Opioid-sparing effects of ketorolac and its correlation with the recovery of postoperative bowel function in colorectal surgery patients: a prospective randomized double-blinded study

Early administration of ketorolac after cardiac surgery and postoperative complications: Analysis of the MIMIC-IV database

Inflammation may contribute to postoperative cardiac complications and ketorolac, an anti-inflammatory agent inhibiting cyclooxygenase (COX), shows promise in enhancing cardiac graft patency by suppressing endothelial cell proliferation in animal studies. However, the safety of postoperative ketorolac use remains controversial. This study investigates the association between early ketorolac application and complications following cardiac surgery. Data from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database fueled this retrospective cohort study. The primary outcome is a composite of mortality, pulmonary insufficiency, severe acute kidney injury (AKI), hemorrhage or hematoma, infection, cardiogenic shock, and cerebrovascular infarction postcardiac surgery. Propensity score matching (PSM; 1:1 match, caliper 0.2), multivariate logistic regression, interaction stratification analysis, pairwise algorithmic, and overlap weight model analyses were employed. Following inclusion and exclusion criteria, 7143 patients who underwent valvular surgery or coronary artery bypass grafting (CABG) were included. PSM created a balanced cohort of 3270 individuals (1635 in the ketorolac group). The matched cohort exhibited an 8.1% overall rate of postoperative complications, with a lower composite outcome rate in patients receiving ketorolac within 48 h of surgery compared with those without (PSM, OR 0.70 [95% CI, 0.54-0.90]). Consistent associations were observed in total cohort analyses, sensitivity, and subgroup analyses. Early ketorolac use within 48 h post-CABG or valvular procedures in adults is independently associated with a lower incidence of composite postoperative adverse events. Prospective trials are warranted to assess causality.

Risks of serious adverse events with non-steroidal anti-inflammatory drugs in gastrointestinal surgery: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended for perioperative opioid-sparing multimodal analgesic treatments. Concerns regarding the potential for serious adverse events (SAEs) associated with perioperative NSAID treatment are especially relevant following gastrointestinal surgery. We assessed the risks of SAEs with perioperative NSAID treatment in patients undergoing gastrointestinal surgery.

METHODS

We conducted a systematic review of randomised clinical trials assessing the harmful effects of NSAIDs versus placebo, usual care or no intervention in patients undergoing gastrointestinal surgery. The primary outcome was an incidence of SAEs. We systematically searched for eligible trials in five major databases up to January 2024. We performed risk of bias assessments to account for systematic errors, trial sequential analysis (TSA) to account for the risks of random errors, performed meta-analyses using R and used the Grading of Recommendations Assessment, Development and Evaluation framework to describe the certainty of evidence.

RESULTS

We included 22 trials enrolling 1622 patients for our primary analyses. Most trials were at high risk of bias. Meta-analyses (risk ratio 0.78; 95% confidence interval [CI] 0.51-1.19; I2 = 4%; p = .24; very low certainty of evidence) and TSA indicated a lack of information on the effects of NSAIDs compared to placebo on the risks of SAEs. Post-hoc beta-binomial regression sensitivity analyses including trials with zero events showed a reduction in SAEs with NSAIDs versus placebo (odds ratio 0.73; CI 0.54-0.99; p = .042).

CONCLUSION

In adult patients undergoing gastrointestinal surgery, there was insufficient information to draw firm conclusions on the effects of NSAIDs on SAEs. The certainty of the evidence was very low.

S-Nitrosylation of Septin2 Exacerbates Aortic Aneurysm and Dissection by Coupling the TIAM1-RAC1 Axis in Macrophages

BACKGROUND

S-Nitrosylation (SNO), a prototypic redox-based posttranslational modification, is involved in cardiovascular disease. Aortic aneurysm and dissection are high-risk cardiovascular diseases without an effective cure. The aim of this study was to determine the role of SNO of Septin2 in macrophages in aortic aneurysm and dissection.

METHODS

Biotin-switch assay combined with liquid chromatography-tandem mass spectrometry was performed to identify the S-nitrosylated proteins in aortic tissue from both patients undergoing surgery for aortic dissection and Apoe-/- mice infused with angiotensin II. Angiotensin II-induced aortic aneurysm model and β-aminopropionitrile-induced aortic aneurysm and dissection model were used to determine the role of SNO of Septin2 (SNO-Septin2) in aortic aneurysm and dissection development. RNA-sequencing analysis was performed to recapitulate possible changes in the transcriptome profile of SNO-Septin2 in macrophages in aortic aneurysm and dissection. Liquid chromatography-tandem mass spectrometry and coimmunoprecipitation were used to uncover the TIAM1-RAC1 (Ras-related C3 botulinum toxin substrate 1) axis as the downstream target of SNO-Septin2. Both R-Ketorolac and NSC23766 treatments were used to inhibit the TIAM1-RAC1 axis.

RESULTS

Septin2 was identified S-nitrosylated at cysteine 111 (Cys111) in both aortic tissue from patients undergoing surgery for aortic dissection and Apoe-/- mice infused with Angiotensin II. SNO-Septin2 was demonstrated driving the development of aortic aneurysm and dissection. By RNA-sequencing, SNO-Septin2 in macrophages was demonstrated to exacerbate vascular inflammation and extracellular matrix degradation in aortic aneurysm. Next, TIAM1 (T lymphoma invasion and metastasis-inducing protein 1) was identified as a SNO-Septin2 target protein. Mechanistically, compared with unmodified Septin2, SNO-Septin2 reduced its interaction with TIAM1 and activated the TIAM1-RAC1 axis and consequent nuclear factor-κB signaling pathway, resulting in stronger inflammation and extracellular matrix degradation mediated by macrophages. Consistently, both R-Ketorolac and NSC23766 treatments protected against aortic aneurysm and dissection by inhibiting the TIAM1-RAC1 axis.

CONCLUSIONS

SNO-Septin2 drives aortic aneurysm and dissection through coupling the TIAM1-RAC1 axis in macrophages and activating the nuclear factor-κB signaling pathway-dependent inflammation and extracellular matrix degradation. Pharmacological blockade of RAC1 by R-Ketorolac or NSC23766 may therefore represent a potential treatment against aortic aneurysm and dissection.

Understanding Hematoma Risk: Study of Patient and Perioperative Factors in a Large Cohort of Young Women Undergoing Reduction Mammaplasty

BACKGROUND

Despite high satisfaction rates, reduction mammaplasty can have complications such as hematoma. Factors such as age, tobacco use, and comorbidities are known contributors, whereas the influence of race, BMI, certain medications, and blood pressure (BP) remain contentious. This study investigates hematoma risk factors in young women undergoing reduction mammaplasty.

STUDY DESIGN

A retrospective review was conducted including all female patients who underwent bilateral reduction mammaplasty at a single institution between 2012 and 2022. Data on demographics, BMI, medical comorbidities, surgical techniques, medications, and perioperative BP were collected. Differences between patients who developed a hematoma and those who did not were assessed using chi-square, Fisher's exact, and t -tests. The relationship between perioperative BP and hematoma formation was assessed using logistic regression.

RESULTS

Of 1,754 consecutive patients, 3% developed postoperative hematoma of any kind, with 1.8% returning to the operating room. Age (odds ratio [OR] 1.14, p = 0.01) and ketorolac use (OR 3.93, p = 0.01) were associated with hematoma development. Controlling for baseline BP, each 10 mmHg incremental increase in peak intraoperative BP (systolic BP [SBP]: OR 1.24, p = 0.03; mean arterial pressure: OR 1.24, p = 0.01) and postoperative BP (SBP: OR 1.41, p = 0.01; mean arterial pressure: OR 1.49, p = 0.01) escalated the odds of hematoma. Postoperative SBP variability also incrementally increased hematoma odds (OR 1.48, p < 0.01). Other factors, including race and surgical technique, were not significantly influential.

CONCLUSIONS

Age, ketorolac use, and intra- and postoperative BP peaks and variability are risk factors for hematoma in reduction mammaplasty. This emphasizes the importance of perioperative BP management and optimizing pain management protocols.

