Opioid-free anesthesia in oncologic surgery: the rules of the game

The Surgical Stress Response and Anesthesia: A Narrative Review

The human physiological response "to stress" includes all metabolic and hormonal changes produced by a traumatic event at the micro or macro cellular levels. The main goal of the body's first response to trauma is to keep physiological homeostasis. The perioperative non-specific adaptation response can sometimes be detrimental and can produce systemic inflammatory response syndrome (SIRS), characterized by hypermetabolism and hyper catabolism. We performed a narrative review consisting of a description of the surgical stress response's categories of changes (neurohormonal and immunological response) followed by reviewing methods found in published studies to modulate the surgical stress response perioperatively. We described various preoperative measures cited in the literature as lowering the burden of surgical trauma. This article revises the anesthetic drugs and techniques that have an impact on the surgical stress response and proven immune-modulatory effects. We also tried to name present knowledge gaps requiring future research. Our review concludes that proper preoperative measures, adequate general anesthetics, multimodal analgesia, early postoperative mobilization, and early enteral nutrition can decrease the stress response to surgery and ease patient recovery. Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system and inflammatory system, with a consecutive impact on cancer recurrence and long-term outcomes.

External Oblique Intercostal Plane Block Versus Port-Site Infiltration for Laparoscopic Sleeve Gastrectomy: A Randomized Controlled Study

PURPOSE

Although laparoscopic sleeve gastrectomy (LSG) is a minimally invasive surgery, postoperative pain is common. A novel block, the external oblique intercostal (EOI) block, can be used as part of multimodal analgesia for upper abdominal surgeries. The aim of our study is to investigate the effectiveness of EOI block in patients undergoing LSG.

MATERIALS AND METHODS

Sixty patients were assigned into two groups either EOI or port-site infiltration (PSI). The EOI group received ultrasound-guided 30 ml 0.25% bupivacaine, while the PSI group received 5 ml of 0.25% bupivacaine at each port sites by the surgeon. Data on clinical and demographic were collected and analyzed.

RESULTS

There were no statistical differences in terms of demographic details (p > 0.05). VAS scores were statistically lower during resting at PACU, 1, 2, 4, 8, and 12 h postoperatively in the EOI group than PSI group (p < 0.05), The VAS scores were also lower during active movement at PACU, 1, 2, 4, and 8 h postoperatively in the EOI group than PSI group (p < 0.05). Twenty-four-hour fentanyl consumption was lower in the EOI than in the PSI group (505.83 ± 178.56 vs. 880.83 ± 256.78 μg, respectively, p < 0.001). Rescue analgesia was higher in PSI group than EOI group (26/30 vs. 14/30, respectively, p = 0.001).

CONCLUSION

EOI block can be used as a part of multimodal analgesia due to its simplicity and effective postoperative analgesia in LSG.

Interpectoral and Pectoserratus Plane Block vs. Local Anesthetic Infiltration for Partial Mastectomy: A Prospective Randomized Trial

Background

Patients undergoing breast surgery are at risk of severe postoperative pain. Several opioid-sparing strategies exist to alleviate this condition. Regional anesthesia has long been a part of perioperative pain management for these patients.

Aim

This randomized study examined the benefits of interpectoral and pectoserratus plane block (IPP/PSP), also known as pectoralis nerve plain block, compared with advanced local anesthetic infiltration.

Methods

We analyzed 57 patients undergoing partial mastectomy with sentinel node dissection. They received either an ultrasound-guided IPP/PSP block performed preoperatively by an anesthetist or local anesthetic infiltration performed by the surgeon before and during the surgery.

Results

Pain measured with the numerical rating scale (NRS) indicated no statistically significant difference between the groups (IPP/PSP 1.67 vs. infiltration 1.97; p value 0.578). Intraoperative use of fentanyl was significantly lower in the IPP/PSP group (0.18 mg vs 0.21 mg; p value 0.041). There was no statistically significant difference in the length of stay in the PACU (166 min vs 175 min; p value 0.51). There were no differences in reported postoperative nausea and vomiting (PONV) between the groups. The difference in postoperative use of oxycodone in the PACU (p value 0.7) and the use of oxycodone within 24 hours postoperatively (p value 0.87) was not statistically significant.

