, Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, VA 22908, USA.
| | - Kirby C Tanner Kurtz
- Thornton Gynecology Oncology Service, Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Elizabeth B Pelkofski
- Thornton Gynecology Oncology Service, Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - John Nakayama
- Thornton Gynecology Oncology Service, Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - Linda R Duska
- Thornton Gynecology Oncology Service, Department of Obstetrics and Gynecology, University of Virginia Health System, Charlottesville, VA 22908, USA
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Perioperative analgesia outcomes and strategies. Best Pract Res Clin Anaesthesiol 2014; 28:105-15. [DOI: 10.1016/j.bpa.2014.04.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 04/16/2014] [Accepted: 04/28/2014] [Indexed: 11/18/2022]
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Rivard C, Dickson EL, Vogel RI, Argenta PA, Teoh D. The effect of anesthesia choice on post-operative outcomes in women undergoing exploratory laparotomy for a suspected gynecologic malignancy. Gynecol Oncol 2014; 133:278-82. [PMID: 24582989 DOI: 10.1016/j.ygyno.2014.02.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 02/15/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine how anesthesia choice in women undergoing laparotomy for gynecologic malignancy affects pain control and narcotic use. METHODS This is a retrospective study of women who underwent laparotomy for suspected gynecologic malignancy from May 2012 to January 2013. Patients were categorized into one of three groups: 1) patient controlled analgesia (PCA); 2) PCA+transversus abdominis plane block (TAP); and 3) patient-controlled epidural analgesia (PCEA). Mean narcotic use and patient reported pain scores were compared. RESULTS The analysis includes 112 women (44 PCA, 30 TAP, 38 PCEA). Intraoperative factors were not different between groups with the exception of a significant difference in the rate of intra-operative complications (p=0.020), with lower rates in the PCEA group. The groups differed in intravenous narcotic use in each of the first three postoperative days (day 0: p=0.014; day 1: p<0.0001; day 2: p=0.048), with patients in the TAP group using the least on day 0 and those in the PCEA group using less on postoperative days 1 and 2. In addition, the PCEA group reported lower pain scores on postoperative days 1 and 2 (day 1: p=0.046; day 2: p=0.008). CONCLUSIONS The use of patient controlled epidural anesthesia after laparotomy for gynecologic malignancy is associated with decreased IV and PO narcotic use and improved pain control without increasing complications or length of hospital stay. Further investigation with prospective randomized trials is warranted to elucidate the optimal post-operative pain management technique.
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Affiliation(s)
- Colleen Rivard
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, USA.
| | - Elizabeth L Dickson
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, USA
| | - Rachel Isaksson Vogel
- Masonic Cancer Center, Biostatistics and Bioinformatics, University of Minnesota, USA
| | - Peter A Argenta
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, USA
| | - Deanna Teoh
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, USA
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Kara I, Apiliogullari S, Oc B, Celik JB, Duman A, Celik C, Dogan NU. The effects of intrathecal morphine on patient-controlled analgesia, morphine consumption, postoperative pain and satisfaction scores in patients undergoing gynaecological oncological surgery. J Int Med Res 2012; 40:666-72. [PMID: 22613428 DOI: 10.1177/147323001204000229] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Gynaecological oncological surgery (GOS) includes a wide variety of surgical procedures and postoperative pain is a major concern. This study compared the impact of intrathecal morphine (ITM) plus patient-controlled analgesia (PCA) with PCA alone on morphine consumption, pain relief and patient satisfaction after GOS. METHODS Sixty women undergoing GOS under general anaesthesia were randomized to receive either 0.3 mg ITM or placebo. On arrival at the postanaesthesia care unit each patient received a morphine PCA pump. The three primary outcome measures were pain, patient satisfaction scores evaluated using a 100-mm visual analogue scale and cumulative PCA morphine consumption. RESULTS No significant differences were observed in the demographic data. Cumulative PCA morphine consumption was significantly lower in the ITM group compared with the control group. Fatigue scores were lower in the ITM group compared with the control group but did not reach statistical significance. Pain, sedation and patient satisfaction scores, and the rate of side-effects were similar for the two groups. CONCLUSIONS Administering ITM in GOS could improve postoperative analgesia and reduce morphine consumption without serious side-effects.
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Affiliation(s)
- I Kara
- Department of Anaesthesia and Intensive Care, Selcuklu Medical Faculty, Selcuk University, 42075 Selcuklu, Konya, Turkey.
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Setti T, Sanfilippo F, Leykin Y. Transdermal buprenorphine for postoperative pain control in gynecological surgery: a prospective randomized study. Curr Med Res Opin 2012; 28:1597-608. [PMID: 22876835 DOI: 10.1185/03007995.2012.719864] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Although numerous methods are available for postoperative pain (POP) management, new approaches are constantly being investigated. This feasibility study assessed the buprenorphine transdermal therapeutic system (Bup-TTS) for the treatment of POP after gynecological open surgery. RESEARCH DESIGN AND METHODS Forty-five patients were prospectively randomized to different Bup-TTS dosages (17.5, 35, or 52.5 μg/h). Patients were blinded with regard to patch dose. MAIN OUTCOME MEASURES Efficacy was evaluated in terms of rescue boluses (intravenous morphine 2 mg in the first six postoperative hours, intravenous ketorolac 30 mg thereafter) required to achieve a static and dynamic Numerical Rating Scale (sNRS and dNRS) score ≤4. Side effects were evaluated from patch application (12 hours before surgery) until the 72nd postoperative hour. Patient satisfaction regarding POP management was assessed via anonymous questionnaire. RESULTS All Bup-TTS groups required additional postoperative analgesia, particularly in the first postoperative hour. No between-group differences in sNRS/dNRS values were recorded at emergence from anesthesia. A significant inverse correlation occurred between Bup-TTS dosage and use of morphine (p = 0.04), ketorolac (p = 0.04) or both rescues (p = 0.02). Postoperative nausea/vomiting occurred in 3.1% of assessments, with no between-group differences and a significant correlation with morphine amount (p = 0.01). No serious side effects occurred. Despite no between-group difference, patient satisfaction was inversely correlated with the number of rescue doses (p < 0.001). Study limitations include the small sample size, the absence of a control group treated with a more conventional technique for POP relief, the focus on selected patients at low perioperative risk and the presence of slightly different types of open surgery (hysterectomy vs myomectomy only). CONCLUSION Bup-TTS efficacy was directly proportional to its dosage, although additional analgesia was required, particularly in the first postoperative hour. Moreover, the consumption of morphine and ketorolac was inversely correlated to the Bup-TTS dosage. Increasing Bup-TTS doses were not associated with an increased incidence of side effects. Bup-TTS appears a safe and feasible approach for moderate POP management; further larger studies are warranted.
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Affiliation(s)
- Tommaso Setti
- Department of Anesthesia and Intensive Care, Hospital Santa Maria degli Angeli, Pordenone, Italy.
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Should epidural analgesia be dismissed in gynecologic oncology surgery? Of course not! Gynecol Oncol 2010. [DOI: 10.1016/j.ygyno.2010.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Should epidural analgesia be dismissed in gynecologic oncology surgery? Gynecol Oncol 2010; 117:508-9; author reply 509. [PMID: 20163848 DOI: 10.1016/j.ygyno.2010.01.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Accepted: 01/22/2010] [Indexed: 11/23/2022]
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