Colonic Resection

Expand all

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

Overall PROSPECT Recommendations for open and laparoscopic colonic resection

Algorithm for the management of postoperative pain

Not recommended for open and laparoscopic colonic resection

This algorithm for treating postoperative pain is based on the PROSPECT Recommendations and illustrates the different treatment pathways for patients with no contra-indications to epidurals, patients with contra-indications to epidurals, patients undergoing laparoscopic colonic resection, as well as describing the steps of the peri-operative pathway and therapies that apply to all patients. Therapies that are not recommended are also indicated.

 

Literature search

 • Systematic review of the literature from 1966–March 2009 using MEDLINE and EmBASE, following the protocol of the Cochrane Collaboration

 • Inclusion of randomised studies assessing analgesic interventions in colonic resection and reporting pain on a linear analogue scale (Colonic Resection Search terms March 2009)

 • Identification of studies of peri-operative interventions for postoperative pain following colonic resection

80 studies included (Click here for further information)

73 studies excluded (Click here for further information)

• The most common reasons for exclusion were the lack of VAS postoperative pain scores (32 studies), and the lack of a defined subgroup of patients undergoing colonic resection (16 studies)

This website provides recommendations for open and laparoscopic colonic resection. Results from the open and laparoscopic colonic resection studies are dealt with separately, because of the different pain profiles associated with these approaches.

• A majority of the studies assessed the effect of analgesic interventions in open colonic resection with the exception of:

• In five of seven studies, laparoscopic colonic resection was superior to open colonic resection for reducing postoperative pain scores: at rest, during coughing and mobilisation at 6 h (all p<0.05; n=29) (Stage 1997; LoE 2); at rest at 48 h (p<0.01) and during coughing 24–72 h, (p<0.01; n=44) (Danelli 2002; LoE 2); at rest and on coughing within the first week (p<0.02; n=60) (Schwenk 1998; LoE 2) and on Day 1 in two studies (p=0.003; n=403; p<0.05, n=39) (Leung 2004; LoE 1, Liang 2002; LoE 2). One study reported that open colonic resection was superior to laparoscopic colonic resection for the reduction of VAS pain scores at rest and activity at day 1 (p<0.05; n=60), but not from days 2–30 (Basse 2005; LoE 1). Another study showed no significant difference between laparoscopic-assisted colectomy and open colectomy for pain distress scores from baseline to 2 days, 2 weeks and 2 months postoperatively (Weeks 2002; LoE 1)

• In two of three studies, hand-assisted laparoscopic colonic surgery was superior to open colonic surgery for reduction of postoperative pain scores: during the first postoperative week (p<0.001; n=81) (Chung 2007; LoE 1), and on Day 1 (p=0.03), Day 3 and Day 14 (p<0.001; n=60) (Kang 2004; LoE 2); the third study reported no significant difference in postoperative VAS pain scores at rest and during movement on Days 1, 2, 3 and 7, and at Week 4 (n=55) (Maartense 2004; LoE 1)

• In addition, a meta-analysis of randomized clinical trials (comprising of 2512 procedures from 12 trials) comparing the short-term outcomes of laparoscopic with those of open resection for colorectal cancer demonstrated that laparoscopic colonic resection is associated with lower morbidity, reduced pain and/or analgesic consumption, a faster recovery and a shorter hospital stay than open resection, without compromising oncological clearance (Abraham 2004; LoE 1)

Study quality assessments, levels of evidence and 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 recommendations in PROSPECT reviews (from 2006).

Click here for quality scores and levels of evidence for included procedure-specific studies: Colonic Resection September 2009 Quality Scoring + Levels of Evidence. 

Transferable evidence

Transferable evidence of analgesic efficacy from comparable procedures, or evidence of other outcomes such as adverse effects, has been included to support the procedure-specific evidence where this is insufficient to formulate the recommendations.

Most of the transferable evidence for colonic resection was supplemented from major abdominal surgery and gynaecological procedures.

Quantitative analyses

Overall, few meta-analyses could be performed that used data from more than two studies. This is because there are a limited number of studies of homogeneous design that report similar outcome measures. Therefore, the majority of the procedure-specific evidence was assessed only qualitatively.

Topics for future research

In certain circumstances, recommendations for a type of treatment cannot be made due to limited or conflicting evidence. Areas which have been identified as requiring further investigation in the future are as follows:

  • TAP blocks
  • Alpha-2-delta ligands
  • NMDA receptor antagonists
  • Postoperative continuous LA wound infusion
Abbreviations

AUC

area under curve

GA

general anaesthetic

IM

intramuscular

Intra-op

intra-operatively

IV

intravenous

LA

local anaesthetic

NRS  

numerical rating scale

PACU

post-anaesthesia care unit

PCA   

patient-controlled analgesia

PCEA

patient-controlled epidural analgesia

POD

postoperative day

PONV

postoperative nausea and vomiting

Postop

postoperatively

Pre-op

pre-operatively

VAS   

visual analogue scale

VRS   

verbal rating scale

VNS

verbal numerical scale

In this section, data are available from studies that assessed pre-operative analgesia versus pre-operative placebo, as well as those that examine the concept of pre-emptive – or preventive – analgesia, assessed pre-operative analgesia versus the same analgesia given postoperatively.

A previous systematic review of pre-emptive analgesia for postoperative pain relief in a variety of surgical procedures – such as orthopaedic, dental, gynaecological and abdominal – concluded that there is no benefit of pre-emptive over postoperative administration (Møiniche 2002). More recently, a meta-analysis of studies comparing pre-operative interventions with similar postoperative interventions in various procedures, found that pre-operative epidural analgesia was effective in reducing postoperative pain scores, but that pre-operative NSAIDs, local anaesthetic wound infiltration, NMDA antagonists and opioids did not improve postoperative analgesia (Ong 2005b).

 Despite these findings, it is considered that analgesic medication needs to be initiated in time to ensure an adequate analgesic effect in the immediate postoperative period. This may necessitate administration prior to the postoperative period.

PROSPECT Recommendations

  • Clonidine is not recommended (Grade D), despite limited procedure-specific evidence for analgesic efficacy, because it is associated with an increased risk of hypotension and bradycardia (LoE 4)

Clinical Practice

  • The risk:benefit ratio for clonidine is unclear. Recognised side-effects include hypotension, sedation, dizziness and bradycardia
  • There is no consensus among clinicians on the optimum dose of clonidine that should be used

Transferable Evidence from Other Procedures

Open Colonic Resection-Specific Evidence - Study information

PROSPECT Recommendations

  • Pre-operative COX-2-selective inhibitors are recommended (Grade B) for colonic resection based on procedure-specific evidence that they have an analgesic effect postoperatively (LoE 2), only for patients who do not receive epidural analgesia (LoE 4)
  • It is recommended that the use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (Grade B): cardiovascular morbidity (transferable evidence, LoE 1), renal function and hepatic function (transferable evidence, LoE 3), or actual or recent gastroduodenal ulcer history (LoE 4). In addition, the potential risk of anastomotic leakage needs to be considered (transferable evidence, LoE 3). Further observations are required regarding the potential risk of N

Clinical Practice

  • Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries
  • There is no procedure-specific evidence that pre-operative administration of COX-2-selective inhibitors is more effective than postoperative administration

Transferable Evidence from Other Procedures - Study information

  • COX-2-selective inhibitors provide similar postoperative analgesia to conventional NSAIDs
  • A pre-operative single bolus of parecoxib was superior to placebo for postoperative pain scores on sitting-up over 24 h (p=0.02), providing a mean decrease of 14 mm in VAS scores on a 100 mm scale in patients undergoing abdominal hysterectomy (n=36)
  • Pre-operative oral etoricoxib was superior to placebo for reducing pain scores at rest and on coughing at a minority of timepoints Chau-in et al 2008 Click here for more information
  • A pre-operative single bolus of IV parecoxib or oral rofecoxib reduced morphine consumption over 24 h compared with placebo in patients undergoing abdominal hysterectomy Ng et al 2003 Click here for more information
  • One study found that pre-operative oral etoricoxib was superior to placebo for reducing mean postoperative morphine consumption after 24 h (120 and 180 mg etoricoxib versus placebo, p=0.012) (n=49)
  • Pre-operative oral rofecoxib was associated with a lower incidence of PONV compared with placebo in one study (p<0.05; n=40)
  • Pre-operative oral COX-2-selective inhibitors were as effective as oral conventional NSAIDs for reducing postoperative pain scores in two studies of patients undergoing abdominal hysterectomy (n=25; n=40)
  • COX-2-selective inhibitors are similarly effective compared with conventional NSAIDs for reducing postoperative opioid consumption in patients undergoing abdominal hysterectomy Celik et al 2003 Click here for more information
  • Pre-operative oral rofecoxib compared with placebo had significantly lower pain scores at rest and after spirometry at 12 h postoperatively in patients undergoing abdominal surgery (rofecoxib 25 mg and 50 mg versus placebo p<0.05; n=48)
  • Pre-operative oral rofecoxib reduced morphine consumption at 24 h postoperatively compared with placebo in patients undergoing abdominal surgery (rofecoxib 25 mg versus placebo p<0.01; n=48)
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation
  • A randomised clinical trial showed that the COX-2-selective inhibitor rofecoxib was associated with significantly less intra-operative blood loss than the conventional NSAID diclofenac in patients undergoing abdominal or vaginal hysterectomy or breast surgery
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following noncardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062)
  • A review concluded that COX-2-selective inhibitors were as effective as conventional NSAIDs for treatment of postoperative pain in various surgical models, and offer a number of other advantages including: reduced incidence of gastrointestinal ulceration, no inhibitory effect on platelet function (and thereby a reduced risk of blood loss) and no induction of bronchospasm in patients with aspirin-sensitive asthma
  • A meta-analysis that included data from 17 parecoxib and 15 valdecoxib placebo-controlled trials in non-cardiac surgery showed that there was no significant association between short-term treatment with parecoxib and/or valdecoxib and an increase in cardiovascular thromboembolic adverse events, compared with placebo (n=8511 overall)
  • A retrospective cohort study showed that the COX-2-selective inhibitors rofecoxib and celecoxib were associated with a lower risk of acute kidney infection than less-selective NSAIDs
  • A pre-operative single bolus of COX-2-selective inhibitor did not significantly reduce postoperative pain scores at rest compared with placebo within 0–24 h in two studies of patients undergoing abdominal hysterectomy (n=40; n=36)
  • Two meta-analyses comparing pre-incisional and post-incisional NSAIDs/COX-2-selective inhibitors have found no significant benefit of pre-incisional administration for reducing pain scores
  • Two clinical trials showed that in patients who had undergone CABG surgery COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication
  • Although there is some concern COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting (
  • One study in patients undergoing fast-track colonic surgery found that postoperative analgesia with the COX-2-selective inhibitor celecoxib was associated with a higher risk of anastomotic leakage, compared with when celecoxib was not used

Open Colonic Resection-Specific Evidence – Study information

  • Pre-operative + postoperative oral valdecoxib was superior to placebo for reducing postoperative pain scores Sim et al 2007 Click here for more information
  • Pre-operative parecoxib was superior to placebo for reducing postoperative morphine consumption at a minority of timepoints Lee et al 2008 Click here for more information
  • Pre-operative + postoperative oral valdecoxib was superior to placebo for reducing postoperative morphine consumption Sim et al 2007 Click here for more information
  • The time until first flatus and first bowel movement was significantly shorter with pre-operative + postoperative oral valdecoxib, compared with placebo (p=0.003 and p=0.041, respectively; n=79)
  • The time taken to tolerate a solid diet was significantly shorter with pre-operative + postoperative oral valdecoxib versus placebo (p=0.029; n=79)
  • The length of hospital stay was significantly shorter for patients in the pre-operative + postoperative oral valdecoxib group, compared with the placebo group (p=0.009; n=79)
  • Pre-operative + postoperative administration of oral valdecoxib was associated with superior patient-assessed global evaluation scores (p=0.001; n=79), compared with placebo, but not with surgeon-assessed global evaluation scores
  • Pre-operative IV parecoxib did not confer any significant benefit over intra-operative IV parecoxib or placebo for the reduction of postoperative pain scores Lee et al 2008 Click here for more information
  • There was no significant difference in postoperative morphine consumption between the pre-operative IV parecoxib and intra-operative IV parecoxib groups from 0–48 h postoperatively (n=40)
  • The incidence of postoperative nausea and vomiting, dizziness and pruritus was similar between the pre-operative IV parecoxib, intra-operative IV parecoxib and placebo groups (n=60)
  • The incidence of postoperative sedation and nausea was similar with pre-operative + postoperative oral valdecoxib, and placebo (n=79)
  • Pre-operative + postoperative oral valdecoxib had no significant effect on the time taken to tolerate intake of liquids compared with placebo (n=79)
  • The hospital re-admission rate was similar in both the pre-operative + postoperative oral valdecoxib, and placebo groups (n=79)
  • The incidence of postoperative nausea and vomiting, dizziness and pruritus was similar in the pre-operative IV parecoxib and intra-operative IV parecoxib groups

PROSPECT Recommendations

  • Pre-operative conventional NSAIDs are not recommended (Grade B) despite their analgesic efficacy, because pre-operative administration of these agents can increase the risk of intra- and postoperative bleeding (transferable evidence, LoE 1)
  • In addition, pre-operative conventional NSAIDs are not recommended, because there is evidence from other procedures that pre-operative administration of conventional NSAIDs is no more effective than postincisional administration for reducing pain scores (Grade B) (transferable evidence, LoE 1). In addition, the potential risk of anastomotic leakage needs to be considered (transferable evidence, LoE 3)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures - Study information

