Liposomal Bupivacaine Transversus Abdominis Plane Block Versus Epidural Analgesia in a Colon and Rectal Surgery Enhanced Recovery Pathway: A Randomized Clinical Trial

Vesicle-based formulations for pain treatment: a narrative review

Pain, a complex and debilitating condition, necessitates innovative therapeutic strategies to alleviate suffering and enhance patients' quality of life. Vesicular systems hold the potential to enhance precision of drug localisation and release, prolong the duration of therapeutic action and mitigate adverse events associated with long-term pharmacotherapy. This review critically assesses the current state-of-the-art in vesicle-based formulations (liposomes, polymersomes, ethosomes, and niosomes) for pain management applications. We highlight formulation engineering strategies used to optimise drug pharmacokinetics, present preclinical findings of experimental delivery systems, and discuss the clinical evidence for the benefits of clinically approved formulations. We present the challenges and outlook for future improvements in long-acting anaesthetic and analgesic formulation development.

A randomised comparison of transverse abdominal plane block versus thoracic epidural analgesia on postoperative opioid consumption for colorectal enhanced recovery after surgery programme (OPIATE study)

BACKGROUND

The transverse abdominis plane block is increasingly being used as a less-invasive alternative to thoracic epidural analgesia for effective pain management. This study aimed to compare transverse abdominis plane block with opioid-based thoracic epidural analgesia in terms of postoperative opioid consumption.

METHODS

Patients in the thoracic epidural analgesia group received a continuous infusion of 0.1% levobupivacaine with 2mcg/ml of fentanyl, while those in the transverse abdominis plane group received 6-hourly boluses of 0.4ml/kg of 0.25% levobupivacaine. The primary objective was to compare the average fentanyl consumption, measured as intravenous fentanyl equivalents, over 72 hours.

RESULTS

Data of 35 patients were analysed. Fentanyl consumption at the end of 72 hours was significantly lower in the transverse abdominis plane group (median [interquartile range] 495 mcg (255, 750), and mean (95% confidence interval) 717.35mcg (403.54-1031.16)) compared to the thoracic epidural analgesia group (median [interquartile range] 760mcg (750, 760), and mean (95% confidence interval) 787mcg (746.81-827.19)) with a p value of 0.010. Pain scores at rest and during movement were comparable between the groups (p > 0.05). However, the median pain scores during movement were significantly lower in the thoracic epidural analgesia group at 60 and 72 hours (p ⩽ 0.05).

CONCLUSION

Multimodal analgesia with transverse abdominis plane resulted in lower opioid consumption over 72 hours compared to thoracic epidural analgesia.

[Implementation of the Intraoperative Surgically-set, Laparoscopically-view-controlled "Transversus Abdominis Plane" Block with Bupivacaine in Elective Laparoscopic Bowel Resections]

Das moderne multimodale perioperative Schmerzmanagement bietet sowohl auf anästhesiologischer als auch auf chirurgischer Seite diverse Möglichkeiten, den postoperativen Schmerz optimal zu kontrollieren. Bei starker Empfehlung der aktuellen ERAS-Kolorektal-Guidelines (2018) zur Nutzung eines laparoskopischen „Transversus-Abdominis-Plane“-Block (L-TAP) wurde dieser im Universitätsklinikum Mannheim modifiziert, um den Patienten sowohl ein möglichst schmerzarmes Erwachen im Aufwachraum als auch eine schmerzfreie 1. postoperative Nacht zu ermöglichen.

Der L-TAP ist bei allen laparoskopisch-kolorektalen Operationen indiziert. Insbesondere bei Verfahren, die einen vergrößerten Bergeschnitt (z. B. Pfannenstiel-Schnitt im Unterbauch) zur Bergung des Präparates erfordern.

Der L-TAP wird zweizeitig, am Anfang der Operation nach Anlegen des Pneumoperitoneums, sowie am Ende der Operation, vor Entfernung der Trokare, durchgeführt. Insgesamt werden bei dieser L-TAP-Technik ca. 266 mg Bupivacainhydrochlorid verabreicht. Die Mischung aus 30 ml Natriumchlorid 0,9% und 60 ml Bupivacainhydrochlorid 0,5% wird an 3 Lokalisationen je Bauchseite injiziert. Die Injektionsstellen befinden sich in der vorderen Axillarlinie 2 cm oberhalb der Crista iliaca, 2 cm oberhalb der erstgenannten Injektionsstelle sowie in der Medioklavikularlinie 2 cm unterhalb des Rippenbogens. An diesen Stellen wird dem Patienten jeweils ca. 7 ml gespritzt. Während dieser Injektionen findet eine intraabdominelle Sichtkontrolle nach Setzung des Kameratrokars laparoskopisch statt. Dabei ist darauf zu achten, dass sich zwischen den Muskelschichten langsam eine deutliche Vorwölbung nach intraabdominell ausbildet.

Durch ein intensives postoperatives Monitoring der Patienten und Schulung des Personals konnte gezeigt werden, dass die Patienten signifikant profitieren durch eine streng korrekte Durchführung des L-TAP. So konnte der postoperative mediane Gesamtmorphiumbedarf der ersten 3 Tage von 25,625 mg (0–150 mg) für einen inkorrekt durchgeführten L-TAP (n = 13) auf 5,625 mg (0–215,625 mg) für einen korrekt durchgeführten L-TAP (n = 49) signifikant reduziert werden (p = 0,024). Die Patienten profitierten ebenfalls subjektiv von der Durchführung eines korrekten L-TAP mit einer signifikanten Reduktion der Schmerzen auf der NRS im Aufwachraum von 4 (0–7) auf 1 (0–7; p = 0,044).

Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients

Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.

Clinical impact of a multimodal pain management protocol for loop ileostomy reversal

PURPOSE

As introduced, multimodal pain management bundle for ileostomy reversal may be considered to reduce postoperative pain and hospital stay. The aim of this study was to evaluate clinical efficacy of perioperative multimodal pain bundle for ileostomy.

METHODS

Medical records of patients who underwent ileostomy reversal after rectal cancer surgery from April 2017 to March 2020 were analyzed. Sixty-seven patients received multimodal pain bundle protocol with ileostomy reversal (group A) and 41 patients underwent closure of ileostomy with conventional pain management (group B).

RESULTS

Baseline characteristics, including age, sex, body mass index, American Society of Anesthesiologists classification, diabetes mellitus, and smoking history, were not significantly different between the groups. The pain score on postoperative day 1 was significant lower in group A (visual analog scale, 2.6 ± 1.3 vs. 3.2 ± 1.2; P = 0.013). Overall consumption of opioid in group A was significant less than group B (9.7 ± 9.5 vs. 21.2 ± 8.8, P < 0.001). Hospital stay was significantly shorter in group A (2.3 ± 1.5 days vs. 4.1 ± 1.5 days, P < 0.001). There were no significant differences between the groups in postoperative complication rate.

CONCLUSION

Multimodal pain protocol for ileostomy reversal could reduce postoperative pain, usage of opioid and hospital stay compared to conventional pain management.

PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management

Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.

Two-stage laparoscopic transversus abdominis plane block as an equivalent alternative to thoracic epidural anaesthesia in bowel resection-an explorative cohort study

PURPOSE

We evaluated the effect of the two-stage laparoscopic transversus abdominis plane block (TS-L-TAPB) in comparison to thoracic epidural anaesthesia (TEA) and a one-stage L-TAPB (OS-L-TAPB) in patients who underwent elective laparoscopic bowel resection.

METHODS

We compared a TS-L-TAPB (266 mg bupivacaine), which was performed bilaterally at the beginning and end of surgery, with two retrospective cohorts. These were patients who had undergone a TEA (ropivacaine/sufentanil) or an OS-L-TAPB (200 mg ropivacaine) at the beginning of surgery. Oral and i.v. opiate requirements were documented over the first 3 postoperative days (POD).

RESULTS

Patients were divided into three groups TEA (n = 23), OS-L-TAPB (n = 75), and TS-L-TAPB (n = 49). By the evening of the third POD, patients with a TEA had a higher cumulative opiate requirement with a median of 45.625 mg [0; 202.5] than patients in the OS-L-TAPB group at 10 mg [0; 245.625] and the TS-L-TAPB group at 5.625 mg [0; 215.625] (p = 0.1438). One hour after arrival in the recovery room, significantly more patients in the TEA group (100%) did not need oral and i.v. opioids than in the TS-L-TAPB (78%) and OS-L-TAPB groups (68%) (p = 0.0067).This was without clinical relevance however as the median in all groups was 0 mg. On the third POD, patients in the TEA group had a significantly higher median oral and i.v. opioid dose at 40 mg [0; 80] than the TS-L-TAPB and OS-L-TAPB groups, both at 0 mg [0; 80] (p = 0.0009).

CONCLUSION

The TS-L-TAP showed statistically significant and clinically meaningful benefits over TEA and OS-L-TAP in reducing postoperative opiate requirements.

Process, structural, and outcome quality indicators to support perioperative opioid stewardship: a rapid review

Opioids are effective analgesics but can cause harm. Opioid stewardship is key to ensuring that opioids are used effectively and safely. There is no agreed set of quality indicators relating to the use of opioids perioperatively. This work is part of the Yorkshire Cancer Research Bowel Cancer Quality Improvement programme and aims to develop useful quality indicators for the improvement of care and patient outcomes at all stages of the perioperative journey.A rapid review was performed to identify original research and reviews in which quality indicators for perioperative opioid use are described. A data tool was developed to enable reliable and reproducible extraction of opioid quality indicators.A review of 628 abstracts and 118 full-text publications was undertaken. Opioid quality indicators were identified from 47 full-text publications. In total, 128 structure, process and outcome quality indicators were extracted. Duplicates were merged, with the final extraction of 24 discrete indicators. These indicators are based on five topics: patient education, clinician education, pre-operative optimization, procedure, and patient-specific prescribing and de-prescribing and opioid-related adverse drug events.The quality indicators are presented as a toolkit to contribute to practical opioid stewardship. Process indicators were most commonly identified and contribute most to quality improvement. Fewer quality indicators relating to intraoperative and immediate recovery stages of the patient journey were identified. An expert clinician panel will be convened to agree which of the quality indicators identified will be most valuable in our region for the management of patients undergoing surgery for bowel cancer.

