Intraoperative local anesthesia decreases postoperative parenteral opioid requirements for transperitoneal laparoscopic renal and adrenal surgery: a randomized, double-blind, placebo controlled investigation

How long to wait after local infiltration anaesthesia: systematic review

BACKGROUND

Conflicting evidence exists regarding the optimal waiting time for stable analgesic and vasoconstrictive effects after local infiltration of lidocaine with epinephrine. An objective review is needed to dispel surgical dogma.

METHODS

This systematic review (PROSPERO ID: CRD42022362414) included RCTs and prospective cohort studies. Primary outcomes were (1) onset of analgesia and (2) onset of stable hypoperfusion, assessed directly, or measured indirectly using perfusion imaging. Other data extracted include waiting strategies, means of outcome assessment, anaesthetic concentrations, volume/endpoint of infiltration, and injection sites. Methodological quality was evaluated using the Cochrane risk-of-bias tool for randomized trials. Articles describing waiting strategies were critically appraised by the Joanna Briggs Institute tools.

RESULTS

Twenty-four articles were analysed, comprising 1013 participants. Ten investigated analgesia onset. Their pooled mean was 2.1 min (range 0.4-9.0 min). This varied with anatomic site and targeted nerve diameter. Fourteen articles investigated onset of stable hypoperfusion. Four observed bleeding intraoperatively, finding the minimum time to hypoperfusion at 7.0 min in the eyelid skin and 25.0 min in the upper limb. The ten remaining studies used perfusion imaging, reporting a wide range of results (0.0-30.0 min) due to differences in anatomic sites and depth, resolution and artefacts. Studies using near-infrared reflectance spectroscopy and hyperspectral imaging correlated with clinical observations. Thirteen articles discussed waiting strategies, seven relating to large-volume tumescent local infiltration anaesthesia. Different waiting strategies exist for emergency, arthroscopic and cosmetic surgeries, according to the degree of hypoperfusion required. In tumescent liposuction, waiting 10.0-60.0 min is the norm.

CONCLUSION

Current literature suggests that around 2 min are required for most patients to achieve complete analgesia in all sites and with all anaesthesia concentrations. Waiting around 7 min in eyelids and at least 25 min in other regions results in optimal hypoperfusion. The strategies discussed inform decisions of when and how long to wait.

Safe transition to opioid-free pathway after robotic-assisted laparoscopic prostatectomy

To determine whether local anesthetic infiltration and non-narcotic pain medications can safely reduce or eliminate opioid use following robotic-assisted laparoscopic prostatectomy while maintaining adequate pain control. After initiation of this quality-improvement project, patients undergoing robotic-assisted laparoscopic prostatectomy had surgeon-administered local anesthesia around all incisions into each successive layer from peritoneum to skin, with the majority infiltrated into the transversus abdominis muscle plane and posterior rectus sheath of the midline extraction incision. Post-operatively patients received scheduled acetaminophen plus ketorolac, renal function permitting. A retrospective review was performed for all cases over 19 months, spanning project implementation. 157 cases (76 in opioid-free pathway, 81 in standard pathway) were included. Five patients (6.6%) in the opioid-free pathway required post-operative opioids while inpatient, versus 61 (75.3%) in the standard pathway, p < .001. Mean patient-reported pain score on each post-operative day was lower in the opioid-free pathway compared to the standard pathway [day 0: 2.4 (SD 2.6) vs. 3.9 (SD 2.7), p < .001; day 1: 1.4 [SD 1.6] vs. 3.3 (SD 2.2), p < .001; day 2 0.9 (SD 1.5) vs. 2.6 (SD 1.9), p < .001]. Fewer post-operative complications were seen in the opioid-free pathway versus standard [0 vs. 5 (6.2%), p = 0.028], and there was no statistically significant difference in number of emergency room visits or readmissions within 3 weeks of surgery. The use of surgeon-administered local anesthetic plus scheduled non-narcotic analgesics can safely and significantly reduce opioid use after robotic-assisted laparoscopic prostatectomy while improving pain control.

