Laparoscopic colonic resection studies

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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