  • Pre-operative naproxen was equally as effective as the COX-2-selective inhibitor rofecoxib for reducing postoperative pain scores at rest over 24 h, in patients undergoing abdominal hysterectomy (n=40)
  • Conventional NSAIDs have proven analgesic efficacy in a variety of surgical procedures
  • A meta-analysis of randomised controlled trials performed to evaluate the risk of morphine-related adverse effects in patients treated with NSAIDs, demonstrated that NSAIDs decreased the incidence of nausea, vomiting and sedation, but not pruritus, urinary retention or respiratory depression
  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo
  • Pre-operative rofecoxib was superior to naproxen for reducing the use of postoperative supplementary analgesics within 12–18 h (p<0.05), but there was no significant difference within 0–24 h in patients undergoing abdominal hysterectomy
  • Two meta-analyses comparing pre-incisional and post-incisional NSAIDs/COX-2-selective inhibitors have found no significant benefit of pre-incisional administration for reducing pain scores
  • Two of three studies showed no significant difference between single bolus conventional NSAIDs administered before or after incision for postoperative pain scores in patients undergoing abdominal hysterectomy Nakayama et al 2001a Click here for more information
  • Of three studies in abdominal hysterectomy, all showed no significant difference between pre-incisional and post-incisional conventional NSAIDs for supplementary analgesic consumption (n=65; n=30; n=77)
  • Post-incisional NSAID was superior to pre-incisional NSAID for extending the time to first analgesic request in one study (n=30)
  • Pre-incisional administration of conventional NSAIDs conferred no significant benefit over post-incisional administration for reducing the incidence of PONV in two studies of patients undergoing abdominal hysterectomy (n=65, n=30)
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo
  • Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery
  • A randomised clinical trial showed that the conventional NSAID diclofenac was associated with significantly greater intra-operative blood loss than the COX-2-selective inhibitor rofecoxib in patients undergoing abdominal or vaginal hysterectomy or breast surgery
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication
  • A restrospective, case-control study showed that postoperative analgesia with the conventional NSAID diclofenac (150 mg daily) was associated with a significantly higher number of anastomotic leakages than postoperative opioid analgesia in patients undergoing laparoscopic colorectal surgery

Open Colonic Resection-Specific Evidence

  • Pre-operative + postoperative IV flurbiprofen was superior to placebo for reducing postoperative pain scores Xu et al 2008 Click here for more information
  • Pre-operative + postoperative IV flurbiprofen axetil was superior to placebo for reducing the time to first pass of flatus and first bowel movement (both p=0.01; n=40)
  • The incidence of postoperative nausea and vomiting was similar in the pre-operative + postoperative flurbiprofen axetil and placebo groups (n=40)

PROSPECT Recommendations

  • Pre-operative corticosteroids are not recommended for analgesia (Grade A) because of procedure-specific evidence showing no significant benefit in reducing VAS pain scores (LoE 1) and concerns that they could affect anastomotic and wound integrity (LoE 4). However, they may be used for reduction of PONV (transferable evidence, LoE 1)

Clinical Practice

  • Nausea and vomiting are frequent in abdominal surgeries, and corticosteroids may be used for their anti-emetic effects in patients at risk
  • A single pre-operative high-dose bolus of corticosteroid may be considered in high-risk pulmonary patients
  • Corticosteroids are not used in routine clinical practice because of the concerns that they could affect anastomotic and wound integrity

Transferable Evidence from Other Procedures - Study information

  • A single prophylactic dose of corticosteroid is effective for preventing PONV in surgery associated with high emetic effects
  • A review of major abdominal surgery, a randomised study of patients at high-risk of nausea and vomiting undergoing surgery, and a systematic review of drugs that prevent PONV, all showed that corticosteroids decrease PONV
  • IV methylprednisolone significantly improved postoperative recovery outcomes compared with placebo in abdominal surgery Krantz et al 1990 Click here for more information
  • A meta-analysis showed that a single pre-operative dose of IV methylprednisolone (15–30 mg/kg) was associated with significantly fewer pulmonary complications compared with placebo or no treatment, but data on postoperative pain could not be meta-analysed Sauerland et al 2000 Click here for more information
  • IV methylprednisolone (30 mg/kg) significantly decreased pulmonary complications compared with placebo in one study identified in a review of major abdominal surgery
  • Corticosteroids did not significantly decrease pain compared with placebo in two studies identified in a review of major abdominal surgery

Open Colonic Resection-Specific Evidence - Study information

  • IV methylprednisolone sodium succinate (30 mg/kg) given 90 min before induction of anaesthesia significantly improved mobilisation and recovery compared with IV placebo (p<0.05) Schulze et al 1997 Click here for more information
  • IV methylprednisolone sodium succinate (30 mg/kg) given 90 min before induction of anaesthesia significantly improved pulmonary function (as measured by peak flow, forced vital capacity, and forced expiratory volume) compared with IV placebo 6 hours postoperatively (p<0.05; n=24)
  • IV methylprednisolone sodium succinate (30 mg/kg) given 90 min before induction of anaesthesia and epidural analgesia did not confer a significant benefit over IV placebo for cumulative VAS pain scores Schulze et al 1997 Click here for more information
  • Pre-operative IV dexamethasone did not confer a significant benefit over placebo for reduction of VAS pain scores at rest at any time point assessed (4 and 8 h, Days 1, 2 and 3) (n=27)
  • Pre-operative IV dexamethasone had no signficant effect on postoperative IM morphine (10 mg) requirements, compared with placebo (n=27)
  • Incidence of postoperative nausea and vomiting was similar in the pre-operative IV dexamethasone and placebo groups (n=27)
  • There were no significant differences in the time to first flatus, first bowel sound or first bowel movement with pre-operative IV dexamethasone versus placebo (n=27)
  • The length of hospital stay was similar for patients in the pre-operative IV dexamethasone and placebo groups (n=27)

PROSPECT Recommendations

  • Gabapentin/pregabalin cannot be recommended at this time (Grade D, LoE 4) due to a lack of procedure-specific evidence, although analgesic data from other procedures are promising

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Four systematic reviews and a meta-analysis evaluated the use of gabapentinoids for postoperative analgesia and demonstrated significant reductions in postoperative pain and supplementary analgesic requirements compared with inactive controls
  • Two systematic reviews
  • Two systematic reviews

Open Colonic Resection-Specific Evidence

  • [No data found within the parameters of the systematic review]

PROSPECT Recommendations

  • Continuous administration of IV lidocaine limited to the pre-/intra-operative period is not recommended (Grade D, LoE 4) because of inconsistent and insufficient procedure-specific evidence (LoE 1)
  • Continuous administration of pre/intra-operative IV lidocaine is recommended if continued during the immediate postoperative period, when epidural analgesia is not feasible or contra-indicated (Grade B), based on transferable evidence (LoE 1) and limited procedure-specific evidence (LoE 2) for recovery benefits, compared with control (see Intra-operative and Postoperative IV lidocaine sections)

Clinical Practice

  • IV lidocaine can be considered as an alternative when there are contra-indications to epidural analgesia techniques
  • Further evidence is needed to precisely define the role of IV lidocaine in this setting, including direct comparisons with epidural analgesia
  • IV lidocaine may induce hypotension
  • If IV lidocaine is used it is recommended that safety data are taken into account

Transferable Evidence from Other Procedures

  • [None cited]

Open Colonic Resection-Specific Evidence - Study information

  • Pre-/intra-operative IV lidocaine reduced postoperative pain scores at rest and on coughing at a minority of time points compared with control Kuo et al 2006 Click here for more information
  • Pre-/intra-operative IV lidocaine significantly reduced postoperative morphine requirement compared with control Kuo et al 2006 Click here for more information
  • Pre-/intra-operative IV lidocaine significantly reduced intra-operative fentanyl requirement compared with control Kuo et al 2006 Click here for more information
  • Pre-/intra-operative IV lidocaine was associated with a lower incidence of morphine-related nausea or vomiting compared with control (p<0.01; n=40)
  • Pre-/intra-operative IV lidocaine significantly reduced the time to first flatus, compared with the control group (p<0.01; n=40)
  • Peri-operative IV lidocaine significantly reduced the time to first flatus, compared with the control group (p<0.05; n=60)
  • The time to first bowel movement was significantly shorter with peri-operative IV lidocaine, compared with the control (p<0.05; n=60)
  • Peri-operative IV lidocaine significantly reduced the time taken to solid food intake compared with the control (p<0.001; n=60)
  • Peri-operative IV lidocaine significantly reduced the duration of hospital stay compared with the control (p=0.004; n=60)
  • Pre-/intra-operative IV lidocaine conferred no significant benefit over control for reducing the length of hospital stay (n=40)
  • Peri-operative IV lidocaine conferred no significant benefit over the control for the reduction of VAS pain scores at rest or during movement at any of the time points assessed (n=60)
  • Peri-operative IV lidocaine conferred no significant benefit over control for reducing the consumption of PCA IV piritramide (2 mg dose with a lockout period of 10 minutes) (n= 60)

PROSPECT Recommendations

  • Pre-operative NMDA receptor antagonists are not recommended (Grade D, LoE 4) because of limited procedure-specific evidence of analgesic efficacy

Clinical Practice

  • There is a lack of clinical experience with NMDA receptor antagonists. Moreover, NMDA receptor antagonists are associated with adverse events, e.g. ketamine is known for its increased risk of CNS side effects

Transferable Evidence from Other Procedures

  • Studies of intravenous or neuraxial ketamine in a variety of surgeries, including abdominal, gynaecological, orthopaedic, gastric, hepatic, and genitourinary surgery, showed a reduction in postoperative pain and opioid use when used as an adjunct to morphine
  • In patients undergoing laparoscopic cholecystectomy, dextromethorphan (pre- incisional and post gallbladder removal) was superior to control for reducing VAS scores, reducing the use of supplementary analgesics, and increasing the time to first analgesic request
  • Low-dose ketamine was associated with few and mild adverse effects, especially when administered in conjunction with general anaesthesia
  • A systematic review found that dextromethorphan did not reduce postoperative pain scores with a clinically significant magnitude, and although significant decreases in supplemental opioid consumption were observed, these were of questionable clinical importance in most cases
  • Two meta-analyses comparing pre-incisional and postincisional treatments found no significant analgesic benefit of pre-incisional administration of NMDA receptor antagonists
  • Two systematic reviews of randomised controlled trials comparing magnesium with placebo demonstrated inconclusive results overall with regards to pain scores and supplemental analgesic use

Open Colonic Resection-Specific Evidence - Study information

  • IM dextromethorphan was superior to control for reducing postoperative pain scores during coughing at 1, 2, 4, 8 and 24 h (p<0.001; n=60), although there were no significant differences in resting pain scores between the groups at any time point assessed
  • IM dextromethorphan was more effective than control for reducing postoperative opioid requirements Yeh et al 2005 Click here for more information
  • IM dextromethorphan significantly reduced the time to passage of first flatus, compared with the control (p<0.0001; n=60)
  • IV magnesium provided no significant benefit over placebo for reducing the following postoperative outcomes: pain scores at rest or during movement; morphine requirements for 0–24 h; sedation scores 0–48 h; incidence of nausea and vomiting; time to first bowel movement; and time to first flatus (n=47)
  • The incidence of morphine-related side-effects (drowsiness, dizziness, nausea, vomiting and pruritus) was similar in both the IM dextromethorphan and control groups (n=60)
  • Dextromethorphan conferred no significant benefit over control for reducing the length of hospital stay (n=60)

PROSPECT Recommendations

  • Pre-operative administration of strong opioids is not recommended (Grade B) for colonic resection as they are significantly less effective than postoperative strong opioids for reducing postoperative pain (transferable evidence, LoE 1)

Clinical Practice

  • [None Cited]

Transferable Evidence from Other Procedures - Study information

  • Pre-incisional strong opioids showed no significant benefit over post-incisional strong opioids for reducing postoperative pain scores (LoE 1) Fassoulaki et al 1995 Click here for more information
  • Pre-incisional strong opioids did not confer a significant benefit over post-incisional strong opioids for reducing supplementary analgesic consumption in patients undergoing abdominal hysterectomy (LoE 1) Kilickan et al 2001 Click here for more information
  • Pre-incisional strong opioids provided no significant benefit over post-incisional strong opioids for increasing the time to first analgesic request in three studies of patients undergoing abdominal hysterectomy reporting this parameter (n=34, n=85, n=39)
  • A meta-analysis of studies comparing pre-operative interventions with similar postoperative interventions in various procedures found that pre-operative NSAIDs and local anaesthetic wound infiltration improved analgesic consumption and time to first rescue analgesic request, but not pain scores. Evidence did not support an improvement in postoperative analgesia following administration of pre-operative NMDA antagonists and opioids
  • Pre-incisional strong opioids were associated with a similar incidence of PONV to post-incisional strong opioids in patients undergoing abdominal hysterectomy (n=34, n=40, n=60)

Open Colonic Resection-Specific Evidence

  • [No data found within the parameters of the systematic review]

PROSPECT Recommendations

  • Pre-operative administration of weak opioids is not recommended (Grade B) based on procedure-specific evidence that it has limited postoperative analgesic benefit compared with postoperative administration (LoE 2)

Clinical Practice

  • Tramadol 300 mg is considered to be a clinically effective dose, and therefore the 100 mg dose used in the study by Wordliczek et al. is probably too low to provide sufficient pain relief

Transferable Evidence from Other Procedures

  • A systematic review of pre-emptive analgesia for postoperative pain relief in a variety of surgical procedures – such as orthopaedic, dental, gynaecological and abdominal – has concluded that there is no benefit of pre-emptive over postoperative administration
  • A meta-analysis of studies comparing pre-operative interventions with similar postoperative interventions in various procedures found that pre-operative NSAIDs and local anaesthetic wound infiltration improved analgesic consumption and time to first rescue analgesic request, but not pain scores. Evidence did not support an improvement in postoperative analgesia following administration of pre-operative NMDA antagonists and opioids

Open Colonic Resection-Specific Evidence - Study information

  • Pre-operative administration of IV tramadol was superior to administration immediately after peritoneal closure or postoperatively for reducing total tramadol consumption (p<0.05; n=90)
  • Pre-, or intra-operative IV tramadol 100 mg did not confer any benefit for reducing postoperative pain scores compared with postoperative IV tramadol 100 mg Wordliczek et al 2002 Click here for more information
  • Pre-operative administration of IV tramadol resulted in a significantly shorter time to first analgesic request compared with administration immediately after peritoneal closure, or immediately following surgery (p<0.01; n=90)
  • Tramadol 100 mg administered pre- or intra-operatively, did not confer any benefit for reducing the incidence of PONV compared with postoperative IV tramadol 100 mg (n=90)

PROSPECT Recommendations

  • Continuous thoracic epidural anaesthesia and analgesia at a level appropriate to the site of incision are recommended for routine use (Grade A), based on superior postoperative analgesic and safety benefits compared with systemic techniques (procedure-specific evidence, LoE 1, also see Intra-operative and Postoperative Epidural Analgesia sections), except in a minority of patients with a contra-indication to epidural administration
  • Pre-operative administration of a single-shot epidural analgesia produces a similar postoperative analgesic efficacy to postoperative administration
  • Where epidural techniques are used, it is recommended that a combination of strong opioid and local anaesthetic is used (Grade A) because of the increased analgesic efficacy of the combination compared with strong opioids alone and to reduce the dose of strong opioid and its associated side-effects (procedure-specific evidence, LoE 1, see Intra-operative and Postoperative Epidural Analgesia sections)
  • Where epidural techniques are used, it is recommended that the epidural catheter is inserted pre-operatively because this is the most practical timing for insertion (Grade D, LoE 4)