Transperitoneal versus retroperitoneal laparoscopic adrenalectomy for adrenal tumours in adults

BACKGROUND

Laparoscopic adrenalectomy is an accepted treatment worldwide for adrenal gland disease in adults. The transperitoneal approach is more common. The retroperitoneal approach may be preferred, to avoid entering the peritoneum, but no clear advantage has been demonstrated so far.

OBJECTIVES

To assess the effects of laparoscopic transperitoneal adrenalectomy (LTPA) versus laparoscopic retroperitoneal adrenalectomy (LRPA) for adrenal tumours in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, ICTRP Search Portal, and ClinicalTrials.gov to 3 April 2018. We applied no language restrictions.

SELECTION CRITERIA

Two review authors independently scanned the abstract, title, or both sections of every record retrieved to identify randomised controlled trials (RCTs) on laparoscopic adrenalectomy for preoperatively assessed adrenal tumours. Participants were affected by corticoid and medullary, benign and malignant, functional and silent tumours or masses of the adrenal gland, which were assessed by both laboratory and imaging studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed trials for risk of bias, and evaluated overall study quality using GRADE criteria. We calculated the risk ratio (RR) for dichotomous outcomes, or the mean difference (MD) for continuous variables, and corresponding 95% confidence interval (CI). We primarily used a random-effects model for pooling data.

MAIN RESULTS

We examined 1069 publications, scrutinized 42 full-text publications or records, and included five RCTs. Altogether, 244 participants entered the five trials; 127 participants were randomised to retroperitoneal adrenalectomy and 117 participants to transperitoneal adrenalectomy. Two trials had a follow-up of nine months, and three trials a follow-up of 31 to 70 months. Most participants were women, and the average age was around 40 years. Three trials reported all-cause mortality; in two trials, there were no deaths, and in one trial with six years of follow-up, four participants died in the LRPA group and one participant in the LTPA group (164 participants; low-certainty evidence). The trials did not report all-cause morbidity. Therefore, we analysed early and late morbidity, and included specific adverse events under these outcome measures. The results were inconclusive between LRPA and LTPA for early morbidity (usually reported within 30 to 60 days after surgery; RR 0.56, 95% CI 0.27 to 1.16; P = 0.12; 5 trials, 244 participants; very low-certainty evidence). Nine out of 127 participants (7.1%) in the LRPA group, compared with 16 out of 117 participants (13.7%) in the LTPA group experienced an adverse event. Participants in the LRPA group may have a lower risk of developing late morbidity (reported as latest available follow-up; RR 0.12, 95% CI 0.01 to 0.92; P = 0.04; 3 trials, 146 participants; very low-quality evidence). None of the 78 participants in the LRPA group, compared with 7 of the 68 participants (10.3%) in the LTPA group experienced an adverse event.None of the trials reported health-related quality of life. The results were inconclusive for socioeconomic effects, assessed as time to return to normal activities and length of hospital stay, between the intervention and comparator groups (very low-certainty evidence). Participants who had LRPA may have had an earlier start on oral fluid or food intake (MD -8.6 hr, 95% CI -13.5 to -3.7; P = 0.0006; 2 trials, 89 participants), and ambulation (MD -5.4 hr, 95% CI -6.8 to -4.0 hr; P < 0.0001; 2 trials, 89 participants) than those in the LTPA groups. Postoperative and operative parameters (duration of surgery, operative blood loss, conversion to open surgery) showed inconclusive results between the intervention and comparator groups.

AUTHORS' CONCLUSIONS

The body of evidence on laparoscopic retroperitoneal adrenalectomy compared with laparoscopic transperitoneal adrenalectomy is limited. Late morbidity might be reduced following laparoscopic retroperitoneal adrenalectomy, but we are uncertain about this effect because of very low-quality evidence. The effects on other key outcomes, such as all-cause mortality, early morbidity, socioeconomic effects, and operative and postoperative parameters are uncertain. LRPA might show a shorter time to oral fluid or food intake and time to ambulation, but we are uncertain whether this finding can be replicated. New long-term RCTs investigating additional data, such as health-related quality of life, surgeons' level of experience, treatment volume of surgical centres, and details on techniques used are needed.

