Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review

An Interdisciplinary, Comprehensive Recovery Pathway Improves Microsurgical Breast Reconstruction Delivery

INTRODUCTION

Free-flap (autologous) breast reconstruction demonstrates superiority over alloplastic approaches but is offered infrequently. Enhanced recovery protocols can address postoperative challenges, but most literature is limited to inpatient interventions and outcomes. This study describes an adoptable, longitudinally comprehensive and multidisciplinary recovery pathway for autologous reconstruction which adds to the current guidelines. The authors aimed to allow perioperative outcomes comparable to alloplastic reconstructions.

METHODS

All autologous Comprehensive Recovery Pathway (CRP) subjects from a single surgeon were retrospectively included. A comparator group of equal size was randomly selected from institutional subpectoral and dual-plane tissue expander patients having Enhanced Recovery After Surgery guideline-directed care. All subjects in both cohorts received preoperative paravertebral regional blocks. Operative detail, inpatient recovery, longitudinal morphine equivalents (MEs) required, and complications were compared.

RESULTS

Each cohort included 71 cases (99 breasts). Despite longer operations, intraoperative MEs were fewer in autologous cases ( P = 0.02). Morphine equivalents during inpatient stay were similar between cohorts, with both being discharged on median day 2. Multivariate regression demonstrated a 0.8-day increased stay for autologous subjects with additional contribution from bilateral cases, body mass index, and age ( P < 0.05). Autologous subjects were regularly discharged postoperative day 1 (17%) and postoperative day 2 (39%), with trend toward earlier discharge ( P < 0.01). Outpatient MEs were significantly fewer in autologous subjects, corresponding to a 30- to 150-mg oxycodone difference ( P < 0.01). Major complication occurred in 12.7% of autologous and 22.5% of alloplastic subjects ( P = 0.11). Flap loss occurred in 1 autologous subject versus 11 alloplastic failures ( P < 0.01).

CONCLUSIONS

This study details partnership between the plastic surgery service, regional and acute pain anesthesia services, and dedicated nursing with longitudinal optimizations allowing perioperative outcomes improved over current literature. Patients in the CRP used fewer opioids from operation through follow-up with comparable length of stay and significantly fewer reconstructive failures than alloplastic subjects. The pathway may be quickly adopted into academic practice patterns and mitigates traditional barriers, allowing extension of autologous reconstruction offerings.

Regional anesthesia for transplantation surgery - A White Paper Part 2: Abdominal transplantation surgery

Transplantation surgery continues to evolve and improve through advancements in transplant technique and technology. With the increased availability of ultrasound machines as well as the continued development of Enhanced Recovery after Surgery (ERAS) protocols, regional anesthesia has become an essential component of providing analgesia and minimizing opioid use perioperatively. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures. To date, no formal guidelines or recommendations exist which address the use of regional anesthesia in transplantation surgery. In response, the Society for the Advancement of Transplant Anesthesia (SATA) identified experts in both transplantation surgery and regional anesthesia to review available literature concerning these topics. The goal of this task force was to provide an overview of these publications to help guide transplantation anesthesiologists in utilizing regional anesthesia. The literature search encompassed most transplantation surgeries currently performed and the multitude of associated regional anesthetic techniques. Outcomes analyzed included analgesic effectiveness of the blocks, reduction in other analgesic modalities-particularly opioid use, improvement in patient hemodynamics, as well as associated complications. The findings summarized in this systemic review support the use of regional anesthesia for postoperative pain control after transplantation surgeries. Part 1 of the manuscript focused on regional anesthesia performed in thoracic transplantation surgeries, and part 2 in abdominal transplantations. Specifically, regional anesthesia in liver, kidney, pancreas, intestinal, and uterus transplants or applicable surgeries are discussed.

A prospective randomized study of multimodal analgesia combined with single injection transversus abdominis plane block versus epidural analgesia against postoperative pain after laparoscopic colon cancer surgery

PURPOSE

Transversus abdominis plane (TAP) block is a safe, effective, and promising analgesic procedure, but TAP block only cannot overcome postoperative pain. We conducted a prospective randomized study to evaluate postoperative pain control using multimodal analgesia (MA) combined with a single injection TAP block compared with epidural analgesia (EA) after laparoscopic colon cancer surgery.

METHODS

Sixty-seven patients scheduled for elective laparoscopic colon cancer surgery were enrolled in this study and randomized into EA and MA groups. The primary endpoint was the frequency of additional analgesic use until postoperative day (POD) 2. The VAS score, blood pressure, time to bowel movement, time to mobilization, postoperative complications, and length of hospital stay were also compared between the two groups.

RESULTS

Sixty-four patients (EA group, n = 33; MA group, n = 31) were analyzed. The patient characteristics did not differ markedly between the two groups. The frequency of additional analgesic use was significantly lower in the MA group than in the EA group (P < 0.001), whereas the VAS score did not differ markedly between the two groups. The postoperative blood pressure on the day of surgery was significantly lower in the MA group than in the EA group (P = 0.016), whereas urinary retention was significantly higher in the EA group than in the MA group (P < 0.001).

CONCLUSION

MA combined with a single injection TAP block after laparoscopic colon cancer surgery may be comparable to EA in terms of analgesia and superior to EA in terms of urinary retention.

Erector spinae plane block for radiofrequency ablation of hepatic focal lesions: Randomized controlled trial

OBJECTIVE

This study evaluated the opioid sparing and pain relief effect of erector spinae plane block (ESPB) for radiofrequency ablation (RFA) of hepatic focal lesions under conscious sedation.

DESIGN

A randomized controlled trial.

SETTING

Tanta University Hospitals.

PATIENTS

Fifty patients aged 30-60 years old and eligible for RFA of hepatic focal lesions were included.

INTERVENTIONS

Patients randomized to receive either local anesthetic infiltration (group I) or ESPB (group II). Both groups received sedation by propofol infusion.

MAIN OUTCOME MEASURE(S)

The primary outcome was total fentanyl consumption. Secondary outcomes were nonverbal pain score (NVPS), time to first analgesic request post-procedure, radiologist's satisfaction, and complications.

RESULTS

In group I, NVPS was significantly increased at 10, 15, 25, and 30 minutes during RFA compared to group II (p = 0.008, <0.001, 0.018, and 0.001, respectively) with no significant differences on arrival to post-anesthesia care unit (PACU) and after 1 hour. Total fentanyl consumption during the procedure was significantly increased in group I compared to group II (160.9 ± 38.2 and 76 ± 21 µg, respectively; p < 0.001) with prolonged time to first analgesia request post-procedure in group II compared to group I (392.7 ± 38.8 and 101.1 ± 13.6 minutes, respectively; p < 0.001). The level of radiologist's satisfaction was significantly increased in the group II (p = 0.010). Three patients in group I and one patient in group II needed general anesthesia. Lower incidence of complications in group II occurred with statistical insignificance.

CONCLUSIONS

The ESPB provided adequate analgesia and reduced opioids consumption during the hepatic RFA, with high radiologist's satisfaction.

Training programmes for healthcare professionals in managing postoperative epidural analgesia: A scoping review protocol

BACKGROUND

Epidural analgesia is an effective technique advocated worldwide for postoperative analgesia after a wide range of surgical procedures. Despite the benefits of epidural analgesia for pain management, systematic education of ward nurses in managing epidural analgesia appears to be lacking.

