Laparoscopic Cholecystectomy 2005

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

• Eight studies out of ten showed a significant benefit of conventional NSAIDs over placebo or no treatment for reducing VAS pain scores Munro et al 1998 Click here for more information
• Five studies out of ten showed a significant benefit of conventional NSAIDs compared with placebo or no treatment for reducing supplementary analgesic use Forse et al 1996 Click here for more information
• One study measured parameters of pulmonary function and found that the values of FEV₁ and FEF_25–75 were significantly higher at 4 h after surgery in the ketorolac group compared with the placebo group (p<0.05) Liu et al 1993
• One study out of one showed that tenoxicam (20 mg) + ondansetron (4 mg), administered in 20 ml saline before induction of anaesthesia, significantly reduced the time to first flatus compared with ondansetron alone (p<0.05) Elhakim et al 1995
• One study showed that IP NSAID + IP LA significantly reduced abdominal VAS pain scores at 0, 1, 2 and 6 h compared with placebo, but not at 12 or 24 h, whereas IV NSAID + IP LA significantly reduced VAS pain scores at all time points (p<0.05, in all cases); IP NSAID + IP LA and IV NSAID + IP LA also significantly reduced shoulder VAS pain scores at 0 and 6 h and at 0, 1 and 6 h, respectively (p<0.05, in all cases) Jabbour-Khoury et al 2005
• One study showed that the number of patients needing rescue analgesics (type, dose and time of administration not stated) was significantly lower in the IV NSAID + IP LA group, but not the IP NSAID + IP LA group, compared with the placebo group (p<0.05) Jabbour-Khoury et al 2005
• The incidence of vomiting was significantly lower in the IV NSAID + IP LA group, but not the IP NSAID + IP LA group, compared with the placebo group (p<0.05) Jabbour-Khoury et al 2005
• IV tenoxicam significantly reduced the time to bowel recovery compared with IP tenoxicam Elhakim et al 2000a

Arguments against…

• Two studies out of seven that recorded the incidence of nausea and/or vomiting showed that conventional NSAIDs significantly reduced the incidence of nausea and/or vomiting compared with placebo or no treatment Elhakim et al 1995Click here for more information
• One study out of one found no significant difference for the duration of hospital stay between IM ketorolac, administered intra-operatively pre- and post-procedure, and placebo Lane et al 1996
• One study out of one found no significant difference for the time to hospital discharge between IM diclofenac, administered after induction of anaesthesia (n=26), and control (n=23) Wilson et al 1994
• Postoperative ketoprofen significantly increased VAS pain scores compared with pre-operative ketoprofen during the first 12 h following surgery (p<0.05), with the effect being most evident during the first 3 h (p=0.001), although there was no significant difference between the two groups at 24 h Boccara et al 2005
• Postoperative ketoprofen significantly decreased the time to first analgesic demand compared with pre-operative ketoprofen (p<0.05) Boccara et al 2005
• Postoperative ketoprofen did not significantly reduce opioid use compared with pre-operative ketoprofen Boccara et al 2005
• One study out of one showed that IM ketorolac (60 mg), administered intra-operatively post-procedure (n=20) significantly decreased the time to first analgesic request (p<0.05) compared with IM ketorolac, administered intra-operatively pre-procedure (n=31)  Lane et al 1996
• One study showed no significant difference between IV and IP administration of tenoxicam for VAS pain scores (at rest, on movement or on coughing), opioid use (postoperative opioid was 20 mg IM nalbuphine, every 4 h, or on request), incidence of nausea or vomiting and length of hospital stay  Elhakim et al 2000a
• A study which compared IV tenoxicam + intraperitoneal (IP) lidocaine + IP saline with IP tenoxicam + IP lidocaine + IV saline, administered at the end of surgery, showed no significant difference between IV and IP administration of tenoxicam for VAS pain scores, opioid use, incidence of nausea or vomiting and length of hospital stay  Elhakim et al 2000a
• One study that compared IM ketorolac + glycerin suppository (n=17), administered after the induction of anaesthesia, with IM saline + indomethacin suppository, showed no significant difference in pain scores, opioid use and incidence of nausea/vomiting Forse et al 1996
• Pre-operative ketoprofen significantly reduced opioid use compared with pre-operative propacetamol, but there was no significant difference between these agents given postoperatively Boccara et al 2005 Click here for more information
• One study showed that there was no significant difference between postoperative ketoprofen and postoperative propacetamol for the time to first analgesic demand Boccara et al 2005
• There were no significant differences between postoperative ketoprofen and postoperative propacetamol, for the incidence of nausea or vomiting Boccara et al 2005
• Study details Boccara et al 2005 Click here for more information
• Table 1. Systemic conventional NSAIDs versus placebo or no treatment: Study details Elhakim et al 1995 Click here for more information