Total postoperative opioid dose is an independent risk factor for prolonged postoperative ileus after laparoscopic colorectal surgery: a case-control study

BACKGROUND

Prolonged postoperative ileus (PPOI) is a major complication of colorectal surgery. Increased opioid consumption has been proposed to increase the risk of PPOI. This study aimed to test the hypothesis that an increased total postoperative opioid dose (TPOD) is associated with the increased incidence of PPOI.

METHODS

For this matched case-control study, patients who underwent elective laparoscopic colorectal procedures at the Peking University People's Hospital between January 2018 and June 2020 were retrospectively reviewed. Patients with PPOI were assigned to the ileus group, while patients without PPOI (control group) were matched at a 1:1 ratio to the ileus group according to age, American Society of Anesthesiologists physical status score, and type of surgical procedure. The primary outcome was the TPOD between the ileus and control groups. The secondary outcome was risk factors of PPOI.

RESULTS

A total of 267 participants were included in the final analysis. No differences in baseline or operative factors were found between the two groups. The TPOD, intravenous sufentanil dose on postoperative day 1 (POD1), and the use of patient-controlled analgesia with basal infusion were associated with PPOI (P < 0.05). Multivariate logistic regression analysis revealed that an increased TPOD was an independent risk factor for developing PPOI after laparoscopic colorectal procedures (Odd ratio: 1.67, 95% CI [1.03, 2.71], P = 0.04).

CONCLUSIONS

The TPOD is an independent risk factor for PPOI after laparoscopic colorectal surgery. We need to explore new strategies of postoperative analgesia to reduce the dosage of TPOD.

Postoperative ileus after digestive surgery: Network meta-analysis of pharmacological intervention

AIMS

Several medicinal treatments for avoiding postoperative ileus (POI) after abdominal surgery have been evaluated in randomized controlled trials (RCTs). This network meta-analysis aimed to explore the relative effectiveness of these different treatments on ileus outcome measures.

METHODS

A systematic literature review was performed to identify RCTs comparing treatments for POI following abdominal surgery. A Bayesian network meta-analysis was performed. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis.

RESULTS

A total of 38 RCTs were included in this network meta-analysis reporting on 6371 patients. Our network meta-analysis shows that prokinetics significantly reduce the duration of first gas (mean difference [MD] = 16 h; credible interval -30, -3.1; surface under the cumulative ranking curve [SUCRA] 0.418), duration of first bowel movements (MD = 25 h; credible interval -39, -11; SUCRA 0.25) and duration of postoperative hospitalization (MD -1.9 h; credible interval -3.8, -0.040; SUCRA 0.34). Opioid antagonists are the only treatment that significantly improve the duration of food recovery (MD -19 h; credible interval -26, -14; SUCRA 0.163).

CONCLUSION

Based on our meta-analysis, the 2 most consistent pharmacological treatments able to effectively reduce POI after abdominal surgery are prokinetics and opioid antagonists. The absence of clear superiority of 1 treatment over another highlights the limits of the pharmacological principles available.

PREEMPTIVE ANALGESIA IN ANORECTAL SURGERY: RESULTS OF THE PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL

Aim: To assess the efficiency of preemptive analgesia with Ketoprofen 100 mg 2 hours before procedure per os to decrease postoperative pain. Methods: This prospective, randomized, double-blind study was conducted in the surgical department of the Lomonosov MSU Medical Center. Patients who were diagnosed with anorectal disease without contraindication to perform subarachnoid anesthesia or other somatic diseases and underwent anorectal procedure were included. After signing the consent all participants were randomly divided: the first group got a 100 mg Ketoprofen tablet, the second one got a starch tablet 2 hours before surgery. Following the procedure the primary and secondary outcomes were evaluated: opioid administration intake, the pain at rest and during defecation, duration and frequency of other analgesics intake, readmission rate, life quality, time to return to previous lifestyle, the complications rate. Results: 134 participants were included in the study: 68 in the main group, 66 in the control one. Postoperative pain syndrome was statistically less in the main group on the 4,5,7 days (p=0,035; p=0,023; p=0,046, respectively). Opioid intake after surgery was significantly lower in the main group (p=0.174). The side effects frequency, live quality, time to return to previous lifestyle also didn’t differ in both groups. Conclusion: Preoperative analgesia is safe and effective in reducing postoperative pain in anorectal surgery, reduces the opioid usе, doesn’t increase the ketoprophen side effects frequency. It should be a part of the routine patients’ multimodal management in anorectal surgery.

Age Increases the Risk of Mortality by Four-Fold in Patients with Emergent Paralytic Ileus: Hospital Length of Stay, Sex, Frailty, and Time to Operation as Other Risk Factors

Background: In the United States, ileus accounts for USD 750 million of healthcare expenditures annually and significantly contributes to morbidity and mortality. Despite its significance, the complete picture of mortality risk factors for these patients have yet to be fully elucidated; therefore, the aim of this study is to identify mortality risk factors in patients emergently admitted with paralytic ileus. Methods: Adult and elderly patients emergently admitted with paralytic ileus between 2005−2014 were investigated using the National Inpatient Sample Database. Clinical outcomes, therapeutic management, demographics and comorbidities were collected. Associations between mortality and all other variables were established via univariable and multivariable logistic regression models. Results: A total of 81,674 patients were included, of which 45.2% were adults, 54.8% elderly patients, 45.8% male and 54.2% female. The average adult and elderly ages were 48.3 and 78.8 years, respectively. Elderly patients displayed a significantly (p < 0.01) higher mortality rate (3.0%) than adults (0.7%). The final multivariable logistic regression model showed that for every one-day delay in operation, the odds of mortality for adult and elderly patients increased by 4.1% (p = 0.002) and 3.2% (p = 0.014), respectively. Every additional year of age corresponded to 3.8% and 2.6% increases in mortality for operatively managed adult (p = 0.026) and elderly (p = 0.015) patients. Similarly, non-operatively treated adult and elderly patients displayed associations between mortality and advanced age (p = 0.001). The modified frailty index exhibited associations with mortality in operatively treated adults, conservatively managed adults and conservatively managed elderly patients (p = 0.001). Every additional day of hospitalization increased the odds of mortality in non-operative adult and elderly patients by 7.6% and 5.8%, respectively. Female sex correlated to lower mortality rates in non-operatively managed adult patients (odds ratio = 0.71, p = 0.028). Undergoing invasive diagnostic procedures in non-operatively managed elderly patients related to reduced mortality (odds ratio = 0.78, p = 0.026). Conclusions: Patients emergently admitted for paralytic ileus with increased hospital length of stay, longer time to operation, advanced age or higher modified frailty index displayed higher mortality rates. Female sex and invasive diagnostic procedures were negatively correlated with death in nonoperatively managed patients with paralytic ileus.

Anesthesia and cancer recurrence: an overview

Several perioperative factors are responsible for the dysregulation or suppression of the immune system with a possible impact on cancer cell growth and the development of new metastasis. These factors have the potential to directly suppress the immune system and activate hypothalamic-pituitary-adrenal axis and the sympathetic nervous system with a consequent further immunosuppressive effect.Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system, inflammatory system, and angiogenesis, with a possible impact on cancer recurrence and long-term outcome. Even if the current data are controversial and contrasting, it is crucial to increase awareness about this topic among healthcare professionals for a future better and conscious choice of anesthetic techniques.In this article, we aimed to provide an overview regarding the relationship between anesthesia and cancer recurrence. We reviewed the effects of surgery, perioperative factors, and anesthetic agents on tumor cell survival and tumor recurrence.

Preemptive analgesia for hemorrhoidectomy: study protocol for a prospective, randomized, double-blind trial

BACKGROUND

Hemorrhoidectomy is associated with intense postoperative pain that requires multimodal analgesia. It includes nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and local anesthetics to reach adequate pain control. There are data in literature preemptive analgesia could decrease postoperative pain after hemorrhoidectomy. The aim of this study is to assess the efficacy of preemptive analgesia with ketoprofen 100 mg 2 h before procedure per os with spinal anesthesia to decrease postoperative pain according to visual analog scale and to reduce the opioids and other analgesics consumption.