METHODS

The aim of the proposed scoping review is to map the body of evidence and identify training programmes for healthcare professionals in the safe management of postoperative epidural analgesia. The methodology will follow the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). In addition, the five main steps set forth by Arksey and O'Malley and refined by Levac for guidance of the process will be used. The scoping review will include any study design of any date, design, setting and duration.

RESULTS

We will present results descriptively, accompanied with visual presentations as tables and graphs.

CONCLUSION

The outlined scoping review will provide an overview of existing training programmes for healthcare professionals in the safe management of postoperative epidural analgesia and map the body of available evidence on the topic. The study may support the development of a training programme for ward nurses caring for patients receiving postoperative epidural analgesia.

Outcomes in pediatric liver transplant recipients receiving bilateral continuous erector spinae plane blocks

BACKGROUND

Regional anesthesia allows for opioid-sparing and enhanced recovery after many major surgeries. Erector spinae blockade, with reduced bleeding risk and the option for continuous infusion, offers an opportunity to promote this principle in pediatric liver transplant patients. Our goal was to evaluate pain scores, opioid use, and return of bowel function following continuous ESP blockade in pediatric liver transplant recipients.

METHODS

This retrospective cohort study included extubated patients who received a liver transplant at St. Louis Children's Hospital from July 2016 to July 2021. The control group, which did not meet the criteria for ESP blockade and received standard analgesia regimens, was compared to the group receiving continuous ESP blockade. Measured outcomes included pain scores, opioid consumption through postoperative day two, date of first bowel movement, and length of stay in the ICU and the hospital.

RESULTS

Patient demographics between control and ESP groups showed no significant differences. Pain scores between control and ESP groups also showed no significant differences. Intraoperative and postoperative opioid requirements, studied in oral morphine equivalents per kilogram (OME/kg), were significantly lower for patients with ESP blockade. Time to first bowel movement was also significantly earlier for the ESP group. No significant differences were found in length of ICU or hospital stay. There were no safety concerns or complications related to ESP blockade.

CONCLUSIONS

Use of continuous ESP blockade resulted in reduced opioid consumption through postoperative day two and earlier return of bowel function.

Necessity of routine perioperative epidural catheter placement in laparoscopic colorectal resections: a retrospective data analysis

PURPOSE

Whether epidural anesthesia leads to further improvement in the postoperative course of colorectal procedures is under discussion. The aim of this study was to evaluate the effects of minimally invasive colorectal oncological interventions without epidural anesthesia (EDA).

METHODS

This retrospective data analysis included the clinical data of all patients who underwent minimally invasive oncological colorectal resection at our clinic between January 2013 and April 2019. Of 385 patients who met the inclusion criteria, 183 (group I; 47.5% of 385) received EDA, and 202 (group II; 52.5% of 385) received transversus abdominis plane block instead. The relevant target parameters were evaluated and compared between the groups. The postoperative complications were graded according to the Clavien-Dindo classification.

RESULTS

The patients in group I (n=183; women, 77; men, 106; age 66.8 years) were younger (p=0.0035), received a urinary catheter more often (99.5% versus [vs.] 28.2% p<0.001), required longer, more frequent arterenol treatment (1.1 vs. 0.6 days; p<0.001), and had a longer intermediate care unit stay than those in group II (2.8 vs. 1.1 days; p<0.001). Postoperative pain levels were not significantly different between the groups (p=0.078). The patients in group I were able to ambulate later than those in group II (4 vs. 2 days; p<0.001). The difference in the postoperative day of the first defecation was not significant between the groups (p=0.236). The incidence of postoperative complications such as bleeding (p=0.396), anastomotic leaks (p=0.113), and wound infections (p=0.641) did not differ between the groups. The patients in group I had significantly longer hospital stays than those in group II (12.2 vs. 9.4 days; p<0.001).

CONCLUSION

EDA can be safely omitted from elective minimally invasive colorectal resections, and its omission is not accompanied by any relevant disadvantages to the patient.

A pregnant lady with compound bowel obstruction managed with thoracic epidural as sole anesthesia in a resource-restricted setting: a case report

BACKGROUND

Preserving the mother's safety, sustaining the pregnancy state, and achieving the optimal fetal outcome are the major priorities when managing obstetric patients for non-obstetric surgery. Only necessary and urgent surgeries are carried out during pregnancy due to the effects of anesthesia and surgery on the fetus. Compound bowel obstruction (small and large bowel obstruction) is rare, especially during the third trimester of pregnancy. Besides this, the procedure (laparotomy) was done with awake opioid-based thoracic epidural anesthesia as the sole anesthesia. This case report of awake laparotomy for major abdominal surgery is the first of its kind with an excellent feto-maternal outcome.

CASE PRESENTATION

A 30-year-old African pregnant lady presented to the emergency department with a chief complaint of abdominal pain and vomiting for an 8-hour duration; associated with this, she had a history of blurred vision, lightheadedness, loss of appetite, low-grade fever, and constipation. Later, she was diagnosed with large bowel obstruction and underwent an emergency laparotomy, managed with a thoracic epidural sole anesthesia.

CONCLUSION

A multidisciplinary team approach is greatly recommended to safeguard a sufficient standard of care for both the mother and fetus. The provision of regional anesthesia for patients with high risks in perioperative periods is crucial for a better postoperative outcome. We have confidence that thoracic epidural anesthesia can be used as another anesthetic option for major abdominal surgery in a resource-restricted setting for patients who are expected to have a significant risk of perioperative adverse events under general anesthesia.

Opioid-Free Anesthesia for Open Radical Cystectomy Is Feasible and Accelerates Return of Bowel Function: A Matched Cohort Study

The aim of this study was to evaluate the feasibility of opioid-free anesthesia (OFA) in open radical cystectomy (ORC) with urinary diversion and to assess the impact on recovery of gastrointestinal function. We hypothesized that OFA would lead to earlier recovery of bowel function. A total of 44 patients who underwent standardized ORC were divided into two groups (OFA group vs. control group). In both groups, patients received epidural analgesia (OFA group: bupivacaine 0.25%, control group: bupivacaine 0.1%, fentanyl 2 mcg/mL, and epinephrine 2 mcg/mL). The primary endpoint was time to first defecation. Secondary endpoints were incidence of postoperative ileus (POI) and incidence of postoperative nausea and vomiting (PONV). The median time to first defecation was 62.5 h [45.8-80.8] in the OFA group and 118.5 h [82.6-142.3] (p < 0.001) in the control group. With regard to POI (OFA group: 1/22 patients (4.5%); control group: 2/22 (9.1%)) and PONV (OFA group: 5/22 patients (22.7%); control group: 10/22 (45.5%)), trends but no significant results were found (p = 0.99 and p = 0.203, respectively). OFA appears to be feasible in ORC and to improve postoperative functional gastrointestinal recovery by halving the time to first defecation compared with standard fentanyl-based intraoperative anesthesia.

