Laparoscopic Sleeve Gastrectomy 2018

Laparoscopic Sleeve Gastrectomy-Specific Evidence

Data table: Paracetamol and NSAIDs/COX-2-selective inhibitors

Arguments for…

• One study favoured IV paracetamol compared with placebo, administered for 24 h, with significantly lower pain scores at all time points: 12, 16, 20 h (p=0.02, p=0.03, p=0.01 respectively) (n=23) (Strode 2016; LoE 1). Opioid requirements were not significantly different
• One study found no significant differences in pain scores between IM diclofenac plus IV tramadol PCA compared with fentanyl PCA (n=28) (Mansour 2013; LoE 2)

Arguments against…

• One study showed no significant difference between IV paracetamol and placebo, administered for 24 h, in terms of pain scores or opioid requirements (n=128) (Cooke 2018; LoE 1)

PROSPECT Recommendations

• Peri-operative pain management for LSG is recommended to include paracetamol (Grade A) and, unless contraindicated, an NSAID/COX-2-selective inhibitor (Grade A), administered pre-operatively or intra-operatively and continued into the postoperative period
• Although there was limited procedure-specific evidence to support the use of paracetamol and NSAIDs/COX-2-selective inhibitors, the analgesic benefits of these non-opioids are well described. They are considered “basic analgesics”

Laparoscopic Sleeve Gastrectomy-Specific Evidence

Data table: Gabapentinoids

Arguments for…

• Pre-operative gabapentin or pregabalin were associated with lower pain scores and opioid consumption compared with placebo in three studies (Rupniewska-Ladyko 2018, LoE 1, n=113; Cabrera Schulmeyer MC 2010, LoE 1, n=80; and Salama 2016, LoE 1, n=60)
  • Pain scores at 4 and 8 h (p=0.02) and opioid requirements (p=0.0085) were lower with gabapentin (1200 mg) compared with placebo (Rupniewska-Ladyko 2018, LoE 1, n=113)
  • Pregabalin (150 mg) was associated with lower pain scores at all time points (p<0.05) and lower rescue opioid requirement (p<0.0001) compared with placebo (Cabrera Schulmeyer MC 2010, LoE 1, n=80)
  • A lower dose of pregabalin (75 mg) with dexmedetomidine was associated with lower pain scores at all time points compared with placebo. Rescue morphine requirement was also lower in the treatment group than placebo (p<0.001) (Salama 2016, LoE 1, n=60)

PROSPECT Recommendations

• Gabapentinoids may be considered with caution when a ‘‘basic’’ analgesic regimen such as paracetamol and NSAID/COX-2-selective inhibitor is not possible (Grade A)
• The recommendation is based on evidence of analgesic benefit in procedure-specific studies (LoE 1), but caution is advised as doses in these studies varied substantially and there are concerns that gabapentinoids may increase opioid-induced respiratory depression (Cavalcante 2017), especially in the obese or obstructive sleep apnoea populations (Joshi 2012)

Laparoscopic Sleeve Gastrectomy-Specific Evidence

Data table: Alpha-2 adrenergic agonists

Arguments for…

• Propofol and dexmedetomidine produced significantly lower pain scores (p<0.0001) and required less opioid use compared with desflurane anaesthesia (n=100) (Elbakry 2018; LoE 1)
• One study showed that pain scores were significantly lower with clonidine (0.8–1.2 mcg/kg IV) versus dexmedetomidine (0.5–0.8 mcg/kg) at 12-h mobilization, but not in the immediate postoperative period or after 24 h or at rest (n=60) (Naja 2014; LoE 1)

PROSPECT Recommendations

• Alpha-2 adrenergic agonists such as dexmedetomidine are not recommended (Grade D) due to limited and inconsistent procedure-specific evidence of analgesic benefit (LoE 4) as well as concerns regarding potential sedative and hypotensive effects

Laparoscopic Sleeve Gastrectomy-Specific Evidence

Data table: Dexamethasone, ondansetron, and haloperidol

Arguments for…

• A placebo-controlled study compared ondansetron (8 mg); ondansetron and dexamethasone (8 mg); and a combination of ondansetron, dexamethasone and haloperidol (2 mg). Triple therapy reduced pain intensity (p=0.046), opioid use (p=0.037) and nausea intensity (p=0.001) compared with ondansetron but there was no significant difference versus dexamethasone (n=90) (Benevides 2013; LoE 1)

PROSPECT Recommendations

• A single, low dose of IV dexamethasone is recommended (Grade A) for its ability to decrease analgesic use and act as an anti-emetic (LoE 1)
• Although only one procedure-specific study reported on the analgesic effects (LoE 1), the anti-emetic effects of dexamethasone are well established, and it is likely to be of benefit in LSG