METHODS

Patients of our clinic who meet the following inclusion criteria are included: hemorrhoids grade III-IV and the planned Milligan-Morgan hemorrhoidectomy. After signing the consent all participants are randomly divided into 2 groups: the first one gets a tablet with 100 mg ketoprofen, the second one gets a tablet containing starch per os 2 h before surgery (72 participants per arm). Patients of both arms receive spinal anesthesia and undergo open hemorrhoidectomy. Following the procedure the primary and secondary outcomes are evaluated: opioid administration intake, the pain at rest and during defecation, duration, and frequency of other analgesics intake, readmission rate, overall quality of life, time from the procedure to returning to work, and the complications rate.

DISCUSSION

Multimodality pain management has been shown to improve pain control and decrease opioid intake in patients after hemorrhoidectomy in several studies. Gabapentin can be considered as an alternative approach to pain control as NSAIDs have limitative adverse effects. Systemic admission of ketorolac with local anesthetics also showed significant efficacy in patients undergoing anorectal surgery. We hope to prove the efficacy of multimodal analgesia including preemptive one for patients undergoing excisional hemorrhoidectomy that will help to hold postoperative pain levels no more than 3-4 points on VAS with minimal consumption of opioid analgesics.

TRIAL REGISTRATION

ClinicalTrial.gov NCT04361695 . Registered on April 24, 2020, version 1.0.

Ketorolac Administration After Colorectal Surgery Increases Anastomotic Leak Rate: A Meta-Analysis and Systematic Review

Objective

This meta-analysis aimed to evaluate whether ketorolac administration is associated with an increased anastomotic leak rate after colorectal surgery.

Methods

The literature was searched using the Web of Science, Embase, and PubMed databases, and the search ended on May 31, 2020. The Newcastle–Ottawa Scale was used to assess methodological quality. Statistical heterogeneity was assessed using the Chi-square Q test and I² statistics. Subgroup analysis was performed, and Egger's test was used to assess publication bias.

Results

This meta-analysis included seven studies with 400,822 patients. Our results demonstrated that ketorolac administration after surgery increases the risk of anastomotic leak [OR = 1.41, 95% CI: 0.81–2.49, Z = 1.21, P = 0.23]. Low heterogeneity was observed across these studies (I² = 0%, P = 0.51). The results of subgroup analysis showed that the use of ketorolac in case–control and retrospective cohort studies significantly increased the risk of anastomotic leak (P < 0.05). Furthermore, the subgroup analysis revealed that ketorolac use increased anastomotic leak rate in patients in the United States and Canada, and ketorolac plus morphine use did not increase anastomotic leak rate in Taiwanese patients (P < 0.05). No significant publication bias was observed (P = 0.126). Moreover, the analysis of risk factors related to anastomotic leak rate indicated that the total use of ketorolac did not increase the risk of anastomotic leak similar to the control group (P > 0.05).

Conclusion

The meta-analysis indicates that the use of ketorolac increases the risk of anastomotic leak after colorectal surgery.

Systematic Review Registration

PROSPERO, identifier CRD42020195724.

Opioid-sparing effects of ketorolac in palliative care patients receiving opioids for chronic cancer-related pain: A systematic literature review

BACKGROUND

Standard of care in treatment of cancer-related pain involves opioids in combination with non-steroidal anti-inflammatory drugs (NSAID). Ketorolac, a NSAID, has demonstrated opioid-sparing effects in other clinical settings.

AIM

This systematic literature review investigated ketorolac's opioid-sparing effects in patients receiving opioids for chronic, cancer-related pain.

DESIGN

The primary outcome was total daily dose of opioids. Secondary outcomes included frequency of opioid use, use and frequency of 'rescue' medication and adverse events. Outcomes were described, and meta-analysed where possible. PROSPERO registration CRD42019130894.

DATA SOURCES

Articles included original research, from any study phase or methodology, published in English in a peer-reviewed journal or conference between 1990 and 2020; included subjects >18 years; had chronic cancer-related pain and described the use of opioid-sparing effect of ketorolac.

RESULTS

Nine articles were included. While there was significant heterogeneity, ketorolac may have an opioid-sparing effect, with significant reductions in total daily dose of morphine observed in a single randomised controlled trial (SMD -4.30 mg, 95% CI -5.36 to -3.25), but the changes in the before and after studies were not statistically significant -0.46 mg (95% CI -1.14 to 0.22). Ketorolac was associated with greater likelihood of complete pain relief, but the data were heterogeneous. Insufficient data were available to analyse frequency of opioid use, or rescue medication requirements.

CONCLUSIONS

Given the heterogeneity of the data, adequately powered, randomised controlled trials are required to establish any opioid-sparing effect of ketorolac. For patients not responding to conventional pain management, ketorolac may have a role in treatment augmentation.

Reducing ileus after colorectal surgery: A network meta-analysis of therapeutic interventions

BACKGROUND

Several treatment strategies for avoiding post-operative ileus have been evaluated in randomised controlled trials. This network meta-analysis aimed to explore the relative effectiveness of these different therapeutic interventions on ileus outcome measures.

METHODS

A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing treatments for post-operative ileus following colorectal surgery. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis.

RESULTS

A total of 48 randomised controlled trials were included in this network meta-analysis reporting on 3614 participants. Early feeding was found to be the best treatment for time to solid diet tolerance and length of hospital stay with a probability of P = 0.96 and P = 0.47, respectively. Early feeding resulted in significantly shorter time to solid diet tolerance (Mean Difference (MD) 58.85 h; 95% Credible Interval (CrI) -73.41, -43.15) and shorter length of hospital stay (MD 2.33 days; CrI -3.51, -1.18) compared to no treatment. Epidural analgesia was ranked best treatment for time to flatus (P = 0.29) and time to stool (P = 0.268). Epidural analgesia resulted in significantly shorter time to flatus (MD -18.88 h; CrI -33.67, -3.44) and shorter time to stool (MD -26.05 h; 95% CrI -66.42, 15.65) compared to no intervention. Gastrograffin was ranked best treatment to avoid the requirement for post-operative nasogastric tube insertion (P = 0.61) however demonstrated limited efficacy (OR 0.50; CrI 0.143, 1.621) compared to no intervention. Nasogastric and nasointestinal tube insertion, probiotics, and acupuncture were found to be least efficacious as interventions to reduce ileus.

CONCLUSION

This network meta-analysis identified early feeding as the most efficacious therapeutic intervention to reduce post-operative ileus in patients undergoing colorectal surgery, in addition to highlighting other therapies that require further investigation by high quality study. In patients undergoing colorectal surgery, emphasis should be placed on early feeding as soon as can be appropriately initiated to support the return of gastrointestinal motility.

PREEMPTIVE ANALGESIA IN ANORECTAL SURGERY: STUDY PROTOCOL FOR A PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND TRIAL

Aim: To assess the efficiency of preemptive analgesia with Ketoprofen 10 mg 2 hours before procedure per os with spinal anesthesia to decrease postoperative pain and the amount of used analgesics.Methods: Patients of our clinic who meet the following inclusion criteria are included: they must be diagnosed with anorectal disease and planned anorectal procedure. After signing the consent all participants are randomly divided into 2 groups: the first one gets a tablet with 10 mg Ketoprofen, the second one gets a tablet containing starch per os 2 hours before surgery (72 participants per arm). Patients of both arms receive spinal anesthesia and undergo open hemorrhoidectomy. Following the procedure the primary and secondary outcomes are evaluated: opioid administration intake, the pain at rest and during defecation, duration and frequency of other analgesics intake, readmission rate, overall quality of life, time from the procedure to returning to work and the complications rate.Discussion: Multimodality pain management has been shown to improve pain control and decrease opioid intake in patients after anorectal surgery in several studies. Gabapentin can be considered as an alternative approach to pain control as NSAIDs have limitative adverse effects. Systemic admission of ketorolac with local anesthetics also showed significant efficacy in patients undergoing anorectal surgery. We hope to prove the efficacy of multimodal analgesia including preemptive one for patients undergoing anorectal procedure that will help to hold postoperative pain level no more than 3-4 points on VAS with minimal consumption of opioid analgesics.