Conclusions

Our study showed decreased intraoperative opioid use in the IPP/PSP group and no difference in postoperative pain scores up to 24 hours. Both groups reported low postoperative pain scores. This trial is registered with NCT04824599.

Evaluation of the Efficacy of Pectoral Nerve-2 Block (PECS 2) in Breast Cancer Surgery

This study aimed to evaluate the efficacy of the pectoral nerves interfacial plane block (PECS II) in breast cancer surgery focusing on postoperative pain management and patient satisfaction. A prospective study was conducted, including 200 patients scheduled for breast cancer surgery. The participants were randomly assigned to the PECS II block and control groups. The PECS II block group received a preoperative interfascial plane block, while the control group received standard analgesia. Postoperative pain scores at 4 h intervals for the first 3 postoperative days, as well as opioid consumption and patient-reported satisfaction, were measured and compared between both groups. The PECS II block group demonstrated significantly lower postoperative pain scores at all measured time points (p < 0.001). Additionally, the PECS II block group showed reduced opioid consumption (p < 0.001), reported higher levels of patient satisfaction compared to the control group, and had a notably shorter stay in the postoperative care unit (p < 0.001). Integrating the PECS block with general anesthesia in breast cancer surgeries enhances pain management, reduces opioid use, and shorten postanesthesia care unit stay. The evident benefits suggest PECS as a potential standard in breast surgeries. Future research should further investigate its long-term impacts and broader applications.

Effect of rectus sheath anaesthesia versus thoracic epidural analgesia on postoperative recovery quality after elective open abdominal surgery in a French regional hospital: the study protocol of a randomised controlled QoR-RECT-CATH trial

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols increase patient well-being while significantly reducing mortality, costs and length-of-stay after surgery. A key component is multimodal analgesia that prevents postoperative pain and facilitates early refeeding and mobilisation. Thoracic epidural analgesia (TEA) was long the gold standard for locoregional anaesthesia in anterior abdominal wall surgery. However, newer wall-block techniques such as rectus-sheath block (RSB) may be preferable because they are less invasive and may provide equivalent analgesia with fewer side effects. Since the evidence base remains limited, the Quality Of Recovery enhanced by REctus sheat CATHeter (QoR-RECT-CATH) randomised controlled trial (RCT) was designed to assess whether RSB elicits better postoperative rehabilitation than TEA after laparotomy.

METHODS AND ANALYSIS

This open-label parallel-arm 1:1-allocated RCT will determine whether RSB is superior to TEA in 110 patients undergoing scheduled midline laparotomy in terms of postoperative rehabilitation quality. The setting is a regional French hospital that provides opioid-free anaesthesia for all laparotomies within an ERAS programme. Recruited patients will be ≥18 years, scheduled to undergo laparotomy, have American Society of Anesthesiologists (ASA) score 1-4 and lack contraindications to ropivacaine/TEA. TEA-allocated patients will receive an epidural catheter before surgery while RSB-allocated patients will receive rectus sheath catheters after surgery. All other pre/peri/postoperative procedures will be identical, including multimodal postoperative analgesia provided according to our standard of care. Primary objective is a change in total Quality-of-Recovery-15 French-language (QoR-15F) score on postoperative day (POD) 2 relative to baseline. QoR-15F is a patient-reported outcome measure that is commonly used to measure ERAS outcomes. The 15 secondary objectives include postoperative pain scores, opioid consumption, functional recovery measures and adverse events.

ETHICS AND DISSEMINATION

The French Ethics Committee (Sud-Ouest et Outre-Mer I Ethical Committee) gave approval. Subjects are recruited after providing written consent after receiving the information provided by the investigator. The results of this study will be made public through peer-reviewed publication and, if possible, conference publications.

TRIAL REGISTRATION NUMBER

NCT04985695.