ERAS Protocol Options for Perioperative Pain Management of Substance Use Disorder in the Ambulatory Surgical Setting

Even prior to the COVID-19 pandemic, rates of ambulatory surgeries and ambulatory patients presenting with substance use disorder were increasing, and the end of lockdown has further catalyzed the increasing rates of ambulatory patients presenting for surgery with substance use disorder (SUD). Certain subspecialty groups of ambulatory procedures have already established protocols to optimize early recovery after surgery (ERAS), and these groups have subsequently enjoyed improved efficiency and reduced adverse outcomes as a result. In this present investigation, we review the literature as it relates to substance use disorder patients, with a particular focus on pharmacokinetic and pharmacodynamic profiles, and their resulting impact on the acute- or chronic user ambulatory patient. The systematic literature review findings are organized and summarized. We conclude by identifying areas of opportunity for further study, specifically with the aim of developing a dedicated ERAS protocol for substance use disorder patients in the ambulatory surgery setting. - Healthcare in the USA has seen an increase in rates of both substance use disorder patients and separately in ambulatory surgery cases. - Specific perioperative protocols to optimize outcomes for patients who suffer from substance use disorder have been described in recent years. - Agents of interest like opioids, cannabis, and amphetamines are the top three most abused substances in North America. - A protocol and recommend further work should be done to integrate with concrete clinical data, in which strategies should be employed to confer benefits to patient outcomes and hospital quality metrics like those enjoyed by ERAS protocol in other settings.

Effect of thoracic epidural anesthesia on postoperative outcome in major liver surgery: a retrospective cohort study

PURPOSE

Postoperative complications after major liver surgery are common. Thoracic epidural anesthesia may provide beneficial effects on postoperative outcome. We strove to compare postoperative outcomes in major liver surgery patients with and without thoracic epidural anesthesia.

METHODS

This was a retrospective cohort study in a single university medical center. Patients undergoing elective major liver surgery between April 2012 and December 2016 were eligible for inclusion. We divided patients into two groups according to whether or not they had thoracic epidural anesthesia for major liver surgery. The primary outcome was postoperative hospital length of stay, i.e., from day of surgery until hospital discharge. Secondary outcomes included 30-day postoperative mortality and major postoperative complications. Additionally, we investigated the effect of thoracic epidural anesthesia on perioperative analgesia doses and the safety of thoracic epidural anesthesia.

RESULTS

Of 328 patients included in this study, 177 (54.3%) received thoracic epidural anesthesia. There were no clinically important differences in postoperative hospital length of stay (11.0 [7.00-17.0] vs. 9.00 [7.00-14.0] days, p = 0.316, primary outcome), death (0.0 vs. 2.7%, p = 0.995), or the incidence of postoperative renal failure (0.6 vs. 0.0%, p = 0.99), sepsis (0.0 vs. 1.3%, p = 0.21), or pulmonary embolism (0.6 vs. 1.4%, p = 0.59) between patients with or without thoracic epidural anesthesia. Perioperative analgesia doses - including the intraoperative sufentanil dose (0.228 [0.170-0.332] vs. 0.405 [0.315-0.565] μg·kg-1·h-1, p < 0.0001) - were lower in patients with thoracic epidural anesthesia. No major thoracic epidural anesthesia-associated infections or bleedings occurred.

CONCLUSION

This retrospective analysis suggests that thoracic epidural anesthesia does not reduce postoperative hospital length of stay in patients undergoing major liver surgery - but it may reduce perioperative analgesia doses. Thoracic epidural anesthesia was safe in this cohort of patients undergoing major liver surgery. These findings need to be confirmed in robust clinical trials.

Pain management after robot-assisted minimally invasive esophagectomy

Background

Adequate pain control after open esophagectomy is associated with reduced complications, earlier recovery and higher patient satisfaction. While further developing surgical procedures like robot-assisted minimally invasive esophagectomy (RAMIE) it is relevant to adapt postoperative pain management. The primary question of this observational survey was whether one of the two standard treatments, thoracic epidural analgesia (TEA) or intravenous patient-controlled analgesia (PCA), is superior for pain control after RAMIE as the optimal pain management for these patients still remains unclear. Use of additional analgesics, changes in forced expiratory volume in 1 s (FEV1), postoperative complications and duration of intensive care and hospital stay were also analyzed.

Methods

This prospective observational pilot study analyzed 50 patients undergoing RAMIE (postoperative PCA with piritramide or TEA using bupivacaine; each n = 25). Patient reported pain using the numeric rating scale score and differences in FEV1 using a micro spirometer were measured at postoperative day 1, 3 and 7. Additional data of secondary endpoints were collected from patient charts.

Results

Key demographics, comorbidity, clinical and operative variables were equivalently distributed. Patients receiving TEA had lower pain scores and a longer-lasting pain relief. Moreover, TEA was an independent predictive variable for reduced length of hospital stay (HR -3.560 (95% CI: -6.838 to -0.282), p = 0.034).

Conclusions

Although RAMIE leads to reduced surgical trauma, a less invasive pain therapy with PCA appears to be inferior compared to TEA in case of sufficient postoperative analgesia and length of hospital stay. According to the results of this observational pilot study analgesia with TEA provided better and longer-lasting pain relief compared to PCA. Further randomized controlled trials should be conducted to evaluate the optimal postoperative analgesic treatment for RAMIE.

Enhanced recovery after gynecological surgery: A meta-analysis of randomized controlled trials

Enhanced recovery after surgery protocol is a multidisciplinary and multimodal approach designed to improve perioperative outcomes for patients. This meta-analysis aimed to identify and elaborate on the efficacy of this protocol in women undergoing gynecologic surgery. Four databases were searched for randomized controlled trials from inception to December 2021. A total of 14 studies met the inclusion criteria and were analyzed. There was a significant reduction in the length of stay, the time to first flatus and first defecation, complications, and readmission rates in patients undergoing enhanced recovery after surgery when compared to routine care. The rate of discharge on the first postoperative day significantly increased in patients from the enhanced recovery group. There was no significant difference in the surgery time and blood loss. In conclusion, the enhanced recovery after surgery protocol might have a positive effect on patients undergoing gynecologic surgery. However, there is still heterogeneity between the included studies, and we need more research to draw reliable conclusions that enhanced recovery after surgery is favorable.

Early Postoperative Low Compliance to Enhanced Recovery Pathway in Rectal Cancer Patients

Early postoperative low compliance to enhanced recovery protocols has been associated with morbidity following colon surgery. The purpose of this study is to evaluate the possible causes of early postoperative low compliance to the enhanced recovery pathway and its relationship with morbidity following rectal surgery for cancer. A total of 439 consecutive patients who underwent elective surgery for rectal cancer have been included in the study. Compliance to enhanced recovery protocol on postoperative day (POD) 2 was evaluated in all patients. Indicators of compliance were naso-gastric tube and urinary catheter removal, recovery of both oral feeding and mobilization, and the stopping of intravenous fluids. Low compliance on POD 2 was defined as non- adherence to two or more items. One-third of patients had low compliance on POD 2. Removal of urinary catheter, intravenous fluids stop, and mobilization were the items with lowest adherence. Advanced age, duration of surgery, open surgery and diverting stoma were predictive factors of low compliance at multivariate analysis. Overall morbidity and major complications were significantly higher (p < 0.001) in patients with low compliance on POD 2. At multivariate analysis, failure to remove urinary catheter on POD 2 (OR = 1.83) was significantly correlated with postoperative complications. Low compliance to enhanced recovery protocol on POD 2 was significantly associated with morbidity. Failure to remove the urinary catheter was the most predictive indicator. Advanced age, long procedure, open surgery and diverting stoma were independent predictive factors of low compliance.

Laparoscopic rectal resection without epidural catheters-does it work?