Clinical Practice

  • In colonic surgery, the analgesic and recovery benefits of an epidural outweigh the risks of rare major complications and warrant the use of this more labour-intensive treatment
  • Where epidural techniques are used, the most practical timing for insertion of the epidural catheter is pre-operatively
  • 1 mg epidural morphine is considered inadequate to block visceral pain; however, larger doses are likely to cause bladder dysfunction. Therefore, pre-operative epidural administration of local anaesthetic with opioids is preferred to opioids alone

Transferable Evidence from Other Procedures - Study information

  • Pre-operative epidural morphine bolus was superior to epidural saline placebo for reducing postoperative pain scores at rest and on movement at 1 and 6 h (p<0.05 for all comparisons; n=36) in patients undergoing abdominal hysterectomy
  • Pre-operative epidural morphine bolus was superior to epidural saline placebo for reducing postoperative supplementary analgesic consumption at 6 and 12 h (p<0.05 for both times; n=36) in patients undergoing abdominal hysterectomy
  • Pre-operative epidural morphine bolus was superior to epidural saline placebo for extending the time to first analgesic request (p<0.05; n=36) in patients undergoing abdominal hysterectomy
  • Pre-operative epidural morphine and placebo were not different for the incidence of postoperative nausea in patients undergoing abdominal hysterectomy (n=36)
  • Pre- plus intra-operative epidural ropivacaine was superior to placebo for reducing intra-operative sufentanil in major abdominal tumour surgery (p<0.001; n=30)
  • Pre- plus intra-operative epidural ropivacaine provided no significant benefit over placebo for reducing postoperative pain scores for 0–96 h following major abdominal tumour surgery (both groups received postoperative epidural) (n=30)
  • Pre- plus intra-operative epidural ropivacaine provided no significant benefit over placebo for reducing supplementary analgesic consumption for 0–96 h following major abdominal tumour surgery (both groups received postoperative epidural) (n=30)
  • Pre- plus intra-operative epidural ropivacaine provided no significant benefit over placebo for reducing side-effects for 0–96 h following major abdominal tumour surgery (both groups received postoperative epidural) (n=30)
  • Pre-incisional epidural analgesia provided no significant benefit for reducing postoperative pain scores compared with post-incisional administration in a variety of abdominal procedures (LoE 1) Abdel-Ghaffar et al 1998 Click here for more information
  • Evidence for the benefit of pre-incisional compared with post-incisional epidural analgesia for reducing supplementary analgesic consumption in abdominal procedures is inconsistent (LoE 4) Espinet et al 1996 Click here for more information

Open Colonic Resection-Specific Evidence - Study information

  • Pre-operative bolus epidural morphine 1 mg plus postoperative parenteral analgesia was superior to postoperative parenteral analgesia alone on the day of surgery for VAS scores Simpson et al 1993 Click here for more information
  • Adding pre-operative bolus epidural morphine reduced parenteral opioid consumption on the first and second postoperative day compared with parenteral analgesia alone (p=0.002 and p=0.07, respectively; n=13)
  • Adding pre-operative bolus epidural morphine increased the time to first request of analgesia compared with parenteral analgesia alone (p=0.03; n=13)
  • Pre-operative + postoperative epidural clonidine was superior to control for the reduction of postoperative pain scores Wu et al 2004 Click here for more information
  • Pre-operative + postoperative epidural clonidine was superior to control for reducing postoperative analgesic requirement Wu et al 2004 Click here for more information
  • Pre-operative + postoperative epidural clonidine significantly reduced the time to return of normal bowel function, compared with control (p<0.001; n=40)
  • The incidence of morphine-associated nausea, vomiting, and itching was significantly lower with pre-operative + postoperative epidural clonidine, compared with control (p<0.001; n=40)
  • Epidural LA plus morphine 40 min before surgical incision conferred no significant benefit over administration at wound closure for reducing postoperative VAS pain scores Dahl et al 1992 Click here for more information
  • Epidural LA plus morphine given 40 min before surgical incision was similar to that given at closure for level of sensory block to pinprick for 0–72 h (n=32)
  • The length of hospital stay was similar for patients in the pre-operative + postoperative epidural clonidine and control groups (n=40)

PROSPECT Recommendations

  • Spinal morphine is not recommended (Grade D) because of the risk of side-effects (LoE 4)
  • Spinal clonidine is not recommended (Grade B) because of limited analgesic effect (procedure-specific evidence LoE 2) and the risk of side-effects (LoE 4)

Clinical Practice

  • Spinal morphine may produce some postoperative pain relief but also produces risk of PONV and prolongation of postoperative ileus, and limited duration of analgesic effect

Transferable Evidence from Other Procedures

  • [None Cited]

Open Colonic Resection-Specific Evidence - Study information

  • The incidence of postoperative nausea or vomiting was similar with pre-operative spinal morphine + IV PCA morphine, compared with PCA morphine alone (n=52)
  • Pre-operative spinal morphine + IV PCA morphine was superior to IV PCA morphine alone for reducing postoperative pain scores Click here for more information
  • Spinal clonidine was superior to placebo for reducing postoperative pain at a minority of time points Click here for more information
  • Spinal clonidine was superior to placebo for reducing postoperative morphine requirements Click here for more information
  • Pre-operative spinal bupivacaine significantly reduced the incidence of postoperative residual pain, compared with placebo, at 2 weeks, and after 1 month (p<0.05; n=40)
  • Spinal bupivacaine significantly reduced the area of hyperalgesia around the incision site, compared with placebo, at 24, 48, and 72 h postoperatively (p<0.05; n=40)
  • Spinal bupivacaine was superior to placebo for reducing postoperative PCA morphine consumption Click here for more information
  • There were no significant differences between the spinal morphine and spinal morphine + sufentanil groups for VAS pain scores at rest and coughing during the first 48 h postoperatively (n=77)
  • There was no significant difference in postoperative PCA morphine consumption with spinal morphine versus spinal morphine + sufentanil in the PACU, or at 24 or 48 h postoperatively (n=77)
  • Intra-operative IV sufentanil requirements were similar in the spinal morphine and spinal morphine + sufentanil groups (n=77)
  • There was no significant difference in patient satisfaction (VAS scale 1–100) with pre-operative spinal morphine versus spinal morphine + sufentanil (n=77)
  • Incidence of postoperative nausea and vomiting was similar between the pre-operative spinal morphine group and the pre-operative spinal morphine + sufentanil group (n=77)
  • Spinal bupivacaine conferred no significant benefit over placebo for reducing VAS pain scores at rest, mobilisation or during coughing at any of the time points assessed (2, 6 and 12 h, Days 1, 2 and 3) (n=40)
  • Spinal clonidine conferred no significant benefit over spinal bupivacaine for reducing VAS pain scores at rest, mobilisation or during coughing at any of the time points assessed (2, 6 and 12 h, Days 1, 2 and 3) (n=40)
  • The incidence of intra-operative adverse haemodynamic events was significantly greater with pre-operative spinal clonidine compared with pre-operative spinal bupivacaine or placebo (p<0.05) (n=20/group)
  • Pre-operative spinal morphine + IV PCA morphine versus IV PCA morphine alone
  • Spinal morphine versus spinal morphine + sufentanil
  • Spinal clonidine versus placebo
  • Spinal bupivacaine versus placebo
  • Spinal clonidine versus spinal bupivacaine

PROSPECT Recommendations

  • Bilateral TAP block is not recommended at the current time (Grade D, LoE 4) because of limited procedure-specific evidence, despite some positive transferable evidence (LoE 1)

Clinical Practice

  • The single-shot TAP block technique may provide effective postoperative analgesia but the duration is limited. Despite this, further study evidence is expected which may support the use of this technique

Transferable Evidence from Other Procedures

  • Unilateral TAP block significantly reduced postoperative VAS pain scores and postoperative morphine consumption compared with control, in patients undergoing open appendicectomy (n=52)
  • Bilateral TAP block with ropivacaine significantly reduced postoperative VAS pain scores, postoperative morphine consumption and the incidence of postoperative sedation, compared with placebo, in patients undergoing abdominal hysterectomy (n=50)

Open Colonic Resection-Specific Evidence - Study information

  • Pre-operative bilateral TAP block was superior to control for reducing postoperative pain scores Click here for more information
  • Pre-operative bilateral TAP block was superior to control for reducing postoperative morphine requirements Click here for more information
  • Pre-operative bilateral TAP block significantly reduced postoperative sedation scores, compared with control, at 4 and 6 h postoperatively (p=0.01), although there was no significant difference between the groups at 2 and 24 h, or in the PACU
  • Pre-operative bilateral TAP block was associated with a significantly higher incidence of PONV, compared with control (p<0.05)

PROSPECT Recommendations

  • Pre-operative use of guided imagery is not recommended (Grade D, LoE 4) because of limited procedure-specific evidence, despite some evidence of analgesic effect (LoE 1)

Clinical Practice

  • [None Cited]

Transferable Evidence from Other Procedures

  • Pre-operative use of guided imagery was significantly more effective for reducing postoperative pain intensity (p<0.05), distress from pain (p<0.01) and the ability to cope with pain (p<0.01) compared with routine postoperative care, in patients undergoing abdominal surgery (n=51)
  • Pre-operative use of guided imagery resulted in significantly lower supplementary analgesic consumption over 0–48 h compared with routine postoperative care (p<0.05; n=51)

Open Colonic Resection-Specific Evidence - Study information

  • One of two studies showed that care by guided imagery was more effective than standard care for reducing postoperative pain scores Click here for more information
  • One of two studies found that care by guided imagery was more effective than routine postoperative care for reducing postoperative analgesic requirements Click here for more information
  • One of two studies showed that care by guided imagery was more effective than routine postoperative care for reducing time to first bowel movement Click here for more information
  • Guided imagery tapes provided no significant benefit over relaxation tapes for reducing VAS pain scores at rest or coughing during postoperative Days 1–4 (n=38)
  • Relaxation tapes provided no significant benefit over routine postoperative care for the reduction of VAS pain scores at rest or coughing during postoperative Days 1–4 (n=40)
  • There was no significant difference in the total analgesic consumption or the number of analgesic requests between patients in the relaxation and guided imagery groups (n=42)
  • Time to first flatus and first bowel movement was similar for patients in the guided imagery and relaxation groups (n=42)
  • Time to first flatus and first bowel movement was similar for patients in the relaxation and routine care groups (n=42)
  • One study found that care by guided imagery provided no benefit over routine postoperative care for reducing the median length of hospital stay, postoperative ileus or the incidence of nausea or vomiting (n=130)

PROSPECT Recommendations

  • Laxatives are not recommended for analgesia (Grade B) because limited procedure-specifc evidence shows no analgesic benefit (LoE 2), but they may be used for reasons other than pain relief (LoE 4)

Clinical Practice

  • [None Cited]

Transferable Evidence from Other Procedures

  • Time until first defecation and GI recovery were significantly shorter with biscodyl versus placebo (p=0.001 and p=0.007, respectively; n=169)
  • Pre-operative + postoperative administration of biscodyl provided no significant benefit over placebo for the reduction of VAS pain scores (n=169)
  • There was no significant difference in the level of opioid consumption between patients who received bisacodyl or placebo during the first 8 postoperative days (n=169)
  • The incidence of postoperative cramping and nausea was similar in the biscodyl and placebo groups (n=169)
  • Biscodyl conferred no significant benefit over placebo for reducing the length of hospital stay (n=169)

Open Colonic Resection-Specific Evidence - Study information

  • [None Cited]

PROSPECT Recommendations

  • Pre-operative pentoxifylline is not recommended (Grade D, LoE 4) due to limited procedure-specific evidence of its analgesic effect

Clinical Practice

  • Further studies are needed to recommend the use of pentoxifylline in clinical practice

Transferable Evidence from Other Procedures

  • [None Cited]

Open Colonic Resection-Specific Evidence - Study information

  • Pre-operative IV pentoxifylline was superior to placebo for the reduction of VAS pain scores during coughing after 1, 2, and 4 h, and on Days 1 and 2 (p<0.05; n=40), however, there was no siginificant difference between the groups for resting pain scores at each of the time points assessed (1, 2, 4 h and Days 1, 2 and 3)
  • Pre-operative IV pentoxifylline was superior to placebo for reducing morphine consumption during Days 1–3 (p<0.0001; n=40)
  • Pre-operative IV pentoxifylline was superior to placebo for extending the time until first PCA morphine trigger (p<0.0001; n=40)
  • Pre-operative IV pentoxifylline was superior to placebo for reducing the time until first flatus
  • Pre-operative IV pentoxifylline was superior to placebo for reducing inflammatory cytokines related to postoperative pain
  • The incidence of morphine-related adverse effects (drowsiness, dizziness, nausea, and vomiting) was similar in both the pre-operative IV pentoxifylline and placebo groups

PROSPECT Recommendations

  • Intra-operative COX-2-selective inhibitors are recommended (Grade B) for colonic resection based on procedure-specific evidence that they have an analgesic effect postoperatively (LoE 2), only for patients who do not receive epidural analgesia (LoE 4)
  • It is recommended that the use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (Grade B) (cardiovascular morbidity [transferable evidence, LoE 1], renal function and hepatic function [transferable evidence, LoE 3], or actual or recent gastroduodenal ulcer history [LoE 4]). In addition, the potential risk of anastomotic leakage needs to be considered (transferable evidence, LoE 3). Further observations are required regarding the potential risk of NSAIDs and

Clinical Practice

  • Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries
  • There is no procedure-specific evidence that intra-operative administration of COX-2-selective inhibitors is more effective than postoperative administration

Transferable Evidence from Other Procedures - Study information

  • COX-2-selective inhibitors provide similar postoperative analgesia to conventional NSAIDs
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation
  • A randomised clinical trial showed that the COX-2-selective inhibitor rofecoxib was associated with significantly less intra-operative blood loss than the conventional NSAID diclofenac in patients undergoing abdominal or vaginal hysterectomy or breast surgery
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following noncardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062)
  • A review concluded that COX-2-selective inhibitors were as effective as conventional NSAIDs for treatment of postoperative pain in various surgical models, and offer a number of other advantages including: reduced incidence of gastrointestinal ulceration, no inhibitory effect on platelet function (and thereby a reduced risk of blood loss) and no induction of bronchospasm in patients with aspirin-sensitive asthma
  • A meta-analysis that included data from 17 parecoxib and 15 valdecoxib placebo-controlled trials in non-cardiac surgery showed that there was no significant association between short-term treatment with parecoxib and/or valdecoxib and an increase in cardiovascular thromboembolic adverse events, compared with placebo (n=8511 overall)
  • A retrospective cohort study showed that the COX-2-selective inhibitors rofecoxib and celecoxib were associated with a lower risk of acute kidney infection than less-selective NSAIDs
  • A pre-operative single bolus of COX-2-selective inhibitor did not significantly reduce postoperative pain scores at rest compared with placebo within 0–24 h in two studies of patients undergoing abdominal hysterectomy (n=40; n=36)
  • Two clinical trials showed that in patients who had undergone CABG surgery COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication
  • Although there is some concern COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting
  • One study in patients undergoing fast-track colonic surgery found that postoperative analgesia with the COX-2-selective inhibitor celecoxib was associated with a higher risk of anastomotic leakage, compared with when celecoxib was not used

