Open Colorectal Surgery 2016

Arguments for…

• Preperitoneal continuous wound infusions of either 0.38% ropivacaine or 0.9% saline (5 mL/h after laparotomy or 2 mL/h after laparoscopy) resulted in a decrease in the total morphine consumption in the ropivacaine group after laparoscopy (p=0.010) and after laparotomy (p=0.041), with no increase in side effects (Fustran et al. 2015, n=60; LoE 1).
• Patients undergoing elective midline laparotomy given either two catheters placed over the fascia (suprafascial group) before surgical wound closure or with catheters placed between the two sheaths of each rectus muscle (interfascial group). Interfascial catheter administration of bupivacaine led to significantly lower VAS scores compared with the suprafascial catheter group for up to 36 h after surgery (p<0.05) (Khorgami et al. 2013, n=60; LoE 1).
• CWI with intraperitoneal ropivacaine (75 mg before dissection, postop CWI 0.2% solution at 4 mL/h for 3 days) resulted in significantly lower VAS at rest and on moving, up to 12 h post op (p=0.001) compared with placebo (treated as above with 0.9% saline solution) (Kahokehr et al. 2011, n=60, LoE 1).
• Postop local anesthetic infusion with 0.2% ropivacaine at the fascial plane of a midline laparotomy wound compared with infusion with normal saline is resulted in a significant decrease in morphine PCA requirement (p=0.01). There was no detectable difference in patient-reported pain scores (Wang et al. 2010, n=55; LoE 1).
• Infusion of 10 mL 0.25 % levobupivacaine twice a day postop via preperitoneal catheter resulted in a significant decrease in PCA bupivacaine/fentanyl requirement compared with control (10 mL 0.9% saline) (p=0.032). VAS scores were similar for both groups (Ozturk et al. 2011, n=50; LoE 1)
• A systematic review of 12 randomized trials evaluating novel local anesthetic wound infiltration techniques in colorectal surgery appears to show a reduction in postoperative opiate requirements (p=0.07) and pain scores on movement (p=0.004) along with improvement in postop recovery compared with placebo or routine analgesia (Ventham et al. 2014, n=902, LoE 1).

Wound infiltration or infusion study details Click here for more information

Arguments for…

• Continuous pre-peritoneal infusion of LA may be considered as an alternative when epidural analgesia is not feasible or contraindicated based on limited procedure-specific evidence for analgesic benefit (LoE 2)

Arguments against…

• Intra-operative wound infiltration is a well-established method of analgesia with a favourable safety profile. However, methods of postoperative wound infusion are not well established

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

Arguments against…

• Continuous LM-TAP block (infusion of 0.35% ropivacaine at a rate of 2 to 2.5 mL/h + rescue PCA) was not siginificantly different to TEA (PCEA with 0.1% bupivacaine with 10µg/ml hydromorphone) for pain scores (VAS 1-10) either at rest (p=0.829) or on coughing (p=0.551). (Ganapathy et al. 2015, n=50; LoE 1).
• A systematic review of 8 randomized controlled trials comparing TAP block or rectus sheath block with no TAP or rectus sheath block; placebo; systemic, epidural or any other analgesia concluded that there is only limited evidence to suggest use of perioperative TAP block reduces opioid consumption and pain scores after abdominal surgery when compared with no intervention or placebo (Charlton et al. 2010, n=337; LoE 1).

LM-TAP block study details Click here for more information

Continuous LM-TAP block cannot be recommended due to a lack of procedure-specific evidence, however, may be considered for management of acute pain after Colorectal surgery when epidural analgesia is not feasible or is contra-indicated (GoR B).