PURPOSE

Placement of an epidural catheter (EC) in colorectal resections is still recommended as a valid measure to achieve a low level of pain. However, EC is associated with increased invasiveness and with an increased risk of bladder emptying disorders and a decrease in blood pressure, which all relate to delayed mobilization. Preliminary data shows that EC placement may not be necessary for laparoscopic colon resections. The aim of this prospective study was to investigate how the omission of EC placement influences short-term postoperative outcomes in laparoscopic rectal resections.

METHODS

All laparoscopic rectal resections occurring between 2013 and 2020 were prospectively examined. Resections from January 2013 to February 2018 (group A) were compared with resections from March 2018 to December 2020 (group B; after the internal change of the perioperative pain regime). In addition to EC placement, the other target parameters of our study were urinary catheter placement during the inpatient stay, postoperative pain > 3 days on a numerical rating scale (NRS), mobilization in the first 5 postoperative days, time until the first postoperative bowel movement, postoperative complications according to Clavien-Dindo, intermediate care unit stay (IMC stay) in days, and hospital length of stay in days.

RESULTS

In the entire study period, 221 laparoscopic rectal resections were performed: 122 in group A and 99 resections in group B. The frequency of EC placement and urinary catheter placement, postoperative IMC stay, and hospital length of stay was significantly lower in group B (p < 0.05). The postoperative mobilization of patients in group B was possible more quickly. There were no differences in the level of pain, time until the first postoperative bowel movement, and postoperative complications according to Clavien-Dindo.

CONCLUSION

Omission of EC placement in laparoscopic rectal resections led to faster mobilization, a shorter IMC stay, and a shorter hospital stay without increasing the pain level. Postoperative complications did not change when an EC was not placed. Therefore, routine EC placement in laparoscopic rectal resections is unnecessary.

Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions

Poorly controlled postoperative pain is associated with increased morbidity, negatively affects quality of life and functional recovery, and is a risk factor for persistent pain and longer-term opioid use. Up to 10% of opioid-naïve patients have persistent opioid use after many types of surgeries. Opioid-related side-effects and the opioid abuse epidemic emphasise the need for alternative, opioid-minimising, multimodal analgesic strategies, including neuraxial (epidural/intrathecal) techniques, truncal nerve blocks, and lidocaine infusions. The preference for minimally invasive surgical techniques has changed anaesthetic and analgesic requirements in abdominal surgery compared with open laparotomy, leading to a decline in popularity of epidural anaesthesia and an increasing interest in intrathecal morphine and truncal nerve blocks. Limited research exists on patient quality of recovery using specific analgesic techniques after intra-abdominal surgery. Poorly controlled postoperative pain after major abdominal surgery should be a research priority as it affects patient-centred short-term and long-term outcomes (including quality of life scores, return to function measurements, disability-free survival) and has broad community health and economic implications.

Designer self-assembling peptide nanofibers induce biomineralization of lidocaine for slow-release and prolonged analgesia

The burst release of small molecular water-soluble drugs is a major problem when pursuing their long-acting formulations. Although various types of carrier materials have been developed for tackling this problem, it is still a big challenge to prevent water-soluble small molecules from fast release and diffusion. In this study, a biomineralization strategy based upon a self-assembling peptide is proposed for the slow release of lidocaine, a classic anesthetic with high solubility and a very small molecular weight. A bolaamphiphilic peptide was designed to self-assemble and produce negatively charged nanofibers, which were used as the template to absorb positively charged lidocaine molecules through an electrostatic interaction. The biomineralization of lidocaine was then induced by adjusting the pH, which lead to the formation of lidocaine microcrystals with a homogenous size. The microcrystals were incorporated into a hyaluronic acid hydrogel to form an injectable formulation. This formulation slowly released lidocaine and generate a prolonged anesthetic and analgesic effect in rodent models. Due to the constrained local and plasma lidocaine concentration, as well as the biocompatibility and biodegradability of the peptide materials, this formulation also showed considerable safety. These results suggest that nanofiber assisted biomineralization can provide a potential strategy for the fabrication of long-acting formulations for small molecular water-soluble drugs. STATEMENT OF SIGNIFICANCE: Long-acting formulations are highly pursued to achieve stronger therapeutic effect, or to avoid repeated administration of drugs, especially through painful injection. Using carrier materials to slow down the release of bioactive molecules is a common strategy to reach this goal. However, for many water-soluble small molecular drugs currently used in clinic, it is notoriously difficult to slow down their release and diffusion. This study proposes a novel strategy based on a controllable mineralization process using self-assembling peptide nanofibers as the template. Taking lidocaine as an example, we showed how peptide-drug microcrystals with well-controlled size and shape could be obtained, which exhibit significantly prolonged anesthetic and analgesic effect. As a proof-of-concept study, this work proposes a promising strategy to control the release of water-soluble small molecular drugs.

Epidural Analgesia and Postoperative Complications in Colorectal Cancer Surgery. An Observational Registry-based Study

BACKGROUND

In colorectal cancer, surgical resection is fundamental for curative treatment. Epidural analgesia mitigates the perioperative physiologic stress response caused by surgery, and reduction in perioperative stress may reduce postoperative complications. Nevertheless, epidural analgesia also causes hypotension and lower limb motor weakness that can impair postoperative recovery. Here, we aimed to assess the association between epidural analgesia and postoperative complications after colorectal cancer surgery.

METHODS

We identified patients undergoing colorectal cancer surgery 2008-2018 in Denmark in the Danish Colorectal Cancer Group Database and obtained anaesthesia data from the Danish Anaesthesia Database. The Danish National Prescription Registry was used to obtain data on prescriptions filled preoperatively reflecting current comorbidities. Databases were linked using the Danish Central Person Registry number and the operation day. Patients were classified according to preoperative insertion of an epidural catheter for analgesia. Confounders were adjusted by propensity score matching. Logistic regression was used to compute effect estimates of epidural analgesia on postoperative complications.

RESULTS

We identified 19932 individuals undergoing colorectal cancer surgery with available anaesthesia data. Propensity score matching yielded 5691 individuals in each group with balanced preoperative covariates. In the epidural analgesia group 1400 (24.6%) experienced complications compared with 1453 (25.5%) without epidural analgesia. We found no statistically significant association between epidural use and postoperative complications (OR 0.95, 95% CI 0.87-1.04).

CONCLUSION

In total, in this observational study based on Danish registries, we found no association between epidural analgesia and postoperative complications after colorectal cancer surgery.

Epidural Oxycodone for Acute Pain

Epidural analgesia is commonly used in labour analgesia and in postoperative pain after major surgery. It is highly effective in severe acute pain, has minimal effects on foetus and newborn, may reduce postoperative complications, and enhance patient satisfaction. In epidural analgesia, low concentrations of local anaesthetics are combined with opioids. Two opioids, morphine and sufentanil, have been approved for epidural use, but there is an interest in evaluating other opioids as well. Oxycodone is one of the most commonly used opioids in acute pain management. However, data on its use in epidural analgesia are sparse. In this narrative review, we describe the preclinical and clinical data on epidural oxycodone. Early data from the 1990s suggested that the epidural administration of oxycodone may not offer any meaningful benefits over intravenous administration, but more recent clinical data show that oxycodone has advantageous pharmacokinetics after epidural administration and that epidural administration is more efficacious than intravenous administration. Further studies are needed on the safety and efficacy of continuous epidural oxycodone administration and its use in epidural admixture.

Postoperative opioid prescribing, use and pain trends following general surgery procedures: a retrospective cohort study among veterans comparing non-opioid versus chronic opioid users

INTRODUCTION

Understanding postoperative opioid use patterns among different populations is key to developing opioid stewardship programs.