Open Colonic Resection-Specific Evidence - Study information

  • Intra-operative parecoxib was superior to placebo for the reduction of postoperative morphine consumption Click here for more information
  • Intra-operative IV parecoxib (40 mg) conferred some benefit over placebo for the reduction of postoperative resting pain scores Click here for more information
  • There were no significant differences between the intra-operative IV parecoxib and pre-operative IV parecoxib groups for NRS pain scores at rest, or during coughing, during the first 48 h postoperatively
  • Intra-operative IV parecoxib conferred no significant benefit over placebo for reducing PCA morphine consumption in the recovery room
  • There was no significant difference in postoperative morphine consumption between the intra-operative IV parecoxib group and the pre-operative IV parecoxib group within 0–48 h after surgery
  • The incidence of postoperative nausea and vomiting, dizziness and pruritus was similar between the intra-operative IV parecoxib, pre-operative IV parecoxib, and placebo groups

PROSPECT Recommendations

  • Clonidine is not recommended (Grade D), despite limited procedure-specific evidence for analgesic efficacy, because it is associated with an increased risk of hypotension, sedation and bradycardia (LoE 4)

Clinical Practice

  • The risk/benefit ratio for clonidine is unclear. Recognised side effects include hypotension, sedation, dizziness and bradycardia
  • There is no consensus among clinicians on the optimum dose of clonidine that should be used

Transferable Evidence from Other Procedures

Open Colonic Resection-Specific Evidence - Study information

  • IV clonidine given before skin incision, or before peritoneal incision, was superior to fentanyl given before skin incision for postoperative analgesic outcomes Click here for more information

PROSPECT Recommendations

  • Pre- or intra-operative calcium channel antagonists are not recommended (Grade B), based on limited procedure-specific evidence showing a lack of postoperative analgesic effect (LoE 2)

Clinical Practice

  • Clinical experience with calcium channel antagonists is lacking

Transferable Evidence from Other Procedures

  • [None Cited]

Open Colonic Resection-Specific Evidence - Study information

  • IV nimodipine conferred no significant benefit over placebo for postoperative pain scores at rest or movement 0–120 h postoperatively, except at 72 h when a reduction in movement pain reached significance (n=47)
  • Oral nifedipine was significantly inferior to placebo for postoperative pain scores at rest at 16 and 24 h (p<0.05; n=46)
  • Nimodipine or nifedipine provided no significant benefit over placebo for reducing the following postoperative outcomes: morphine requirements for 0–24 h; sedation scores for 0–48 h; the incidence of nausea and vomiting; time to first bowel movement and time to first flatus (n=69)

PROSPECT Recommendations

  • Gabapentin/pregabalin cannot be recommended at this time (Grade D, LoE 4) due to a lack of procedure-specific evidence, although analgesic data from other procedures are promising

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Four systematic reviews and a meta-analysis evaluated the use of gabapentinoids for postoperative analgesia and demonstrated significant reductions in postoperative pain and supplementary analgesic requirements compared with inactive controls
  • Two systematic reviews
  • Two systematic reviews

Open Colonic Resection-Specific Evidence

  • [No data found within the parameters of the systematic review]

PROSPECT Recommendations

  • Continuous administration of IV lidocaine limited to the pre/intra-operative period is not recommended (Grade D) because of inconsistent and insufficient procedure-specific evidence
  • Continuous administration of pre/intra-operative IV lidocaine continuous administration is recommended if continued during the immediate postoperative period when epidural analgesia is not feasible or contra-indicated (Grade B), based on transferable evidence (LoE 1) and limited procedure-specific evidence (LoE 2) for recovery benefits compared with control

Clinical Practice

  • IV lidocaine can be considered as an alternative when there are contra-indications to epidural analgesia techniques
  • Further evidence is needed to precisely define the role of IV lidocaine in this setting, including direct comparisons with epidural analgesia
  • IV lidocaine may induce hypotension
  • If IV lidocaine is used it is recommended that safety data are taken into account

Transferable Evidence from Other Procedures - Study information

  • A meta-analysis of randomised 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

Open Colonic Resection-Specific Evidence - Study information

  • Pre-/intra-operative IV lidocaine reduced postoperative pain scores compared with control Click here for more information
  • Pre-/intra-operative IV lidocaine significantly reduced postoperative morphine requirement compared with control Click here for more information
  • Pre-/intra-operative IV lidocaine significantly reduced intra-operative fentanyl requirement compared with control Click here for more information
  • Pre-/intra-operative IV lidocaine was associated with a lower incidence of morphine-related nausea or vomiting compared with control (p<0.01; n=40)
  • Pre-/intra-operative IV lidocaine significantly reduced the time to first flatus compared with the control group (p<0.01; n=40)
  • Peri-operative IV lidocaine significantly reduced the time to first flatus compared with the control group (p<0.05; n=60)
  • The time to first bowel movement was significantly shorter with peri-operative IV lidocaine compared with the control (p<0.05; n=60)
  • Peri-operative IV lidocaine significantly reduced the time taken to solid food intake, compared with the control (p<0.001; n=60)
  • Peri-operative IV lidocaine significantly reduced the duration of hospital stay, compared with the control (p=0.004; n=60)
  • Pre-/intra-operative IV lidocaine conferred no significant benefit over control for reducing the length of hospital stay (n=40)
  • Peri-operative IV lidocaine conferred no significant benefit over the control for the reduction of VAS pain scores at rest or during movement at any of the time points assessed (n=60)
  • Peri-operative IV lidocaine conferred no significant benefit over control for reducing the consumption of PCA IV piritramide (2 mg dose with a lockout period of 10 minutes) (n= 60)

PROSPECT Recommendations

  • Intra-operative NMDA receptor antagonists are not recommended (Grade D, LoE 4) because of limited procedure-specific evidence of analgesic efficacy

Clinical Practice

  • There is a lack of clinical experience with NMDA receptor antagonists. Moreover, NMDA receptor antagonists are associated with adverse events, e.g. ketamine is known for its increased risk of CNS side effects

Transferable Evidence from Other Procedures

  • Studies of intravenous or neuraxial ketamine in a variety of surgeries, including abdominal, gynaecological, orthopaedic, gastric, hepatic, and genitourinary surgery, showed a reduction in postoperative pain and opioid use when used as an adjunct to morphine
  • In patients undergoing laparoscopic cholecystectomy, dextromethorphan (pre- incisional and post gallbladder removal) was superior to control for reducing VAS scores, reducing the use of supplementary analgesics, and increasing the time to first analgesic request
  • Low-dose ketamine was associated with few and mild adverse effects, especially when administered in conjunction with general anaesthesia
  • A systematic review found that dextromethorphan did not reduce postoperative pain scores with a clinically significant magnitude, and although significant decreases in supplemental opioid consumption were observed, these were of questionable clinical importance in most cases
  • Two meta-analyses comparing pre-incisional and postincisional treatments found no significant analgesic benefit of pre-incisional administration of NMDA receptor antagonists
  • Two systematic reviews of randomised controlled trials comparing magnesium with placebo demonstrated inconclusive results overall with regards to pain scores and supplemental analgesic use (

Open Colonic Resection-Specific Evidence - Study information

  • Intra-operative ketamine was superior to placebo for reducing postoperative pain scores in the first 15 min (p<0.05), decreasing morphine use for 0–24 h compared with placebo (p<0.01), and extending the time to first analgesic request (p<0.001) compared with placebo (n=50)
  • IV magnesium provided no significant benefit over placebo for reducing the following postoperative outcomes: pain scores at rest or during movement; morphine requirements for 0–24 h; sedation scores 0–48 h; incidence of nausea and vomiting; time to first bowel movement; and time to first flatus (n=47)

PROSPECT Recommendations

  • In patients undergoing colonic resection and receiving epidural anaesthesia, intra-operative administration of systemic, long-acting strong opioids to provide postoperative analgesia is not recommended (Grade D, LoE 4)
  • However, in patients not indicated for epidural anaesthesia, systemic intra-operative strong opioids are recommended to provide early postoperative pain relief (Grade B), based on transferable evidence (LoE 1) of analgesic efficacy

Clinical Practice

  • [None Cited]

Transferable Evidence from Other Procedures - Study information

  • Intra-operative strong opioid provided a benefit over placebo up to 4 h for reducing postoperative pain scores at rest (one of three studies) and reducing the supplementary analgesic consumption (three studies), but showed no significant difference for the time to first analgesic request (one study), in patients undergoing hysterectomy Click here for more information

Open Colonic Resection-Specific Evidence - Study information

  • Low-dose remifentanil infusion plus titrated desflurane conferred a benefit for reducing postoperative pain scores at 3 and 4 h compared with a high-dose remifentanil infusion plus fixed-dose desflurane (both times p<0.05; n=49)
  • Low-dose remifentanil infusion plus titrated desflurane was superior for reducing cumulative supplementary analgesic consumption compared with a high-dose remifentanil infusion plus fixed-dose desflurane (p<0.01; n=49)
  • Low-dose remifentanil infusion plus titrated desflurane increased the number of patients classified as 'calm' compared with a high-dose remifentanil infusion plus fixed-dose desflurane Click here for more information
  • Low-dose remifentanil infusion plus titrated desflurane had a similar time to first request of supplementary analgesia and a similar incidence of PONV compared with a high-dose remifentanil infusion plus fixed-dose desflurane (n=49)
  • Sufentanil anaesthesia was superior to remifentanil anaesthesia plus intra-operative bolus IV morphine for reducing postoperative pain scores at 2 h, but the scores were similar from 2–12 h (p<0.01; n=30)
  • Sufentanil anaesthesia was superior to remifentanil anaesthesia plus intra-operative bolus IV morphine for the reduction of supplementary analgesic consumption in the PACU and at 4, 12 and 24 h (p<0.05; n=30)
  • Sufentanil anaesthesia was superior to remifentanil anaesthesia plus intra-operative bolus IV morphine for extending the time to first analgesic request (p<0.05; n=30)
  • Sufentanil anaesthesia was similar to remifentanil anaesthesia plus intra-operative bolus IV morphine for the incidence of PONV and sedation scores (n=30)
  • Remifentanil infusion at a low-dose compared with remifentanil infusion at a high-dose was associated with a similar percentage of sedated patients Click here for more information

PROSPECT Recommendations

  • Intra-operative systemic weak opioids are not recommended (Grade D, LoE 4), as placebo-controlled evidence for their benefit in reducing postoperative pain is limited. Moreover, epidural LA + strong opioid is the regimen recommended for routine use in patients undergoing colonic resection
  • In patients not receiving epidural anaesthesia, intra-operative strong opioids, not weak opioids, are recommended to provide early postoperative pain relief (Grade B, see Intra-operative Strong Opioid section)

Clinical Practice

  • Tramadol 300 mg is considered to be a clinically effective dose, and therefore the 100 mg dose used in the study by Wordliczek et al. is likely to be too low to provide sufficient pain relief

Transferable Evidence from Other Procedures - Study information

  • Intra-operative IV tramadol was superior to placebo for reducing tramadol use and postoperative pain scores in the PACU following abdominal surgery (p<0.05 for all comparisons; n=60)
  • Intra-operative IV tramadol was superior to placebo for reducing the incidence (p<0.05) and severity (p<0.05) of PONV following abdominal surgery (n=60)
  • For patients undergoing laparoscopic cholecystectomy, intra-operative tramadol IV at wound closure was superior to control for reducing VAS scores, reducing the use of supplementary analgesics and increasing the time to first analgesic request
  • Intra-operative IV tramadol was similar to placebo for the number of postoperative PCA boluses delivered and total tramadol consumption (n=60)

Open Colonic Resection-Specific Evidence - Study information

  • Administration of IV tramadol immediately after peritoneal closure, or immediately following surgery extended the time to first analgesic request compared with pre-operative administration (p<0.01; n=90)
  • Pre-, or intra-operative IV tramadol 100 mg did not confer any benefit for reducing postoperative pain scores compared with postoperative IV tramadol 100 mg Click here for more information
  • Tramadol 100 mg administered pre- or intra-operatively, did not confer any benefit for reducing the incidence of PONV compared with postoperative IV tramadol 100 mg (n=90)
  • Pre-operative administration of IV tramadol was superior to administration immediately after peritoneal closure or postoperatively for reducing total tramadol consumption (p<0.05; n=90)

PROSPECT Recommendations

  • Continuous thoracic epidural anaesthesia and analgesia is recommended (Grade A) for routine use in colonic resection based on its benefit in reducing postoperative pain, systemic opioid use and bowel recovery time (procedure-specific evidence, LoE 1)
  • A combination of epidural local anaesthetic (LA) and strong opioid is recommended for epidural analgesia (Grade A), based on procedure-specific evidence of their combined efficacy in reducing postoperative pain and systemic opioid use, compared with LA alone (LoE 1). However, the addition of opioid to epidural LA results in an increase in time to first bowel movement (LoE 1)
  • Addition of clonidine to the combination of epidural LA + opioid is not recommended (Grade D) because of side effects, despite favourable effects on pain scores

Clinical Practice

  • Thoracic epidural is considered to be more appropriate than lumbar epidural for anaesthesia and analgesia in colonic resection
  • Epidural analgesia is associated with a relatively high degree of patient monitoring and rare major complications
  • A minority of patients may need to receive general anaesthesia plus systemic analgesia due to a contra-indication to the epidural technique

Transferable Evidence from Other Procedures

  • [None Cited]

Open Colonic Resection-Specific Evidence - Study information

  • 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
  • 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)

PROSPECT Recommendations

  • Spinal analgesia is not recommended in combination with epidural anaesthesia (Grade B), based on a lack of benefit in reducing postoperative pain in colonic resection (LoE 2). Moreover, it introduces a greater level of complexity (LoE 4)

Clinical Practice

  • [None Cited]

Transferable Evidence from Other Procedures

  • [None Cited]

Open Colonic Resection-Specific Evidence - Study information

  • 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)

PROSPECT Recommendations

  • No recommendation can be made about general anaesthetic techniques for open colonic resection because of limited procedure-specific evidence