Peripherally Acting μ-Opioid Receptor Antagonists in the Management of Postoperative Ileus: a Clinical Review

Postoperative ileus (POI) and constipation are common secondary effects of opioids and carry significant clinical and economic impacts. μ-Opioid receptors mediate opioid analgesia in the central nervous system (CNS) and gastrointestinal-related effects in the periphery. Peripherally acting μ-opioid receptor antagonists (PAMORAs) block the peripheral effects of opioids in the gastrointestinal tract, while maintaining opioid analgesia in the CNS. While most are not approved for POI or postoperative opioid-induced constipation (OIC), PAMORAs have a potential role in these settings via their selective effects on the μ-opioid receptor. This review will discuss recent clinical trials evaluating the safety and efficacy of PAMORAs, with a focus on alvimopan (Entereg^®) and methylnaltrexone (Relistor^®) in patients with POI or postoperative OIC. We will characterize potential factors that may have impacted the efficacy observed in phase 3 trials and discuss future directions for the management and treatment of POI.

State-of-the-art colorectal disease: postoperative ileus

PURPOSE

Postoperative Ileus (POI) remains an important complication for patients after abdominal surgery with an incidence of 10-27% representing an everyday issue for abdominal surgeons. It accounts for patients' discomfort, increased morbidity, prolonged hospital stays, and a high economic burden. This review outlines the current understanding of POI pathophysiology and focuses on preventive treatments that have proven to be effective or at least show promising effects.

METHODS

Pathophysiology and recommendations for POI treatment are summarized on the basis of a selective literature review.

RESULTS

While a lot of therapies have been researched over the past decades, many of them failed to prove successful in meta-analyses. To date, there is no evidence-based treatment once POI has manifested. In the era of enhanced recovery after surgery or fast track regimes, a few approaches show a beneficial effect in preventing POI: multimodal, opioid-sparing analgesia with placement of epidural catheters or transverse abdominis plane block; μ-opioid-receptor antagonists; and goal-directed fluid therapy and in general the use of minimally invasive surgery.

CONCLUSION

The results of different studies are often contradictory, as a concise definition of POI and reliable surrogate endpoints are still absent. These will be needed to advance POI research and provide clinicians with consistent data to improve the treatment strategies.

Liposomal Bupivacaine Decreases Postoperative Length of Stay and Opioid Use in Patients Undergoing Radical Cystectomy

OBJECTIVE

To analyze differences in length of stay, opioid use, and other perioperative outcomes in patients undergoing radical cystectomy with urinary diversion who received either liposomal bupivacaine (LB) or epidural analgesia.

METHODS

This was a single center, retrospective cohort study of patients undergoing open radical cystectomy with urinary diversion from 2015-2019 in the early recovery after surgery (ERAS) pathway. Patients received either LB or epidural catheter analgesia for post-operative pain control. LB was injected at the time of fascial closure to provide up to 72 hours of local analgesia. The primary outcome was post-operative length of stay. Secondary outcomes were post-operative opioid use, time to solid food, time to ambulation, and direct hospitalization costs. Multivariable Cox proportional hazards regression was used to determine associations between analgesia type and discharge.

RESULTS

LB use was independently associated with shorter post-operative length of stay compared to epidural use (median (IQR) 4.9 days (3.9-5.8) vs 5.9 days (4.9-7.9), P<.001), less total opioid use (mean 188.3 vs 612.2 OME, P <.001), earlier diet advancement (mean 1.6 vs 2.4 days, P <.001), and decreased overall direct costs ($23,188 vs $29,628, P <.001). 45% of patients who received LB were opioid-free after surgery, none in the epidural group. On multivariable Cox proportional hazards regression modeling, LB use was independently associated with earlier discharge (HR 2.1, IQR 1.0-4.5).

CONCLUSION

Use of LB in open radical cystectomy is associated with reduced LOS, less opioid exposure, and earlier diet advancement.

Intravenous ketorolac is associated with reduced mortality and morbidity after open abdominal aortic aneurysm repair

OBJECTIVES

The role of non-steroidal anti-inflammatory drugs in aortic aneurysm disease has been debated. Animal studies demonstrated that intrathecal ketorolac reduces the inflammatory response associated with aortic clamping. However, no human-subject study evaluated this association. Therefore, we sought to explore the effects of ketorolac use in open abdominal aortic aneurysm repair.

METHODS

The Premier Healthcare Database (June 2009-March 2015) was inquired to capture patients who underwent open abdominal aortic aneurysm repair for non-ruptured abdominal aortic aneurysm, identified via International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Intravenous ketorolac was coded as any or none. Outcomes were in-hospital mortality, cardiac, respiratory, renal, neurological, and hemorrhagic complications. Multivariable logistic regression coarsened exact matching followed by conditional fixed-effect regression modeling were performed.

RESULTS

A total of 6394 patients were identified (ketorolac: 806; 12.6%). Patients who received ketorolac were younger and less likely to have hypertension (76.1% vs. 79.3%), diabetes mellitus (12.5% vs. 17.4%), or chronic kidney disease (8.3% vs. 21.4%; all p values ≤ .033). There was no significant difference in medication use including oral non-steroidal anti-inflammatory drugs and malignant or musculoskeletal diseases. Mortality, respiratory, and renal complications were less prevalent with ketorolac (2.5% vs. 4.9%, 25.2% vs. 34.6%, 10.0% vs. 21.1%; p ≤ .002). Ketorolac was associated with lower adjusted odds for those events: 0.58 (0.36-0.93), 0.53 (0.42-0.68), and 0.72 (0.60-0.86), respectively (all p values ≤ .025). There was no association with neurological, cardiac, or hemorrhagic complications. The findings were replicated by coarsened exact matching analysis.

CONCLUSION

This study demonstrated 40% mortality reduction with intravenous ketorolac following open abdominal aortic aneurysm repair. The survival benefit could be due to its anti-inflammatory and opioid-sparing properties. This is evident by its protective effect against respiratory outcomes. The lack of association with the classical non-steroidal anti-inflammatory drugs-related cardiac and hemorrhagic complication could be attributable to the short-term use of ketorolac compared with non-steroidal anti-inflammatory drugs chronic use.

Intraoperative nasogastric tube during colorectal surgery may not be mandatory: a propensity score analysis of a prospective database

BACKGROUND

Avoiding the use of nasogastric tubes (NGTs) is recommended after colorectal surgery but there is no consensus on intraoperative gastric decompression using NGTs during colorectal surgery. The objective was to assess the effect of avoiding insertion of NGTs during colorectal surgery for the recovery of gastrointestinal (GI) functions.

METHOD

1561 patients undergoing colorectal surgery, for whom information on NGT use was available, were included in this retrospective analysis and propensity score analysis of the prospective GRACE Audit database. Patients who did and did not have an NGT during surgery were compared.

RESULTS

Among the study population of 1561 patients, 696 patients were matched to correct baseline differences between groups. The no-NGT group significantly improved GI motility impairment (e.g., less postoperative nausea [OR = 0.59; CI 95%: 0.42-0.84] and a better tolerance of early feeding [OR = 2.07; CI 95%: 1.33-3.22]). Such an association was also highlighted for reduced postoperative morbidity [OR = 0.60; CI 95%: 0.43-0.83], and especially pulmonary complications [OR = 0.08; CI 95%: 0.01-0.59], or parietal complications [OR = 0.29; CI 95%: 0.09-0.87]. The risk of postoperative ileus was not significantly reduced in the no-NGT group [OR = 0.67; CI 95%: 0.43-1.06].

CONCLUSION

No NGT insertion during colorectal surgery is safe and could improve postoperative GI function recovery.

Postoperative non-steroidal anti-inflammatory drugs and anastomotic leakage after gastrointestinal anastomoses: Systematic review and meta-analysis

AIM

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to control postoperative pain; however, their postoperative use has been associated with anastomotic leakage after gastrointestinal surgery. This systematic review and meta-analysis aimed to determine the correlation between the use of NSAIDs and anastomotic leakage.