METHODS

We performed a retrospective cohort study on opioid prescribing, use, and pain after general surgery procedures for patients cared for by a transitional pain service at a veterans administration hospital. Discharge opioid prescription quantity, 90-day opioid prescription, and patient reported outcome pain measures were compared between chronic opioid users and non-opioid users (NOU). Additionally, 90-day total opioid use was evaluated for NOU.

RESULTS

Of 257 patients, 34 (13%) were on chronic opioid therapy, over 50% had a mental health disorder, and 29% had a history and/or presence of a substance use disorder. NOU were prescribed a median (IQR) of 10 (7, 12) tablets at discharge, while chronic opioid users were prescribed 6 (0, 12) tablets (p<0.001). 90-day opioid prescription (not including baseline opioid prescription for chronic users) was 10 (7, 15) and 6 (0, 12) tablets, respectively (p=0.001). There were no differences in changes in pain intensity or pain interference scores during recovery between groups. Median 90-day opioid use post discharge for NOU was 4 (0, 10) pills.

DISCUSSION

Non-opioid and chronic opioid users required very few opioid pills following surgery, and patients on chronic opioid therapy quickly returned to their baseline opioid use after a small opioid prescription at discharge. There was no difference in pain recovery between groups. Opioid prescribing guidelines should include patients on chronic opioid therapy and could consider recommending a more conservative prescribing approach.

Centenary of epidural anaesthesia

March 2021 marked the first centenary of the publication of Fidel Pagés Miravé's seminal article Anestesia metamérica in the Revista Española de Cirugía. Pagés' knowledge of Bier and Tuffier's intradural (1889-1900) and Gil Vernet's sacral (1917-1918) techniques played a pivotal role in the development of the epidural anesthesia technique. Fidel Pagés' extensive experience with treating the casualties of armed conflicts, his proficiency in French and German, and his vast knowledge of anatomy, physiology and pharmacology lie behind the accuracy with which he describes the different approaches, the different anesthetic solutions, or the different instruments used, and the indications, contraindications and complications associated with his technique. In the centenary of his article, we would like to thank Fidel Pagés' for describing an anesthetic and analgesic technique that has improved the lives of so many patients.

Postoperative Pain Management in Enhanced Recovery Pathways

Postoperative pain is a common but often inadequately treated condition. Enhanced recovery pathways (ERPs) are increasingly being utilized to standardize perioperative care and improve outcomes. ERPs employ multimodal postoperative pain management strategies that minimize opioid use and promote recovery. While traditional opioid medications continue to play an important role in the treatment of postoperative pain, ERPs also rely on a wide range of non-opioid pharmacologic therapies as well as regional anesthesia techniques to manage pain in the postoperative setting. The evidence for the use of these interventions continues to evolve rapidly given the increasing focus on enhanced postoperative recovery. This article reviews the current evidence and knowledge gaps pertaining to commonly utilized modalities for postoperative pain management in ERPs.

Regional techniques for pain management following laparoscopic elective colonic resection: A systematic review

Introduction

Pain management is an integral part of Enhanced Recovery After Surgery (ERAS) following laparoscopic colonic resection. A variety of regional and neuraxial techniques were proposed, but their efficacy is still controversial. This systematic review evaluates published evidence on analgesic techniques and their impact on postoperative analgesia and recovery for laparoscopic colonic surgery patients.

Methods

We conducted bibliographic research on May 10, 2021, through PubMed, Cochrane database, and Google scholar. We retained meta-analysis and randomized clinical trials. We graded the strength of clinical data and subsequent recommendations according to the Oxford Centre for Evidence-Based Medicine.

Results

Twelve studies were included. Thoracic epidural analgesia improved postoperative analgesia and bowel function following laparoscopic colectomy. However, it lengthens the hospital stay. Transversus abdominis plane block was as effective as thoracic epidural analgesia concerning pain control but with better postoperative recovery and lower length of hospital stay. Moreover, Lidocaine intravenous infusion improved postoperative pain management and recovery; Quadratus lumborum block provided similar postoperative analgesia and recovery. Finally, wound infiltration reduced postoperative pain without improving recovery of bowel function, and it could be proposed as an alternative to thoracic epidural analgesia.

Conclusions

Several analgesic techniques have been investigated. We found that abdominal wall blocks were as effective as thoracic epidural analgesia for pain management but with lower hospital stay and better recovery. We registered this review on PROSPERO (ID: CRD42021279228).

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First systematic review assessing the efficacy of analgesic techniques following laparoscopic elective colonic resection.

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Only colonic resection was evaluated contrary to other studies, including rectal surgery.

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High-quality studies (randomized controlled trials and meta-analyses) were assessed.

Risk factors and outcomes associated with postoperative ileus following ileostomy formation: a retrospective study

Background

Postoperative ileus (POI) is associated with increased patient discomfort, length of stay (LOS), and healthcare cost. There is a paucity of literature examining POI in patients who have an ileostomy formed at the time of surgery. We aimed to identify risk factors for and outcomes associated with POI following ileostomy formation.

Methods

We included 261 consecutive non-emergent cases that included formation of an ileostomy by a board-certified colorectal surgeon at our institution from July 1, 2015, to June 30, 2020. Demographic, clinical, and intraoperative factors associated with increased odds of POI were evaluated. Post-procedure LOS, hospitalization cost, and re-admissions between patients with and without POI were compared.

Results

Out of 261 cases, 85 (32.6%) were associated with POI. Patients with POI had significantly higher body mass index (BMI) than those without POI (26.6 kg/m² vs. 24.8kg/m²; p = 0.01). Intraoperatively, patients with POI had significantly longer procedure duration than those without POI (313 min vs. 279 min; p = 0.02). Patients with POI had a significantly higher net fluid balance at postoperative day (POD) 2 than those without POI (+ 2.65 L vs. + 1.80 L; p = 0.004), with POD2 fluid balance greater than + 807 mL (determined as the maximum Youden index for sensitivity over 80%) associated with a higher rate of POI (p = 0.006). This difference remained significant when adjusted for age, gender, BMI, pre-operative opioid use, procedure duration, and operative approach (p = 0.01). Patients with POI had significantly longer LOS (11.40 days vs. 5.12 days; p < 0.001) and direct cost of hospitalization ($38K vs. $22K; p < 0.001).

Conclusions

Minimizing fluid overload, particularly in the first 48 h after surgery, may be a strategy to reduce POI in patients undergoing ileostomy formation, and thus decrease postoperative LOS and hospitalization cost. Fluid restriction, diuresis, and changes in diet advancement or early stoma intubation should be considered measures that may improve outcomes and should be studied more intensively.

Level of ERAS understanding affects practitioners' practice and perception of early postoperative resumption of oral intake: a nationwide survey

BACKGROUND

Early postoperative resumption of oral intake is supposed to be safe and beneficial to patients recovery. However, practitioners still have great confusion and disagreement about postoperative resumption of oral intake. This is a nationwide survey to investigate the current status of clinical practice and practitioners' attitude toward postoperative resumption of oral intake along with their level of understanding of the ERAS guidelines.

METHODS

An anonymous web-based survey questionnaire via mobile social platform was carried out in mainland China from December 11-20, 2020. The Wilcoxon signed rank test or chi-square test was used to compare the propensity of the resumption of oral intake.