Clinical Practice

  • For laparoscopic procedures, the use of nitrous oxide may result in increased bowel distension

Transferable Evidence from Other Procedures

  • One randomised study investigating the efficacy of prophylactic antimetic interventions in patients undergoing surgery with general anaesthesia concluded that the risk of PONV was 12% greater with N2O compared with nitrogen
  • One randomised study comparing nitrous oxide-based anaesthesia with nitrous oxide-free anaesthesia in patients undergoing major surgery, found that the avoidance of nitrous oxide decreased the incidence of postoperative complications, but did significantly reduce the length of hospital stay (Myles 2007)

Open Colonic Resection-Specific Evidence - Study information

  • 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
  • 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)

PROSPECT Recommendations

  • 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, LoE 4)
  • Laparoscopic colonic resection is recommended over open colon surgery for reducing postoperative pain (Grade A), if the conditions outlined above allow, based on procedure-specific evidence (LoE 1).
  • See laparoscopic section for recommendations on pain management for laparoscopic colonic resection
  • A horizontal/curved (transverse) incision is recommended over a vertical incision for analgesic and other benefits, if the operative conditions allow (Grade B) based on limited procedure-specific evidence (LoE 2) and transferable evidence. In addition, the horizontal/curved incision is preferred for its cosmetic benefits (Grade D, LoE 4)
  • Diathermy is recommended over the scalpel (Grade B), based on analgesic benefits as well as greater speed of incision and less blood loss (transferable evidence, LoE 2)

Clinical Practice

  • The decision to employ a laparoscopic versus open approach for colonic surgery is based on multiple factors such as the indication for surgery (e.g. benign or malignant disease) and surgical expertise, as well as the desired outcomes
  • If the surgical indication allows, a transverse incision is preferred for abdominal procedures such as colonic resection

Transferable Evidence from Other Procedures

  • The transverse incision was similar to the vertical incision for access to intra-abdominal structures and resulted in significantly less postoperative pain and a lower incidence of pulmonary complications; however, vertical laparotomy is associated with a shorter operating time and better possibilities for extension of the incision, as found in a systematic review in abdominal surgery
  • Laparotomy incisions using diathermy had significantly lower VAS scores at 48 h (p<0.05), morphine consumption over the first 5 days (p<0.04), less blood loss (p=0.002), and were associated with a faster speed of incision (p<0.04) compared with scalpel incisions in patients undergoing elective midline laparotomy (n=100)
  • Laparoscopic surgery resulted in an increased operating time, but reduced postoperative pain, hospital stay and return to normal activity compared with open surgery, as demonstrated in a number of reviews of the literature of patients undergoing resection for colonic cancer, cholecystectomy, appendectomy (systematic) and groin hernia (systematic)

Open Colonic Resection-Specific Evidence - Study information

  • 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)
  • A systematic review comparing laparoscopic versus open total mesorectal excision for rectal cancer reported that two of three randomised studies found no significant difference between laparoscopic and open techniques for reducing postoperative analgesic consumption. However, there was a trend for less analgesia in the laparoscopic group
  • 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 was no significant difference 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)

PROSPECT Recommendations

  • Maintenance of normothermia is recommended (Grade A) for improved clinical outcomes (procedure-specific evidence, LoE 1) but it is not helpful for reducing postoperative pain (LoE 1)

Clinical Practice

  • Although there are no benefits for pain reduction, keeping patients normothermic has benefits for reducing oxygen consumption and decreasing myocardial work, which is important for elderly patients and those at risk of cardiac events

Transferable Evidence from Other Procedures - Study information

  • One study showed that aggressive warming was superior to conventional warming in total hip arthroplasty for reducing intra-operative and total blood loss (p=0.002), but no difference in postoperative blood loss was observed (n=150)
  • A randomized controlled trial in high-risk patients showed that maintenance of normothermia reduced the incidence of morbid cardiac events in the peri-operative period compared with routine thermal care (p=0.02, n=300)
  • Maintenance of normothermia decreased the post-anaesthetic recovery time compared with routine thermal management (p<0.001, n=150) in patients undergoing abdominal surgery
  • Maintenance of normothermia may prevent adverse effects of mild hypothermia, which reduces resistance to wound infection, is associated with increased protein wasting and decreased collagen synthesis, reduces platelet function and impairs coagulation, increases the incidence of morbid cardiac events, decreases drug metabolism, increases anaesthetic recovery time, and induces shivering
  • Patients kept normothermic showed no significant difference in postoperative pain scores compared with patients kept hypothermic during elective major abdominal surgery (n=150)

Open Colonic Resection-Specific Evidence - Study information

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

PROSPECT Recommendations

  • COX-2-selective inhibitors are recommended (Grade B) based on limited procedure-specific evidence (LoE 2) and transferable evidence (LoE 1). They should be given in combination with strong opioids for high-intensity pain, or with weak opioids for moderate- or low-intensity pain (Grade D, LoE 4), only for patients who do not receive epidural analgesia or with cessation of epidural analgesia (Grade D, LoE 4)
  • COX-2-selective inhibitors may be preferred to conventional NSAIDs in the peri-operative setting, in patients who have an increased risk of bleeding, or who are at risk of gastroduodenal ulcer/erosion (Grade B, transferable evidence, LoE1) or who have NSAID-induced asthma (transferable, LoE 1)
  • The use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (Grade B), cardiovascular morbidity (transferable evidence, LoE 1), actual or recent gastroduodenal ulcer history (LoE 4), renal function and hepatic function (transferable evidence, LoE 3). In addition, the potential risk of anastomotic leakage should be considered (transferable evidence, LoE 3). Further observations are required regarding the potential risk of NSAIDs and COX-2-selective inhibitors o

Clinical Practice

  • Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries

Transferable Evidence from Other Procedures

  • COX-2-selective inhibitors provide similar postoperative analgesia to conventional NSAIDs
  • Parecoxib 20 or 40 mg IV every 12 h reduced supplementary analgesic consumption compared with placebo in patients undergoing major gynaecological surgery (p<0.05; n=60)
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following noncardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062)
  • A meta-analysis that included data from 17 parecoxib and 15 parecoxib placebo-controlled trials in non-cardiac surgery, showed that there was no significant association between short-term treatment with parecoxib and/or valdecoxib and an increase in cardiovascular thromboembolic adverse events, compared with placebo (n=8511 overall)
  • A retrospective cohort study showed that the COX-2-selective inhibitors rofecoxib and celecoxib were associated with a lower risk of acute kidney infection than less-selective NSAIDs
  • Parecoxib 20 or 40 mg IV every 12 h did not significantly reduce postoperative pain scores compared with placebo in patients undergoing major gynaecological surgery (p<0.05; n=60)
  • Two clinical trials showed that in patients who had undergone CABG surgery COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting
  • One study in patients undergoing fast-track colonic surgery found that postoperative analgesia with the COX-2-selective inhibitor celecoxib was associated with a higher risk of anastomotic leakage, compared with when celecoxib was not used

Open Colonic Resection-Specific Evidence

  • Pre-operative + postoperative oral valdecoxib was superior to placebo for reducing postoperative pain scores Click here for more information
  • Pre-operative + postoperative oral valdecoxib was superior to placebo for reducing postoperative morphine requirement Click here for more information
  • Pre-/postoperative oral valdecoxib was associated with superior patient-assessed global evaluation scores (p=0.001; n=79), compared with placebo, but not with surgeon-assessed global evaluation scores
  • The time until first flatus and first bowel movement was significantly shorter with pre-/postoperative oral valdecoxib, compared with placebo (p=0.003 and p=0.041, respectively)
  • The time taken to tolerate solids was significantly shorter with pre-operative + postoperative oral valdecoxib versus placebo (p=0.029)
  • The length of hospital stay was significantly shorter for patients in the pre-/ postoperative oral valdecoxib group, compared with the placebo group (p=0.009)
  • The incidence of postoperative sedation or nausea was similar with pre-/ postoperative oral valdecoxib, and placebo (n=79)
  • Pre-operative + postoperative oral valdecoxib had no significant effect on the time taken to tolerate intake of liquids compared with placebo
  • The hospital re-admission rate was similar for patients in the pre-/ postoperative oral valdecoxib and placebo groups

PROSPECT Recommendations

  • Conventional NSAIDs are recommended (Grade A), for their analgesic and opioid-sparing effect (procedure-specific evidence, LoE 1). They should be given in combination with strong opioids for high-intensity pain, or with weak opioids for moderate- or low-intensity pain (Grade D, LoE 4), only for patients who do not receive epidural analgesia or with cessation of epidural analgesia (Grade D, LoE 4)
  • Conventional NSAIDs are not recommended in patients who have an increased risk of bleeding, or who are at risk of gastroduodenal ulcer/erosion (Grade B, transferable evidence, LoE 1)
  • The use of conventional NSAIDs should depend upon assessment of individual patient risks (Grade B), including bleeding complications, actual or recent gastroduodenal ulcer history (transferable evidence, LoE 1), cardiovascular morbidity (LoE 4), aspirin-sensitive asthma, renal function and hepatic function (transferable evidence, LoE 3)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures - Study information

  • Conventional NSAIDs have proven analgesic efficacy in a variety of surgical procedures
  • A meta-analysis of randomised controlled trials that was performed to evaluate the risk of morphine-related adverse effects in patients treated with NSAIDs demonstrated that NSAIDs decreased the incidence of nausea, vomiting and sedation, but not pruritus, urinary retention or respiratory depression
  • Six out of eight studies showed a significant benefit of postoperative conventional NSAIDs compared with placebo for reducing postoperative pain scores in patients undergoing hysterectomy Click here for more information
  • Conventional NSAIDs conferred a significant benefit over placebo for reducing supplementary analgesia requirements over 24 h or more in patients undergoing abdominal hysterectomy Click here for more information
  • Conventional NSAIDs were superior to placebo for reducing morphine consumption in abdominal surgery but did not consistently reduce pain scores in two studies in abdominal surgery Click here for more information
  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo
  • Two of three studies showed no significant analgesic benefit of conventional NSAIDs plus epidural analgesia compared with epidural analgesia alone Click here for more information
  • Results were inconsistent for conventional NSAIDs compared with placebo for the time to first analgesic request following abdominal hysterectomy Click here for more information
  • Conventional NSAIDs and placebo were not significantly different for the incidence of PONV (all groups received background strong opioid) in patients undergoing abdominal surgery Click here for more information
  • Diclofenac 50 mg IM bolus pre-operatively then postoperatively at 4 and 10 h, plus epidural analgesia using bupivacaine 0.5% continually infused at 8 mL/h did not confer a benefit for extending the time to first analgesic request compared with epidural analgesia alone in patients undergoing abdominal hysterectomy (n=26)
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo
  • Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease. Aspirin-induced asthma occurs in approximately 4–10% of the adult asthmatic population
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication
  • A restrospective, case-control study showed that postoperative analgesia with the conventional NSAID diclofenac (150 mg daily) was associated with a significantly higher number of anastomotic leakages than postoperative opioid analgesia in patients undergoing laparoscopic colorectal surgery

Open Colonic Resection-Specific Evidence - Study information

  • Pre-operative + postoperative IV flurbiprofen was superior to placebo for reducing postoperative pain scores Click here for more information
  • Pre-operative + postoperative IV flurbiprofen axetil was superior to placebo for reducing the time to first pass of flatus and first bowel movement (both p=0.01; n=40)
  • Regular IM ketorolac was superior to regular IV morphine for reducing supplementary PCA morphine use 0–24 h and total morphine consumption 0–72 h (p=0.001; n=30)
  • IM ketorolac (PRN) was superior to IM morphine (PCA or PRN) alone for reducing postoperative pain scores at 3–6 h and 18–110 h (dosing regimens not clear) (all p<0.05; n=90)
  • IM ketorolac (PRN) was superior to IM morphine (PCA or PRN) for reducing the time to first flatus (p<0.05) and length of hospital stay (dosing regimens not clear) (p<0.01; n=90)
  • IM ketorolac was superior to IM ketorolac plus IM or IV morphine on demand for reducing the length of time taken to recover from postoperative ileus (2.3 ± 0.5 days versus 4.2 ± 0.6 days; p<0.05; n=14)
  • IV PCA morphine + ketorolac was superior to IV PCA morphine alone for reducing total morphine consumption (p<0.05; n=74); however there was no significant difference between the groups for the duration of IV PCA morphine use
  • IV PCA morphine + ketorolac significantly reduced the time to first mobilisation, compared with IV PCA morphine alone (p<0.05; n=74)
  • IV PCA morphine + ketorolac significantly reduced the time to first bowel movement, compared with IV PCA morphine alone (P<0.05; n=74)
  • The incidence of postoperative nausea and vomiting was similar in the pre-operative + postoperative flurbiprofen axetil and placebo groups (n=40)
  • IM ketorolac plus PCA morphine conferred no significant benefit over PCA morphine alone for reducing postoperative pain scores, time to first flatus, time to first bowel movement and tolerance to liquids and regular diet (n=30)
  • There were no significant differences between the groups receiving IV PCA morphine or IV PCA morphine + ketorolac for VAS pain scores at rest or movement during postoperative Days 1–3 (n=74)
  • IV PCA morphine + ketorolac conferred no significant benefit over IV PCA morphine alone for reducing the time to first flatus (n=74)
  • The incidence of morphine-related side-effects (pruritus, nausea and vomiting and dizziness) was similar in the groups receiving IV PCA morphine + ketorolac or IV PCA morphine alone (n=74)
  • IV PCA morphine + ketorolac and IV PCA morphine alone were associated with a similar length of hospital stay (n=74)

PROSPECT Recommendations

  • Gabapentin/pregabalin cannot be recommended at this time (Grade D, LoE 4) due to a lack of procedure-specific evidence, although analgesic data from other procedures are promising

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Four systematic reviews and a meta-analysis evaluated the use of gabapentinoids for postoperative analgesia and demonstrated significant reductions in postoperative pain and supplementary analgesic requirements compared with inactive controls
  • Two systematic reviews
  • Two systematic reviews

Open Colonic Resection-Specific Evidence

  • [No data found within the parameters of the systematic review]

PROSPECT Recommendations

  • Postoperative IV lidocaine is recommended (Grade D, LoE 4) for open colonic resection when epidural analgesia is not feasible or contra-indicated (Grade B) based on transferable evidence (LoE 1) and limited procedure-specific evidence (LoE 2) for recovery benefits compared with control

Clinical Practice

  • IV lidocaine can be considered as an alternative when there are contra-indications to epidural analgesia techniques
  • If IV lidocaine is used it is recommended that safety data be taken into account
  • IV lidocaine may induce hypotension
  • Further evidence is needed to precisely define the role of IV lidocaine in this setting, including direct comparisons with epidural analgesia