METHODS

We conducted a comprehensive electronic literature search up to August 2018 to identify studies comparing anastomotic leakage in patients with and without postoperative NSAID use following gastrointestinal surgery. We then carried out a meta-analysis using random-effects models to calculate odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Twenty-four studies were included in this meta-analysis, including a total of 31 877 patients. Meta-analysis showed a significant association between NSAID use and anastomotic leakage (OR 1.73; 95% CI = 1.31-2.29, P < .0001). Subgroup analyses showed that non-selective NSAIDs, but not selective cyclooxygenase-2 inhibitors, were significantly associated with anastomotic leakage. However there was no significant subgroup difference between selective and non-selective NSAIDs.

CONCLUSION

Results of this meta-analysis indicate that postoperative NSAID use is associated with anastomotic leakage following gastrointestinal surgeries. Caution is warranted when using NSAIDs for postoperative analgesic control in patients with gastrointestinal anastomoses.

Length of Hospital Stay for Osteoarthritic Primary Hip and Knee Replacement Surgeries in New Zealand

This study aims to explore the length of stay (LOS) of publicly funded osteoarthritic primary hip and knee replacement surgeries in New Zealand. Patients with osteoarthritis who underwent publicly funded primary hip and knee replacement surgery in 2005-2017 were included. We have identified 53,439 osteoarthritic primary hip replacements and 50,072 osteoarthritic primary knee replacements. LOS has been reduced by almost 40% over the last 13 years. Logistic regression showed that women, Māori, Pacific and Asian patients, older patients, people with more comorbidities and those having opiates on discharge and patients in earlier years were more likely to have extended LOS following hip replacements and knee replacements. Regional differences were noted in LOS between the Waitemata District Health Board (DHB) compared to Tairāwhiti DHB where patients were the most likely to have a LOS of more than 5 days after hip and knee replacements. LOS after hip and knee replacements has been reduced dramatically. Women, Māori, Pacific and Asian patients, older patients and people with more comorbidities are more likely to have extended LOS. Patients dispensed opiates on discharge had a longer LOS. There are great geographical variations in LOS for primary hip and knee surgeries in New Zealand.

Trend and Economic Burden of Intravenous Narcotic Analgesic Utilization in Major Vascular Interventions in the United States

BACKGROUND

The use of IV narcotic analgesics (IVNA) within the context of vascular procedures is not fully described. We sought to evaluate the burden of IVNA including narcotic analgesia-related adverse drug events (NARADE), associated mortality and hospitalization cost in open and endovascular vascular procedures, and to compare it with nonnarcotic analgesia (IVNNA).

METHODS

Retrospective cross-sectional study in hospitals participating in Premier database (2009-2015). Logistic regression analysis was implemented to report the risks of NARADE and in-hospital mortality. Negative binomial regression was used to assess length of stay and generalized linear modeling was used to estimate the hospitalization cost.

RESULTS

A total of 171,473 patients were identified. NARADE occurred in 6.2% of the cohort. NARADE group was similar in gender and race but was slightly older (median age 71 vs. 70; P < 0.001). After risk-adjustment, NARADE risk was higher in patients who received IVNA-alone in carotid and lower extremity revascularization (LER) [OR (odds ratio) (95% confidence interval [CI]): 1.17 (1.02-1.34) and 1.31 (1.14-1.50)] or combined with IVNNA [OR (95% CI): 1.34 (1.13-1.59) and 1.81 (1.54-2.13)], respectively. Patients receiving aortic repair benefited from the use of IVNA + IVNNA [OR (95% CI): 0.82 (0.69-0.98)]. Occurrence of NARADE doubled the LOS, amplified mortality risk and increased cost in all domains. NARADE increased the odds of mortality by 24.3, 6.5 (4.9-8.68) and 16.6 times and added $5,368, $12,737 and $11,349 to the cost of carotid, aortic and LER interventions, respectively. In contrast, IVNNA was not associated with NARADE risk, increased LOS or cost and showed a survival benefit in patients undergoing open aortic repair [aOR (95% CI): 0.52 (0.36-0.75)].

CONCLUSIONS AND RELEVANCE

The use of opioid-based narcotics had increased the risk of NARADE, resources utilization and NARADE-related mortality. Yet the use of nonopioid-based analgesic was safe, did not increase the cost and reduced mortality in open AA repair. This entices shifting the paradigm toward exploring nonopioid-based analgesia options in order to replace or minimize opioid requirements.

Regional analgesia modalities in abdominal and lower limb surgery - comparison of efficacy

A significant component of all surgical procedures and postoperative treatment is pain management.Due to the physiological and psychological advantages of pain relief, it is one of the foremost indicators of quality of care. Today, there are various modalities of pain reduction, aimed to reduce patient discomfort andminimize side effects, which can be divided by therapeutic agents used (opioid or non-opioid), route of administration (intravenous, regional, oral, etc.) and modality (controlled by patients or "as needed"). Although opioids have proven to be very effective pain relief agents and are commonly used in postoperative analgesia, concerns about their side effects have spurred the development of modified, multimodal treatments that seek to minimize opioid use and associated drawbacks. Enhanced recovery protocols that emphasize sparing administration of opioids are growing in importance, andresulting in reduced length of hospital stay after abdominal and lower limb surgery. To further improve such protocols and optimize postoperative care for individual patient needs, it is imperative to fully assess the efficacy of available drugs and analgesia modalities.

Postoperative Ileus

Postoperative ileus (POI) is a common complication following colon and rectal surgery, with reported incidence ranging from 10 to 30%. It can lead to increased morbidity, cost, and length of stay. Although definitions vary considerably in the literature, in its pathologic form, it can be characterized by a temporary inhibition of gastrointestinal motility after surgical intervention due to nonmechanical causes that prevents sufficient oral intake. Various risk factors for development of POI have been identified including increasing age, American Society of Anesthesiologists scores 3 to 4, open approach, operative difficulty, operative duration more than 3 hours, bowel handling, drop in hematocrit or need for a transfusion, increasing crystalloid administration, and delayed mobilization. While treatment is expectant and supportive, significant investigations into strategies to mitigate development of POI or shorten its duration have been undertaken with mixed results. There is significant evidence to suggest that a minimally invasive approach and multimodal pain regimens reduce the development of POI. The beneficial effect of chewing gum, alvimopan, and enhanced recovery after surgery protocols may decrease development of POI in selected groups of patients who undergo elective colorectal surgery, and shorten time to return of bowel function, but overall, the data remain inconclusive.

Pain Management in Enhanced Recovery after Surgery (ERAS) Protocols

Pain control is an integral part of Enhanced Recovery after Surgery (ERAS) protocols for colorectal surgery. While opioid therapy remains the mainstay of therapy for postsurgical pain, opioids have undesired side effects including delayed recovery of bowel function, respiratory depression, and postoperative nausea and vomiting. A variety of nonopioid systemic medical therapies as well as regional and neuraxial techniques have been described as improving pain control while reducing opioid use. Multimodal and preemptive analgesia as part of an ERAS protocol facilitates early mobility and early return of bowel function and decreases postoperative morbidity. In this review, we examine several multimodal therapies and their impact on postoperative analgesia, opioid use, and recovery for patients undergoing colorectal surgery.

Systematic Review and Meta-analysis of Nonsteroidal Anti-inflammatory Drugs to Improve GI Recovery After Colorectal Surgery

BACKGROUND

The management of delayed GI recovery after surgery is an unmet challenge. Uncertainty over its pathophysiology has limited previous research, but recent evidence identifies intestinal inflammation and activation of µ-opioid receptors as key mechanisms. Nonsteroidal anti-inflammatory drugs are recommended by enhanced recovery protocols for their opioid-sparing and anti-inflammatory properties.

OBJECTIVES

The purpose of this study was to explore the safety and efficacy of nonsteroidal anti-inflammatory drugs to improve GI recovery and to identify opportunities for future research.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Library were systematically searched from inception up to January 2018.

STUDY SELECTION

Randomized controlled trials assessing the effect of nonsteroidal anti-inflammatory drugs on GI recovery after elective colorectal surgery were eligible.

