Colonic Resection "2009"

PROSPECT Colonic Resection Subgroup

For each review, a Subgroup of the prospect Working Group performs an initial evaluation of the evidence and also drafts clinical practice statements and recommendations, which are then discussed by the whole Working Group before a final consensus is reached. The Subgroup may sometimes include a non-Working Group member, to provide additional expertise in the procedure being reviewed.

For the colonic resection surgery review (update 2009), the Subgroup members were:

• Professor Francis Bonnet (PROSPECT Working Group member)
• Professor Frederic Camu (PROSPECT Working Group member)

Grades of Recommendation

Recommendations are graded according to the overall level of evidence (LoE) on which the recommendations are based, which is determined by the quality and source of evidence: Levels of evidence and grades of recommendation in PROSPECT reviews (from 2006)

PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

Summary Recommendations

Pre-, intra- and postoperative interventions have been evaluated for the management of postoperative pain following colonic resection. Unless otherwise stated, ‘pre-operative’ refers to interventions applied before surgical incision, ‘intra-operative’ refers to interventions applied after incision and before wound closure, ‘postoperative’ refers to interventions applied at or after wound closure. The following pre-, intra- and postoperative interventions have been evaluated, for the management of postoperative pain following open colonic resection:

Pre-operative

Recommended:

Systemic analgesia

• COX-2-selective inhibitors (Grade B) (only for patients who do not receive epidural analgesia)
• Continuous administration of pre-/intra-operative IV lidocaine if continued during the immediate postoperative period (Grade B), when epidural analgesia is not feasible or contra-indicated

Epidural analgesia

• Continuous thoracic epidural anaesthesia and analgesia, at a level appropriate to the site of incision are recommended for routine use (Grade A)
• A combination of strong opioid and local anaesthetic is recommended (Grade A) because of the increased analgesic efficacy of the combination compared with strong opioids alone

Not recommended:

Systemic analgesia

• IV clonidine (Grade D) because it is associated with an increased risk of hypotension and bradycardia
• Conventional NSAIDs (Grade B) because pre-operative administration of these agents can increase the risk of intra- and postoperative bleeding
• Corticosteroids for analgesia (Grade A) because of procedure-specific evidence showing no significant benefit in reducing pain scores and concerns that they could affect anastomotic and wound integrity (but they may be used for reduction of PONV)
• Gabapentin/pregabalin (Grade D) due to a lack of procedure-specific evidence
• Continuous administration of IV lidocaine limited to the pre-/intra-operative period (Grade D) because of inconsistent and insufficient procedure-specific evidence
• NMDA receptor antagonists (Grade D) because of limited procedure-specifc evidence
• Strong opioids (Grade B) as they are significantly less effective than postoperative strong opioids for reducing postoperative pain
• Weak opioids (Grade B) based on procedure-specific evidence that they provide limited postoperative analgesic benefit compared with postoperative administration
• Calcium channel antagonists (Grade B) based on limited procedure-specific evidence showing a lack of postoperative analgesic effect

Spinal anaesthesia

• Spinal morphine (Grade D) because of the risk of side effects
• Spinal clonidine (Grade B) based on procedure-specific evidence showing limited analgesic effect and the risk of side effects

Non-pharmacological therapy

• Pre-operative use of guided imagery (Grade D) because of limited procedure-specific evidence
• Laxatives for analgesia (Grade B) because limited procedure-specific evidence shows no analgesic benefit (but they may be used for reasons other than pain relief
• Pentoxifylline (Grade D) due to limited procedure-specific evidence of its analgesic effect

LA for analgesia

• Bilateral TAP block (Grade D) because of limited procedure-specific evidence

Intra-operative

Recommended:

Systemic analgesia

• COX-2-selective inhibitors (Grade B) (only for patients who do not receive epidural anaesthesia)
• Strong opioids (Grade B) (only for patients who do not receive epidural anaesthesia) 
• Continuous administration of pre-/intra-operative IV lidocaine if continued during the immediate postoperative period, when epidural analgesia is not feasible or contra-indicated (Grade B)

Epidural analgesia

• Continuous thoracic epidural anaesthesia and analgesia, at a level appropriate to the site of incision are recommended for routine use (Grade A)
• Combination of strong opioid and local anaesthetic is recommended (Grade A) based on procedure-specific evidence of their combined efficacy, in reducing postoperative pain and opioid use, compared with LA alone

Operative techniques

• The decision concerning the type of operative technique or incision to use for colonic resection should be primarily based on factors other than the management of postoperative pain, e.g. malignancy versus benign disease operative risk factors of the patient, risk of wound infection, and availability of surgical expertise (Grade D)
• Laparoscopic colonic resection is recommended over open colon surgery for reducing postoperative pain, if the conditions outlined above allow (Grade A)
• Horizontal/curved (transverse) incision is recommended over a vertical incision for analgesic and other benefits if the operative conditions allow (Grade B). In addition, the horizontal/curved incision is preferred for its cosmetic benefits (Grade D)
• Diathermy is recommended over the scalpel (Grade C)
• Maintenance of normothermia is recommended for improved clinical outcomes, but it is not helpful for reducing postoperative pain (Grade A)