Transferable Evidence from Other Procedures

  • A meta-analysis of randomised 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

Open Colonic Resection-Specific Evidence - Study information

  • Peri-operative IV lidocaine significantly reduced the time to first flatus compared with the control group (p<0.05; n=60)
  • The time to first bowel movement was significantly shorter with peri-operative IV lidocaine compared with the control (p<0.05; n=60)
  • Peri-operative IV lidocaine significantly reduced the time taken to solid food intake compared with the control (p<0.001; n=60)
  • Peri-operative IV lidocaine significantly reduced the duration of hospital stay compared with control (p=0.004; n=60)
  • Peri-operative IV lidocaine conferred no significant benefit over the control for the reduction of VAS pain scores at rest or during movement at any of the time points assessed (n=60)
  • Peri-operative IV lidocaine conferred no significant benefit over control for reducing the consumption of PCA IV piritramide (2 mg dose with a lockout period of 10 min) (n= 60)

PROSPECT Recommendations

  • Postoperative NMDA receptor antagonists are not recommended (Grade D, LoE 4) because of limited procedure-specific evidence of analgesic efficacy

Clinical Practice

  • The maximum dose of ketamine that should be given to avoid side effects is 0.5 mg/kg
  • Clinical experience with NMDA receptor antagonists is lacking. Moreover, NMDA receptor antagonists are associated with adverse events, e.g. ketamine is known for its increased risk of CNS side effects

Transferable Evidence from Other Procedures

  • Studies of intravenous or neuraxial ketamine in a variety of surgeries, including abdominal, gynaecological, orthopaedic, gastric, hepatic, and genitourinary surgery, showed a reduction in postoperative pain and opioid use when used as an adjunct to morphine
  • In patients undergoing laparoscopic cholecystectomy, dextromethorphan (pre- incisional and post gallbladder removal) was superior to control for reducing VAS scores, reducing the use of supplementary analgesics, and increasing the time to first analgesic request
  • Low-dose ketamine was associated with few and mild adverse effects, especially when administered in conjunction with general anaesthesia
  • A systematic review found that dextromethorphan did not reduce postoperative pain scores with a clinically significant magnitude, and although significant decreases in supplemental opioid consumption were observed, these were of questionable clinical importance in most cases
  • Two systematic reviews of randomised controlled trials comparing magnesium with placebo demonstrated inconclusive results overall with regards to pain scores and supplemental analgesic use

Open Colonic Resection-Specific Evidence - Study information

  • IV magnesium provided no significant benefit over placebo for reducing the following postoperative outcomes: pain scores at rest or during movement; morphine requirements for 0–24 h; sedation scores 0–48 h; incidence of nausea and vomiting; time to first bowel movement; and time to first flatus (n=47)

PROSPECT Recommendations

  • Systemic strong opioids are recommended (Grade B) following colonic resection, based on transferable evidence for their efficacy in reducing high-intensity postoperative pain (VAS =50 mm) (LoE 1), with the following considerations:
  • In patients receiving epidural anaesthesia, epidural strong opioids are recommended 2–3 days postoperatively; after the catheter has been removed, systemic strong opioids can be administered for analgesia (Grade D, LoE 4)
  • Systemic strong opioids should only be used in combination with conventional NSAIDs or COX-2-selective inhibitors and paracetamol to reduce opioid use and its associated side-effects (Grade D, LoE 4)
  • Even though IV PCA strong opioids showed no analgesic benefit over IM PRN opioids in procedure-specific evidence (LoE 1), they are recommended (Grade B) based on greater patient satisfaction compared with regular (fixed-interval) or PRN dosing (transferable evidence, LoE 1); however, fixed-interval IV administration titrated to pain intensity is also recognised as an effective mode of administration (LoE 4)
  • IM strong opioids are not recommended because of the pain associated with these injections (Grade D, LoE 4)

Clinical Practice

  • Regular administration, titrated for pain intensity, is generally accepted as an effective method of administering strong opioids
  • Strong opioids are not associated with a ceiling effect, and thus can provide effective analgesia for most types of surgical procedures
  • Strong opioids may be used in a variety of preparations and routes of administration, enabling choice for onset, duration of action, and mode of delivery
  • The opioid antagonist alvimopan has been demonstrated to reduce the incidence of postoperative ileus and accelerate GI function without compromising opioid analgesia in patients undergoing bowel resection (Ludwig 2008)
  • Most clinical trials showing benefits of intramuscular strong opioids use nurse-administered regimens. In regular clinical practice, full adherence to nurse-administered regimens is not usually achievable, and the full analgesic benefits of intramuscular strong opioids are also not achieved
  • Intramuscular administration of strong opioids is considered to be more painful than intravenous administration; however, the dose and rapidity of intravenous administration should be assessed to minimise the risk of respiratory depression

Transferable Evidence from Other Procedures - Study information

  • Three out of five studies showed a significant benefit of IV PCA over IM regular/PRN administration of strong opioids for reducing postoperative pain scores in patients undergoing abdominal hysterectomy Click here for more information
  • Evidence for a benefit of PCA compared with regular/PRN IM administration of strong opioids for reducing overall opioid consumption is inconsistent, although one study suggests that they produced different patterns of dosing in patients undergoing abdominal hysterectomy Click here for more information
  • The incidence of PONV was not significantly different between PCA and IM morphine Click here for more information
  • Opioids administered by PCA improved analgesia, decreased the risk of pulmonary complications and patients preferred them compared with regular IM, IV or SC opioid treatment, as determined in a quantitative systematic review of randomised trials in various surgical procedures
  • Strong opioids are effective for reducing high- and moderate-intensity postoperative pain
  • Strong opioids are associated with adverse effects, including nausea, vomiting, sedation, confusion, paralytic ileus and urinary retention

Open Colonic Resection-Specific Evidence - Study information

  • IM regular or PRN morphine was superior to IV PCA morphine for reducing daily opioid use (both p<0.05) and the total amount of opioid used in two studies (no statistics provided, n=41; p<0.05, n=62)
  • IM morphine was similar to PCA morphine for the frequency of PONV in one study reporting this parameter (n=41)
  • IM morphine was similar to PCA morphine for the level of postoperative pain and activity (measured by patient questionnaire), frequency of PONV, level of sedation and the duration of ileus and of hospital stay. However, this study did not record pain on a linear scale (n=62)
  • PCA morphine had a similar effect to PRN or regular IM morphine for reducing postoperative pain scores in two studies Click here for more information
  • PCA morphine and IM morphine use were associated with similar length of hospital stay in two studies (n=41, n=62)
  • IM or IV morphine plus IM ketorolac prolonged the length of time taken to recover from postoperative ileus compared with IM ketorolac alone (2.3 ± 0.5 days versus 4.2 ± 0.6 days; p<0.05; n=14)

PROSPECT Recommendations

  • Weak opioids are not recommended for controlling high-intensity pain (Grade D, LoE 4)
  • Weak opioids are recommended to be used for moderate- or low-intensity pain if non-opioid analgesia is insufficient or is contra-indicated (Grade B, transferable evidence, LoE 1)
  • Weak opioids are recommended to be used in combination with non-opioid analgesics (Grade B, transferable evidence, LoE 1)

Clinical Practice

  • Tramadol 300 mg is considered to be a clinically effective dose, and therefore the 100 mg dose used in the study by Wordliczek et al. is probably too low to provide sufficient pain relief

Transferable Evidence from Other Procedures

  • Tramadol was more effective than placebo for pain relief in a meta-analysis of post-surgical patients
  • The combination of tramadol and paracetamol enhances analgesic efficacy compared with either agent alone
  • A systematic review found that the combination of dextropropoxyphene 65 mg with paracetamol 650 mg showed similar efficacy to tramadol 100 mg but with a lower incidence of adverse effects
  • A systematic review found that the combination of codeine with paracetamol provided additional pain relief compared with paracetamol alone
  • Two studies found that codeine 30mg + paracetamol 300 mg was associated with a higher incidence of constipation and vomiting than tramadol 37.5 mg + paracetamol 325 mg following arthroscopy
  • Adverse effects associated with tramadol include headache, nausea, vomiting, dizziness, somnolence. A meta-analysis of individual patient data from randomised controlled trials found a dose-response of adverse effects with tramadol; postsurgical patients had fewer side-effects than dental patients
  • A systematic review found that the combination of codeine with paracetamol was associated with an increase in drowsiness and dizziness compared with paracetamol alone
  • A systematic review found an increased incidence of central nervous system adverse effects with paracetamol plus dextropropoxyphene compared with placebo

Open Colonic Resection-Specific Evidence - Study information

  • Administration of IV tramadol immediately after peritoneal closure, or immediately following surgery extended the time to first analgesic request compared with pre-operative administration (p<0.01; n=90)
  • Pre-, intra- or postoperative IV tramadol 100 mg were similar for postoperative pain scores Click here for more information
  • Pre-, intra- or postoperative administration of tramadol 100 mg were similar for the incidence of PONV (n=90)
  • Pre-operative administration of IV tramadol was superior to administration immediately after peritoneal closure or postoperatively for reducing total tramadol consumption (p<0.05; n=90)

PROSPECT Recommendations

  • Paracetamol is recommended for pain of moderate- (>30 VAS <50) or low- (VAS =30) intensity, in combination with COX-2-selective inhibitors or conventional NSAIDs (Grade B), based on its mild analgesic and opioid-sparing effect in transferable evidence (LoE 1), only for patients who do not receive epidural analgesia or with cessation of epidural analgesia (Grade D, LoE 4)
  • However, paracetamol is not recommended for high-intensity pain (VAS =50 mm) (Grade B) because it has no additional analgesic benefit over that conferred by conventional NSAIDs in transferable evidence (LoE 1)

Clinical Practice

  • Paracetamol is a well-established analgesic for low- (VAS=30) or moderate- (VAS>30<50) intensity pain and has a favourable safety profile
  • If paracetamol is used as part of a multi-modal regimen, the anti-pyretic effect can mask complications such as anastomotic leakage

Transferable Evidence from Other Procedures - Study information

  • Paracetamol was superior to placebo for reducing postoperative pain scores, but produced reductions in VAS scores of <13 mm Click here for more information
  • Paracetamol was superior to placebo for reducing supplementary analgesic consumption within 0–24 h in patients undergoing abdominal hysterectomy Click here for more information
  • One study showed that IV paracetamol was equally as effective as IV ketorolac for reducing postoperative pain scores in patients undergoing abdominal hysterectomy (n=176)
  • Paracetamol combined with weak opioids (codeine, tramadol) is superior to weak opioids alone in a review of dental, gynaecological and orthopaedic surgery
  • A meta-analysis of randomised controlled trials showed that paracetamol combined with PCA morphine induced a significant morphine-sparing effect but did not change the incidence of morphine-related adverse effects in the postoperative period
  • There is evidence that concurrent use of paracetamol and conventional NSAIDs improves pain relief compared with paracetamol alone, but there is no evidence for a superior analgesic effect of the combination compared with conventional NSAIDs alone
  • One study showed a marginal but significant benefit of rectal diclofenac over rectal paracetamol for reducing average pain scores over 24 h, (p=0.008; n=44) in patients undergoing abdominal hysterectomy
  • In a systematic review of a variety of surgical procedures, paracetamol plus NSAID conferred no significant benefit over NSAID alone for reducing pain scores in orthopaedic and gynaecological operations. However, a significant benefit was seen in the lower-intensity pain associated with dental operations
  • Paracetamol 1.5 g plus diclofenac 100 mg was not significantly different from diclofenac 100 mg alone given once pre-operatively, for reducing postoperative pain in abdominal gynaecological surgery

Open Colonic Resection-Specific Evidence

  • [No data found within the parameters of the systematic review]

PROSPECT Recommendations

  • Continuous epidural anaesthesia and postoperative analgesia is recommended for routine use in colonic resection (Grade A), based on its benefits for reducing postoperative pain, systemic opioid use and improving bowel recovery time (procedure-specific evidence, LoE 1)
  • A combination of epidural local anaesthetic (LA) and strong opioid is recommended for epidural analgesia (Grade A), based on procedure-specific evidence of their combined efficacy, in reducing postoperative pain and systemic opioid use, compared with LA alone (LoE 1). However, the addition of opioid to epidural LA results in an increase in time to first bowel movement (LoE 1)

Clinical Practice

  • Thoracic epidural is considered to be more appropriate than lumbar epidural for anaesthesia and analgesia in open colon surgery
  • Epidural analgesia is associated with a relatively high degree of patient monitoring and rare major complications
  • Clonidine is not used routinely because it is associated with an increased risk of hypotension, sedation and bradycardia

Transferable Evidence from Other Procedures - Study information

  • 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
  • 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
  • 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
  • Epidural LA was superior to epidural LA plus opioid for reducing the time to first passage of stool Click here for more information
  • Epidural LA was suggested to be the most effective method of reducing ileus and improving postoperative catabolism in patients undergoing abdominal surgery Click here for more information
  • 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 Click here for more information
  • Epidural clonidine is associated with an increased risk of hypotension, sedation and bradycardia Click here for more information