MAIN OUTCOME MEASURES

Postoperative GI recovery, including first passage of flatus, stool, and oral tolerance, were measured.

RESULTS

Six randomized controlled trials involving 563 participants were identified. All of the participants received patient-controlled morphine and either nonsteroidal anti-inflammatory drug (nonselective: n = 4; cyclooxygenase-2 selective: n = 1; either: n = 1) or placebo. Patients receiving the active drug had faster return of flatus (mean difference: -17.73 h (95% CI, -21.26 to -14.19 h); p < 0.001), stool (-9.52 h (95% CI, -14.74 to -4.79 h); p < 0.001), and oral tolerance (-12.00 h (95% CI, -18.01 to -5.99 h); p < 0.001). Morphine consumption was reduced in the active groups of 4 studies (average reduction, 12.9-30.0 mg), and 1 study demonstrated significantly reduced measures of systemic inflammation. Nonsteroidal anti-inflammatory drugs were not associated with adverse events, but 1 study was temporarily suspended for safety.

LIMITATIONS

The data presented are relatively outdated but represent the best available evidence.

CONCLUSIONS

Nonsteroidal anti-inflammatory drugs may represent an effective and accessible intervention to improve GI recovery, but hesitancy over their use after colorectal surgery persists. Additional preclinical research to characterize their mechanisms of action, followed by well-designed clinical studies to test safety and patient-reported efficacy, should be considered.

Ketorolac Use and Anastomotic Leak in Elective Colorectal Surgery: A Detailed Analysis

BACKGROUND

Recent population-level analyses have linked ketorolac use to adverse outcomes. However, its use is also associated with decreased opioids and faster return of bowel function.

OBJECTIVE

This study aims to assess the association between ketorolac and anastomotic leak. We hypothesize that receiving at least 1 dose of ketorolac will not be associated with anastomotic leak in elective colorectal surgery.

DESIGN

This is a retrospective, observational cohort study of a prospectively collected data base. Anastomotic leak rates and other patient outcomes were adjusted for patient-level factors and then compared via a multivariable logistic regression. A secondary analysis assessed a dose-response association with anastomotic leak.

SETTING

This study was conducted at a tertiary care colorectal surgery service.

PATIENTS

Consecutive patients undergoing elective colorectal surgery with a nondiverted anastomosis were identified from 2012 to 2016.

INTERVENTION

Exposure was defined as any administration of ketorolac during the perioperative time period.

MAIN OUTCOME MEASURES

The primary outcome measured was anastomotic leak.

RESULTS

A total of 877 patients met inclusion criteria. Of these, 479 (54.6%) were women, and the median age was 55 years. Overall, 566 (64.5%) patients were exposed to ketorolac. In the cohort, 27 (3.1%) patients experienced an anastomotic leak. In an unadjusted analysis, there was no association between ketorolac exposure and anastomotic leak (ketorolac: 3.1% vs no ketorolac: 3.3%; p = 0.84). This persisted in a multivariable model (OR, 0.98; 95% CI, 0.38-2.57; p = 0.98). Neither AKI (OR, 3.24; 95% CI, 0.51-20.6; p = 0.21), return to the operating room (OR, 1.07; 95% CI, 0.40-2.85; p = 0.88), nor readmission (OR, 1.03; 95% CI, 0.59-1.80; p = 0.93) was associated with ketorolac use. In a secondary analysis of patients receiving ketorolac, there was no association between total ketorolac dosing and anastomotic leak (OR, 0.99; 95% CI, 0.99-1.00; p = 0.20).

LIMITATIONS

This study was a retrospective review, and there was a low incidence of anastomotic leak.

CONCLUSION

Ketorolac exposure was associated with neither anastomotic leak nor other important postoperative outcomes. See Video Abstract at http://links.lww.com/DCR/A784.

Anti-inflammatory Effects of Enhanced Recovery Programs on Early-Stage Colorectal Cancer Surgery

BACKGROUND

Postoperative ileus (POI) is observed in 20-30% of patients undergoing colorectal cancer surgery, despite enhanced recovery programs (ERPs). Cyclooxygenase (COX)-2 is identified as a key enzyme in POI, but other arachidonic acid pathway enzymes have received little attention despite their potential as selective targets to prevent POI. The objectives were to compare the expression of arachidonic acid metabolism (AAM) enzymes (1) between patients who underwent colorectal cancer surgery and followed an ERP or not (NERP), (2) and between ERP patients who experimented POI or not and (3) to determine the ability of antagonists of these pathways to modulate contractile activity of colonic muscle.

METHODS

This was a translational study. Main outcome measures were gastrointestinal motility recovery data, mRNA expressions of key enzymes involved in AAM (RT-qPCR) and ex vivo motility values of the circular colon muscle. Twenty-eight prospectively included ERP patients were compared to eleven retrospectively included NERP patients that underwent colorectal cancer surgery.

RESULTS

ERP reduced colonic mucosal COX-2, microsomal prostaglandin E synthase (mPGES1) and hematopoietic prostaglandin D synthase (HPGDS) mRNA expression. mPGES1 and HPGDS mRNA expression were significantly associated with ERP compliance (respectively, r2 = 0.25, p = 0.002 and r2 = 0.6, p < 0.001). In muscularis propria, HPGDS mRNA expression was correlated with GI motility recovery (p = 0.002). The pharmacological inhibition of mPGES1 increased spontaneous ex vivo contractile activity in circular muscle (p = 0.03).

CONCLUSION

The effects of ERP on GI recovery are correlated with the compliance of ERP and could be mediated at least in part by mPGES1, HPGDS and COX-2. Furthermore, mPGES1 shows promise as a therapeutic target to further reduce POI duration among ERP patients.

Nonsteroidal anti-inflammatory drugs reduce the time to recovery of gut function after elective colorectal surgery: a systematic review and meta-analysis

AIM

Postoperative ileus causes significant patient morbidity after abdominal surgery. Some evidence suggests nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce time to gut recovery, but there has not been a meta-analysis to assess their efficacy. This systematic review and meta-analysis aimed to determine the benefit of NSAIDs for recovery of postoperative gut function in patients undergoing elective colorectal surgery.

METHOD

MEDLINE, EMBASE, CENTRAL and reference lists were searched with no date or language restrictions. Randomized controlled trials comparing the use of NSAIDs with placebo in the perioperative or postoperative period were identified. Included studies reported outcomes relevant to gut function: time to pass flatus or stool and time to tolerate an oral diet. The mean difference in time from surgery until passage of flatus, stool and tolerance of diet were meta-analysed using a random-effects model in RevMan 5.3.

RESULTS

This study identified 992 relevant articles. Five randomized controlled trials on patients undergoing elective colorectal surgery met our inclusion criteria and were meta-analysed. Compared with placebo, NSAIDs significantly improved the time to pass flatus (mean difference -9.44 h, 95% CI: -17.22, -1.65, I² = 70%, P = 0.02), time to pass stool (mean difference -12.09 h, 95% CI: -17.16, -7.02, I² = 0%, P < 0.001) and time to tolerate a diet (mean difference -11.95 h, 95% CI: -18.66, -5.24, I² = 0%, P < 0.001).

CONCLUSION

NSAIDs significantly improve time to gut recovery after elective colorectal surgery. Current evidence is not adequate to identify whether selective or nonselective drugs should be recommended. Further high-power studies using selective drugs are required.

The analgesic effects of intraoperative total intravenous anesthesia (TIVA) with propofol versus sevoflurane after colorectal surgery

Clinical studies have shown that total intravenous anesthesia (TIVA) with propofol is associated with better postoperative pain control compared with inhalational anesthesia, while other studies have not shown any benefit. The analgesic effect of TIVA with propofol in colorectal surgery has not been studied. The aim of this study is to evaluate the postoperative analgesic effects of TIVA with propofol versus inhalational sevoflurane in colorectal surgery.This is a retrospective case-control study. Records of patients undergoing colorectal surgery from 2014 to 2016 (36 months) were retrieved. Ninety-five patients who received TIVA with propofol were matched against 95 patients who received inhalational sevoflurane. Acute postoperative numerical rating scale (NRS) pain scores, postoperative morphine consumption, patient satisfaction, and side effects were compared and analyzed for differences between TIVA with propofol and sevoflurane.There were no significant differences in NRS pain scores, incidence of side effects, and patient satisfaction between the 2 groups. Patients receiving TIVA with propofol had significantly reduced total morphine consumption (P < .001), and daily morphine consumption on postoperative days 1 (P = .031), 2 (P = .002), and 3 (P = .031) compared with those receiving sevoflurane.TIVA with propofol was not associated with improved postoperative analgesia, better patient satisfaction, or reduced side effects. It may reduce postoperative opioid consumption after colorectal surgery.