RESULTS

Totally 5370 responses were received, and 89% of them were from anesthesiology departments. The nature of the responses from clinical practitioners was highly diverse, but each of the three surgery types showed unique patterns of ERAS implementation. The respondents were more conservative regarding the commencement of both fluid and solid diets after gastrointestinal (GI) and hepato-pancreato-biliary (HPB) surgery than after non-abdominal (NA) surgery. Most respondents agreed that early oral intake is beneficial to reduce postoperative complications improve bowel recovery and overall outcome. 55% respondents considered themselves to have a better understanding of ERAS and tended to initiate oral intake early for all three surgery types (P < 0.001).

CONCLUSIONS

The postoperative resumption of oral intake is highly variable among GI, HPB and NA surgeries. A better understanding of ERAS would encourage practitioners to commence oral intake resumption much earlier.

Epidural analgesia is associated with earlier gastrointestinal transit after radical cystectomy but does not reduce the incidence of postoperative ileus: A retrospective cohort study

Objective:

To compare the effect of combined epidural thoracic analgesia and general anaesthesia (CEGA) in radical cystectomy (RC) with respect to the return of gastrointestinal passage, the incidence of paralytic postoperative ileus (POI) compared to general anaesthesia (GA) only.

Patients and methods:

We conducted a retrospective review using the electronic medical records of 236 patients who underwent RCs between July 2011 and September 2018 at the Medical Center – University of Freiburg.

Results:

A CEGA was administered to 202 patients, while 34 patients received only GA. The baseline characteristics of patients with and without CEGA showed no significant differences. CEGA will decrease the time required for return of gastrointestinal transit as measured by time to first defecation by about 13 hours. In the first 90 days after surgery, 82 (34.7%) patients had a POI. There was no significant difference between complications in the CEGA and GA groups.

Conclusion:

A CEGA accelerates the return of the gastrointestinal transit but does not reduce the incidence of postoperative ileus.

Level of evidence:

2b

Influence of Catheter-Incision Congruency in Epidural Analgesia on Postcesarean Pain Management: A Single-Blinded Randomized Controlled Trial

Patient-controlled epidural analgesia (PCEA) or epidural morphine may alleviate postcesarean pain; however, conventional lumbar epidural insertion is catheter–incision incongruent for cesarean delivery. Methods: In total, 189 women who underwent cesarean delivery were randomly divided into four groups (low thoracic PCEA, lumbar PCEA, low thoracic morphine, and lumbar morphine groups) for postcesarean pain management. Pain intensities, including static pain, dynamic pain, and uterine cramp, were measured using a 100 mm visual analog scale (VAS). The proportion of participants who experienced dynamic wound pain with a VAS score of >33 mm was evaluated as the primary outcome. Adverse effects, including lower extremity blockade, pruritus, postoperative nausea and vomiting, sedation, and time of first passage of flatulence, were evaluated. Results: The low thoracic PCEA group had the lowest proportion of participants reporting dynamic pain at 6 h after spinal anesthesia (low thoracic PCEA, 28.8%; lumbar PCEA, 69.4%; low thoracic morphine, 67.3%; lumbar morphine group, 73.9%; p < 0.001). The aforementioned group also reported the most favorable VAS scores for static, dynamic, and uterine cramp pain during the first 24 h after surgery. Adverse effect profiles were similar among the four groups, but a higher proportion of participants in the lumbar PCEA group (approximately 20% more than in the other three groups) reported prolonged postoperative lower extremity motor blockade (p = 0.005). In addition, the first passage of flatulence after surgery reported by the low thoracic PCEA group was approximately 8 h earlier than that of the two morphine groups (p < 0.001). Conclusions: Epidural congruency is essential to PCEA for postcesarean pain. Low thoracic PCEA achieves favorable analgesic effects and may promote postoperative gastrointestinal recovery without additional adverse effects.

Purely ropivacaine-based TEA vs single TAP block in pain management after elective laparoscopic colon surgery within an upgraded institutional ERAS program

Background

The aim of this study was to compare thoracic epidural analgesia (TEA) with transversus abdominis plane (TAP) block in post-operative pain management after laparoscopic colon surgery.

Methods

One hundred thirty-six patients undergoing laparoscopic colon resection randomly received either TEA or TAP with ropivacaine only. The primary endpoint was opioid requirement up to 48 h postoperatively. Intensity of pain, time to onset of bowel function, time to mobilization, postoperative complications, length of hospital stay, and patients’ satisfaction with pain management were also assessed.

Results

We observed a significant decrease in opioid consumption on the day of surgery with TEA compared with TAP block (30 mg vs 14 mg, p < 0.001). On the first two postoperative days (POD), the balance shifted to opioid consumption being smaller in the TAP group: on POD 1 (15.2 mg vs 10.6 mg; p = 0.086) and on POD 2 (9.2 mg vs 4.6 mg; p = 0.021). There were no differences in postoperative nausea/vomiting or time to first postoperative bowel movement between the groups. No direct blockade-related complications were observed and the length of stay was similar between TEA and TAP groups.

Conclusion

TEA is more efficient for acute postoperative pain than TAP block on day of surgery, but not on the first two PODs. No differences in pain management-related complications were detected.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08647-z.

[Peripheral Regional Anaesthesia for Perioperative Analgesia]

Peripheral Regional Anaesthesia for Perioperative Analgesia Abstract. Peripheral regional anaesthesia is the actual gold standard of opioid-sparing perioperative analgesia and is mainly used for surgery of the shoulder, arm and leg. Well-trained anaesthesiologists are the prerequisite for the correct individual risk-benefit assessment and the performance of the nerve blocks using a combination of ultrasound guidance and peripheral nerve stimulation (dual guidance). The postoperative care of the patients requires trained staff.

Evaluation of early postoperative intravenous opioid rescue as a novel quality measure in patients who receive thoracic epidural analgesia: a retrospective cohort analysis and prospective performance improvement intervention

BACKGROUND

In this study, we explored the utility of intravenous opioid rescue analgesia in the post anesthesia care unit (PACU-OpResc) as a single marker of thoracic epidural analgesia (TEA) failure and evaluated the resource implications and quality improvement applications of this measure.

METHODS

We performed a retrospective analysis of all TEA placements over a three-year period at a single academic medical center in Boston, Massachusetts. The study exposure was PACU-OpResc. Primary outcome was PACU length of stay (LOS). Secondary outcomes included reasons for delayed PACU discharge and intraoperative hypotension. The analyses were adjusted for confounding variables including patient comorbidities, surgical complexity, intraoperative intravenous opioids, chronic opioid use and local anesthetic bolus through TEA catheter. Post analysis chart review was conducted to determine the positive predictive value (PPV) of PACU-OpResc for inadequate TEA. As a first Plan-Do-Study-Act cycle, we then introduced a checkbox for documentation of a sensory level check after TEA placement. Post implementation data was collected for 7 months.

RESULTS

PACU-OpResc was required by 211 (22.1%) patients who received preoperative TEA, was associated with longer PACU LOS (incidence rate ratio 1.20, 95% CI:1.07-1.34, p = 0.001) and delayed discharge due to inadequate pain control (odds ratio 5.15, 95% CI 3.51-7.57, p <  0.001). PACU-OpResc had a PPV of 76.3 and 60.4% for re-evaluation and manipulation of the TEA catheter in PACU, respectively. Following implementation of a checkbox, average monthly compliance with documented sensory level check after TEA placement was noted to be 39.7%. During this time, a reduction of 8.2% in the rate of PACU-OpResc was observed.