Dual Therapy Coating on Micro/Nanoscale Porous Polyetheretherketone to Eradicate Biofilms and Accelerate Bone Tissue Repair

Defective osteogenesis and latent infections continue to be two major issues in the therapy of bone tissue regeneration. In this study, a unique hierarchically micro/nanoscale-architecture is first proposed and produced on polyetheretherketone (PEEK). Besides, a "simvastatin-PLLA film-tobramycin microspheres" delivery system is subsequently fabricated to endow the PEEK implant with osteogenic and antibacterial capabilities. In vitro antibacterial evaluations confirm that the decorated PEEK scaffolds possess excellent resistance against planktonic/adherent bacteria. In vitro cell attachment/proliferation, lactate dehydrogenase (LDH) content, alkaline phosphatase (ALP) activity, calcium mineral deposition experiments, and real-time PCR analysis all exhibit that the superior proliferation rate and osteo-differentiation potential of MC3T3-E1 pre-osteoblasts are presented on the PEEK samples with dual functional decoration. In the mouse calvarial defect model, the micro-CT and histological results demonstrate that our scaffolds display a remarkable bone forming capability. Generally, the PEEK scaffolds co-endowed with simvastatin and tobramycin microspheres possess great potential in clinics.

Dual Ag/ZnO-Decorated Micro-/Nanoporous Sulfonated Polyetheretherketone with Superior Antibacterial Capability and Biocompatibility via Layer-by-Layer Self-Assembly Strategy

Polyetheretherketone is attractive for dental and orthopedic applications due to its mechanical attributes close to that of human bone; however, the lack of antibacterial capability and bioactivity of polyetheretherketone has substantially impeded its clinical applications. Here, a dual therapy implant coating is developed on the 3D micro-/nanoporous sulfonated polyetheretherketone via layer-by-layer self-assembly of Ag ions and Zn ions. Material characterization studies have indicated that nanoparticles consisting of elemental Ag and ZnO are uniformly incorporated on the porous sulfonated polyetheretherketone surface. The antibacterial assays demonstrate that Ag-decorated sulfonated polyetheretherketone and Ag/ZnO-codecorated sulfonated polyetheretherketone effectively inhibit the reproduction of Gram-negative and Gram-positive bacteria. Owing to the coordination of micro-/nanoscale topological cues and Zn induction, the Ag/ZnO-codecorated sulfonated polyetheretherketone substrates are found to enhance biocompatibility (cell viability, spreading, and proliferation), and hasten osteodifferentiation and -maturation (alkaline phosphate activity (ALP) production, and osteogenesis-related genetic expression), compared with the Ag-decorated sulfonated polyetheretherketone and the ZnO-decorated sulfonated polyetheretherketone counterparts. The dual therapy Ag/ZnO-codecorated sulfonated polyetheretherketone has an appealing bacteriostatic performance and osteogenic differentiation potential, showing great potential for dental and orthopedic implants.

Laparoscopic surgery: a narrative review of pharmacotherapy in pain management

Laparoscopic surgery is widespread, and an increasing number of surgeries are performed laparoscopically. Early pain after laparoscopy can be similar or even more severe than that after open surgery. Thus, proactive pain management should be provided. Pain after laparoscopic surgery is derived from multiple origins; therefore, a single agent is seldom sufficient. Pain is most effectively controlled by a multimodal, preventive analgesia approach, such as combining opioids with non-opioid analgesics and local anaesthetics. Wound and port site local anaesthetic injections decrease abdominal wall pain by 1-1.5 units on a 0-10 pain scale. Inflammatory pain and shoulder pain can be controlled by NSAIDs or corticosteroids. In some patient groups, adjuvant drugs, ketamine and α2-adrenergic agonists can be helpful, but evidence on gabapentinoids is conflicting. In the present review, the types of pain that need to be taken into account while planning pain management protocols and the wide range of analgesic options that have been assessed in laparoscopic surgery are critically assessed. Recommendations to the clinician will be made regarding how to manage acute pain and how to prevent persistent postoperative pain. It is important to identify patients at the highest risk for severe and prolonged post-operative pain, and to have a proactive strategy in place for these individuals.

