Colonic Resection "2009"

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Epidural LA and opioid showed a significant benefit for reducing postoperative pain scores compared with GA plus systemic analgesia in six studies Click here for more information
• Epidural LA and strong opioid produced a significant reduction in the use of supplementary analgesia compared with GA plus systemic analgesia in two studies (p<0.05, n=64; p<0.001, n=20)
• Epidural LA and strong opioid was superior to GA plus systemic analgesia for increasing the time to first request of supplementary analgesia in one study (p<0.005; n=20)
• Epidural LA plus opioid was associated with a similar length of hospital stay compared with GA plus systemic analgesia in two studies (n=42, n=20)
• Epidural LA plus opioid produced a significantly quicker time for first flatus and time for first bowel movement compared with GA plus systemic analgesia in two studies (all p<0.05; n=64, n=42)
• Epidural bupivacaine plus morphine was associated with recovery of gastrointestinal function and fulfilled discharge criteria approximately 1.5 days earlier compared with GA and IV plus postoperative PCA morphine (p<0.005; n=26)
• Epidural bupivacaine plus morphine had a similar incidence of orthostatic hypotension compared with GA and IV plus postoperative PCA morphine (n=26)
• Two studies demonstrated that epidural bupivacaine conferred a benefit over general anaesthesia and systemic analgesia for reducing postoperative pain scores at rest for 1–72 h in one study (all p<0.05; n=116)
• Epidural bupivacaine administration resulted in significantly fewer patients requiring supplementary analgesia compared with GA plus systemic analgesia for 1–48 h postoperatively (p<0.05; n=116)
• Epidural bupivacaine administration resulted in significantly more patients having a bowel movement by Day 4 compared with GA plus systemic analgesia (p<0.05; n=116)
• Epidural bupivacaine was associated with recovery of gastrointestinal function and fulfilled discharge criteria approximately 1.5 days earlier compared with GA and IV bolus plus postoperative PCA morphine (p<0.005; n=26)
• A meta-analysis of randomised studies performed to compare the effect of local anaesthetic epidural analgesia with parenteral opioid analgesia in patients undergoing colorectal surgery, reported that epidural analgesia significantly reduced postoperative VAS pain scores at 24 h (11 studies analysed, n=630) and 48 h postoperatively (6 studies analysed, n=281) (p<0.001 for both comparisons)
• A meta-analysis of 11 randomised studies showed that the duration of gastrointestinal dysfunction was significantly shorter with epidural analgesia, compared with parenteral opioid analgesia (n=510, p<0.001)
• GA + intra-operative epidural lidocaine + postop PCEA was superior to GA alone + postop PCEA for reducing VAS pain scores on coughing at a minority of time points Click here for more information
• GA + intra-operative epidural lidocaine + postoperative PCEA was more effective than GA alone + postoperative PCEA for reducing postoperative opioid requirements Click here for more information
• GA + intra-operative epidural lidocaine + postoperative PCEA significantly reduced the time to first flatus compared with GA alone + postoperative PCEA (p<0.0001; n=60)
• Epidural lidocaine was more effective than the control for the reduction of postoperative pain scores Click here for more information
• Epidural lidocaine was superior to the control for reducing postoperative opioid requirement Click here for more information
• The proportion of patients receiving intra-operative epidural lidocaine that required an intra-operative fentanyl supplement, was significantly lower compared with the control group (n=40)
• Epidural lidocaine was superior to control for reducing the time until first flatus (p<0.01; n=40)
• Epidural lidocaine was associated with a lower incidence of morphine-related nausea or vomiting, compared with control (p<0.01; n=40)
• The addition of opioid to epidural LA conferred a benefit over epidural LA alone in reducing postoperative pain scores in two studies Click here for more information
• Intra-/postoperative epidural bupivacaine-sufentanil-clonidine was superior to intra-operative IV lidocaine-sufentanil-clonidine + postoperative IV lidocaine-morphine-clonidine for reducing postoperative pain Click here for more information
• Cumulative number of satisfied analgesic requests was significantly lower with intra-/postoperative epidural bupivacaine-sufentanil-clonidine + intra-operative IV ketamine, compared with intra-operative IV lidocaine-sufentanil-clonidine + intra-operative IV ketamine + postoperative IV lidocaine-morphine-clonidine, from 24–72 h after surgery (p<0.05; n=40), but not at 12 h