Open Colonic Resection-Specific Evidence - Study information

  • Epidural LA and opioid showed a significant benefit for reducing postoperative pain scores compared Click here for more information
  • Epidural LA plus 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 plus 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)
  • Postoperative thoracic epidural analgesia was superior to postoperative PCA for reduction of VAS pain scores at Day 2 (p=0.01; n=59), but there was no significant difference between the groups at discharge, or on Days 1, 10 and 30
  • 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)
  • Continuous epidural infusion of opioids was superior to systemic regimens for reducing postoperative pain scores in two out of three studies Click here for more information
  • Continuous epidural morphine was superior to control for reducing supplementary analgesic consumption in one study (p<0.01; n=30)
  • Daily bolus epidural morphine was superior to IM oxycodone for reducing postoperative pain scores at 3 h (n=30) Click here for more information
  • Daily bolus epidural morphine was superior to IM oxycodone for reducing supplementary analgesic consumption (p<0.01; n=30)
  • 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
  • Continuous epidural bupivacaine was similar to continuous epidural morphine for reducing postoperative pain scores (n=45) Click here for more information
  • Continuous epidural bupivacaine was associated with similar supplementary analgesic consumption compared with epidural morphine (bolus or continuous) (n=45)
  • Continuous epidural bupivacaine was superior to epidural morphine (bolus or continuous) in reducing the time to first bowel movement (p<0.05; n=45)
  • Epidural clonidine was superior to control for reducing the amount of fentanyl administered postoperatively for 12–24 and 24–36 h (all p<0.05; n=25)
  • Pre-/postoperative epidural clonidine was superior to control for the reduction of postoperative pain scores Click here for more information
  • Pre-/postoperative epidural clonidine was superior to the control for reducing postoperative analgesic requirement Click here for more information
  • Pre-/postoperative epidural clonidine significantly reduced the time to return of normal bowel function compared with control (p<0.001; n=40)
  • The incidence of morphine-associated nausea, vomiting, and itching was significantly lower with pre-/postoperative epidural clonidine, compared with control (p<0.001; n=40)
  • Intra-/postoperative epidural bupivacaine-sufentanil-clonidine + intra-operative IV ketamine was superior to intra-operative IV lidocaine-sufentanil-clonidine + intra-operative IV ketamine + 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
  • Mean summary area under the curve (AUC) of VRS pain scores at rest for 0–72 h postoperatively was significantly lower with PCEA, compared with continuous epidural analgesia (p<0.001; n=205), and median summary VRS pain scores on movement for 24–72 h postoperatively were significantly lower in the PCEA group compared with the continuous epidural group (p<0.001; n=205)
  • PCEA was superior to continuous epidural infusion for reducing postoperative analgesic consumption Click here for more information
  • A significantly higher proportion of patients in the PCEA group were 'very satisfied' with the treatment compared with the continuous epidural infusion group at 72 h postoperatively and at discharge (both p<0.0001; n=205)
  • 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
  • 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)
  • Postoperative thoracic epidural analgesia conferred no significant benefit over postoperative PCA for reducing the time to first bowel movement (n=34 analysed)
  • There was no significant difference in patient quality of life or satisfaction with hospital stay scores between the groups receiving postoperative thoracic epidural analgesia and postoperative PCA (n=59)
  • There was no significant difference between the postoperative thoracic epidural analgesia group and postoperative PCA group for a return to normal levels of activities at discharge, 10 days and 30 days postoperatively ((n=59)
  • Postoperative thoracic epidural analgesia conferred no significant benefit over postoperative PCA for reducing the length of hospital stay (n=59)
  • Epidural morphine (bolus or continuous) was similar to IM baralgine or IM oxycodone for the time to first bowel movement in two studies (n=21, n=30)
  • 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)
  • Continuous epidural morphine was similar to systemic analgesia for the length of postoperative hospital stay in two studies (n=21, n=24)
  • High dose continuous epidural infusion of bupivacaine plus fentanyl provided no significant benefit over a lower dose regimen for improving various postoperative outcomes (n=100) Click here for more information
  • Epidural clonidine provided no significant benefit for postoperative pain scores 0–72 h (n=25)
  • Epidural clonidine provided no significant benefit for sedation scores compared with control at 12–24 h and 24–36 h postoperatively (p<0.05; n=25)
  • Pre-/postoperative epidural clonidine provided no significant benefit for reducing the length of hospital stay compared with control (n=40)
  • 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)

PROSPECT Recommendations

  • Continuous postoperative wound infusion with LA is not recommended (Grade D, LoE 4) as procedure-specific evidence is limited and inconsistent
  • Pre-closure wound infiltration with local anaesthetic is not recommended for open colonic resection (Grade D, LoE 4), due to lack of procedure-specific evidence and inconclusive transferable evidence from other large abdominal surgeries

Clinical Practice

  • 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)
  • 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

Transferable Evidence from Other Procedures - Study information

  • A qualitative and quantitative systematic review compared continuous postoperative wound infusion with LA versus control in multiple surgical procedures (cardiothoracic, general, gynaecology-urology, orthopaedics). Meta-analysis of 44 randomised studies showed that continuous wound infusion with LA was superior to control for reduction of postoperative pain scores and postoperative morphine consumption (n=1814)
  • Five of eight studies showed no significant benefit of intra-operative wound infiltration over placebo for reducing postoperative pain scores following abdominal hysterectomy Click here for more information
  • Postoperative PCA wound infiltration with LA following hysterectomy provided limited benefit over placebo for reducing postoperative pain scores, but significantly reduced postoperative analgesic consumption Click here for more information
  • A systematic review of incisional local anaesthesia showed that evidence of analgesic efficacy in hysterectomy (4 studies), open cholecystectomy (8 studies) and a variety of other surgical procedures (9 studies) was inconclusive Click here for more information
  • Three randomised trials in patients undergoing abdominal hysterectomy showed that single-shot postoperative LA wound infiltration conferred no significant benefit over placebo/no treatment for reducing postoperative pain scores

Open Colonic Resection-Specific Evidence - Study information

  • Continuous wound infusion with Lidocaine and bupivacaine was similar to an intermittent IV morphine infusion for postoperative pain scores Click here for more information
  • Continuous wound infusion with Lidocaine and bupivacaine was superior to IV morphine infusion for the total amount of morphine used (p<0.001; n=70)
  • Continous wound infusion with ropivacaine was superior to placebo for reducing postoperative pain scores during movement at a minority of timepoints Click here for more information
  • Continuous pre-peritoneal infusion with ropivacaine was superior to placebo for reducing postoperative pain scores Click here for more information
  • Continuous pre-peritoneal infusion with 0.2% ropivacaine significantly reduced postoperative consumption of PCA morphine compared with placebo during the first 3 postoperative days (p=0.0004) (n=42)
  • Continuous pre-peritoneal infusion with ropivacaine was superior to placebo for reducing the time to hospital discharge (p=0.02) (n=42)
  • Continuous wound infusion with lidocaine and bupivacaine conferred no benefit over intermittent IV morphine infusion for reducing time to first bowel movement, time to first flatus and timing of postoperative mobilisation (n=70)
  • Continuous wound infusion with lidocaine and bupivacaine was associated with a similar incidence of vomiting compared with intermittent IV PCA morphine infusion (n=70)
  • Continuous wound infusion with 0.54% ropivacaine conferred no significant benefit over placebo for reducing PCA morphine use on postoperative Days 1, 2 and 3 (n=310 analysed)
  • Continuous wound infusion with ropivacaine conferred no significant benefit over placebo for reducing the length of hospital stay (n=310)
  • Continuous wound infusion with ropivacaine had no significant effect on the incidence of postoperative nausea and vomiting, compared with placebo (n=42)
  • Pre-peritoneal continuous infusion with ropivacaine had no significant effect on the incidence of postoperative nausea and vomiting, compared with placebo (n=310)
  • Continuous wound infusion with 0.54% ropivacaine conferred no significant benefit over placebo for the reduction of VAS mobility scores on postoperative Days 1,2, and 3 (n=310)

PROSPECT Recommendations

  • Care protocols (which include controlled rehabilitation with early ambulation and diet, or multi-modal optimisation programmes) following colonic resection are recommended (Grade A) based on factors other than the management of postoperative pain (e.g. postoperative ileus (procedure specific LoE 1) and length of hospital stay (procedure specifc LoE 1)), as postoperative pain benefits are inconsistent (LoE 4). Controlled studies are necessary to define the influence of the various components
  • The 'anti-inflammatory regimen' (GA combined with spinal, epidural, IV corticosteroid and NSAID) is not recommended over GA + IV opioid analgesia (Grade D, LoE 4) because of limited evidence in colonic resection. Moreover, it introduces an increased level of complexity

Clinical Practice

  • Epidural anaesthesia combined with general anaesthesia is used routinely for colonic resection, except in patients with contra-indications to epidurals, where general anaesthesia alone is used.
  • Nasogastric tubes should be removed as early as possible to avoid gastroparesis.

Transferable Evidence from Other Procedures - Study information

  • Multimodal rehabilitation protocols (the fast-track methodology, enhanced recovery programmes, etc.) have been assessed in large prospective cohort studies, randomised trials and systematic reviews. These concluded that integration of optimised pain relief together with early oral nutrition, anti-ileus treatment, mobilisation, appropriate fluid therapy and revision of perioperative care principles hasten recovery, thereby decreasing duration of postoperative hospitalisation as well as reducing m
  • Studies integrating continuous epidural LA with enforced early nutrition and mobilisation uniformly suggest an improved recovery, and decreased hospital stay and convalescence Click here for more information
  • A meta-analysis showed that omitting nasogastric tubes conferred a significant benefit over their use for reducing the time to first oral intake, pulmonary complications, fever, atelectasis and pneumonia
  • A meta-analysis showed that patients managed without nasogastric tubes had significantly greater abdominal distension and vomiting

Open Colonic Resection-Specific Evidence - Study information

  • Care by CREAD numerically, but not statistically, lowered morphine consumption compared with patients undergoing TRAD care (137 ± 109 versus 187 ± 125 mg; p=0.08; n=64)
  • Care by CREAD was superior to TRAD care for reducing the time to discharge and length of hospital stay (5.4 versus 7.1 days, p=0.02; n=64)
  • Care by CREAD numerically but not statistically reduced the number of patients with postoperative ileus or small-bowel obstruction compared with patients undergoing TRAD care (3 versus 4 patients; n=64)
  • A multi-modal optimisation programme conferred a significant benefit over traditional care for reducing postoperative pain scores Click here for more information
  • A multi-modal optimisation programme conferred a significant benefit over traditional care for reducing postoperative fatigue scores on Day 7 (p=0.008; n=25)
  • A multi-modal optimisation programme conferred a significant benefit over traditional care for tolerating a regular hospital diet earlier (48 versus 76 h; p<0.001), and reduced the median length of hospital stay (3 versus 7 days; p<0.002; n=25)
  • Gastrostomy tubes were superior to nasogastric tubes for reducing patient discomfort levels (p<0.01; n=107)
  • Patients receiving gastrostomy tubes reported significantly less tube-related inconvenience than patients receiving nasogastric tubes on postoperative Day 2, at discharge and at 4 weeks postoperatively (all p<0.02; n=107)
  • Mechanical massage with aspiration of abdominal wall was superior to mechanical massage without aspiration for reducing mean postoperative pain scores from Days 2–5 (p<0.001; n=50)
  • Mechanical massage with aspiration of abdominal wall was superior to mechanical massage without aspiration for reducing supplementary analgesic consumption Days 1–3 (p<0.05; n=50)
  • Mechanical massage with aspiration of abdominal wall was superior to mechanical massage without aspiration for reducing the time to first flatus (p<0.01; n=50)
  • The 'anti-inflammatory' regimen (GA, spinal, epidural, IV corticosteroid and NSAID) reduced VAS pain scores at rest and during coughing for 0–8 days postoperatively compared with GA and IV opioid analgesia (p<0.001; n=20)
  • The 'anti-inflammatory' regimen (GA, spinal, epidural, IV corticosteroid and NSAID) significantly reduced fatigue compared with GA and IV opioid analgesia (p<0.05; n=20) Schulze et al 1992
  • The 'anti-inflammatory' regimen (GA, spinal, epidural, IV corticosteroid and NSAID) significantly enhanced ambulatory function (i.e. washing and mobility) compared with GA and IV opioid analgesia (p<0.05; n=20) Schulze et al 1992
  • Care by CREAD did not confer a benefit over TRAD care for reducing postoperative pain scores on Days 2, 10 or 30 (n=64)
  • Care by CREAD showed that pain scores evaluated by the McGill pain questionnaire were higher at discharge but were equal on postoperative Day 10 compared with care by TRAD (p<0.02; n=64)
  • Mechanical massage with aspiration of abdominal wall and mechanical massage without aspiration groups both demonstrated similar Hamilton anxiety scores at the end of the study (n=50)
  • Mechanical massage with aspiration of abdominal wall and mechanical massage without aspiration groups had a similar time to discharge from hospital (n=50)
  • Gastrostomy and nasogastric tubes were associated with similar postoperative pain scores (n=107)
  • Postoperative restriction of IV fluids did not confer any benefit over the standard IV fluid regimen for reducing VAS pain scores at rest or during movement during the hospital stay (n=80)
  • Postoperative restriction of IV fluids did not confer any benefit over the standard IV fluid regimen for reducing the consumption of postoperative supplementary analgesics (n=80) Click here for more information
  • Postoperative restriction of IV fluids did not confer any benefit over the standard IV fluid regimen for reducing the incidence of postoperative nausea and vomiting (n=80)
  • Time to passage of first flatus was similar for patients allocated to the restricted postoperative IV fluid and standard postoperative IV fluid regimens (n=80)
  • Postoperative restriction of IV fluids conferred no significant benefit over the standard postoperative fluid regimen for reducing the time to medical discharge or hospital discharge (n=80)
  • Peri-operative IV glucose + amino acids conferred no signficant benefit over peri-operative IV glucose alone, for the reduction of VAS pain scores at rest or during movement at 12, 24, 36 or 48 h postoperatively (n=16)

PROSPECT Recommendations

  • Conventional NSAIDs are recommended (Grade B) based on limited procedure-specific evidence (LoE 2) and transferable evidence (LoE1) showing analgesic benefit

Clinical Practice

  • Conventional NSAIDs are used in preference to strong opioids in laparoscopic procedures

Transferable Evidence from Other Procedures

  • Conventional NSAIDs have proven analgesic efficacy in a variety of surgical procedures
  • A meta-analysis of randomised controlled trials that was performed to evaluate the risk of morphine-related adverse effects in patients treated with NSAIDs demonstrated that NSAIDs decreased the incidence of nausea, vomiting and sedation, but not pruritus, urinary retention or respiratory depression
  • Six out of eight studies showed a significant benefit of postoperative conventional NSAIDs compared with placebo for reducing postoperative pain scores in patients undergoing hysterectomy Click here for more information
  • Conventional NSAIDs conferred a significant benefit over placebo for reducing supplementary analgesia requirements over 24 h or more in patients undergoing abdominal hysterectomy Click here for more information
  • Conventional NSAIDs were superior to placebo for reducing morphine consumption in abdominal surgery but did not consistently reduce pain scores in two studies in abdominal surgery Click here for more information
  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo
  • Two of three studies showed no significant analgesic benefit of conventional NSAIDs plus epidural analgesia compared with epidural analgesia alone Click here for more information
  • Results were inconsistent for conventional NSAIDs compared with placebo for the time to first analgesic request following abdominal hysterectomy Click here for more information
  • Conventional NSAIDs and placebo were not significantly different for the incidence of PONV (all groups received background strong opioid) in patients undergoing abdominal surgery Click here for more information
  • Diclofenac 50 mg IM bolus pre-operatively then postoperatively at 4 and 10 h, plus epidural analgesia using bupivacaine 0.5% continually infused at 8 mL/h did not confer a benefit for extending the time to first analgesic request compared with epidural analgesia alone in patients undergoing abdominal hysterectomy (n=26)
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo
  • Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication
  • A case-control study in patients undergoing laparoscopic colonic resection with primary anastomosis found that patients given postoperative oral diclofenac (150 mg daily) were at higher risk of anastomotic leakage, compared with patients receiving postoperative opioid analgesics