Comparıson of different postoperative paın managements in patients submitted to transperitoneal laparoscopic renal and adrenal surgery

Purpose:

We compared the effects of local levobupivacaine infiltration, intravenous paracetamol, intravenous lornoxicam treatments on postoperative analgesia in patients submitted to transperitoneal laparoscopic renal and adrenal surgery.

Materials and Methods:

Sixty adult patients 26 and 70 years who underwent laparoscopic renal and adrenal surgery were randomized into three groups with 20 patients each: Group 1 received local 20mL of levobupivacaine 0.25% infiltration to the trocar incisions before skin closure. In group 2, 1g paracetamol was given to the patients intravenously 30 minutes before extubation and 5g paracetamol was given intravenoulsy in the 24 postoperative period. In group 3, 8mg lornoxicam i.v. was given 30 minutes before extubation and 8mg lornoxicam i.v. was given in the 24 postoperative period. In the postoperative period, pain scores, cumulative tramadol, and additional pethidine consumption were evaluated.

Results:

Postoperative pain scores significantly reduced in each group (p < 0.05). Although pain levels of the groups were not significantly different at 1, 2, 4, 8, 12 and 24 hours postoperatively, cumulative tramadol consumptions were higher in group 1 than the others. (Group 1 = 370.6 ± 121.6mg, Group 2: 220.9 ± 92.5mg, Group 3 = 240.7 ± 100.4mg.) (p < 0.005). The average dose of pethidine administered was significantly lower in groups 2 and 3 compared with group 1 (Group 1: 145mg, Group 2: 100mg, Group 3: 100mg) (p = 0.024).

Conclusions:

Levobupivacaine treated group required significantly more intravenous tramadol when compared with paracetamol and lornoxicam groups in patients submitted to transperitoneal laparoscopic renal and adrenal surgery.

Effects of intravenous diclofenac on postoperative sore throat in patients undergoing laparoscopic surgery at Aga Khan University Hospital, Nairobi: a prospective, randomized, double blind controlled trial

BACKGROUND

postoperative sore throat is the commonest complication after endotracheal intubation. The efficacy of intravenous non-steroidal anti-inflammatory drugs in alleviating postoperative sore throat has not been investigated.

OBJECTIVE

To evaluate the effect of intravenous diclofenac sodium on the occurrence and severity of postoperative sore throat.

METHODS

42 in-patients scheduled for laparoscopic surgery were randomized into two equal groups to receive either a single dose of 75mg intravenous diclofenac sodium in addition to standard treatment taken at our hospital for the prevention of postoperative sore throat or to receive standard treatment only. All patients were interviewed postoperatively at 2, 6 and 18 hours. Data of the baseline characteristics, the incidence and severity of sore throat were collected. If sore throat was present, a Visual Analogue Score was used to assess its severity.

RESULTS

the baseline characteristics of the participants were similar. The majority of the patients undergoing laparoscopic surgery were women. There was no statistically significant difference in the occurrence or severity of postoperative sore throat between the diclofenac and standard treatment groups at 2, 6 and 18 hours postoperatively.

CONCLUSION

Intravenous diclofenac sodium does not reduce the occurrence or severity of postoperative sore throat.

Regional anesthesia for laparoscopic surgery: a narrative review

Laparoscopic surgery has advanced remarkably in recent years, resulting in reduced morbidity and shorter hospital stay compared with open surgery. Despite challenges from the expanding array of laparoscopic procedures performed with the use of pneumoperitoneum on increasingly sick patients, anesthesia has remained largely unchanged. At present, most laparoscopic operations are usually performed under general anesthesia, except for patients deemed "too sick" for general anesthesia. Recently, however, several large, retrospective studies questioned the widely held belief that general anesthesia is the best anesthetic method for laparoscopic surgery and suggested that regional anesthesia could also be a reasonable choice in certain settings. This narrative review is an attempt to critically summarize current evidence on regional anesthesia for laparoscopic surgery. Because most available data come from large, retrospective studies, large, rigorous, prospective clinical trials comparing regional vs. general anesthesia are needed to evaluate the true value of regional anesthesia in laparoscopic surgery.

Endogenous opiates and behavior: 2004

This paper is the 27th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over 30 years of research. It summarizes papers published during 2004 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.