Not recommended:

Systemic analgesia

• IV clonidine (Grade D) because it associated with an increased risk of hypotension, sedation and bradycardia
• Calcium channel antagonists (Grade B), based on limited procedure-specific evidence showing a lack of postoperative analgesic effect
• Gabapentin/pregabalin (Grade D) due to a lack of procedure-specific evidence
• Continuous administration of IV lidocaine limited to the pre-/intra-operative period (Grade D) because of inconsistent and insufficient procedure-specific evidence
• NMDA receptor antagonists (Grade D) because of limited procedure-specific evidence of analgesic efficacy
• Strong opioids (Grade D), in patients receiving epidural analgesia
• Weak opioids (Grade D), as placebo-controlled evidence for their benefit in reducing postoperative pain is limited. In patients not receiving epidural analgesia, strong opioids, not weak opioids, are recommended

Epidural analgesia

• Addition of clonidine to the combination of epidural LA + opioid (Grade D) because of side effects

Spinal analgesia

• Spinal analgesia in combination with epidural anaesthesia (Grade B) based on a lack of benefit in reducing postoperative pain in colonic resection

Postoperative

Recommended:

Systemic analgesia

• COX-2-selective inhibitors (Grade B) (only for patients who do not receive epidural analgesia or with the cessation of epidural analgesia)
• Conventional NSAIDs (Grade A) (only for patients who do not receive epidural analgesia or with cessation of epidural analgesia)
• IV lidocaine (Grade B) (when epidural is not feasible or contra-indicated)
• Strong opioids (Grade B) (for high-intensity pain)
• Weak opioids (Grade B) in association with other non-opioid analgesics (for moderate- or low-intensity pain), or if non-opioid analgesia is insufficient or contra-indicated
• Paracetamol (Grade B) for moderate- or low-intensity pain (only for patients that do not receive epidural analgesia, or after cessation of epidural analgesia)

Epidural analgesia

• Continuous thoracic epidural anaesthesia and analgesia at a level appropriate to the site of incision (Grade A)
• A combination of strong opioid and local anaesthetic is recommended for epidural analgesia (Grade A)

Wound infiltration or infusion

• Continuous pre-peritoneal infusion of LA, as an alternative when epidural analgesia is not feasible or contra-indicated (Grade B)

Multi-modal rehabilitation protocols

• Care protocols (which include controlled rehabilitation with early ambulation and diet, or multi-modal optimisation programmes) (Grade A)

Not recommended:

Systemic analgesia

• Gabapentin/pregabalin (Grade D) due to a lack of procedure-specific evidence
• NMDA receptor antagonists (Grade D) because of limited procedure-specific evidence of analgesic efficacy
• IM strong opioids (Grade D)
• Weak opioids (for controlling high-intensity pain) (Grade B)

Wound infiltration or infusion

• Continuous postoperative wound infusion with LA (Grade D) as procedure-specific evidence is limited and inconsistent
• Pre-closure wound infiltration with local anaesthetic (Grade D) due to lack of procedure-specific evidence and inconclusive transferable evidence from other large abdominal surgeries

Multi-modal rehabilitation protocols

• Mechanical massage with aspiration of abdominal wall (Grade D) as further supportive data are needed
• Nasogastric tubes (Grade A) because they are associated with discomfort and inconvenience and do not decrease the duration of postoperative ileus

Laparoscopic colonic resection:

Recommended:

Systemic analgesia

• Conventional NSAIDs (Grade B) based on limited procedure-specific evidence

Epidural analgesia

• Epidural analgesia is recommended in high-risk pulmonary patients (Grade D)

Wound infiltration/infusion

• Pre-closure wound infiltration with LA (Grade B)

Operative techniques

• The decision concerning the type of operative technique or incision to use for colonic resection should be primarily based on factors other than the management of postoperative pain, e.g. malignancy versus benign disease; operative risk factors of the patient; risk of wound infection; and availability of surgical expertise (Grade D)
• Laparoscopic colonic resection is recommended over open colon surgery for reducing postoperative pain, if the conditions outlined above allow (Grade A)

Not recommended:

Systemic analgesia

• Continuous intra-/postoperative IV lidocaine (Grade D) because of limited procedure-specific data, despite some postive transferable evidence

Spinal analgesia

• Combination of spinal analgesia and general anaesthesia (Grade D) as the risk: benefit balance is not positive, and because of limited procedure-specific evidence

Epidural analgesia

• Epidural LA + strong opioid (Grade D) due to poor risk:benefit ratio

Gasless laparoscopic colectomy

• Gasless laparoscopy (Grade B) based on procedure-specific evidence showing lack of analgesic effect

Laxatives

• Laxatives for analgesia (Grade B) because limited procedure-specific evidence shows no analgesic benefit (but they may be used for reasons other than pain relief)

Multi-modal rehabilitation protocols

• Postoperative restriction of IV fluids (Grade B) due to procedure-specific evidence showing limited analgesic efficacy

See Overall PROSPECT Recommendations for the overall strategy for managing pain after colonic resection