Efficacy of Magnesium Sulfate as an Adjuvant to Bupivacaine in Transversus Abdominis Plane Block for Abdominal Hysterectomy Surgeries

Background Major abdominal surgeries are often accompanied by excruciating pain, which, if not adequately managed, can reduce patient comfort and satisfaction, delay mobilization, compromise respiratory and cardiac functioning, and increase healthcare costs. The transversus abdominis plane (TAP) block is an efficient and safe complement to multimodal postoperative analgesia for abdominal surgery. This study evaluates the efficacy of combining magnesium sulfate (MgSO₄) with bupivacaine for TAP block in patients posted for total abdominal hysterectomy (TAH). Methodology Seventy female patients between the ages of 35 and 60 who were scheduled to have a TAH under spinal anesthesia were divided randomly into two groups of 35 each: group Bupivacaine (B) and group Bupivacaine-Magnesium sulfate (BM). Group B received 18 milliliters (mL) of bupivacaine 0.25 percentage (%) 45 milligrams (mg) with 2 mL normal saline (NS) whereas group BM received 18 mL of bupivacaine 0.25% (45 mg) with 1.5 mL of 10% weight/volume (w/v) MgSO₄ (150 mg) and 0.5 mL NS in the ultrasonography-guided (USG) bilateral TAP block performed after the end of surgery. Groups were compared for the postoperative visual analog scale (VAS) scores, the time required for first rescue analgesia, the number of analgesic rescues at various time intervals, patient satisfaction score, and any side effects. Results Postoperative VAS scores at 4, 6, 12 and 24th hour (hr) (p < 0.05) in group BM were lower compared to group B. Time required for rescue analgesia was significantly prolonged in group BM (882.94 ± 70.22 minutes) compared to group B (459 ± 100.53 minutes) with minimal usage of rescue analgesia (p < 0.05) up to 12 hr. In group BM, the patient satisfaction score was higher (p = 0.001). Conclusion In addition to a considerable reduction in post operative VAS scores and overall use of rescue analgesia, the addition of magnesium to bupivacaine significantly prolongs the TAP block and increases the initial postoperative period of bearable pain.

Transverse abdominis plane block compared with patient-controlled epidural analgesia following abdominal surgery: a meta-analysis and trial sequential analysis

Thoracic epidural analgesia (TEA) and transversus abdominis plane (TAP) block are used for pain control after abdominal surgery. Although there have been several meta-analyses comparing these two techniques, the conclusion was limited by a small number of studies and heterogeneity among studies. Our meta-analysis used the Medline, EMBASE, and Cochrane central library databases from their inception through September 2022. Randomized controlled trials (RCTs) comparing TEA and TAP block were included. The pre-specified primary outcome was the pain score at rest at 12 h postoperatively. Twenty-two RCTs involving 1975 patients were included. Pooled analyses showed the pain score at rest at 12 h postoperatively was significantly different between groups favoring TEA group (Mean difference [MD] 0.58, 95% confidence interval CI - 0.01, 1.15, P = 0.04, I² = 94%). TEA group significantly reduced the pain score at 48 h at rest (MD 0.59, 95% CI 0.15, 1.03, P = 0.009, I² = 86%) and at 48 h at movement (MD 0.53, 95% CI 0.07, 0.99, P = 0.03, I² = 76%). However, there was no significant difference at other time points. Time to ambulation was shorter in TAP block but the incidence of hypotension at 24 h and 72 h was significantly lower in TAP block compared to TEA. Trial sequential analysis showed that the required information size has not yet been reached. Our meta-analysis demonstrated there was no significant or clinically meaningful difference in the postoperative pain scores between TEA and TAP block group. Given the insufficient information size revealed by TSA, the high risk of bias of our included studies, and the significant heterogeneity of our meta-analysis results, our results should be interpreted carefully but it is not likely that the addition of further studies could prove any clinically meaningful difference in pain score between these two techniques.

Economic Outcomes and Incidence of Postsurgical Hypotension With Liposomal Bupivacaine vs Epidural Analgesia in Abdominal Surgeries

Background: Epidural analgesia can be associated with high costs and postsurgical risks such as hypotension, despite its widespread use and value in providing opioid-sparing pain management. We tested the hypothesis that liposomal bupivacaine (LB) might be a reliable alternative to epidural analgesia in this real-world study. Objectives: To compare economic outcomes and hypotension incidence associated with use of LB and epidural analgesia for abdominal surgery. Methods: This retrospective analysis identified records of adults who underwent abdominal surgeries between January 2016 and September 2019 with either LB administration or traditional epidural analgesia using the Premier Healthcare Database. Economic outcomes included length of stay, hospital costs, rates of discharge to home, and 30-day hospital readmissions. Secondary outcomes included incidence of postsurgical hypotension and vasopressor use. Subgroup analyses were stratified by surgical procedure (colorectal, abdominal) and approach (endoscopic, open). A generalized linear model adjusted for patient and hospital characteristics was used for all comparisons. Results: A total of 5799 surgical records (LB, n=4820; epidural analgesia, n=979) were included. Compared with cases where LB was administered, cases of epidural analgesia use were associated with a 1.6-day increase in length of stay (adjusted rate ratio [95% confidence interval (CI), 1.2 [1.2-1.3]]; P<.0001) and $6304 greater hospital costs (adjusted rate ratio [95% CI], 1.2 [1.2-1.3]]; P<.0001). Cost differences were largely driven by room-and-board fees. Epidural analgesia was associated with reduced rates of discharge to home (P<.0001) and increased 30-day readmission rates (P=.0073) compared with LB. Epidural analgesia was also associated with increased rates of postsurgical hypotension (30% vs 11%; adjusted odds ratio [95% CI], 2.8 [2.3-3.4]; P<.0001) and vasopressor use (22% vs 7%; adjusted odds ratio [95% CI], 3.1 [2.5-4.0]; P<.0001) compared with LB. Subgroup analyses by surgical procedure and approach were generally consistent with overall comparisons. Discussion: Our results are consistent with previous studies that demonstrated epidural analgesia can be associated with higher utilization of healthcare resources and complications compared with LB. Conclusions: Compared with epidural analgesia, LB was associated with economic benefits and reduced incidence of postsurgical hypotension and vasopressor use.

Peripheral nerve blocks with liposomal bupivacaine are associated with increased opioid use compared to thoracic epidural in patients with an epigastric incision

BACKGROUND

Thoracic epidurals are commonly recommended in enhanced recovery protocols, though they may cause hypotension and urinary retention. Peripheral nerve blocks using liposomal bupivacaine are a potential alternative, though they have not been extensively studied in major cancer operations with an epigastric incision.

METHODS

We conducted a retrospective review of prospectively collected data following the transition from thoracic epidural to liposomal peripheral nerve blocks in patients undergoing major oncologic surgery. Patients receiving peripheral nerve blocks were compared to those receiving thoracic epidural. Outcome variables included postoperative opioid use (milligram morphine equivalents [MME]), severe pain, and postoperative complications.

RESULTS

Forty-seven of 102 patients studied (46%) received peripheral nerve blocks. Opioid use was higher in the peripheral nerve block group during the 0-24 h (116 vs. 94 MME, p = 0.04) and 24-48 h postoperative period (94 vs. 23 MME, p < 0.01). There was no significant difference in severe pain, hypotension, urinary retention, or ileus. Peripheral nerve blocks were associated with earlier ambulation (1 vs. 2 days, p = 0.04), though other milestones were similar.

CONCLUSIONS

Liposomal peripheral nerve blocks were associated with increased opioid use compared to thoracic epidural. On the basis of our results, thoracic epidural might be preferred in surgical oncology patients with an epigastric incision.

Transversus abdominis plane blocks for complex abdominal wall reconstruction decrease hospital length of stay compared to epidurals

BACKGROUND

Complex abdominal wall reconstruction for ventral and incisional hernias can be quite painful with prolonged length of stay (LOS). There are a variety of options to manage post-operative pain after a ventral hernia repair, including epidural catheters, transversus abdominis plane (TAP) blocks, and intravenous narcotic pain medications (IVPM). We hypothesized that TAP blocks with liposomal bupivacaine decrease the LOS compared to epidurals and IVPM.

METHODS

A retrospective review of all patients who underwent an open ventral hernia repair with retromuscular mesh between 2016 and 2020 was conducted. LOS was used as the primary outcome. Secondary outcomes included post-operative pain and 90-day post-operative complications.

RESULTS

An epidural was used in 66 patients, a TAP block with liposomal bupivacaine in 18 patients, and IVPM in 11 patients. The epidural group was noted to have a significantly longer duration of surgery (251.11 vs. 207.94 min; P < 0.05) and larger area of mesh (461.85 vs. 338.17 cm²; P < 0.05) when compared to the TAP block group. Hospital LOS was significantly shorter for the TAP block group compared to the epidural group (4.22 vs. 5.62 days; P < 0.05). There were no differences in post-operative complications between the groups. The epidural group reported significantly lower post-operative day one (POD1) pain scores measured on a 10-point scale, compared to the IVPM and TAP block groups (5.00 vs. 6.91 vs. 7.50; P < 0.05).

CONCLUSION

Patients who received a TAP block for post-operative pain management had a significantly shorter length of stay compared to those patients who received an epidural. While the TAP block group reported higher POD1 pain scores, they did not have a significant difference in post-operative complications. TAP blocks with liposomal bupivacaine should be considered for post-operative pain control in complex ventral hernia repairs.

Transversus abdominis plane block with liposomal bupivacaine versus continuous epidural analgesia for major abdominal surgery: The EXPLANE randomized trial

OBJECTIVE

Compare transversus abdominis plane (TAP) blocks with liposomal bupivacaine were to epidural analgesia for pain at rest and opioid consumption in patients recovering from abdominal surgery.

BACKGROUND

ERAS pathways suggest TAP blocks in preference to epidural analgesia for abdominal surgery. However, the relative efficacies of TAP blocks and epidural analgesia remains unknown.

METHODS

Patients having major abdominal surgery were enrolled at six sites and randomly assigned 1:1 to thoracic epidural analgesia or bilateral/4-quadrant TAP blocks with liposomal bupivacaine. Intravenous opioids were used as needed. Non-inferiority margins were a priori set at 1 point on an 11-point pain numeric rating scale for pain at rest and at a 25% increase in postoperative opioid consumption.