Arguments against…

• Epidural infusion of opioid was similar to GA and IV plus postoperative PCA morphine for postoperative pain scores
• Epidural morphine was associated with a similar incidence of nausea and orthostatic hypotension compared with GA and IV plus postoperative PCA morphine (n=24)
• Epidural bupivacaine was associated with an increased incidence of orthostatic hypotension compared with GA and IV plus postoperative PCA morphine (p<0.05) (n=26)
• Epidural bupivacaine had a similar incidence of nausea compared with GA and IV plus postoperative PCA morphine (n=26)
• A meta-analysis of randomised studies performed to compare the effect of local anaesthetic epidural analgesia with parenteral opioid analgesia in patients undergoing colorectal surgery, found no significant difference in the incidence of PONV (5 studies analysed; n=189), anastomotic leakage (7 studies analysed; n=459), or length of hospital stay (n=716)
• Epidural lidocaine + GA conferred no significant benefit over GA alone for reducing the length of hospital stay (n=60)
• There was no significant difference in the incidence of morphine-related side-effects (drowsiness, dizziness, nausea, vomiting and pruritus) with epidural lidocaine + GA versus GA alone (n=60)
• Epidural lidocaine conferred no significant benefit over the control for reducing the length of hospital stay (n=40)
• Epidural LA plus strong opioid showed no difference in the incidence of nausea and vomiting compared with GA plus systemic analgesia in four studies Click here for more information
• Intra-/postoperative epidural bupivacaine-sufentanil-clonidine + intra-operative IV ketamine was associated with a higher incidence of orthostatic hypotension at first mobilisation, compared with intra-operative IV lidocaine-sufentanil-clonidine + intra-operative IV ketamine + postoperative IV lidocaine-morphine-clonidine (p=0.05; n=40)

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments against…

• Combined spinal/thoracic epidural anaesthesia conferred no additional benefit over peri-operative thoracic epidural infusion alone for postoperative pain scores at rest and on coughing from 4–24 h (n=20)
• Combined spinal/thoracic epidural anaesthesia compared with continuous epidural infusion alone were similar for supplementary analgesic consumption (n=20)

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Two studies reported that postoperative VAS pain scores were significantly lower with nitrogen compared with nitrous oxide after 2 h (p=0.02; n=344 and p=0.014; n=408)
• Two studies reported that VAS nausea scores were significantly lower with nitrogen compared with nitrous oxide (p=0.04; n=344 and p=0.007; n=408)
• One study reported that moderate-to-severe bowel distension was significantly less common in patients following GA with nitrogen, compared with nitrous oxide (p<0.001; n=344)
• Nitrous oxide was superior to intra-operative IV remifentanil for the reduction of VAS pain scores on arrival in the PACU (p<0.05; n=60), but not after 5, 10 or 15 min

Arguments against…

• Two studies reported no significant difference in the level of PCA opioid consumption (piritramide) between patients receiving GA with nitrogen or nitrous oxide (n=344; n=408)
• Two studies showed that the incidence of postoperative nausea and vomiting was similar with nitrous oxide and nitrogen (n=344; n=408)
• There was no significant difference in the time to first flatus, first bowel movement, or first intake of solid food between patients in the groups receiving GA with nitrogen or nitrous oxide (n=408)
• The length of hospital stay was similar for patients in the groups that received general anaesthesia with nitrogen and general anaesthesia with nitrous oxide (n=408)
• There were no significant differences between the nitrous oxide and intra-operative IV remifentanil groups in VAS pain scores at rest or movement from 0–24 h postoperatively (n=60)
• There was no significant difference between the nitrous oxide and intra-operative IV remifentanil groups for postoperative morphine consumption in the PACU, or during the first postoperative day (n=60)
• There was a similar incidence of postoperative nausea and vomiting between patients receiving nitrous oxide and IV remifentanil (n=60)