Arguments for…

• Group I (GI) received postop PCEA with CI of ropivacaine and fentanyl, while Group II (GII) receive postop patient-controlled continuous wound catheter infusion of ropivacaine. Group I had significantly less pain at rest and on movement (p<0.05) and less requirement for rescue medication (p<0.05) up to 24 h compared with GII (De Almeida et al. 2011, n=38; LoE 2).
• Epidural analgesia with 0.375% ropivacaine was compared with continuous wound infusion with 0.2% ropivacaine. Postop pain scores on movement were lower in the epidural group than in the CWI group until hospital discharge (p<0.001) (Jouve et al. 2013, n=50; LoE 1))

Arguments against…

• Pre-incisional administration of epidural morphine 3 mg resulted in higher postop pain scores (p<0.05), greater requirement for analgesics (p<0.05) and poorer patient satisfaction (p<0.05) than post-incisional administration of morphine 3 mg, after colon surgery (Bronstein et al. 2011, n=40; LoE 1).
• The addition of fentanyl 25 μg and/or bupivacaine 2 mg to subarachnoid morphine 200 μg reduces the need for additional intra-op epidural bupivacaine and IV fentanyl (p=0.017), delays the first postop analgesia request (p=0.009), but does not improve postop VAS pain scores (Stamenkovic et al. 2009, n=58; LoE 1).

Epidural analgesia study details Click here for more information

Arguments for…

• Epidural analgesia using LA was superior to systemic strong opioid for reducing postoperative pain scores in six studies identified in a systematic review of abdominal surgery (Jorgensen 2000)
• Epidural analgesia using a combination of LA and strong opioid was superior to epidural LA alone for reducing postoperative pain – 15 mm reduction in VAS score on a 100-mm scale – in a meta-analysis of five studies in abdominal surgery (Jorgensen 2000)
• Epidural analgesia using LA was superior to epidural opioids or systemic opioids for reducing the incidence of postoperative gastrointestinal paralysis, in a systematic review in abdominal surgery (Jorgensen 2000)
• Epidural LA was suggested to be the most effective method of reducing ileus and improving postoperative catabolism in patients undergoing abdominal surgery. A meta-analysis of patients undergoing abdominal surgery demonstrated that epidural LA was superior to epidural LA plus opioid for reducing the time to first passage of stool (WMD (random) -44 hours [-72, -17]) in seven of eight studies. The remaining study showed no significant difference (n=406) (Jorgensen 2000)

Arguments against…

• Results for the incidence of postoperative nausea were inconsistent for comparison of epidural LA with epidural LA plus opioid, and no significant difference for the incidence of vomiting was seen. A systematic review of studies from patients undergoing abdominal surgery demonstrated that epidural LA was superior to epidural LA plus opioid for reducing the incidence of postoperative nausea in two out of ten studies. Seven studies were not significantly different, and the remaining study was in favour of epidural LA plus opioid (n=514). No significant difference between groups was observed for the incidence of postoperative vomiting in four studies that reported this parameter (n=259) (Jorgensen 2000b)
• Epidural clonidine is associated with an increased risk of hypotension, sedation and bradycardia. Two studies reported that intra-operative epidural clonidine was associated with a significant decrease in arterial blood pressure compared with placebo in abdominal hysterectomy (p<0.05 for both; n=40; n=22) (Mogensen 1992a, Samso 1996). Postoperative epidural clonidine was associated with a significant decrease in arterial blood pressure compared with morphine (p<0.05) (Lund 1989), and compared with baseline arterial blood pressure before clonidine treatment (p<0.05) in abdominal hysterectomy (morphine treatment had no significant effect) (VanEssen 1990)

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

Arguments against… 

• There was no significant difference in return of bowel function, duration of hospital stay, or postoperative pain control between patients receiving epidural analgesia (bupivacaine 0.125% + hydromorphone 6 µg/mL at 10 mL/hr) or IV lidocaine (1 mg/min in patients <70 kg, 2 mg/min in patients ≥70 kg) after open colon surgery (Swenson et al. 2010, n=42; LoE 1).

Lidocaine study details Click here for more information

Arguments for…

• A meta-analysis of randomized clinical trials performed to evaluate the effect of continuous IV lidocaine infusion during and after abdominal surgery reported that lidocaine significantly reduced postoperative VAS pain scores, duration of postoperative ileus, incidence of PONV, and length of hospital stay, compared with the controls

Postoperative IV lidocaine is recommended (GoR D) for Colorectal surgery when epidural analgesia is not feasible or contra-indicated (GoR B) based on transferable evidence (LoE 1)