RESULTS

Enrollment was stopped per protocol at 3rd interim analysis after crossing an a priori futility boundary. 498 patients were analyzed (255 had TAP blocks and 243 had epidurals). Pain scores at rest in patients assigned to TAP blocks were significantly non-inferior to those given epidurals, with an estimated difference of 0.09 points (CI: -0.12, 0.30; noninferiority P < 0.001). Opioid consumption during the initial 3 postoperative days in TAP patients was not non-inferior to epidurals, with an estimated ratio of geometric means of 1.37 (CI: 1.05, 1.79; non-inferiority P = 0.754). However, the absolute difference was only 21 mg morphine equivalents over the 3 days. Patients with epidurals were more likely to experience mean arterial pressures <65 mmHg than those given TAP blocks: 48% versus 31%, P = 0.006.

CONCLUSION

Pain scores at rest during the initial three days after major abdominal surgery were similar. Patients assigned to TAP blocks required more opioid then epidural patients but had less hypotension. Clinicians should reconsider epidural analgesia in patients at risk from hypotension.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02996227.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Improving Pain Management After Cesarean Birth Using Transversus Abdominis Plane Block With Liposomal Bupivacaine as Part of a Multimodal Regimen

As educators, advocates, and champions for women's health, nurses play pivotal roles throughout a woman's pregnancy and childbirth journey. Most women experience postsurgical pain after cesarean birth and are prescribed opioids. Caution around opioid use warrants opioid-reducing strategies, particularly because exposure to opioids exacerbates risk for developing persistent postsurgical opioid use. Multimodal approaches can help address this concern. Regional anesthesia using transversus abdominis plane blocks with aqueous formulations of local anesthetics can reduce opioid consumption and pain but has a short duration of action. Liposomal formulation of bupivacaine prolongs its release, overcoming this obstacle. Transversus abdominis plane blocks with liposomal bupivacaine can reduce opioid use and pain after cesarean birth, improving recovery. These findings represent numerous implications for nursing practice to improve postcesarean pain management.

Comparative effectiveness of surgeon-performed transversus abdominis plane blocks and epidural catheters following open hernia repair with transversus abdominis release

PURPOSE

Recovery protocols aim to limit narcotic administration following ventral hernia repair (VHR). However, little is known about the contribution of a protocol's individual components on patient outcomes. We previously reported that surgeon-performed transversus abdominis plane block (TAP-block) is more effective than ultrasound-guided TAP-block following VHR. This study evaluates the effectiveness of two postoperative analgesia modalities: epidural catheter and surgeon-performed TAP-block following VHR performed with transversus abdominis release (TAR).

METHODS

A retrospective analysis was performed on data prospectively collected between 2012 and 2019. All patients undergoing open VHR with TAR performed by a single surgeon were identified. Parastomal hernia repairs and any patients receiving ultrasound-guided TAP blocks or paraspinal blocks were excluded. Primary outcome was length of stay (LOS) with secondary outcomes including pain scores, opioid requirements, and 30-day morbidity. Linear regression was used to model LOS.

RESULTS

One hundred thirty-five patients met inclusion criteria (63 epidural, 72 TAP-block). The majority (67.4%) of patients were modified ventral hernia working group grade 2. The only statistically significant difference in postoperative pain scores between the groups was on postoperative day 2 (TAP block 3.19 versus epidural 4.11, p = 0.0126). LOS was significantly shorter in the TAP block group (4.7 versus 6.2 days, p = 0.0023) as was time to regular diet (3.2 versus 4.7 days, p < 0.0001). After controlling for confounders, epidural was associated with increased LOS by 1.3 days (p = 0.0004).

CONCLUSION

Epidural use following VHR with TAR is associated with increased LOS and increased time to regular diet without reducing pain or opioid use when compared to surgeon-performed TAP block.

Pharmacokinetics and safety of liposomal bupivacaine after local infiltration in healthy Chinese adults: a phase 1 study

Background

Liposomal bupivacaine (LB) is a long-acting formulation of bupivacaine. The safety and efficacy of LB has been demonstrated across surgical procedures. However, pharmacokinetic (PK) parameters and safety of LB in the Chinese population have not been assessed.

Methods

In this single-arm, single center, phase 1, open-label study, PK and safety of local infiltration with LB 266 mg were assessed in healthy Chinese adults. Eligible participants were aged 18 to 55 years with biologic parents and grandparents of Chinese ethnicity, in generally good health (i.e., no clinically significant abnormalities), and with a body mass index (BMI) 19.0 to 24.0 kg/m² (inclusive) and body weight ≥ 50 kg.

Results

Participants (N = 20) were predominantly men (80 %); mean age was 32 years; and mean BMI was 21.8 kg/m². After LB administration, mean plasma levels of bupivacaine rapidly increased during the first hour and continued to increase through 24 h; plasma levels then gradually decreased through 108 h followed by a monoexponential decrease through 312 h. Geometric mean maximum plasma concentration was 170.9 ng/mL; the highest plasma bupivacaine concentration detected in any participant was 374.0 ng/mL. Twenty-two treatment-emergent adverse events were reported (mild, n = 21; moderate, n = 1).

Conclusions

After single-dose administration of LB, PK measures were similar to a previously reported profile in US adults. The highest observed peak plasma concentration of bupivacaine was several-fold below the plasma concentration threshold accepted as being associated with neurotoxicity or cardiotoxicity (2000–4000 ng/mL). These data support that LB is well tolerated and safe in individuals of Chinese descent.

Trial registration

NCT04158102 (ClinicalTrials.gov identifier), Date of registration: November 5, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01407-5.

A Prospective Randomized Trial of Surgeon-Administered Intraoperative Transversus Abdominis Plane Block With Bupivacaine Against Liposomal Bupivacaine: The TINGLE Trial

BACKGROUND

Transversus abdominis plane blocks are increasingly used to achieve opioid-sparing analgesia after colorectal surgery. Traditionally, bupivacaine was the long-acting analgesic of choice, but the addition of dexamethasone and/or epinephrine to bupivacaine may extend block duration. Liposomal bupivacaine has also been suggested to achieve an extended analgesia duration of 72 hours but is significantly more expensive.

OBJECTIVE

The purpose of this study was to compare pain control between laparoscopic transversus abdominis plane blocks using liposomal bupivacaine versus bupivacaine with epinephrine and dexamethasone.

DESIGN

This was a parallel-group, single-institution, randomized clinical trial.

SETTINGS

The study was conducted at a single tertiary medical center.

PATIENTS

Consecutive patients between October 2018 to October 2019, ages 18 to 90 years, undergoing minimally invasive colorectal surgery with multimodal analgesia were included.

INTERVENTIONS

Patients were randomly assigned 1:1 to receive a laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone.

MAIN OUTCOME MEASURES

The primary outcome was total oral morphine equivalents administered in the first 48 hours postoperatively. Secondary outcomes included pain scores, time to ambulation and solid diet, hospital length of stay, and complications.

RESULTS

A total of 102 patients (50 men) with a median age of 42 years (interquartile range, 29-60 y) consented and were randomly assigned. The primary end point, total oral morphine equivalents administered in the first 48 hours, was not significantly different between the liposomal bupivacaine group (median = 69 mg) and the bupivacaine with epinephrine and dexamethasone group (median = 47 mg; difference in medians = 22 mg, (95% CI, -17 to 49 mg); p = 0.60). There were no significant differences in pain scores, time to ambulation, time to diet tolerance, time to bowel movement, length of stay, overall complications, or readmission rate between groups. There were no treatment-related adverse outcomes.

LIMITATIONS

This study was not placebo controlled or blinded.

CONCLUSIONS

This first randomized trial comparing laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone showed that a liposomal bupivacaine block does not provide superior or extended analgesia in the era of standardized multimodal analgesia protocols.See Video Abstract at http://links.lww.com/DCR/B533.

ESTUDIO PROSPECTIVO Y RANDOMIZADO DE BLOQUEO DEL PLANO MUSCULAR TRANSVERSO DEL ABDOMEN REALIZADO POR EL CIRUJANO CON BUPIVACANA VERSUS BUPIVACANA LIPOSOMAL ESTUDIO TINGLE

ANTECEDENTES:El bloqueo anestésico del plano muscular transverso del abdomen se utiliza cada vez más para lograr una analgesia con menos consumo de opioides después de cirugía colorrectal. Tradicionalmente, la Bupivacaína era el analgésico de acción prolongada de elección, pero al agregarse Dexametasona y/o Adrenalina a la Bupivacaína se puede prolongar la duración del bloqueo. También se ha propuesto que la Bupivacaína liposomal logra una duración prolongada de la analgesia de 72 horas, pero es significativamente más cara.OBJETIVO:Comparar el control del dolor entre bloqueo laparoscópico del plano de los transversos del abdomen usando Bupivacaína liposomal versus Bupivacaína con Adrenalina y Dexametasona.DISEÑO:Estudio clínico prospectivo y randomizado de una sola institución en grupos paralelos.AJUSTE:Centro médico terciario único.PACIENTES:Todos aquellos pacientes entre 18 y 90 años sometidos a cirugía colorrectal mínimamente invasiva con analgesia multimodal, entre octubre de 2018 a octubre de 2019 incluidos de manera consecutiva.INTERVENCIONES:Los pacientes fueron seleccionados aleatoriamente 1:1 para recibir un bloqueo laparoscópico del plano de los transversos del abdomen con Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el total de equivalentes de morfina oral administradas en las primeras 48 horas después de la operación. Los resultados secundarios incluyeron puntuaciones de dolor, inicio de dieta sólida, tiempo de inicio a la deambulación, la estadía hospitalaria y las complicaciones.RESULTADOS:Un total de 102 pacientes (50 hombres) con una mediana de edad de 42 años (IQR 29-60) fueron incluidos aleatoriamente. El criterio de valoración principal, equivalentes de morfina oral total administrada en las primeras 48 horas, no fue significativamente diferente entre el grupo de Bupivacaína liposomal (mediana = 69 mg) y el grupo de Bupivacaína con Adrenalina y Dexametasona (mediana = 47 mg; diferencia en medianas = 22 mg, IC del 95% [-17] - 49 mg, p = 0,60). No hubo diferencias significativas en las puntuaciones de dolor, tiempo de inicio a la deambulación, el tiempo de tolerancia a la dieta sólida, el tiempo hasta el primer evacuado intestinal, la duración de la estadía hospitalaria, las complicaciones generales o la tasa de readmisión entre los grupos. No hubo resultados adversos relacionados con el tratamiento.LIMITACIONES:Este estudio no fue controlado con placebo ni de manera cegada.CONCLUSIONES:Este primer estudio prospectivo y randomizado que comparó el bloqueo del plano de los músculos transversos del abdomen por vía laparoscópica, utilizando Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona, demostró que el bloqueo de Bupivacaína liposomal no proporciona ni mejor analgesia ni un efecto mas prolongado.Consulte Video Resumen en http://links.lww.com/DCR/B533.