CONCLUSIONS

This study demonstrates that PACU-OpResc can be used as a quality assurance measure or surrogate for TEA efficacy, to track performance and monitor innovation efforts aimed at improving analgesia, such as our intervention to facilitate sensory level checks and reduced PACU-OpResc.

TRIAL REGISTRATION

not applicable.

Effectiveness of Pain Control of Local Anaesthetic Wound Infusion Following Elective Midline Laparotomy: A Randomized Trial

BACKGROUND

Post-operative pain control is an important pillar in enhanced recovery after surgery. There is a paucity of data that compares efficacy of pain control between continuous local anaesthetic wound infusion and thoracic epidural analgesia in elective midline laparotomy patients OBJECTIVE: To evaluate pain control between continuous local anaesthetic wound infusion and thoracic epidural analgesia in elective laparotomy patients.

DESIGN

A randomized, single-blind, controlled clinical trial.

SETTING

Aga Khan University Hospital, Nairobi, Kenya.

POPULATION

Patients underwent elective laparotomy.

METHODS

Thirty-eight patients scheduled for elective laparotomy were randomized into two equal groups to receive either continuous local anaesthetic wound infusion or thoracic epidural analgesia. Data on the baseline patient characteristics, total morphine consumption at 72 h, visual analogue scores and rates of adverse effects were collected.

RESULTS

Baseline characteristics of the participants were similar. Continuous local anaesthetic wound infusion was equivalent to thoracic epidural analgesia in terms of pain scores and total morphine consumption at 72 h. Duration of hospital stay was shorter in the intervention arm. There were more surgical site infections in the intervention arm, while catheter dislodgement rate was higher in the thoracic epidural arm.

CONCLUSION

Continuous local anaesthetic wound infusion is equivalent to thoracic epidural analgesia in management of post-operative pain following elective midline laparotomy.

CLINICAL TRIAL REGISTRATION

Pan African Clinical Trial registry, number PACTR201808607220790.

Effect of epidural analgesia on postoperative opioid requirements following elective laparotomies performed at Vancouver General Hospital

BACKGROUND

Enhanced recovery pathways aim to reduce postoperative opioid use and opioid-related complications. These pathways often include epidural analgesia (EA). This study examines postoperative opioid use after elective laparotomy with and without EA.

METHODS

Retrospective chart review of elective laparotomies performed by General Surgery at a tertiary academic center during 2017 was completed. Primary outcome was postoperative opioid usage. Secondary outcomes were time to mobilization, duration of urinary catheterization and postoperative ileus.

RESULTS

Among 236 patients, 213 (90%) received EA. There was no significant difference in mean total oral morphine equivalent (OME) usage between EA and non-EA groups. Mean OME use on postoperative day three was higher in the EA group (38.0 vs 22.4 mg, p = 0.02). On multivariate analysis, preoperative opioid use was associated with increased postoperative OME consumption (regression coefficient 147.5, p < 0.001).

CONCLUSIONS

In this cohort, epidural analgesia did not reduce postoperative opioid consumption.

[Effects of different postoperative analgesic strategies on postoperative neurocognitive function and quality of recovery in elderly patients undergoing one lung ventilation]

OBJECTIVE

To evaluate the effects of different postoperative analgesic strategies on neurocognitive function and quality of recovery in elderly patients at 7 days after thoracic surgery with one lung ventilation.

METHODS

Ninety elderly patients undergoing video-assisted thoracic surgery were randomized into 3 groups (n=30) to receive postoperative analgesia with thoracic paravertebral block analgesia (TA), epidural analgesia (EA) and intravenous analgesia (GA). Before and at 7 days after the surgery, the patients' cognitive function was assessed using Mini-Mental State Examination (MMSE), and their early recovery at 7 days postoperatively was evaluated using Quality of Recovery-40 items (QoR-40).

RESULTS

The patients in TA and EA groups had significantly higher MMSE scores and lower incidence of postoperative neurocognitive dysfunction (PNCD) than those in GA group without significant difference between the former two groups. At 7 days after the surgery, serum levels of S100-β and MMP-9 were significantly higher in GA group than in TA and EA group, and did not differ significantly between the latter two groups. QoR-40 scores were significantly higher in TA and EA groups than in GA group, and were higher in TA group than in EA group. The chest intubation time and length of hospital stay were significantly shorter in TA and EA groups than in GA group.

CONCLUSIONS

In elderly patients undergoing surgeries with one lung ventilation, general anesthesia combined with either postoperative continuous thoracic paravertebral block or epidural analgesia can significantly improve postoperative neurocognitive function and quality of recovery, but continuous thoracic paravertebral block analgesia can be more advantageous for improving postoperative quality of recovery.

Postoperative Ileus and Postoperative Gastrointestinal Tract Dysfunction: Pathogenic Mechanisms and Novel Treatment Strategies Beyond Colorectal Enhanced Recovery After Surgery Protocols

Postoperative ileus (POI) and postoperative gastrointestinal tract dysfunction (POGD) are well-known complications affecting patients undergoing intestinal surgery. GI symptoms include nausea, vomiting, pain, abdominal distention, bloating, and constipation. These iatrogenic disorders are associated with extended hospitalizations, increased morbidity, and health care costs into the billions and current therapeutic strategies are limited. This is a narrative review focused on recent concepts in the pathogenesis of POI and POGD, pipeline drugs or approaches to treatment. Mechanisms, cellular targets and pathways implicated in the pathogenesis include gut surgical manipulation and surgical trauma, neuroinflammation, reactive enteric glia, macrophages, mast cells, monocytes, neutrophils and ICC's. The precise interactions between immune, inflammatory, neural and glial cells are not well understood. Reactive enteric glial cells are an emerging therapeutic target that is under intense investigation for enteric neuropathies, GI dysmotility and POI. Our review emphasizes current therapeutic strategies, starting with the implementation of colorectal enhanced recovery after surgery protocols to protect against POI and POGD. However, despite colorectal enhanced recovery after surgery, it remains a significant medical problem and burden on the healthcare system. Over 100 pipeline drugs or treatments are listed in Clin.Trials.gov. These include 5HT4R agonists (Prucalopride and TAK 954), vagus nerve stimulation of the ENS-macrophage nAChR cholinergic pathway, acupuncture, herbal medications, peripheral acting opioid antagonists (Alvimopen, Methlnaltexone, Naldemedine), anti-bloating/flatulence drugs (Simethiocone), a ghreline prokinetic agonist (Ulimovelin), drinking coffee, and nicotine chewing gum. A better understanding of the pathogenic mechanisms for short and long-term outcomes is necessary before we can develop better prophylactic and treatment strategies.

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.

Erector spinae plane block for postoperative pain and recovery in hepatectomy: A randomized controlled trial

BACKGROUND

The randomized controlled study aimed to examine the efficacy of preoperative ultrasound-guided erector spinae plane (ESP) block combined with ropivacaine in patients undergoing hepatectomy.

METHODS

A total of 60 patients were randomized to ESP block group receiving ropivacaine (Group A) and control group (Group B), n = 30 per group. Visual analog scale (VAS) was recorded in both the groups during rest and movement at the various time intervals. Both the groups were also compared for time to initial anal exhaust, analgesic usage, early postoperative complications and side-effects, walk distance after the operation, time to out-of-bed activity, and duration of hospital stay.

