Intrathecal Morphine in Postoperative Analgesia for Colorectal Cancer Surgery: A Retrospective Study

Blended (Combined Spinal and General) vs. General Anesthesia for Abdominal Hysterectomy: A Retrospective Study

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.

Clinical effect of rectus sheath block compared to intrathecal morphine injection for minimally invasive colorectal cancer surgery: a propensity score-matched study

PURPOSE

To evaluate the postoperative outcomes of a multimodal perioperative pain management protocol with rectus sheath blocks (RSBs) or intrathecal morphine (ITM) injection for minimally invasive colorectal cancer surgery.

METHODS

A total of 112 patients underwent minimally invasive colorectal surgery. Forty-one patients underwent RSB (group 1), whereas 71 patients underwent ITM (group 2) in addition to multimodal pain management using enhanced recovery after the surgery protocol. To adjust for the baseline differences and selection bias, baseline characteristics and postoperative outcomes were compared using propensity score matching.

RESULTS

Forty patients were evaluated in each group. There was no significant difference in the length of hospital stay between the two groups. According to the Comprehensive Complication Index (CCI) score, the postoperative complication rate was significantly lower in the RSB group (3.0 ± 7.8) than in the ITM group (8.1 ± 10.9; p = 0.016). During the first 24 h after surgery, the median postoperative visual analog scale score was significantly higher in the RSB group than in the ITM group (2.0 ± 1.1 vs. 1.5 ± 1.2; p = 0.048). Postoperative morphine use was also significantly higher in the RSB group than in the ITM group in the first 24 h (23.7 ± 19.8 vs 11.6 ± 15.6%; p = 0.003) and 48 h (16.9 ± 24.8 vs. 7.5 ± 11.9; p = 0.036) after surgery. Significant urinary retention occurred after the in the RSB and ITM groups (5% vs. 45%; p < 0.001).

CONCLUSION

Although the RSB group had higher morphine use during the first 48 h after surgery, the length of hospital stay remained the same and the complications were less in terms of the CCI score. Thus, transperitoneal RSB is a safe and feasible approach for postoperative pain management following minimally invasive procedures.

The additional analgesic effects of transverse abdominis plane block in patients receiving low-dose intrathecal morphine for minimally invasive colorectal surgery: a randomized, single-blinded study

Purpose

Intrathecal analgesia (ITA) and transverse abdominis plane block (TAPB) are effective pain control methods in abdominal surgery. However, there is still no gold standard for postoperative pain control in minimally invasive colorectal surgery. This study aimed to investigate whether the analgesic effect could be increased when TAPB, which can further reduce wound somatic pain, was administered in low-dose morphine ITA patients.

Methods

Patients undergoing elective colorectal surgery were randomized into an ITA with TAPB group or an ITA group. Patients were evaluated for pain 0, 8, 16, 24, and 48 hours after surgery. The primary outcome was the total morphine milligram equivalents administered 24 hours after surgery. The secondary outcomes were pain scores, ambulatory variables, inflammation markers, hospital stay duration, and complications within 48 hours after surgery.

Results

A total of 64 patients were recruited, and 55 were compared. There was no significant difference in morphine use over the 24 hours after surgery in the 2 groups (ITA with TAPB, 15.3 mg vs. ITA, 10.2 mg; P = 0.270). Also, there was no significant difference in pain scores. In both groups, the average pain score at 24 and 48 hours was 2 points or less, showing effective pain control.

Conclusion

ITA for pain control in patients with colorectal surgery is an effective pain method, and additional TAPB was not effective.

Anesthetic technique and cancer surgery outcomes

PURPOSE OF REVIEW

Surgery remains integral to treating solid cancers. However, the surgical stress response, characterized by physiologic perturbation of the adrenergic, inflammatory, and immune systems, may promote procancerous pathways. Anesthetic technique per se may attenuate/enhance these pathways and thereby could be implicated in long-term cancer outcomes.

RECENT FINDINGS

To date, clinical studies have predominantly been retrospective and underpowered and, thus limit meaningful conclusions. More recently, prospective studies of regional anesthesia for breast and colorectal cancer surgery have failed to demonstrate long-term cancer outcome benefit. However, based on the consistent observation of protumorigenic effects of surgical stress and that of volatile anesthesia in preclinical studies, supported by in vivo models of tumor progression and metastasis, we await robust prospective clinical studies exploring the role of propofol-based total intravenous anesthesia (cf. inhalational volatiles). Additionally, anti-adrenergic/anti-inflammatory adjuncts, such as lidocaine, nonsteroidal anti-inflammatory drugs and the anti-adrenergic propranolol warrant ongoing research.

SUMMARY

The biologic perturbation of the perioperative period, compounded by the effects of anesthetic agents, renders patients with cancer particularly vulnerable to enhanced viability of minimal residual disease, with long-term outcome consequences. However, low level and often conflicting clinical evidence equipoise currently exists with regards to optimal oncoanesthesia techniques. Large, prospective, randomized control trials are urgently needed to inform evidence-based clinical practice guidelines.