Postoperative Pain After Enhanced Recovery Pathway Robotic Colon and Rectal Surgery: Does Specimen Extraction Site Matter?

BACKGROUND

The current opioid crisis has motivated surgeons to critically evaluate ways to balance postoperative pain while decreasing opioid use and thereby reducing opioids available for community diversion. The longest incision for robotic colorectal surgery is the specimen extraction site incision. Intracorporeal techniques allow specimen extraction to be at any location.

OBJECTIVE

This study was designed to determine whether the Pfannenstiel location is associated with less pain and opioid use than other abdominal wall specimen extraction sites.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted with a prospectively maintained colorectal surgery database (July 2018 through October 2019).

PATIENTS

Patients with enhanced recovery robotic colorectal resections with specimen extraction were included.

MAIN OUTCOME MEASURES

Propensity score weighting was used to derive adjusted rates for numeric pain scores, inpatient opioid use, opioids prescribed at discharge, opioid refills after discharge, and other related outcomes. For comparing outcomes between groups, p values were calculated using weighted χ2, Fisher exact, and t tests.

RESULTS

There were 137 cases (70.9%) with Pfannenstiel extraction site incisions and 56 (29.0%) at other locations (7 midline, 49 off-midline). There was no significant difference in transversus abdominis plane blocks and epidural analgesia use between groups. Numeric pain scores, overall benefit of analgesia scores, inpatient postoperative opioid use, opioids prescribed at discharge and taken after discharge, and opioid refills were not significantly different between groups. Nonopioid pain analgesics (acetaminophen, nonsteroidal anti-inflammatory drugs, and gabapentin) prescribed at discharge were significantly less in the Pfannenstiel group (90.19% vs 98.45%; p = 0.006). Postoperative complications and readmissions were not different between groups.

LIMITATIONS

This study was conducted at a single institution.

CONCLUSIONS

The Pfannenstiel incision as the specimen extraction site choice in minimally invasive surgery is associated with similar postoperative pain and opioid use as extraction sites in other locations for patients having robotic colorectal resections. Specimen extraction sites may be chosen based on patient factors other than pain and opioid use. See Video Abstract at http://links.lww.com/DCR/B495.

DOLOR POSTOPERATORIO DESPUS DE VAS DE RECUPERACIN MEJORADA EN CIRUGA ROBTICA DE COLON Y RECTO IMPORTA EL LUGAR DE EXTRACCIN DE LA MUESTRA

ANTECEDENTES:La actual crisis de opioides ha motivado a los cirujanos a evaluar críticamente, formas para equilibrar el dolor postoperatorio, disminuyendo el uso de opioides y por lo tanto, disminuyendo opioides disponibles para el desvío comunitario. La incisión más amplia en cirugía colorrectal robótica, es la incisión del sitio de extracción de la muestra. Las técnicas intracorpóreas permiten que la extracción de la muestra se realice en cualquier sitio.OBJETIVO:El estudio fue diseñado para determinar si la ubicación del Pfannenstiel está asociada con menos dolor y uso de opioides, a otros sitios de extracción de la muestra en la pared abdominal.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Estudio de base de datos de cirugía colorrectal mantenida prospectivamente (7/2018 a 10/2019).PACIENTES:Se incluyeron resecciones robóticas colorrectales con recuperación mejorada y extracción de muestras.PRINCIPALES MEDIDAS DE RESULTADO:Se utilizó la ponderación del puntaje de propensión para derivar las tasas ajustadas para los puntajes numéricos de dolor, uso de opioides en pacientes hospitalizados, opioides recetados al alta, recarga de opioides después del alta y otros resultados relacionados. Para comparar los resultados entre los grupos, los valores p se calcularon utilizando chi-cuadrado ponderado, exacto de Fisher y pruebas t.RESULTADOS:Hubo 137 (70,9%) casos con incisiones en el sitio de extracción de Pfannenstiel y 56 (29,0%) en otras localizaciones (7 en la línea media, 49 fuera de la línea media). No hubo diferencias significativas en los bloqueos del plano transverso del abdomen y el uso de analgesia epidural entre los grupos. Las puntuaciones numéricas de dolor, puntuaciones de beneficio general de la analgesia, uso postoperatorio de opioides en pacientes hospitalizados, opioides recetados al alta y tomados después del alta, y las recargas de opioides, no fueron significativamente diferentes entre los grupos. Los analgésicos no opioides (acetaminofén, antiinflamatorios no esteroideos, gabapentina) prescritos al alta, fueron significativamente menores en el grupo de Pfannenstiel (90,19% frente a 98,45%, p = 0,006). Las complicaciones postoperatorias y los reingresos, no fueron diferentes entre los grupos.LIMITACIONES:Una sola institución.CONCLUSIÓN:La incisión de Pfannenstiel como sitio de extracción de la muestra en cirugía mínimamente invasiva, se asocia con dolor postoperatorio y uso de opioides similar, a otros sitios de extracción en pacientes sometidos a resecciones robóticas colorrectales. Sitios de extracción de la muestra, pueden elegirse en función de factores del paciente distintos al dolor y uso de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B495.).

Comparison of transversus abdominis plane catheters with thoracic epidurals for cost and length of stay in open colorectal surgeries: a cohort study

BACKGROUND

Thoracic epidural analgesia has long been a common method of postoperative analgesia for major open abdominal surgeries and is frequently used within enhanced recovery after surgery programs. An alternative postoperative analgesia method is the single shot transversus abdominis plane block, which has shown promising outcomes with respect to total length of stay, cost, pain scores, and decreased opioid usage. However, far less is known regarding continuous transversus abdominis plane analgesia using catheters. We evaluated the total cost-effectiveness of transversus abdominis plane catheter analgesia compared to thoracic epidural analgesia for patients undergoing open colorectal surgeries within the enhanced recovery after surgery program at our institution.

METHODS

This cohort study included patients booked under the colorectal surgery enhanced recovery after surgery program from November 2016 through March 2018 who received either bilateral transversus abdominis plane catheters (n = 52) or thoracic epidural analgesia (n = 24).

RESULTS

There was no difference in total direct cost (p = 0.660) and indirect cost (p = 0.220), and median length of stay (p = 0.664) in the transversus abdominis plane catheter group compared to the thoracic epidural group. Additionally, the transversus abdominis plane catheter group received significantly less morphine equivalents compared to the thoracic epidural group (p = 0.008) and had a lower mean body mass index (p = 0.019). There was no significant difference between the two groups for age (p = 0.820), or sex (p = 0.330).

CONCLUSIONS

Transversus abdominis plane catheter analgesia is not associated with increased cost or longer hospital stays when compared to thoracic epidural analgesia in patients undergoing open colorectal surgery within an enhanced recovery after surgery program. Furthermore, transversus abdominis plane catheter analgesia led to decreased opioid consumption while maintaining similar pain scores, suggesting similar pain control between the two modalities.

The Efficacy of Liposomal Bupivacaine for Opioid and Pain Reduction: A Systematic Review of Randomized Clinical Trials

Background The opioid crisis has prompted surgeons to search for alternative postoperative methods of analgesia. Liposomal bupivacaine is a long-acting local anesthetic formulation used for pain, potentially reducing opioid use. Evaluation of liposomal bupivacaine as a viable alternative for pain management is needed. The objective was to assess the efficacy of randomized clinical trials (RCTs) of liposomal bupivacaine in postoperative pain management and opioid consumption. Material and Methods The authors extracted RCTs comparing liposomal bupivacaine versus placebo or active comparators for postoperative pain or opioid reduction from PubMED/MEDLINE, Cochrane Library, and ClinicalTrials.gov. Exclusion criteria included nonhuman studies, non-RCTs, pooled studies, and inability to access full text. The following variables were abstracted: surgical specialty, number of subjects, pain and opioid outcomes, and authors' financial conflicts of interest. Results We identified 77 published RCTs, of which 63 studies with a total of 6770 subjects met inclusion criteria. Liposomal bupivacaine did not demonstrate significant pain relief compared to placebo or active agents in 74.58% of RCTs. Of the studies evaluating narcotic use, liposomal bupivacaine did not show a reduction in opioid consumption in 85.71% of RCTs. Liposomal bupivacaine, when compared to standard bupivacaine or another active agent, yielded no reduction in opioid use in 83.33% and 100.00% of studies, respectively. Clinical trials with a financial conflict of interest relating to the manufacturer of liposomal bupivacaine were significantly more likely to show pain relief (OR: 14.31 [95% CI, 2.8, 73.10], P = 0.0001) and decreased opioid consumption (OR: 12.35 [95% CI 1.40, 109.07], P = 0.0237). Of the 265 unpublished RCTs on ClinicalTrials.gov, 47.54% were withdrawn, terminated, suspended, or completed without study results available. Conclusions The efficacy of liposomal bupivacaine for providing superior postoperative pain control relative to placebo or another active agent is not supported by a majority of RCTs. Underreporting of trial results and bias due to underlying financial relationships amongst authors are two major concerns that should be considered when evaluating the available evidence.

Effect of preoperative versus postoperative use of transversus abdominis plane block with plain 0.25 % bupivacaine on postoperative opioid use: a retrospective study

Background

Enhanced recovery protocols optimize pain control via multimodal approaches that include transversus abdominis plane (TAP) block. The aim of this study was to evaluate the effect of preoperative vs. postoperative plain 0.25 % bupivacaine TAP block on postoperative opioid use after colorectal surgery.

Methods

A retrospective cohort study comparing postoperative opioid use in patients who received preoperative (n = 240) vs. postoperative (n = 22) plain 0.25 % bupivacaine TAP blocks. The study was conducted in a single tertiary care institution and included patients who underwent colorectal resections between August 2018 and January 2020. The primary outcome of the study was postoperative opioid use. Secondary outcomes included operative details, length of stay, reoperation, and readmission rates.