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for …

• One study (two reports) showed that parecoxib/valdecoxib were associated with significantly reduced pain compared with placebo Joshi et al 2004 Click here for more information
• Parecoxib/valdecoxib significantly reduced supplemental analgesic use compared with placebo Joshi et al 2004 Click here for more information
• Parecoxib/valdecoxib treatment resulted in significantly improved patient and physician/nurse global evaluations compared with placebo (p<0.05) Joshi et al 2004
• Parecoxib/valdecoxib was associated with reduced incidence of vomiting at 24 h post-discharge (p<0.05) compared with placebo but overall incidence of PONV throughout the study period was not reduced Gan et al 2004 Click here for more information
• Study details Joshi et al 2004 Click here for more information

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

• IV ketamine infusion significantly reduced pain compared with placebo: VAS pain scores at rest at 2–4 h (p<0.05 in each case), but not at 0, 1, 8 or 20 h; VRS pain scores at 2 and 3 h (p<0.05 in both cases), but not at other time points Ayoglu et al 2005
• Postoperative, but not pre-operative, IV ketamine (bolus dose) reduced postoperative pain compared with placebo Mathisen et al 1999 Click here for more information
• IV ketamine infusion significantly reduced VAS pain scores at rest compared with magnesium at 4 and 20 h (p<0.05 in both cases), but not at 0–4 h or at 8 h; ketamine also significantly reduced VRS pain scores compared with magnesium at 4 h (p<0.05), but not at other time points Ayoglu et al 2005
• IV ketamine infusion significantly reduced cumulative opioid use compared with placebo at 2 and 3 h (p<0.05 in both cases), but not at 4 or 20 h (postoperative opioid was PCA bolus of 1 mg morphine, 10-minute lockout, maximum 4 h dose 20 mg) Ayoglu et al 2005
• IV ketamine reduced the amount of rescue tramadol used and the number of patients requesting rescue tramadol compared with tramadol (p values not given) (a rescue dose was administered when VAS >5 on the 0–10 scale) Launo et al 2004

Arguments against…

• IV ketamine and tramadol were equally effective for reducing VAS pain scores 0–24 h after surgery; there were no significant differences between the two treatment groups for VRS pain scores Launo et al 2004
• IV magnesium infusion did not significantly reduce VAS or VRS pain scores compared with placebo at any time during 0–20 h Ayoglu et al 2005
• IV magnesium infusion did not significantly reduce cumulative opioid use compared with placebo at any time during 0–20 h (postoperative opioid was PCA bolus of 1 mg morphine, 10-minute lockout, maximum 4 h dose 20 mg) Ayoglu et al 2005
• Pre-operative and postoperative (R)-ketamine (bolus dose) were similar to placebo for pethidine use in the first 4 h, and for use of paracetamol + codeine at 24 h and 7 days postoperatively (postoperative analgesia: bolus doses of 0.1 mg/kg pethidine, 5-minute lockout, for 4 h, and after discharge, 500 mg paracetamol + 30 mg codeine) Mathisen et al 1999
• IV ketamine and IV magnesium infusion were associated with similar cumulative opioid use during 0–20 h (postoperative opioid was PCA bolus of 1 mg morphine, 10-minute lockout, maximum 4 h dose 20 mg)
• IV ketamine and IV magnesium infusion and placebo were associated with a similar incidence of nausea and vomiting, and similar pulmonary function Ayoglu et al 2005
• IV ketamine increased the incidence of nausea compared with tramadol (p value not given)  Launo et al 2004
• Study details Mathisen et al 1999 Click here for more information

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

• Two studies showed that parenteral strong opioids reduced supplemental analgesic requirements compared with placebo Munoz et al 2002 Click here for more information

Arguments against…

• There were no significant differences between IV morphine and placebo for VAS pain scores at rest or on coughing at any time point (i.e. 0–180 minutes) Munoz et al 2002
• There were no significant differences between groups receiving pre-operative, intra-operative or postoperative IV morphine for VAS pain scores at rest or on coughing at any time point Munoz et al 2002
• Systemic opioid and placebo groups took a similar length of time to first analgesic request Munoz et al 2002
• There was no significant difference between IV morphine and placebo for the incidence of postoperative emesis Munoz et al 2002
• There was no significant difference between the IM pethidine and placebo groups for the duration of hospital stay Lane et al 1996
• There were no significant differences between groups receiving pre-operative, intra-operative or postoperative IV morphine for opioid use or the incidence of emesis. All IV morphine groups took a similar length of time for first analgesia request Munoz et al 2002
• Study details Munoz et al 2002 Click here for more information