Effects of Nonsteroidal Anti-Inflammatory Drugs as Patient Controlled Analgesia on Early Bowel Function Recovery after Radical Cystectomy

This study aimed to evaluate the effects of ketorolac, a commonly used non-steroidal anti-inflammatory drug (NSAID) as patient controlled intravenous infusion analgesia (PCIA) for the patients underwent radical cystectomy (RC) due to bladder cancer regarding post-operational indices of recovery. Total seventy patients who underwent radical cystectomy for the treatment of bladder cancer were included in the study. 35 patients received ketorolac as PCIA (NSAIDS group) and 35 patients had morphine infusion as PCIA (morphine group). Pain intensity, bowel function recovery and length of hospital stay were evaluated. Early postoperative complications were analyzed according to surgical types (robot RC vs. open RC). Demographics were similar between two groups. NSAIDS group showed a significant reduction in postoperative vomiting (p = 0.001), time to flatus (p = 0.028), time to first bowel movement (p = 0.001) and time to first clear liquid diet (p = 0.002) compared with morphine group. No statistically significant differences were observed between two groups regarding length of hospitalization, and postoperative complications. For 48 hours after RC, pain relief was slightly better in morphine group (p < 0.001). Both open RC and robot RC cases showed significantly better bowel function recovery with NSAIDS groups. Ketorolac as PCIA is relatively effective in pain management with better gastrointestinal recovery after RC.

Postoperative ileus following major colorectal surgery

BACKGROUND

Postoperative ileus (POI) is characterized by delayed gastrointestinal recovery following surgery. Current knowledge of pathophysiology, clinical interventions and methodological challenges was reviewed to inform modern practice and future research.

METHODS

A systematic search of MEDLINE and Embase databases was performed using search terms related to ileus and colorectal surgery. All RCTs involving an intervention to prevent or reduce POI published between 1990 and 2016 were identified. Grey literature, non-full-text manuscripts, and reanalyses of previous RCTs were excluded. Eligible articles were assessed using the Cochrane tool for assessing risk of bias.

RESULTS

Of 5614 studies screened, 86 eligible articles describing 88 RCTs were identified. Current knowledge of pathophysiology acknowledges neurogenic, inflammatory and pharmacological mechanisms, but much of the evidence arises from animal studies. The most common interventions tested were chewing gum (11 trials) and early enteral feeding (11), which are safe but of unclear benefit for actively reducing POI. Others, including thoracic epidural analgesia (8), systemic lidocaine (8) and peripheral μ antagonists (5), show benefit but require further investigation for safety and cost-effectiveness.

CONCLUSION

POI is a common condition with no established definition, aetiology or treatment. According to current literature, minimally invasive surgery, protocol-driven recovery (including early feeding and opioid avoidance strategies) and measures to avoid major inflammatory events (such as anastomotic leak) offer the best chances of reducing POI.

Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions

The perioperative surgical home (PSH) model has been created with the intention to reduce costs and to improve efficiency of care and patient experience in the perioperative period. The PSH is a comprehensive model of care that is team-based and patient-centric. The team in each facility should be multidisciplinary and include the input of perioperative services leadership, surgical services, and support personnel in order to provide seamless care for the patient from the preoperative period when decision to undergo surgery is initially made to discharge and, if needed after discharge from the hospital, until full recovery is achieved. PSH is discussed in this consensus article with the emphasis on perioperative care coordination of patients with chronic pain conditions. Preoperative optimization can be successfully undertaken through patient evaluation, screening, and education. Many important positive implications in the PSH model, in particular for those patients with increased potential morbidity, mortality, and high-risk populations, including those with a history of substance abuse or anxiety, reflect a more modern approach to health care. Newer strategies, such as preemptive and multimodal analgesic techniques, have been demonstrated to reduce opioid consumption and to improve pain relief. Continuous catheters, ketamine, methadone, buprenorphine, and other modalities can be best delivered with the expertise of an anesthesiologist and a support team, such as an acute pain care coordinator. A physician-led PSH is a model of care that is patient-centered with the integration of care from multiple disciplines and is ideally suited for leadership from the anesthesia team. Optimum pain control will have a significant positive impact on the measures of the PSH, including lowering of complication rates, lowering of readmissions, improved patient satisfaction, reduced morbidity and mortality, and shortening of hospital stays. All stakeholders should work together and consider the PSH model to ensure the best quality of health care for patients undergoing surgery in the future. The pain management physician's role in the postoperative period should be focused on providing optimal analgesia associated with improved patient satisfaction and outcomes that result in reduced health care costs.

A Comparison of Multimodal Analgesic Approaches in Institutional Enhanced Recovery After Surgery Protocols for Colorectal Surgery: Pharmacological Agents

INTRODUCTION

Enhanced Recovery After Surgery (ERAS^®) protocols are the cornerstone of improved recovery after colorectal surgery. Their implementation leads to reduced morbidity and shorter hospital stays while attenuating the surgical stress response. Multimodal analgesia is an important part of ERAS protocols. We compared and contrasted protocols from 15 institutions to test our hypothesis that there is a fundamental consensus among them.

MATERIALS AND METHODS

ERAS protocols for open and laparoscopic colorectal surgery were compared from 15 different healthcare facilities. We examined each institution's approach to multimodal analgesia related to the use of oral and intravenous analgesics. Preoperative, intraoperative, and postoperative management was examined.

RESULTS

All but three protocols used preoperative multimodal analgesics, with acetaminophen, celecoxib, and gabapentin being the most common. Intraoperative recommendations included the use of ketamine, lidocaine, magnesium, and ketorolac. Some protocols advocated for the use of opiates, while others aimed to minimize total opioid dose. In the postoperative period, the three most utilized agents were acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids.

CONCLUSIONS

There were many similarities and some significant differences among ERAS protocols examined. Acetaminophen was the most widely used nonopioid agent and along with NSAIDs offers a benefit with respect to postoperative analgesia, opioid-sparing effects, earlier ambulation, and reduction in postoperative ileus. Gabapentin was widely used as it may reduce opioid consumption within the first 24 hours postoperatively. Lidocaine infusion was recommended if there were contraindications to or failure of epidural anesthesia. Ketamine is frequently recommended due to its analgesic, antihyperalgesic, antiallodynic, and antitolerance properties. Differences in approaches may be due to both institutional- and provider-level factors.

Ogilvie's Syndrome after Robotic-Assisted Radical Hysterectomy for Cervical Cancer

Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie's syndrome, is defined by poor peristaltic activity of the colon that mimics mechanical obstruction in the absence of any mechanical occlusive gut lesion. This case report is the first to be published on ACPO occurring after robotic-assisted radical hysterectomy. Given that robotic-assisted laparoscopic surgery has become the next major stage of advancement for a range of operations, especially in gynecologic oncology surgery, this report emphasizes the importance of recognizing precipitating factors associated with this syndrome, including minimally invasive surgery.

Influence of perioperative nonsteroidal anti-inflammatory drugs on complications after gastrointestinal surgery: A meta-analysis

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a key part of multimodal perioperative analgesia. This study aimed to evaluate the influence of perioperative NSAIDs application on complications after gastrointestinal surgery by using meta-analysis.