Results

Patients who received postoperative plain 0.25 % bupivacaine TAP blocks were less likely to require postoperative patient-controlled analgesia (PCA) (59.1 % vs. 83.3 %; p = 0.012) and opioid medications on discharge (6.4 % vs. 16.9 %; p = 0.004) relative to patients who received preoperative TAP. When needed, a significantly smaller amount of opioid was prescribed to the postoperative group (84.5 vs. 32.0 mg, p = 0.047). No significant differences were noted in the duration of postoperative PCA use, amount of oral opioid use, and length of stay.

Conclusions

Plain 0.25 % bupivacaine TAP block administered postoperatively was associated with significantly lower need for postoperative PCA and discharge opioid medications. The overall hospital length of stay was not affected by the timing of TAP block. Because of the limited sample size in this study, conclusions cannot be generalized, and more research will be required.

Effect of liposomal bupivacaine on opioid requirements and length of stay in colorectal enhanced recovery pathways: A systematic review and network meta-analysis

AIM

Reducing postoperative opioid consumption is a key aim of enhanced recovery after colorectal surgery protocols. Potential solutions include anaesthetic techniques such as local infiltration of anaesthetic agents or transversus abdominis plane (TAP) blocks. This study aimed to assess the efficacy of liposomal bupivacaine (LB) for colorectal resections, across a variety of anaesthetic techniques.

METHODS

PubMed, Scopus and Embase databases were searched for relevant studies assessing LB, administered by any anaesthetic technique. The primary outcome was postoperative morphine consumed (milligrams) and the secondary outcome was length of stay (days). A Bayesian network meta-analysis comparing LB versus non-LB analgesia was performed alongside meta-regression for different surgical approaches.

RESULTS

Twelve trials were included, with a total of 2512 patients. LB-based wound infiltration was most likely to reduce length of stay followed by TAP block with LB (sum under the cumulative ranking [SUCRA] 85.55 and 70.26, respectively). TAP block with LB was most likely to reduce morphine requirements, followed by wound infiltration with LB (SUCRA 83.94 and 75.73, respectively). Compared to standard analgesia, LB-based wound infiltration reduced morphine usage (mean difference 36.64 mg, 95% credibility interval 15.64-59.20) and length of stay (mean difference 1.79 days, 95% credibility interval 0.59-3.81). On meta-regression, the findings held for minimally invasive surgery only.

CONCLUSION

Although LB-based interventions were associated with reduced postoperative morphine requirements and length of stay in this network meta-analysis, the confidence in these estimates was graded as very low. Further well-executed trials are required before LB can be recommended as a first-line agent.

Adoption of enhanced recovery after surgery and intraoperative transverse abdominis plane block decreases opioid use and length of stay in very large open ventral hernia repairs

BACKGROUND

The effect of an enhanced recovery after surgery (ERAS) pathway including liposomal bupivacaine transversus abdominus plane (TAP)-blocks for abdominal wall reconstruction (AWR) on opioids use is not clear.

METHODS

A prospective, tertiary hernia center database of patients undergoing AWR before and after ERAS and operative TAP-blocks was matched in large ventral hernias.

RESULTS

In 106 patients, non-TAP-block and TAP-block groups were comparable in mean BMI (p = 0.694), hernia defect size (p = 0.424), components separation (p = 0.610), complete fascial closure (p = 1.0), and panniculectomy (p = 1.0). The total morphine milligram equivalents (MME) used during hospitalization was reduced by 3-fold in the TAP-block group (p < 0.001), and opioid usage decreased by 35%-71% during days 1-5. Length of stay (LOS) was shorter in the TAP-block group by average of 1 day (p = 0.011).

CONCLUSION

ERAS and TAP-block in AWR leads to a decrease in mean opioid usage by 65% and decreased LOS by an average of 1 day.

Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia

BACKGROUND

Liposomal bupivacaine is purported to extend analgesia of peripheral nerve blocks when administered perineurally. However, evidence of the clinical effectiveness of perineural liposomal bupivacaine is mixed. This meta-analysis seeks to evaluate the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared with nonliposomal local anesthetics.

METHODS

The authors identified randomized trials evaluating the effectiveness of peripheral nerve block analgesic that compared liposomal bupivacaine with nonliposomal local anesthetics. The primary outcome was the difference in area under the receiver operating characteristics curve (AUC) of the pooled 24- to 72-h rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. AUC pain scores were interpreted in light of a minimal clinically important difference of 2.0 cm · h.

RESULTS

Nine trials (619 patients) were analyzed. When all trials were pooled, AUC pain scores ± SD at 24 to 72 h were 7.6 ± 4.9 cm · h and 6.6 ± 4.6 cm · h for nonliposomal and liposomal bupivacaine, respectively. As such, perineural liposomal bupivacaine provided a clinically unimportant benefit by improving the AUC (95% CI) of 24- to 72-h pain scores by 1.0 cm · h (0.5 to 1.6; P = 0.003) compared with nonliposomal bupivacaine. Excluding an industry-sponsored trial rendered the difference between the groups nonsignificant (0.7 cm · h [-0.1 to 1.5]; P = 0.100). Secondary outcome analysis did not uncover any additional benefits to liposomal bupivacaine in pain severity at individual timepoints up to 72 h, analgesic consumption, time to first analgesic request, opioid-related side effects, patient satisfaction, length of hospital stay, and functional recovery. No liposomal bupivacaine side effects were reported.

CONCLUSIONS

Perineural liposomal bupivacaine provided a statistically significant but clinically unimportant improvement in the AUC of postoperative pain scores compared with plain local anesthetic. Furthermore, this benefit was rendered nonsignificant after excluding an industry-sponsored trial, and liposomal bupivacaine was found to be not different from plain local anesthetics for postoperative pain and all other analgesic and functional outcomes. High-quality evidence does not support the use of perineural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks.

EDITOR’S PERSPECTIVE

Clinical Effectiveness of Liposomal Bupivacaine Administered by Infiltration or Peripheral Nerve Block to Treat Postoperative Pain

The authors provide a comprehensive summary of all randomized, controlled trials (n = 76) involving the clinical administration of liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, USA) to control postoperative pain that are currently published. When infiltrated surgically and compared with unencapsulated bupivacaine or ropivacaine, only 11% of trials (4 of 36) reported a clinically relevant and statistically significant improvement in the primary outcome favoring liposomal bupivacaine. Ninety-two percent of trials (11 of 12) suggested a peripheral nerve block with unencapsulated bupivacaine provides superior analgesia to infiltrated liposomal bupivacaine. Results were mixed for the 16 trials comparing liposomal and unencapsulated bupivacaine, both within peripheral nerve blocks. Overall, of the trials deemed at high risk for bias, 84% (16 of 19) reported statistically significant differences for their primary outcome measure(s) compared with only 14% (4 of 28) of those with a low risk of bias. The preponderance of evidence fails to support the routine use of liposomal bupivacaine over standard local anesthetics.

Epidural analgesia for hepatopancreatobiliary operations and postoperative urinary tract infections: an unrecognized association of "best-practices" and adverse outcomes

BACKGROUND

Thoracic epidural analgesia (TEA) is considered "best-practices" for pain-control following HPB operations. It is unknown if TEA increases the risk of UTI. We sought to examine the association of TEA and UTI following HPB operations.

METHODS

A retrospective cohort study of patients undergoing elective HPB operations was performed (ACS-NSQIP [2014-2016]). Patients were categorized by TEA utilization. The primary outcome was UTI. Multivariable logistic regression models were created to examine the association of TEA with UTI; including sensitivity and interaction analyses for age and gender.

RESULTS

Among 28,571 patients included, 5764 (20.2%) had TEA. UTI occurred more frequently with TEA (3.5% vs. 2.2%, p < 0.01). After multivariable analysis, TEA was associated with increased risk of UTI (1.59 [1.34-1.89]); when stratified by age and gender, the association persisted with an incremental increased risk observed in males over 70 years (1.91 [1.41-2.59]). UTI was associated with increased risk of sepsis (16.8% vs. 5.6%, P < 0.001), LOS (9 versus 6 days, P < 0.001) and readmission rates (21.4% vs. 12.3%, P < 0.001).

CONCLUSION

Despite TEA recommended as a best-practice standard for HPB operations, the increased risk of UTI calls for evaluation of current practices and consideration of alternative strategies for high-risk vulnerable populations - elderly males.

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.

The Efficacy of Liposomal Bupivacaine On Postoperative Pain Following Abdominal Wall Reconstruction: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

To study the efficacy of liposomal bupivacaine on postoperative opioid requirement and pain following abdominal wall reconstruction.

SUMMARY BACKGROUND DATA

Despite the widespread use of liposomal bupivacaine in transversus abdominis plane block, there is inadequate evidence demonstrating its efficacy in open abdominal wall reconstruction. We hypothesized that liposomal bupivacaine plane block would result in decreased opioid requirements compared to placebo in the first 72 hours after surgery.

METHODS

This was a single-center double-blind, placebo-controlled prospective study conducted between July 2018 and November 2019. Adult patients (at least 18 years of age) undergoing open, elective, ventral hernia repairs with mesh placed in the retromuscular position were enrolled. Patients were randomized to surgeon-performed transversus abdominis plane block with liposomal bupivacaine, simple bupivacaine, or normal saline (placebo). The main outcome was opioid requirements in the first 72 hours after surgery. Secondary outcomes included total inpatient opioid use, pain scores determined using a 100 mm visual analog scale, length of hospital stay, and patient-reported quality of life.

RESULTS

Of the 164 patients that were included in the analysis, 57 patients received liposomal bupivacaine, 55 patients received simple bupivacaine and 52 received placebo. There were no differences in the total opioid used in the first 72 hours after surgery as measured by morphine milligram equivalents when liposomal bupivacaine was compared to simple bupivacaine and placebo (325 ± 225 vs. 350 ± 284 vs. 310 ± 272, respectively, p = 0.725). Similarly, there were no differences in total inpatient opioid use, pain scores, length of stay, and patient-reported quality of life.

CONCLUSIONS

There are no apparent clinical benefits to using liposomal bupivacaine transversus abdominis plane block when compared to simple bupivacaine and placebo for open abdominal wall reconstruction.