Laparoscopic Sleeve Gastrectomy-Specific Evidence

Data table: Magnesium sulphate

Arguments for…

• Magnesium sulphate (30mg/kg IV bolus and 20 mg/kg infusion for 24 h) was associated with reduced pain scores at all time points, and lower morphine requirements (p=0.001) compared with placebo (p=0.001) (n=80) (Kizilcik 2018; LoE 1)

PROSPECT Recommendations

• Magnesium sulphate is not recommended (Grade D) because in the one procedure-specific study, its analgesic efficacy was not evaluated in the context of optimal multimodal analgesia including paracetamol and NSAIDs, and due to concerns of potentiation of muscle paralysis and increased incidence of residual paralysis (Thevathasan 2017)

Laparoscopic Sleeve Gastrectomy-Specific Evidence

Data table: Transverse abdominis plane (TAP) block

Arguments for…

• One study reported significantly lower pain scores for 6 h after ultrasound-guided bilateral subcostal TAP blocks compared with control (n=35) (Wassef 2013; LoE 1). A single-port approach was used and the TAP was applied after emergence from anaesthesia. There was no significant difference in opioid use
• Continuous TAP blocks were associated with a significant decrease in pain scores and total opioid consumption for up to 24 h compared with IV morphine (n=90) (Said 2017; LoE 1)
• One study compared ultrasound-guided oblique subcostal TAP (OSTAP) with bupivicane plus saline port infiltration versus saline OSTAP block plus port site infiltration with bupivacaine versus saline OSTAP and port site infiltration (placebo group) (n=63) (Ibrahim 2014; LoE 1). Both OSTAP block and port site infiltration were associated with significantly lower pain scores and opioid consumption compared with placebo:
  • Compared with placebo, OSTAP block was associated with significantly lower pain scores at rest at all measured time points up to 24 h and on movement up to 6 h, and significantly lower opioid consumption
  • The port site infiltration group also reported lower pain scores at 0, 2 and 4 h and lower opioid consumption compared with placebo
  • At 4h and 6h with movement, there was a significant reduction in pain with OSTAP compared with port site infiltration (p<0.05)
  • TAP block was also associated with significantly lower opioid consumption compared with port site infiltration

Arguments against…

• A study comparing subcostal TAP block with sub-costal posterior TAP block, both with bupivacaine, showed similar results but the statistics used were not clear or robust (n=40) (Ari 2017; LoE 2)
• Techniques in the reported studies varied significantly: some blocks used common ultrasound and others used a subcostal approach. Also, some blocks were performed by anaesthesiologists before the surgical procedure and others were performed by surgeons at the end of surgery

PROSPECT Recommendations

• TAP blocks are not recommended (Grade D) despite the reported analgesic benefits, as the optimal technique is unclear and their use in laparoscopic procedures has been questioned (Kehlet 2015)

Laparoscopic Sleeve Gastrectomy-Specific Evidence

Data table: Port site infiltration versus epidural analgesia

Arguments for…

• A three-arm study reported that port site infiltration (bupivacaine 0.25%) plus IV analgesia, and epidural analgesia (levobupivacaine 0.125% at 6 mL/h) plus IV analgesia, were associated with lower pain scores than IV analgesia alone (n=147) (Ruiz-Tovar 2017; LoE 2)

Arguments against…

• There was no significant difference in pain scores between port site infiltration and epidural analgesia in the three-arm study (Ruiz-Tovar 2017; LoE 2)

PROSPECT Recommendations

• Even though there is limited procedure-specific evidence, port-site infiltration may be considered (Grade D). Port-site infiltration is favoured over TAP blocks as it is a simple and inexpensive approach that provides adequate somatic blockade

Laparoscopic Sleeve Gastrectomy-Specific Evidence

Data table: Intraperitoneal local anaesthetic administration

• One study found no improvements in pain scores and opioid use with intraperitoneal ropivacaine (0.2%) infusion compared with placebo (n=82) (Cleveland 2015; LoE 1)

PROSPECT Recommendations

• Intraperitoneal local anaesthetic instillation is not recommended (Grade D) as the one procedure-specific study found no analgesic benefit

Laparoscopic Sleeve Gastrectomy-Specific Evidence

Data table: Single-port approach

• One pilot study examined a single- versus multi-port approach, with mixed outcomes. Lower pain scores on movement were reported with the single- versus multi-port approach on day 1 (p=0.046) and day 2 (p=0.044) but not on day 3. There were no significant differences in pain scores at rest (n=30) (Morales-Conde 2017; LoE 1)

PROSPECT Recommendations

• The single-port approach is not recommended (Grade B) due to limited evidence with inconsistent results