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• A transverse incision conferred significant benefit over a midline vertical incision for reducing postoperative pain on movement on Days 1 and 3, and reducing supplementary analgesic consumption (all p<0.05); however, both incision techniques were similar for postoperative pain scores at rest (n=40)
• A transverse incision was similar to a midline vertical incision for the time to resume normal diet, time to first bowel movement and duration of hospital stay (n=40)
• Laparoscopic resection was superior to open colonic resection for reducing postoperative pain scores Click here for more information
• Laparoscopic resection was superior to open colonic resection for reducing supplementary analgesic consumption Click here for more information
• Laparoscopic resection was superior to open colonic resection for reducing time to first flatus and bowel movement in three studies Click here for more information
• Laparoscopic resection was superior to open colonic resection for reducing length of hospital stay in four of five studies Click here for more information
• One study reported that there was no significant difference in the incidence of PONV between the laparoscopic colonic resection and open colonic resection techniques (n=60)
• A meta-analysis of seven studies reporting analgesic outcomes showed a significant benefit of laparoscopic resection over open colonic resection for reduced pain at rest and on coughing, and reduced analgesic requirement for up to 3 days (not all studies recorded pain scores)
• Meta-analysis of twelve studies showed that laparoscopic resection reduced morbidity, wound infection, time to recovery and hospital stay compared with open resection
• A systematic review of laparoscopic resection of colon cancer, combined with expert opinion, concluded that pain is less severe and that less analgesia is required after laparoscopic resection than open resection
• A systematic review comparing laparoscopic with open surgery for colorectal cancer, concluded that laparoscopic surgery was associated with less blood loss, less postoperative pain, less postoperative analgesic consumption, faster return to normal bowel function, and a shorter hospital stay
• A systematic review comparing laparoscopic versus open total mesorectal excision for rectal cancer reported that one of two randomised controlled studies showed laparoscopic surgery was superior for reducing postoperative pain scores
• Hand-assisted laparoscopic colectomy was superior to open colectomy for the reduction of postoperative pain scores Click here for more information
• Hand-assisted laparoscopic colectomy was superior to open colectomy for reducing supplementary analgesic consumption Click here for more information
• Hand-assisted laparoscopic colectomy was superior to open colectomy for reducing the time to first flatus and first bowel movement Click here for more information
• Two studies showed that hand-assisted laparoscopic colectomy was superior to open colectomy for reducing the length of hospital stay (p=0.004, n=81; p<0.001, n=60)
• One study showed that hand-assisted laparoscopic colectomy was superior to open colectomy for reducing the time until first oral food intake (p<0.05, n=60)

Arguments for…

Hand-assisted laparoscopic proctocolectomy conferred no significant benefit over open proctocolectomy for reducing VAS pain scores at rest and during movement on Days 1, 2, 3 and 7, and at Week 4 (n=55)

There wli class=”case-3″>fference in the postoperative morphine requirement between patients who received hand-assisted laparoscopic proctocolectomy versus open proctolectomy at 24, 48 or 72 h (n=55)

Hand-assisted laparoscopic proctocolectomy conferred no significant benefit over open proctolectomy for reducing the time taken for patients to return to normal fluid or food consumption (n=55)

OPEN COLONIC RESECTION-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Patients kept normothermic required significantly less bupivacaine to maintain adequate epidural blockade than patients kept hypothermic in one study (p=0.006; n=30)
• Maintenance of normothermia was associated with higher comfort scores and a similar heart rate and blood pressure than maintenance of hypothermia in one study (n=74)
• Maintenance of normothermia was associated with lower incidence of wound infections, fewer transfusions and quicker suture removal and hospital discharge compared with maintenance of hypothermia (p=0.01 for all outcomes) (n=200)

Arguments against…

• Patients kept normothermic were similar to patients kept hypothermic for postoperative pain scores in three studies (n=74, n=200, n=30)