Timing of Transversus Abdominis Plane Block and Postoperative Pain Management

Background

Transversus abdominis plane (TAP) blocks using liposomal bupivacaine can reduce postoperative pain and opioid consumption after surgery. The impact of timing of administration of such blocks has not been determined.

Materials and Methods

A retrospective cohort study of all adult patients that underwent colorectal procedures between January 2013 and October 2015 and received TAP blocks with liposomal bupivacaine at our institution was conducted. The primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes included postoperative use of non-opioid analgesics as well as total hospital cost of admission and postoperative hospital length of stay.

Results

A total of 287 patients were identified and included in the analysis. A total of 71 patients received blocks prior to induction of general anesthesia (pre-ind), 85 patients received blocks after induction of general anesthesia but prior to surgical incision (post-ind) and 131 patients received blocks after completion of surgery (post-op). No significant differences were observed in the postoperative pain scores (either in the first 4 hours or for the entire duration of hospital stay) or opioid consumption between the pre-ind and the post-ind groups. More ketorolac was used in the post-op group compared to the pre-ind group (or= 3.36, 95% CI (1.08, 10.43); p=0.03).

Conclusion

Our findings suggest that there seems to be no difference if tap blocks with liposomal bupivacaine are performed before or after induction of anesthesia. Patient preference as well as operating room efficiency should be considered when deciding on the timing of these blocks.

Transversus Abdominis Plane Block With Liposomal Bupivacaine vs. Regular Anesthetics for Pain Control After Surgery: A Systematic Review and Meta-Analysis

Background: Transverse abdominal plane (TAP) blocks are used to provide pain relief after abdominopelvic surgeries. The role of liposomal bupivacaine (LB) for TAP blocks is unclear. Therefore, this study aimed to synthesize evidence on the efficacy of LB vs. regular anesthetics in improving outcomes of TAP block. Methods: PubMed, Science Direct, Embase, Springer, and CENTRAL databases were searched up to July 24, 2020. Studies comparing LB with any regular anesthetic for TAP block for any surgical procedure and reporting total analgesic consumption (TAC) or pain scores were included. Results: Seven studies including five randomized controlled trials (RCTs) were reviewed. LB was compared with regular bupivacaine (RB) in all studies. A descriptive analysis was conducted for TAC due to heterogeneity in data presentation. There were variations in the outcomes of studies reporting TAC. Meta-analysis of pain scores indicated statistically significant reduction of pain with the use of LB at 12 h (MD: -0.89 95% CI: -1.44, -0.34 I2 = 0% p = 0.01), 24 h (MD: -0.64 95% CI: -1.21, -0.06 I2 = 0% p = 0.03), 48 h (MD: -0.40 95% CI: -0.77, 0.04 I2 = 0% p = 0.03) but not at 72 h (MD: -0.37 95% CI: -1.31, 0.56 I2 = 57% p = 0.43). Pooled analysis indicated no difference in the duration of hospital stay between LB and RB (MD: -0.18 95% CI: -0.49, 0.14 I2 = 61% p = 0.27). LB significantly reduced the number of days to first ambulation postsurgery (MD: -0.28 95% CI: -0.50, -0.06 I2 = 0% p = 0.01). Conclusions: Current evidence on the role of LB for providing prolonged analgesia with TAP blocks is unclear. Conflicting results have been reported for TAC. LB may result in a small reduction in pain scores up to 48 h but not at 72 h. Further, high-quality homogenous RCTs are needed to establish high-quality evidence.

Dual adjunct therapy with dexamethasone and dexmedetomidine in transversus abdominis plane blocks reduces postoperative opioid use in colorectal surgery

BACKGROUND

The objective of this study is to determine if the addition of dexmedetomidine to dexamethasone in transversus abdominis plane (TAP) blocks lowers postoperative opioid use following colorectal surgery.

METHODS

Retrospective review of patients undergoing minimally invasive colorectal surgery and perioperative TAP block with either 1) local anesthetic and dexamethasone or 2) local anesthetic, dexamethasone, and dexmedetomidine. Post-operative opioid use was converted to morphine milligram equivalents (MME).

RESULTS

55 patients were identified: 38 (69%) receiving dexamethasone only and 17 (31%) receiving dexamethasone and dexmedetomidine. The dexamethasone and dexmedetomidine group had significantly lower median MME use at 12-h (2 vs. 13 mg), 24-h (4 vs. 28 mg), 36-h (8 vs. 38 mg), and 48-h (17 vs. 53 mg) (all p < 0.05). There was no difference at 72-h.

CONCLUSION

Perioperative TAP blocks with dexamethasone and dexmedetomidine following colorectal surgery results in significantly less postoperative opioid use up to 48 h after surgery.

Transversus abdominis plane block versus thoracic epidural analgesia in colorectal surgery: a systematic review and meta-analysis

BACKGROUND

The efficacy of transversus abdominis plane (TAP) block compared with thoracic epidural analgesia (TEA) in abdominal surgery has been controversial. We conducted this systematic review and meta-analysis to assess outcomes of TAP block and TEA in a procedure-specific manner in colorectal surgery.

METHODS

A systematic literature search of the PubMed, Embase, Cochrane Library, and Scopus databases was conducted through July 10, 2020, to identify randomized controlled trials (RCTs) comparing TAP block with TEA in colorectal surgery. Primary outcomes were pain scores at rest and movement at 24 h postoperatively. Secondary outcomes included postoperative pain scores at 0-2 and 48 h, opioid consumption, postoperative nausea and vomiting (PONV), functional recovery, hospital stay, and adverse events.

RESULTS

Six RCTs with 568 patients were included. Methodological quality of these RCTs ranged from moderate to high. TAP block provided comparable pain control, lower 24 h and total opioid consumption, shorter time to ambulation and urinary catheter time, and lower incidence of sensory disturbance and postoperative hypotension compared with TEA. Meanwhile, the 48-h opioid consumption, PONV incidence, and hospital stay were similar between groups. When laparoscopic surgery was the only surgical approach employed, TAP block provided additional benefits of shorter time to first flatus and lower incidence of PONV compared with TEA.

CONCLUSIONS

Perhaps more germane to minimally invasive procedures, TAP block is equivalent to TEA in terms of postoperative pain control and provides better functional recovery with lower incidence of adverse events in patients undergoing colorectal surgery.

The Effect of Chronic Preoperative Opioid Use on Surgical Site Infections, Length of Stay, and Readmissions

BACKGROUND

Chronic opioid use in the United States is a well-recognized public health concern with many negative downstream consequences. Few data exist regarding the use of preoperative opioids in relation to outcomes after elective colorectal surgery.

OBJECTIVE

The purpose of this study was to determine if chronic opioid use before colorectal surgery is associated with a detriment in postoperative outcomes.

DESIGN

This is a retrospective review of administrative data supplemented by individual chart review.

SETTING

This study was conducted in a single-institution, multisurgeon, community colorectal training practice.

PATIENTS

All patients undergoing elective colorectal surgery over a 3-year time frame (2011-2014) were selected.

MAIN OUTCOME MEASURES

Opioid use was stratified based on total dose of morphine milligram equivalents (naive, sporadic use (>0-15 mg/day), regular use (>15-45 mg/day), and frequent use (>45 mg/day)). Primary outcomes were surgical site infections, length of hospital stay, and readmissions.

RESULTS

Of the 923 patients, 23% (n = 213) were using opioids preoperatively. The preoperative opioid group contained more women (p = 0.047), underwent more open surgery (p = 0.003), had more nonmalignant indications (p = 0.013), and had a higher ASA classification (p = 0.003). Although median hospital stay was longer (4.7 days vs 4.0, p < 0.001), there was no difference in any surgical site infections (10.3% vs 7.1%, p = 0.123) or readmissions (14.2% vs 14.1%, p=0.954). Multivariable analysis identified preoperative opioid use (17.0% longer length of stay; 95% CI, 6.8%-28.2%) and ASA 3 or 4 (27.2% longer length of stay; 95% CI, 17.1-38.3) to be associated with an increase in length of stay.

LIMITATIONS

Retrospectively abstracted opioid use and small numbers limit the conclusions regarding any dose-related responses on outcomes.

CONCLUSIONS

Although preoperative opioid use was not associated with an increased rate of surgical site infections or readmissions, it was independently associated with an increased hospital length of stay. Innovative perioperative strategies will be necessary to eliminate these differences for patients on chronic opioids. See Video Abstract at http://links.lww.com/DCR/B280. EFECTOS DEL CONSUMO CRÓNICO DE OPIOIDES EN EL PREOPERATORIO CON RELACIÓN A LAS INFECCIONES DE LA HERIDA QUIRÚRGICA, LA DURACIÓN DE LA ESTADÍA Y LA READMISIÓN: El consumo crónico de opioides en los Estados Unidos es un problema de salud pública bien reconocido a causa de sus multiples consecuencias negativas ulteriores. Existen pocos datos sobre el consumo de opioides en el preoperatorio relacionado con los resultados consecuentes a una cirugía colorrectal electiva.El propósito es determinar si el consumo crónico de opioides antes de la cirugía colorrectal se asocia con un detrimento en los resultados postoperatorios.Revisión retrospectiva de datos administrativos complementada por la revisión de un gráfico individual.Ejercicio durante la formación de multiples residentes en cirugía colorrectal enTodos los pacientes de cirugía colorrectal electiva durante un período de 3 años (2011-2014).El uso de opioides se estratificó en función de la dosis total de equivalentes de miligramos de morfínicos (uso previo, uso esporádico [> 0-15 mg / día], uso regular (> 15-45 mg / día) y uso frecuente (> 45 mg / día)). Los resultados primarios fueron las infecciones de la herida quirúrgica, la duración de la estadía hospitalaria y la readmisión.De los 923 pacientes, el 23% (n = 213) consumían opioides antes de la operación. El grupo con opioides preoperatorios tenía más mujeres (p = 0.047), se sometió a una cirugía abierta (p = 0.003), tenía mas indicaciones no malignas (p = 0.013) y tenía una clasificación ASA más alta (p = 0.003). Aunque la mediana de la estadía hospitalaria fue más larga (4,7 días frente a 4,0; p <0,001), no hubo diferencia en ninguna infección de la herida quirúrgica (10,3% frente a 7,1%, p = 0,123) o las readmisiones (14,2% frente a 14,1%, p = 0,954). El análisis multivariable identificó que el uso de opioides preoperatorios (17.0% más larga LOS; IC 95%: 6.8%, 28.2%) y ASA 3 o 4 (27.2% más larga LOS; IC 95%: 17.1, 38.3) se asocia con un aumento en LOS.La evaluación retrospectiva poco precisa del consumo de opioides y el pequeño número de casos limitan las conclusiones sobre cualquier respuesta relacionada con la dosis - resultado.Si bien el consumo de opioides preoperatorios no se asoció con un aumento en la tasa de infecciones de la herida quirúrgica o las readmisiones, ella se asoció de forma independiente con un aumento de la LOS hospitalaria. Serán necesarias estrategias perioperatorias innovadoras para eliminar estas diferencias en los pacientes consumidores cronicos de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B280.