RESULTS

No significant differences were observed in the demographic characteristics. For group A, when compared to group B, VAS scores during rest and movement within post-operative 24 hours were decreased, the time of first anus exhaust and ambulation were earlier, analgesic consumption and the incidence of postoperative nausea, vomiting and headache was reduced, the duration of hospital stay were shorter with longer walk distance.

CONCLUSION

ESP block combined with ropivacaine treatment effectively reduced early postoperative pain and improved recovery after hepatectomy.

Continuous thoracic spinal anesthesia with local anesthetic plus midazolam and ketamine is superior to local anesthetic plus fentanyl in major abdominal surgery

BACKGROUND

Limited studies have applied thoracic continuous spinal anesthesia in abdominal surgery, relying exclusively on opioids. This retrospective study analyzes 2 different schemes of thoracic continuous spinal anesthesia and postoperative analgesia in elderly patients undergoing major abdominal surgery.

METHODS

A total of 98 patients aged ≥ 75 years were divided into 2 groups. The control group (60 patients) received bupivacaine plus fentanyl, whereas the study group (38 patients) received bupivacaine plus ketamine and midazolam. Both received analogous postoperative continuous intrathecal analgesia. Several perioperative variables were evaluated.

RESULTS

Spinal anesthesia was performed without complications in all patients. Doses of noradrenaline administered, incidence of respiratory depression, need for intraoperative sedation, and time to first flatus were significantly reduced in the bupivacaine plus ketamine and midazolam group.

CONCLUSION

In a population of frail, elderly patients, thoracic continuous spinal anesthesia with local anesthetic plus midazolam and ketamine was superior to local anesthetic plus fentanyl. In the group receiving local anesthetic plus midazolam and ketamine, the incidence of respiratory depression was reduced, and doses of norepinephrine and intraoperative sedating medications were lower. Intraoperative anesthesia and postoperative analgesia were similar in both groups.

Use and Outcomes of Epidural Analgesia in Upper Gastrointestinal Tract Cancer Resections

BACKGROUND

Epidural analgesia (EA) is an appealing adjunct for esophageal and gastric cancer patients. It remains unclear whether EA usage affects postoperative outcomes. There are no national data on the trends of EA utilization for these procedures. This study aims to use the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to study the utilization and outcomes of EA in open upper GI tract cancer resections.

MATERIALS AND METHODS

A retrospective review of NSQIP was performed for patients undergoing open elective esophagectomies and gastrectomies for nonmetastatic cancer between 2014 and 2017. An Armitage trend test was performed. The population was propensity matched and assessed.

RESULTS

There were 4802 esophagectomies performed. Twenty-nine percent of patients received EA. Of 2599 gastrectomies, 18% of patients received EA. The recent trends of EA use for esophagectomies (EA range [26.9%, 30.3%] P = 0.6535) and gastrectomies (EA [16.9%, 18.4%], P = 0.7797) remain stable. Propensity matching was performed, and the groups with and without EA were compared. For esophagectomies, EA was associated with blood transfusions (EA 14% versus No EA 10.8%, P = 0.0156). For gastrectomies, EA was associated with longer length of stay (LOS) (EA median [IQR] 8 [7,11] versus No EA 7 [6,11], P = 0.0002).

CONCLUSIONS

Despite the current opioid epidemic, the recent trends of EA for esophageal and gastric cancer patients remain stable. EA was associated with blood transfusions for esophagectomies and with a longer LOS for gastrectomies. Therefore, EA should be carefully considered, and its analgesic efficacy in this population should be investigated closely in future studies.

Effect of midodrine versus placebo on time to vasopressor discontinuation in patients with persistent hypotension in the intensive care unit (MIDAS): an international randomised clinical trial

PURPOSE

ICU discharge is often delayed by a requirement for intravenous vasopressor medications to maintain normotension. We hypothesised that the administration of midodrine, an oral α₁-adrenergic agonist, as adjunct to standard treatment shortens the duration of intravenous vasopressor requirement.

METHODS

In this multicentre, randomised, controlled trial including three tertiary referral hospitals in the US and Australia, we enrolled adult patients with hypotension requiring a single-agent intravenous vasopressor for ≥ 24 h. Subjects received oral midodrine (20 mg) or placebo every 8 h in addition to standard care until cessation of intravenous vasopressors, ICU discharge, or occurrence of adverse events. The primary outcome was time to vasopressor discontinuation. Secondary outcomes included time to ICU discharge readiness, ICU and hospital lengths of stay, and ICU readmission rates.

RESULTS

Between October 2012 and June 2019, 136 participants were randomised, of whom 132 received the allocated intervention and were included in the analysis (modified intention-to-treat approach). Time to vasopressor discontinuation was not different between midodrine and placebo groups (median [IQR], 23.5 [10-54] vs 22.5 [10.4-40] h; difference, 1 h; 95% CI - 10.4 to 12.3 h; p = 0.62). No differences in secondary endpoints were observed. Bradycardia occurred more often after midodrine administration (5 [7.6%] vs 0 [0%], p = 0.02).

CONCLUSION

Midodrine did not accelerate liberation from intravenous vasopressors and was not effective for the treatment of hypotension in critically ill patients.

A Comparison of Analgesia After a Thoracoscopic Lung Cancer Operation with a Sustained Epidural Block and a Sustained Paravertebral Block: A Randomized Controlled Study

INTRODUCTION

This study aimed to compare the challenge of puncture and catheterization and the effect of postoperative analgesia of ultrasound-guided continuous thoracic paravertebral block and the continuous epidural analgesia in patients receiving thoracoscopic surgery for lung cancer.

METHODS

One-hundred and fifty patients received elective unilateral thoracoscopic surgery for lung cancer and were randomized into three groups; test group 1 (T group), test group 2 (P group), and the control group (E group). Both of the test groups received ultrasound-guided continuous thoracic paravertebral block (TPVB) while the control group received continuous epidural analgesia. After the operation, all the patients in the test groups received the same postoperative analgesia; loading dose 0.5 mg kg^-1, background dose 0.25 mg kg^-1 h^-1, patient controlled analgesia (PCA) 0.25 mg kg^-1, and a locking time of 60 min, while the patients in the control group received a loading dose of 5 ml, a background dose of 5 ml h^-1, and a locking time of 20 min. The outcomes of this study were the success rate of the puncture and catheter placement, the blocked segments, numerical rating scale (NRS) scores at rest and during coughing, and the segments with reduced or lost cold and pinpricking sensation.

RESULTS

The success rates of the puncture and catheterization in group T were the highest. Compared with group P, the failure rate of the puncture in group E was lower (p < 0.05), but the success rate of catheterization was higher (p < 0.05). The puncture time in group T was the shortest; there was no difference between group E and group T. The time of catheterization in group P was the longest, this was followed by group T, and was the fastest in group E. The stable time of the block level in group E was shorter than that in groups P and T, but was similar between groups P and T. The block level of all three groups in the 4 h postoperative period was similar (p > 0.05), while the 4 h postoperative levels of groups P and T were reduced significantly (p < 0.05).

CONCLUSION

The continuous analgesia technique of paravertebral space catheterization cannot replace the continuous epidural analgesia in thoracoscopic lung cancer surgery as the latter technique is still considered to be the gold standard.

TRIAL REGISTRATION

China Clinical Trial Registration Center identifier ChiCTR1900020973.

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management

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 I of the guidelines highlights preoperative and intraoperative management.

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.

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.