Feasibility study of analgesia via epidural versus continuous wound infusion after laparoscopic colorectal resection.

BACKGROUND: With the adoption of enhanced recovery and emerging new modalities of analgesia after laparoscopic colorectal resection (LCR), the role of epidural analgesia has been questioned. This pilot trial assessed the feasibility of a randomized controlled trial (RCT) comparing epidural analgesia and use of a local anaesthetic wound infusion catheter (WIC) following LCR. METHODS: Between April 2010 and May 2011, patients undergoing elective LCR in two centres were randomized to analgesia via epidural or WIC. Sham procedures were used to blind surgeons, patients and outcome assessors. The primary outcome was the feasibility of a large RCT, and all outcomes for a definitive trial were tested. The success of blinding was assessed using a mixed-methods approach. RESULTS: Forty-five patients were eligible, of whom 34 were randomized (mean(s.d.) age 70(11·8) years). Patients were followed up per-protocol; there were no deaths, and five patients had a total of six complications. Challenges with capturing pain data were identified and resolved. Mean(s.d.) pain scores on the day of discharge were 1·9(3·1) in the epidural group and 0·7(0·7) in the WIC group. Median length of stay was 4 (range 2-35, interquartile range 3-5) days. Mean use of additional analgesia (intravenous morphine equivalents) was 12 mg in the WIC arm and 9 mg in the epidural arm. Patient blinding was successful in both arms. Qualitative interviews suggested that patients found participation in the trial acceptable and that they would consider participating in a future trial. CONCLUSION: A blinded RCT investigating the role of epidural and WIC administration for postoperative analgesia following LCR is feasible. Rigorous standard operating procedures for data collection are required.

A qualitative evaluation of patients' experiences of an enhanced recovery programme for colorectal cancer.

AIM: We explored the patients' views and experiences of surgery for colorectal cancer within an enhanced recovery programme (ERP). METHOD: Semi-structured home interviews were performed within 6 weeks of hospital discharge with participants of a randomized trial comparing laparoscopically assisted surgery with open surgery for colorectal cancer within an ERP. Interviews were tape-recorded, transcribed and analysed using qualitative techniques of constant comparison based upon grounded theory. RESULTS: Interviewees (n = 22) had similar baseline characteristics and clinical outcomes to participants in the full trial. Many participants were pleased to be discharged quickly and they considered that being in their own home-improved recovery because it allowed them to choose how and when to undertake daily activities rather than following the hospital routine. Some participants (n = 9) were less satisfied with the process, and the reasons for this were related to complications requiring readmission or needing to contact a health professional for information after discharge. CONCLUSION: Although many participants reported benefits from an ERP, the study highlighted areas for improvement. In particular participants reported the need for better access to information and specialist advice in the early days after hospital discharge.

The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer.

OBJECTIVE: Optimizing peri-operative care using an enhanced recovery programme improves short-term outcomes following colonic resection. This study compared a prospective group of patients undergoing resection of colorectal cancer within an enhanced recovery programme, with a prospectively studied historic cohort receiving conventional care. PATIENTS AND METHODS: Sixty patients underwent elective resection within an enhanced recovery programme (ERP). This incorporated pre-operative counselling, epidural analgesia, early feeding and mobilization. Clinical outcomes were compared with 86 prospectively studied historic control patients receiving conventional care (CC). All patients completed EORTC QLQ-C30, QLQ-CR38 and health economics questionnaires up to three months after surgery. RESULTS: Baseline clinical data were similar in both groups. Postoperative hospital stay was significantly reduced in the ERP, with patients staying 49% as long as those in the CC group including convalescent hospital stay (95% CI 39% to 61%P < 0.001). There were no differences in the number of complications, readmissions or re-operations. There were no significant differences in quality of life or health economic outcomes. CONCLUSION: Patients undergoing colorectal resection within an ERP stay in hospital half as long as those receiving conventional care, with no increased morbidity, deterioration in quality of life or increased cost.

Outcome following laparoscopic resection for colorectal cancer.

BACKGROUND: A prospective comparison of laparoscopic or laparoscopically assisted colorectal resection versus open resection has been undertaken to evaluate early benefits and cost implications. METHODS: Consecutive patients with colorectal cancer underwent either elective laparoscopic (n = 25) or open (n = 29) resection. RESULTS: Mean hospital stay was significantly shorter in the laparoscopic group: 10.7 versus 17.8 days. Mean morphine requirements were less in patients who had laparoscopic resection and their recovery, as measured by the dynamometer hand grip and the SF-36 symptom score, was more rapid. Adequate tumour clearance was achieved in the laparoscopic group. In both groups, the number of lymph nodes harvested was similar. Port-site or wound recurrence has not been observed at a median follow-up of 28 months. CONCLUSION: When laparoscopic colorectal resection is possible, there are significant early benefits for patients.

Adenosine infusion: a rational approach towards induced hypotension.

OBJECTIVES: To examine the systolic (SBP) and diastolic (DBP) blood pressure (mmHg) and heart rate (beats/min) responses to varying doses and rates of adenosine administration in awake and anesthetized swine. DESIGN: Adult swine underwent sterile insertion of chronic carotid artery and jugular vein catheters. After recovery, baseline blood pressure and heart rate values were obtained. Three rates (mg/kg/min) of adenosine were infused in a randomized block design (low: 0.06 for 20 mins; medium: 0.12 for 10 mins; and high: 0.24 for 5 mins) to a total dose of 1.2 mg/kg. After 5 mins of infusion, three separate doses (0.3 mg/kg; 0.6 mg/kg; and 1.2 mg/kg) were compared. RESULTS: In awake animals, only the highest dose significantly decreased (P < or = 0.0001) SBP by 21% and DBP by 43% while increasing heart rate by 32%. At this high dose, the rate of administration was compared. Medium rates significantly decreased (P < or = 0.0002) SPB by 18%, DBP by 33% and elevated heart rate by 27%. High rates caused even greater changes (SBP 21%, DBP 43%, heart rate 32%). The low rate did not alter SBP, DBP or heart rate. Anesthetized swine had a greater decrease in blood pressure, which was not accompanied by alterations in heart rate. CONCLUSIONS: This study clarifies that the blood pressure and heart rate effects of adenosine are both dose and rate dependent in awake and anesthetized swine. The dose dependent responses can be controlled by the rate of administration. Heart rate increased only in the awake state, while in the anesthetized state no alteration of heart rate was observed. The greater decline in SBP and DBP found in anesthetized swine was likely due to the absence of compensatory increases in heart rate as was observed in awake animals.