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced Recovery After Surgery (ERAS®) Society Recommendations - Part II: Postoperative management and special considerations

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part II of the guidelines highlights postoperative management and special considerations.

METHODS

The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.

RESULTS

Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items. No consensus could be reached regarding the preemptive use of fresh frozen plasma.

CONCLUSION

The present ERAS recommendations for CRS ± HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS ± HIPEC and to prospectively evaluate recommendations in clinical practice.

Postoperative analgesic efficacy of modified continuous transversus abdominis plane block in laparoscopic colorectal surgery: a triple-blind randomized controlled trial

BACKGROUND

The optimal opioid-sparing analgesic regimen following laparoscopic colorectal surgery (LCS) remains uncertain. We sought to determine the efficacy of low-dose bupivacaine infusion via surgeon-inserted modified continuous transversus abdominis plane (mcTAP) catheters after LCS.

METHODS

A parallel-group, placebo-controlled, randomized single-centre trial was conducted between April 2017 and February 2018. Block-of-four randomization and allocation concealment by sequentially-numbered, opaque sealed envelopes were used. Patients, surgeons and assessors were blinded. Fifty-two patients were randomized to receive either 0.2% bupivacaine or saline through mcTAP catheters. A 5 ml bolus followed by a 72 h infusion at 2 ml/h was started, with patient-controlled fentanyl analgesia and oral paracetamol given on demand. Primary outcomes were fentanyl consumptions in the first 24 h, second 24 h, and third 24 h following surgery. Secondary outcomes were pain numeric rating scores, recovery outcomes and complications.

RESULTS

Twenty-five patients in the bupivacaine group and 26 in the control group were analysed. Patients in the bupivacaine group required significantly less fentanyl overall (106.1 vs 484.5 mcg, p < 0.001) and at all time points (first 24 h: 61.0 vs 324.3 mcg, p < 0.001; second 24 h: 36.3 vs 119.0 mcg, p = 0.033; third 24 h: 8.8 vs 41.2, p = 0.030) when compared to placebo. Significantly lower pain scores at rest at 6 h (2.32 vs 4.0, p = 0.002), and 12 h (1.80 vs 3.08, p = 0.011) and on coughing at 6 h (4.56 vs 5.84, p = 0.019), 12 h (3.76 vs 4.96, p = 0.009), and 24 h (3.44 vs 4.24, p = 0.049) as well as significantly lower opioid-related complications such as nausea or vomiting (9 (36%) vs 1 (4%), p = 0.005) were observed in the bupivacaine group. There were no major block-related complications, and recovery outcomes were similar in both groups.

CONCLUSIONS

McTAP block reduces postoperative fentanyl consumption and pain scores after LCS, highlighting its role as a safe and useful opioid-sparing analgesia.

REGISTRATION NUMBER

TCTR20150831001 (Thai Clinical Trials Registry). Full trial protocol can be assessed at https://www.clinicaltrials.in.th/ .

Transversus Abdominis Plane Blocks in Laparoscopic Colorectal Surgery: Better Pain Control and Patient Outcomes with Liposomal Bupivacaine than Bupivacaine

Transversus abdominis plane (TAP) blocks are a safe and effective way to provide immediate postoperative pain relief in surgical patients, and have been shown to decrease narcotic requirements. Concerns about complications of narcotics, increase in hospital length of stay (LOS), and health-care costs make this of particular interest. We compared standard bupivacaine TAP blocks with those carried out using liposomal bupivacaine to evaluate postoperative outcomes. Fifty patients undergoing elective laparoscopic colectomy received laparoscopic liposomal bupivacaine TAP blocks using 80 cc of local anesthetic, and data were collected prospectively during hospitalization. Data collected included amount of narcotic medication used during hospitalization, number of days to ambulation, number of days to bowel function, and LOS. These patients were compared with the last 50 patients recruited to the control/bupivacaine TAP block arm of the study. The same data parameters were collected and all patients were on an enhanced recovery protocol, which included scheduled acetaminophen, ibuprofen, and gabapentin by mouth, as well as clear liquid diet starting on postoperative day zero. Statistical analysis was performed using Student's t test and Fisher's exact test; P < 0.05 was considered statistically significant. Patients treated with liposomal bupivacaine needed less narcotics (5.06 vs 18.75 mg, P = 0.0002), had earlier bowel function (1.7 vs 2.4 days, P = 0.0002), and shorter LOS (2.7 vs 3.4 days, P = 0.0146). Patients undergoing laparoscopic colon resections seem to require fewer narcotics and have better patient outcomes with liposomal bupivacaine TAP blocks. Based on our data, liposomal bupivacaine seems to be superior to bupivacaine for TAP blocks.

Differential Index-Hospitalization Cost Center Impact of Enhanced Recovery After Surgery Program Implementation

BACKGROUND

Most hospitals in the United States are reimbursed for colectomy via a bundled payment based on the diagnosis-related group assigned. Enhanced recovery after surgery programs have been shown to improve the value of colorectal surgery, but little is known about the granular financial tradeoffs required at individual hospitals.

OBJECTIVE

The purpose of this study is to analyze the index-hospitalization impact on specific cost centers associated with enhanced recovery after surgery implementation for diagnosis-related groups commonly assigned to patients undergoing colon resections.

DESIGN

We performed a single-institution retrospective, nonrandomized, preintervention (2013-2014) and postintervention (2015-2017) analysis of hospital costs.

SETTING

This study was conducted at an academic medical center.

PATIENTS

A total of 1297 patients with diagnosis-related group 330 (colectomy with complications/comorbidities) and 331 (colectomy without complications/comorbidities) were selected.

MAIN OUTCOME MEASURES

The primary outcome was total index-hospitalization cost. Secondary outcomes included specific cost center expenses.

RESULTS

Total median cost for diagnosis-related group 330 in the pre-enhanced recovery after surgery group was $24,111 ($19,285-$28,658) compared to $21,896 ($17,477-$29,179) in the enhanced recovery after surgery group, p = 0.01. Total median cost for diagnosis-related group 331 in the pre-enhanced recovery after surgery group was $19,268 ($17,286-$21,858) compared to $18,444 ($15,506-$22,847) in the enhanced recovery after surgery group, p = 0.22. When assessing cost changes after enhanced recovery after surgery implementation for diagnosis-related group 330, operating room costs increased (p = 0.90), nursing costs decreased (p = 0.02), anesthesia costs increased (p = 0.20), and pharmacy costs increased (p = 0.08). For diagnosis-related group 331, operating room costs increased (p = 0.001), nursing costs decreased (p < 0.001), anesthesia costs increased (p = 0.03), and pharmacy costs increased (p = 0.001).

LIMITATIONS

This is a single-center study with a pre- and postintervention design.

CONCLUSIONS

The returns on investment at the hospital level for enhanced recovery after surgery implementations in colorectal surgery result largely from cost savings associated with decreased nursing expenses. These savings likely offset increased spending on operating room supplies, anesthesia, and medications. See Video Abstract at http://links.lww.com/DCR/B204. IMPACTO DE LA IMPLEMENTACIÓN DEL PROTOCOLO DE RECUPERACIÓN MEJORADA DESPUÉS DE CIRUGÍA EN EL COSTO DE LA HOSPITALIZACIÓN ÍNDICE EN CENTROS ESPECÍFICOS: La mayoría de los hospitales en los Estados Unidos son reembolsados por la colectomía a través de un paquete de pago basado en el grupo de diagnóstico asignado. Se ha demostrado que los programas de recuperación después de la cirugía mejoran el valor de la cirugía colorrectal, pero se sabe poco sobre las compensaciones financieras granulares que se requieren en los hospitales individuales.El objetivo de este estudio es analizar el impacto del índice de hospitalización en centros de costos específicos asociados con la implementación de RMDC para grupos relacionados con el diagnóstico comúnmente asignados a pacientes que se someten a resecciones de colon.Realizamos un análisis retrospectivo, no aleatorio, previo (2013-2014) y posterior a la intervención (2015-2017) de los costos hospitalarios de una sola institución.Centro médico académico.Un total de 1. 297 pacientes con diagnóstico relacionado con el grupo 330 (colectomía con complicaciones/comorbilidades) y 331 (colectomía sin complicaciones/comorbilidades).El resultado primario fue el índice total de costos de hospitalización. Los resultados secundarios incluyeron gastos específicos del centro de costos.El costo medio total para el grupo relacionado con el diagnóstico de 330 en el grupo de recuperación pre-mejorada después de la cirugía fue de $24,111 ($19,285- $28,658) en comparación con $21,896 ($17,477- $29,179) en el grupo de recuperación mejorada después de la cirugía, p = 0.01. El costo medio total para DRG 331 en el grupo de recuperación pre-mejorada después de la cirugía fue de $19,268 ($17,286- $21,858) en comparación con $18,444 ($15,506-$22,847) en el grupo de recuperación mejorada después de la cirugía, p = 0.22. Al evaluar los cambios en los costos después de una recuperación mejorada después de la implementación de la cirugía para el grupo 330 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.90), los costos de enfermería disminuyeron (p = 0.02) los costos de anestesia aumentaron (p = 0.20) y los costos de farmacia aumentaron (p = 0.08). Para el grupo 331 relacionado con el diagnóstico, los costos de la sala de operaciones aumentaron (p = 0.001), los costos de enfermería disminuyeron (p < 0.001) los costos de anestesia aumentaron (p = 0.03) y los costos de farmacia aumentaron (p = 0.001).Este es un estudio de un solo centro con un diseño previo y posterior a la intervención.El retorno de la inversión a nivel hospitalario para una recuperación mejorada después de la implementación de la cirugía en la cirugía colorrectal se debe en gran parte al ahorro de costos asociado con la disminución de los gastos de enfermería. Es probable que estos ahorros compensen el aumento de los gastos en suministros de quirófano, anestesia y medicamentos. Consulte Video Resumen en http://links.lww.com/DCR/B204. (Traducción-Dr. Gonzalo Hagerman).