Laparoscopic Colonic Resection-Specific Evidence

  • Postoperative IV ketorolac was superior to placebo for reduction of VAS pain scores during walking on Days 1 (p<0.001), 2 (p<0.05) and 3 (p<0.001), but not on Day 4
  • Postoperative IV ketorolac significantly reduced postoperative PCA morphine requirement, compared with placebo (p=0.011; n=44)
  • Postoperative IV ketorolac was superior to placebo for reducing the time to first flatus (p=0.005; n=44)
  • Postoperative IV ketorolac significantly reduced the time to return to full diet, compared with placebo (p=0.033; n=44)
  • VAS pain scores on coughing were significantly greater with IV ketorolac, compared with placebo at Day 4 (p<0.001), but there was no significant difference between the groups on Days 1, 2, and 3 (n=44)
  • There was no significant difference between the IV ketorolac and placebo groups for VAS pain scores at rest on Days 1–4
  • There was no significant difference in the length of hospital stay between the postoperative IV ketorolac and placebo groups (n=44)
  • There was no significant difference in the incidence of anastomotic leaks in the IV ketorolac and placebo groups (n=44)

PROSPECT Recommendations

  • Continuous intra-/postoperative IV lidocaine is not recommended currently (Grade D, LoE 4) because of limited procedure-specific data, despite some positive transferable evidence

Clinical Practice

  • Further evidence is needed to precisely define the role of IV lidocaine in this setting, including direct comparisons with epidural analgesia
  • IV lidocaine may induce hypotension
  • If IV lidocaine is used, it is recommended that safety data are taken into account

Transferable Evidence from Other Procedures

  • A meta-analysis of randomised 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

Laparoscopic Colonic Resection-Specific Evidence

  • Continuous intra-/postoperative IV lidocaine was superior to placebo for reducing postoperative pain scores during mobilization and on coughing Click here for more information
  • Continuous intra-/postoperative IV lidocaine was superior to placebo for reducing postoperative opioid consumption Click here for more information
  • Continuous intra-/postoperative IV lidocaine significantly reduced the dose of IV sufentanil administered during surgery, compared with placebo (p< 0.001; n=40)
  • Continuous intra-/postoperative IV lidocaine was superior to placebo for reducing the time to first flatus and first bowel movement (both p=0.001; n=40)
  • Continuous intra-/postoperative IV lidocaine significantly reduced the length of hospital stay compared with placebo (p=0.001; n=40)
  • Incidence of postoperative nausea or vomiting was similar in both the continuous intra-/postoperative lidocaine and placebo groups (n=40)

PROSPECT Recommendations

  • Epidural LA + strong opioid reduces postoperative pain (procedure-specific evidence, LoE 1), but is not recommended (Grade D), due to poor risk:benefit ratio (LoE 4)
  • Epidural analgesia is recommended in high-risk pulmonary patients (Grade D; LoE 4)

Clinical Practice

  • The risk of side-effects associated with epidural analgesia may outweigh the benefits of analgesia in laparoscopic colonic resection

Transferable Evidence from Other Procedures

  • None cited

Laparoscopic Colonic Resection-Specific Evidence

  • Two of two studies showed that epidural LA plus opioid was superior to IV PCA morphine for reducing postoperative pain scores Click here for more information
  • One study showed that thoracic epidural LA + opioid was associated with significantly lower VAS fatigue scores on postoperative Day 3 (p=0.025), compared with IV PCA morphine, although there was no significant difference between the groups on Days 1, 2 and 4
  • One study found that thoracic epidural LA + opioid was superior to IV PCA opioid for reducing postoperative vomiting on Days 1 and 2 (p=0.033 and p=0.005; n=50), but not on Days 3 or 4
  • One study showed that time to first flatus and first bowel movement was significantly shorter with thoracic epidural LA + opioid, compared with IV PCA morphine (p=0.0061 and p=0.0027, respectively; n=50)
  • One study reported that time taken to return to fluid diet and full diet was significantly shorter for patients in the thoracic epidural LA + opioid group, compared with the IV PCA group (p=0.0442 and p=0.0436, respectively; n=50)
  • Thoracic epidural ropivacaine + IV PCA morphine was superior to IV PCA opioid alone, for reducing the amount of supplementary IV PCA morphine administered between surgery to Day 2 (p=0.04). However, there was no significant difference between the groups from Day 2–4, or from surgery to Day 4 overall (n=20)
  • VAS pain scores during Days 1–8 were significantly lower in the group receiving GA + thoracic epidural analgesia, compared with the group receiving GA alone (p=0.004; n=75 overall)
  • GA + thoracic epidural analgesia was superior to GA alone for reducing postoperative analgesic consumption Click here for more information
  • GA + thoracic epidural analgesia was associated with a significantly shorter time to recovery of GI function (GI-3) and time to first bowel movement (p=0.025 and p=0.038, respectively; n=75), compared with GA alone, but there was no significant difference for time to first flatus or time to solid food tolerance
  • One study reported that thoracic epidural LA + opioid conferred no significant benefit over IV PCA morphine for reducing postoperative analgesic requirements (n=50)
  • One study reported that the incidence of postoperative nausea was similar in patients receiving thoracic epidural LA + opioid and IV PCA opioid (n=50)
  • One study reported that the incidence of nausea requiring antiemetics, urinary retention, hypotension, and respiratory depression was similar in the groups receiving thoracic epidural LA + opioid and IV PCA morphine (n=38)
  • Two studies of two reported no significant difference in the length of hospital stay between the groups receiving thoracic epidural LA + opioid or PCA IV morphine (n=38)
  • Thoracic epidural ropivacaine + IV PCA morphine did not confer any significant benefit for reducing VAS pain scores at rest, or during coughing, from surgery to Day 4, or the time to first bowel movement, compared with IV PCA morphine alone (n=20)
  • The incidence of postoperative nausea and vomiting, frequency of naso-gastric tube reinsertion and length of hospital stay was similar between the groups receiving GA + thoracic epidural analgesia or GA alone (n=75 overall)
  • Continuous epidural LA + IV PCA opioid versus control (IV PCA opioid alone) Click here for more information
  • GA plus thoracic epidural analgesia (TEA) versus GA alone Click here for more information

PROSPECT Recommendations

  • The combination of spinal analgesia and general anaesthesia is not recommended (Grade D) as the risk:benefit balance is not positive (LoE 4), and because of limited procedure-specific evidence

Clinical Practice

  • Spinal analgesia (LA + opioid) has a limited duration of action
  • Spinal morphine may produce some postoperative pain relief but also produces risk of PONV and prolongation of postoperative ileus, and limited duration of analgesic effect

Transferable Evidence from Other Procedures

  • One study showed that spinal analgesia with fentanyl + LA was superior to spinal analgesia with LA alone for reducing postoperative pain scores during from 0–8 h, but not between 8–24 h, following abdominal hysterectomy (n=20 overall)
  • The same study found spinal fentanyl + LA was superior to spinal LA alone for reducing the time to first analgesia request; the incidence of patients with PONV was similar between the two groups (n=20)

Laparoscopic Colonic Resection-Specific Evidence – Study information

  • Single bolus spinal hyperbaric bupivacaine with morphine was superior to hyperbaric bupivacaine alone for reducing cumulative VAS pain scores at rest or during coughing from 0?48 h (p=0.035 and p=0.01, respectively; n=35)
  • Single bolus spinal hyperbaric bupivacaine with morphine was superior to hyperbaric bupivacaine alone for reducing supplementary morphine consumption over 48 h (p=0.003; n=35)
  • Single bolus spinal hyperbaric bupivacaine with morphine was associated with a similar incidence of nausea/vomiting to hyperbaric bupivacaine alone. However, numerically more metoclopramide tablets were required by patients receiving spinal hyperbaric bupivacaine plus morphine (22 tablets), compared with hyperbaric bupivacaine alone (12 tablets) (n=35)

PROSPECT Recommendations

  • Gasless laparoscopy is not recommended (Grade B) based on procedure-specific evidence showing lack of analgesic effect (LoE 2)

Clinical Practice

  • None cited

Transferable Evidence from Other Procedures

  • None cited

Laparoscopic Colonic Resection-Specific Evidence

  • Gasless pneumoperitoneum was associated with increased cumulative VAS pain scores during mobilization and coughing (p=0.008 and p=0.006, respectively), but not at rest, up to 30 days after surgery, compared with conventional carbon dioxide pneumoperitoneum (n=17 overall)

PROSPECT Recommendations

  • 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, LoE 4)
  • Laparoscopic colonic resection is recommended over open colon surgery for reducing postoperative pain (Grade A), if the conditions outlined above allow, based on procedure-specific evidence (LoE 1)

Clinical Practice

  • The decision to employ a laparoscopic versus open approach for colonic surgery is based on multiple factors such as the indication for surgery (e.g. benign or malignant disease) and surgical expertise, as well as the desired outcomes

Transferable Evidence from Other Procedures

  • None cited

Laparoscopic Colonic Resection-Specific Evidence

  • 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 in four studies of four Click here for more information
  • Laparoscopic resection was superior to open colonic resection for reducing time to first flatus and bowel movement in three of four 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
  • 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)
  • A 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
  • 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)
  • One study reported that there was no significant difference in the incidence of postoperative nausea and vomiting between the laparoscopic colonic resection and open colonic resection techniques (n=60)
  • 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 was no significant difference in the postoperative morphine requirement between patients who received hand-assisted laparoscopic proctocolectomy versus open proctocolectomy at 24, 48 or 72 h (n=55)
  • Hand-assisted laparoscopic proctocolectomy conferred no significant benefit over open proctocolectomy for reducing the time taken for patients to return to normal fluid or food consumption (n=55)

PROSPECT Recommendations

  • The decision concerning the type of laparoscopic technique 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, LoE 4)

Clinical Practice

  • None cited

Transferable Evidence from Other Procedures

  • None cited

Laparoscopic Colonic Resection-Specific Evidence

  • Operative time was significantly shorter with hand-assisted laparoscopic colectomy versus standard laparoscopic colectomy for both sigmoid/left colectomy (p=0.021; n=66) and total colectomy (p=0.015; n=29)
  • Two studies of two reported no significant difference between hand-assisted laparoscopic and conventional laparoscopic techniques for reducing postoperative pain scores Click here for more information
  • Two studies of two reported no significant difference between hand-assisted laparoscopic and conventional laparoscopic techniques for reducing postoperative analgesic requirement Click here for more information
  • One study reported that time to passage of first flatus and return of first bowel movement, was similar with the hand-assisted laparoscopic and standard laparoscopic techniques for both sigmoid/left colectomy (n=66) and total colectomy (n=29)
  • One study found that time to first tolerance of liquids or solids was similar with hand-assisted laparoscopic and standard laparoscopic techniques for both sigmoid/left colectomy (n=66) and total colectomy (n=29)
  • One study reported that the duration of hospital stay was similar with hand-assisted laparoscopic, compared conventional laparoscopic colectomy (n=54)

PROSPECT Recommendations

  • Pre-closure wound infiltration with LA can be recommended (Grade B) for laparoscopic colonic resection based on transferable evidence from other laparoscopic abdominal surgical procedures (LoE 1)

Clinical Practice

  • None cited

Transferable Evidence from Other Procedures

  • Nine out of 11 studies showed a significant benefit of LA wound infiltration over placebo or no treatment for reducing VAS pain scores in laparoscopic cholecystectomy Click here for more information
  • Six studies out of 11 reported that LA wound infiltration reduced analgesic consumption compared with placebo or no treatment; each of those studies also showed significantly reduced VAS pain scores with LA wound infiltration Click here for more information

Laparoscopic Colonic Resection-Specific Evidence

  • None cited

PROSPECT Recommendations

  • Care protocols (which include controlled rehabilitation with early ambulation and diet, or multi-modal optimisation programmes) following colonic resection are recommended (Grade A) based on factors other than the management of postoperative pain (e.g. postoperative ileus (procedure specific LoE 1) and length of hospital stay (procedure specifc LoE 1)), as postoperative pain benefits are inconsistent (LoE 4). Controlled studies are necessary to define the influence of the various components of s
  • Postoperative restriction of IV fluids is not recommended for analgesia (Grade B) due to limited procedure-specific evidence showing lack of analgesic efficacy (LoE 2)

Clinical Practice

  • None cited

Transferable Evidence from Other Procedures

  • Multimodal rehabilitation protocols (the fast-track methodology, enhanced recovery programmes, etc.) have been assessed in large prospective cohort studies, randomised trials and systematic reviews. These concluded that integration of optimised pain relief together with early oral nutrition, anti-ileus treatment, mobilisation, appropriate fluid therapy and revision of perioperative care principles hasten recovery, thereby decreasing duration of postoperative hospitalisation as well as reducing m

Laparoscopic Colonic Resection-Specific Evidence

  • Postoperative restriction of IV fluids did not confer any benefit over the standard IV fluid regimen for reducing VAS pain scores at rest or during movement during the hospital stay (n=80)
  • Postoperative restriction of IV fluids did not confer any benefit over the standard IV fluid regimen for reducing the consumption of postoperative supplementary analgesics (n=80) Click here for more information
  • Postoperative restriction of IV fluids did not confer any benefit over the standard IV fluid regimen for reducing the incidence of postoperative nausea and vomiting (n=80)
  • Time to passage of first flatus was similar for patients allocated to the restricted postoperative IV fluid and standard postoperative IV fluid regimens (n=80)
  • Postoperative restriction of IV fluids conferred no significant benefit over the standard postoperative fluid regimen for reducing the time to medical discharge or hospital discharge (n=80)

PROSPECT Recommendations

  • Laxatives are not recommended for analgesia (Grade D, LoE 4), but may be used for reasons other than pain relief (LoE 4)

Clinical Practice

  • None cited

Transferable Evidence from Other Procedures

  • Time until first defecation and GI recovery were significantly shorter with bisacodyl versus placebo (p=0.001 and p=0.007, respectively; n=169)
  • Pre-operative + postoperative administration of bisacodyl provided no significant benefit over placebo for the reduction of VAS pain scores (n=169)
  • There was no significant difference in the level of opioid consumption between patients who received bisacodyl or placebo during the first 8 postoperative days (n=169)
  • The incidence of postoperative cramping and nausea was similar in the bisacodyl and placebo groups (n=169)
  • Bisacodyl conferred no significant benefit over placebo for reducing the length of hospital stay (n=169)

Laparoscopic Colonic Resection-Specific Evidence

  • None cited

[emc2pdc id=”1513″]