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

• Compared with placebo, tramadol significantly reduced VAS pain scores at 30, 45 and 60 minutes postoperatively (in all cases, p=0.01), but not at any other time point in the first 24 h (i.e. at 2, 4, 6, 8, 10, 12, 18 or 24 h Naguib et al 2000
• Tramadol treatment was significantly superior to placebo treatment for reducing pain scores recorded by an observer at 30 and 45 minutes following surgery (p=0.01, in both cases)  Naguib et al 2000
• Tramadol treatment significantly increased the time to first analgesic request and the proportion of patients not requesting PCA analgesia (postoperative PCA analgesia was 16 mg tramadol, 5-minute lockout; 4-h limit: 400 mg) compared with placebo (p<0.03) Naguib et al 2000
• Tramadol significantly reduced supplementary tramadol use only at 30, 45 and 60 minutes postoperatively compared with placebo (p<0.03), but not at any other time point in the first 24 h Naguib et al 2000

Arguments against…

• One study that compared pre-operative IV tramadol + postoperative IV tramadol PCA with pre-operative IV morphine + postoperative IV morphine PCA, showed that morphine significantly reduced VAS pain scores at 30, 45 and 90 minutes following surgery compared with tramadol (in all cases, p<0.05), but not at any other time (recorded every 2 h until 24 h) or for pain scores recorded by an observer; but not at any other time  Naguib et al 1998
• PCA drug consumption was significantly greater in the pre-operative IV tramadol + postoperative tramadol PCA group at 90 minutes and 4 h postoperatively, compared with the pre-operative IV morphine + postoperative morphine PCA group Naguib et al 1998 Click here for more information
• There were no significant differences between pre-operative IV tramadol + postoperative IV tramadol PCA group and pre-operative IV morphine + postoperative IV morphine group for the time taken to the first analgesic demand or for the proportion of patients not requesting PCA analgesia Naguib et al 1998
• The incidence of nausea and vomiting, as well as respiratory rate were similar in both tramadol and placebo groups Naguib et al 2000
• The incidence of nausea and vomiting and cardiovascular adverse effects was similar in both pre-operative IV tramadol + postoperative IV tramadol PCA group and pre-operative IV morphine + postoperative IV morphine PCA group Naguib et al 1998
• Study details Naguib et al 2000 Click here for more information

LAPAROSCOPIC CHOLECYSTECTOMY-SPECIFIC EVIDENCE

Arguments for…

• Postoperative administration of propacetamol significantly reduced VAS pain scores between 2 and 5 h postoperatively compared with pre-operative administration (p<0.05); the number of patients with severe pain (VAS 50 mm or greater) was significantly lower in the postoperative administration group compared with the pre-operative administration group (p<0.05) Boccara et al 2005
• Two studies showed no significant difference for VAS pain scores between postoperative NSAIDs and postoperative propacetamol/paracetamol but pre-operative propacetamol was associated with significantly higher VAS pain scores compared with pre-operative ketoprofen Boccara et al 2005 Click here for more information
• Ibuprofen sustained-release tablets and paracetamol were associated with similar VRS pain scores all time points (i.e. days 1–7) Owen et al 1997
• Pre-operative propacetamol was associated with significantly greater opioid use compared with pre-operative ketoprofen, but there was no significant difference between these agents given postoperatively Boccara et al 2005 Click here for more information
• The number of patients requiring supplemental nalbuphine, the total dose consumed and the time to first analgesic demand were similar in both pre-operative and postoperative propacetamol groups Boccara et al 2005
• The incidence of nausea or vomiting was similar in both pre-operative and postoperative propacetamol groups Boccara et al 2005

Arguments against…

• There were no significant differences between the paracetamol + codeine and codeine alone groups for VAS pain scores (recorded at 0.5–4 h, then 3 times/day, until 48 h) Chung et al 2004
• Supplemental opioid consumption, the time of onset of analgesia and the overall level of pain relief were similar in both paracetamol + codeine and codeine alone groups Chung et al 2004
• There were no significant differences between the paracetamol + codeine and codeine alone groups for postoperative nausea; the time to discharge was also similar in both groups Chung et al 2004
• Study details Boccara et al 2005 Click here for more information