Analgesic Efficacy of Preemptive Transversus Abdominis Plane Block in Patients Undergoing Laparoscopic Colorectal Cancer Surgery

Despite rapid advancements in laparoscopic surgical devices and techniques, pain remains a significant issue. We examined the efficacy of preemptive transversus abdominis plane (TAP) block for acute postoperative pain in patients undergoing laparoscopic colorectal cancer surgery. We retrospectively analyzed 153 patients who underwent laparoscopic colorectal cancer surgery with or without TAP block; among them, 142 were allocated to the TAP or non-TAP group. We performed between-group comparisons of demographic, clinical, and anesthetic data and pain scores at a postoperative anesthesia care unit (PACU) and at postoperative days 1, 3, and 5. There were no significant between-group differences in demographic and clinical characteristics. The mean arterial pressure, heart rate, and minimum alveolar concentration (MAC) were significantly lower in the TAP group at the start and end of surgery. The post-extubation bispectral index was significantly higher in the TAP group. There were no significant between-group differences in the pain scores and opioid consumption at the PACU or at postoperative days 1, 3, and 5, or in the time to pass flatus, the hospital stay length, and postoperative complications. Preemptive TAP block showed an intraoperative, but not postoperative, analgesic effect, characterized by a low mean arterial pressure, heart rate, and MAC.

Epidural vs. transversus abdominis plane block for abdominal surgery - a systematic review, meta-analysis and trial sequential analysis

Traditionally, pain relief for abdominal surgery has centred on epidural analgesia, but transversus abdominis plane block is increasingly being used. Our aim was to compare the analgesic efficacy and the side-effect profile of transversus abdominis plane block with epidural analgesia in a systematic review with meta-analysis and trial sequential analysis. After a systematic search of the electronic databases, we identified 18 randomised controlled trials with 1220 patients. Confirmed by trial sequential analysis, our first co-primary outcome, postoperative pain score at rest at 12 h, was decreased by a mean difference (95%CI) of 0.69 (0.12-1.27; p = 0.02) with epidural analgesia compared with transversus abdominis plane block, with the quality of evidence graded as low. No difference was found for the second co-primary outcome, postoperative pain score at rest at 24 h, with the quality of evidence rated as very low. Relative to transversus abdominis plane block, epidural analgesia further reduced the need for intravenous morphine-equivalent consumption during the 0-24 h interval by a mean difference (95%CI) of 5.91 mg (2.34-9.49; p = 0.001) at the expense of an increased incidence of hypotension at 72 h, with a risk ratio (95%CI) of 5.88 (2.08-16.67; p < 0.001). Our meta-analysis was limited by detection and performance bias, significant statistical heterogeneity and publication bias. In view of the minimal clinically important difference in postoperative pain scores, epidural analgesia was interpreted to not be clinically different to transversus abdominis plane block after abdominal surgery. With transversus abdominis plane block, the increase in intravenous morphine-equivalent consumption at 24 h should be balanced against the decreased risk of hypotension at 72 h. In choosing between epidural analgesia and transversus abdominis plane block, potential benefits should be balanced against the reported risk of harm, although the confidence in the evidence varied, underlining the uncertainty in our estimates.

Transversus Abdominis Plane Block versus Wound Infiltration with Conventional Local Anesthetics in Adult Patients Underwent Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

How to effectively control the postoperative pain of patients is extremely important to clinicians. Transversus abdominis plane (TAP) block is a novel analgesic method reported to greatly decrease postoperative pain. However, in many areas, there still exists a phenomenon of surgeons using wound infiltration (WI) with conventional local anesthetics (not liposome anesthetics) as the main means to decrease postoperative pain because of traditional wisdom or convenience. Here, we compared the analgesic effectiveness of the two different methods to determine which method is more suitable for adult patients. Materials and methods. A systematic review and meta-analysis of randomized controlled trials (RCTs) comparing TAP block and WI without liposome anesthetics in adult patients were performed. Frequently used databases were extensively searched. The main outcomes were postoperative pain scores in different situations (at rest or during movement) and the time until the first use of rescue analgesics. The secondary outcomes were postoperative nausea and vomiting (PONV) incidence and patient satisfaction scores.

Results

Fifteen studies with 983 participants met the inclusion criteria and were included in the present study. The heterogeneity in the final analysis regarding the pain score was low to moderate. The major results of the sensitivity analysis were stable. WI had the same analgesic effect as TAP block only at the one-hour postoperative time point (mean difference = -0.32, 95% confidence interval (-0.87, 0.24), P = 0.26) and was associated with a shorter time until the first rescue analgesic and poorer patient satisfaction.

Conclusion

TAP block results in a more effective and steady analgesic effect than WI with conventional local anesthetics in adult patients from the early postoperative period and obtains higher patient satisfaction.

Advances of Nano-Structured Extended-Release Local Anesthetics

Extended-release local anesthetics (LAs) have drawn increasing attention with their promising role in improving analgesia and reducing adverse events of LAs. Nano-structured carriers such as liposomes and polymersomes optimally meet the demands of/for extended-release, and have been utilized in drug delivery over decades and showed satisfactory results with extended-release. Based on mature technology of liposomes, EXPAREL, the first approved liposomal LA loaded with bupivacaine, has seen its success in an extended-release form. At the same time, polymersomes has advances over liposomes with complementary profiles, which inspires the emergence of hybrid carriers. This article summarized the recent research successes on nano-structured extended-release LAs, of which liposomal and polymeric are mainstream systems. Furthermore, with continual optimization, drug delivery systems carry properties beyond simple transportation, such as specificity and responsiveness. In the near future, we may achieve targeted delivery and controlled-release properties to satisfy various analgesic requirements.

Implementation of liposomal bupivacaine transversus abdominis plane blocks into the colorectal enhanced recovery after surgery protocol: a natural experiment

BACKGROUND

Enhanced recovery after surgery (ERAS) programs are now standard of care for colorectal surgery. Efforts have been aimed at decreasing postoperative opioid consumption. The goal of this study is to evaluate the effect of liposomal bupivacaine transversus abdominis plane (TAP) blocks on opioid use and its downstream effect on rates of ileus and hospital length of stay (LOS).

METHODS

We performed a retrospective pre- and postintervention time-trend analysis (2016-2018) of ERAS patients undergoing laparoscopic colorectal surgery at two academic medical centers within the same hospital system. The intervention was liposomal bupivacaine TAP blocks versus standard local infiltration with bupivacaine with a primary outcome of total morphine milligram equivalents (MME) administered within 72 h of surgery. Secondary outcomes included hospital LOS and rate of postoperative ileus.

RESULTS

There were 556 patients included at the control hospital, and 384 patients were included at the treatment hospital. Patients at both hospitals were similar with regard to age, body mass index, comorbidities, and surgical indication. In an adjusted time-trend analysis, the treatment hospital was associated with a significant decrease in MME administered (- 15.9 mg, p = 0.04) and hospital LOS (- 0.8 days, p < 0.001). There was no significant decrease in the rate of ileus at the treatment hospital (- 6.9%, p = 0.08).

CONCLUSIONS

In a time-trend analysis, the addition of liposomal bupivacaine TAP blocks into the ERAS protocol resulted in significantly reduced opioid use and shorter hospital LOS for patients undergoing surgery at the treatment hospital. Liposomal bupivacaine TAP blocks should be considered for inclusion in the standard ERAS protocol.

Minimally invasive sigmoidectomy for diverticular disease decreases inpatient opioid use: Results of a propensity score-matched study

BACKGROUND

Patients undergoing gastrointestinal surgery are at high risk for postoperative opioid use.

METHODS

We evaluated inpatient opioid use among patients undergoing sigmoidectomy for diverticular disease from the Premier Hospital Database and compared across surgical approaches using propensity score-matching analysis.

RESULTS

After the day of surgery, minimally invasive (MIS) patients were administered significantly lower doses of parenteral opioids (median daily morphine milligram equivalents [MME]: 33.3 versus 48.3, p < 0.001). Within MIS, significantly less parenteral opioids were used by the robotic-assisted (RS) than the laparoscopic (LS) group (median daily MME: 30.0 versus 36.8, p = 0.012). MIS patients were more likely than open to start oral opioids on the day of surgery (MIS vs. OS: 8.7% vs. 6.6%, p < 0.001; RS vs. LS: 12.6% vs. 10.2%, p = 0.048).

CONCLUSION

Minimally invasive sigmoidectomy for diverticular disease was associated with less postoperative parenteral opioid use and starting oral opioids sooner after surgery compared to the open approach.

Transversus Abdominis Plane Block

In this narrative review article, the authors discuss the anatomy, nomenclature, history, approaches (posterior vs. lateral vs. subcostal), techniques, pharmacology, indications, and complications of transversus abdominis plane blocks, as well as possible alternative truncal blocks.

Despite the scarcity of evidence and contradictory findings, certain clinical suggestions can nonetheless be made. Overall transversus abdominis plane blocks appear most beneficial in the setting of open appendectomy (posterior or lateral approach). Lateral transversus abdominis plane blocks are not suggested for laparoscopic hysterectomy, laparoscopic appendectomy, or open prostatectomy. However, transversus abdominis plane blocks could serve as an analgesic option for Cesarean delivery (posterior or lateral approach) and open colorectal section (subcostal or lateral approach) if there exist contraindications to intrathecal morphine and thoracic epidural analgesia, respectively.

Future investigation is required to compare posterior and subcostal transversus abdominis plane blocks in clinical settings. Furthermore, posterior transversus abdominis plane blocks should be investigated for surgical interventions in which their lateral counterparts have proven not to be beneficial (e.g., laparoscopic hysterectomy/appendectomy, open prostatectomy). More importantly, because posterior transversus abdominis plane blocks can purportedly provide sympathetic blockade and visceral analgesia, they should be compared with thoracic epidural analgesia for open colorectal surgery. Finally, transversus abdominis plane blocks should be compared with newer truncal blocks (e.g., erector spinae plane and quadratus lumborum blocks) with well-designed and adequately powered trials.