METHODS

A systematic review of published literature was conducted by searching computerized databases including PubMed, CBM, Springer, Chinese Academic Journals, and China Info since the databases were published until June 2015. The articles and retrospective references regarding complications after gastrointestinal surgery were collected to compare postoperative complications associated with NSAIDs or other analgesics. After they were assessed by randomized controlled trials and extracted by the standard of the Jadad systematic review, the homogeneous studies were pooled using RevMan 5.3 software. The meta-analysis was performed on five postoperative complications: postoperative anastomotic leak, cardiovascular events, surgical site infection, nausea and vomiting, and intestinal obstruction.

RESULTS

Twelve randomized controlled trials involving 3829 patients met the inclusion criteria. The results of meta-analyses showed the following: (1) postoperative anastomotic leak: NSAIDs (including selective and nonselective NSAIDs) increased the incidence of anastomotic leak [odds ratio (OR)=3.02, 95% confidence interval (CI): 2.16-4.23, p=0.00001]. Further results showed that nonselective NSAIDs significantly increased the incidence of anastomotic leak (OR=2.96, 95% CI: 1.99-4.42, p<0.00001), and selective NSAIDs had no significant difference as compared with the control group using other analgesics (OR=2.27, 95% CI: 0.68-7.56, p=0.18); (2) postoperative cardiovascular events: NSAIDs (selective and nonselective NSAIDs) had no difference when compared with other analgesics (OR=0.50, 95% CI: 0.23-1.12, p=0.09); (3) postoperative surgical site infection: NSAIDs (selective and nonselective NSAIDs) and other analgesics had no difference in surgical site infection (OR=0.77, 95% CI: 0.52-1.15, p=0.20); (4) postoperative nausea and vomiting: NSAIDs (selective and nonselective NSAIDs) decreased the incidence of nausea and vomiting (OR=0.53, 95% CI: 0.34-0.81, p=0.003); (5) postoperative intestinal obstruction: NSAIDs (selective and nonselective NSAIDs) decreased the incidence of intestinal obstruction (OR=0.35, 95% CI: 0.13-0.89, p=0.03).

CONCLUSIONS

The meta-analysis suggests that postoperative NSAIDs, especially nonselective NSAIDs, could increase the incidence of anastomotic leak. NSAIDs could decrease postoperative nausea and vomiting and intestinal obstruction, but showed no difference in cardiovascular events and surgical site infection as compared with other analgesics.

Effects of Pre-Existing Liver Disease on Acute Pain Management Using Patient-Controlled Analgesia Fentanyl With Parecoxib After Major Liver Resection: A Retrospective, Pragmatic Study

BACKGROUND

The aim of this study was to compare the outcomes of pain management with the use of patient-controlled analgesia (PCA) fentanyl with IV parecoxib between patients with healthy liver with patients with diseased liver undergoing major liver resection.

METHODS

Patients with healthy liver undergoing partial hepatectomy as liver donors for liver transplantation (group 1) and patients with liver cirrhosis (Child's criteria A) undergoing major liver resection for hepatoma (group 2) were identified retrospectively. Both groups routinely received post-operative IV PCA fentanyl and a single dose of parecoxib 40 mg. They were followed up for 3 days or until PCA fentanyl was discontinued post-operatively. Daily Visual Analog Scale, PCA fentanyl usage, rescue attempts, and common drug side effects were collected and analyzed with the use of SPSS version 20.

RESULTS

One hundred one patients were included in the study: 54 in group 1, and 47 in group 2. There were no statistical differences between the two groups in terms of the daily and total fentanyl usage, VAS resting, and incidence of itchiness. The rate of rescue analgesia on post-operative day (POD) 1 was lower in group 2, with a value of P = .045. VAS dynamics were better on POD 1 and 2 for group 2, with P = .05 and P = .012, respectively.

CONCLUSIONS

We found that combining a single dose of IV parecoxib 40 mg with PCA fentanyl is an easy and effective method of acute pain control after major liver resection. We propose the careful usage of post-operative fentanyl and parecoxib in patients with diseased liver, given the difference in effect as compared with healthy liver.

Postoperative Nonsteroidal Anti-inflammatory Drug Use and Intestinal Anastomotic Dehiscence: A Systematic Review and Meta-Analysis

BACKGROUND

Nonsteroidal anti-inflammatory drugs are commonly used analgesics in colorectal surgery. Controversy exists regarding the potential association between these drugs and anastomotic dehiscence.

OBJECTIVE

This study aimed to determine whether postoperative nonsteroidal anti-inflammatory drug use is associated with intestinal anastomotic dehiscence.

DATA SOURCES

PubMed, EMBASE, CENTRAL, and references of included articles were searched without date or language restriction.

STUDY SELECTION

Randomized controlled trials and observational studies that compared postoperative nonsteroidal anti-inflammatory drug use with nonuse and reported on intestinal anastomotic dehiscence were selected.

INTERVENTION

The use of postoperative nonsteroidal anti-inflammatory drugs relative to placebo or nonuse was investigated.

MAIN OUTCOME MEASURES

Risk ratios and adjusted or unadjusted odds ratios for anastomotic dehiscence were pooled across randomized controlled trials and observational studies using DerSimonian and Laird random-effects models.

RESULTS

Among 4395 citations identified, 6 randomized controlled trials (n = 473 patients) and 11 observational studies (n > 20,184 patients) were included. Pooled analyses revealed that nonsteroidal anti-inflammatory drug use was nonsignificantly associated with anastomotic dehiscence in randomized controlled trials (risk ratio, 1.96; 95% CI, 0.74-5.16; I = 0%) and significantly associated with anastomotic dehiscence in observational studies (OR, 1.46; 95% CI, 1.14-1.86; I = 54%). In stratified analyses of observational study data, the pooled OR for anastomotic dehiscence was statistically significant for studies of nonselective nonsteroidal anti-inflammatory drug use (6 studies; > 4900 patients; OR, 2.09; 95% CI, 1.65-2.64; I = 0%), but was not statistically significant for studies of cyclooxygenase-2 selective nonsteroidal anti-inflammatory drug use (3 studies; >697 patients; OR, 1.34; 95% CI, 0.78-2.31; I = 0%).

LIMITATIONS

Studies varied by patient selection criteria, drug exposures, and definitions of anastomotic dehiscence. Analyses of randomized controlled trials and cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs were potentially underpowered.

CONCLUSIONS

Pooled observational data suggest an association between postoperative nonsteroidal anti-inflammatory drug use and intestinal anastomotic dehiscence. Caution may be warranted in using these medications in patients at risk for this complication.

Efficacy and tolerability of oxycodone versus fentanyl for intravenous patient-controlled analgesia after gastrointestinal laparotomy: A prospective, randomized, double-blind study

BACKGROUND

It has been suggested that oxycodone is effective in relieving acute postoperative pain. The aim of this study was to investigate the efficacy and tolerability of oxycodone (O) versus fentanyl (F), and the adequate potency ratio of oxycodone and fentanyl in patients with intravenous patient-controlled analgesia after gastric laparotomy.

METHODS

In this double-blinded, randomized, controlled study, 60 patients undergoing elective gastric laparotomy were allocated to receive either oxycodone or fentanyl for postoperative intravenous patient-controlled analgesia (potency ratio 60:1). The patients received ketorolac 60 mg before the end of anesthesia and then continued with patient-controlled analgesia for 48 hours postsurgery. Pain severity, side effects and respiration rate were recorded 30 minutes, 3, 6, 12, 24, and 48 hours after the surgery. Cumulative opioid requirements and patient satisfaction were also measured.

RESULTS

The median consumption more than 48 hours after operation of oxycodone was 50 mg (range: 40.0-62.4 mg) and fentanyl was 0.8 mg (range: 0.6-1.1 mg), and the percentage of patients requiring rescue medication was not statistically significant. Numeric rating scores at rest and upon movement were significantly lower in group O than in F (P < 0.05). Whereas the incidences of adverse events were similar between the groups (33.3% vs 27.6%, P = 0.64), a significant higher sedation scores were found in patients given fentanyl at 30 minutes after the surgery (P = 0.04).

CONCLUSION

Oxycodone was comparable to fentanyl in the relief of postoperative pain following gastric laparotomy. Oxycodone not only provides better postoperative pain relief and less sedation, but also there was a tendency toward more side effects with oxycodone.