Evidence-based management of pain after laparoscopic cholecystectomy: a PROSPECT review update.

BACKGROUND: Significant pain can be experienced after laparoscopic cholecystectomy. This systematic review aims to formulate PROSPECT (PROcedure SPECific Postoperative Pain ManagemenT) recommendations to reduce postoperative pain after laparoscopic cholecystectomy. METHODS: Randomised controlled trials published in the English language from January 2006 (date of last PROSPECT review) to December 2017, assessing analgesic, anaesthetic, or operative interventions for laparoscopic cholecystectomy in adults, and reporting pain scores, were retrieved from MEDLINE and Cochrane databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) search protocols. PROSPECT methodology was used, and recommendations were formulated after review and discussion by the PROSPECT group (an international group of leading pain specialists and surgeons). RESULTS: Of 1988 randomised controlled trials identified, 258 met the inclusion criteria and were included in this review. The studies were of mixed methodological quality, and quantitative analysis was not performed because of heterogeneous study design and how outcomes were reported. CONCLUSIONS: We recommend basic analgesic techniques: paracetamol + NSAID or cyclooxygenase-2 specific inhibitor + surgical site local anaesthetic infiltration. Paracetamol and NSAID should be started before or during operation with dexamethasone (GRADE A). Opioid should be reserved for rescue analgesia only (GRADE B). Gabapentanoids, intraperitoneal local anaesthetic, and transversus abdominis plane blocks are not recommended (GRADE D) unless basic analgesia is not possible. Surgically, we recommend low-pressure pneumoperitoneum, postprocedure saline lavage, and aspiration of pneumoperitoneum (GRADE A). Single-port incision techniques are not recommended to reduce pain (GRADE A).

Systematic review of the systemic concentrations of local anaesthetic after transversus abdominis plane block and rectus sheath block.

BACKGROUND.: Safe and efficacious modalities of perioperative analgesia are essential for enhanced recovery after surgery. Truncal nerve blocks are one potential adjunct for analgesia of the abdominal wall, and in recent years their popularity has increased. Transversus abdominis plane block (TAPB) and rectus sheath block (RSB) have been shown to reduce morphine consumption and improve pain relief after abdominal surgery. These blocks typically require large volumes of local anaesthetic (LA). We aimed to synthesize studies evaluating systemic concentrations of LA after perioperative TAP and RSB to enhance our understanding of systemic LA absorption and the risk of systemic toxicity. METHODS.: An independent literature review was performed in accordance with the methods outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. An electronic search of four databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and PubMed) was conducted. Primary articles measuring systemic concentrations of LA after single-shot bolus TAPB or RSB were included. RESULTS.: Fifteen studies met the inclusion criteria. Rapid systemic LA absorption was observed in all studies. Of a total of 381 patients, mean peak concentrations of LA exceeded toxic thresholds in 33 patients, of whom three reported mild adverse effects. The addition of epinephrine reduced systemic absorption of LA. No instances of seizure or cardiac instability were observed. CONCLUSIONS.: Local anaesthetic in TAPB and RSB can lead to detectable systemic concentrations that exceed commonly accepted thresholds of LA systemic toxicity. Our study highlights that these techniques are relatively safe with regard to LA systemic toxicity.

Systematic review of the role of biomarkers in diagnosing anastomotic leakage following colorectal surgery.

BACKGROUND: Anastomotic leakage (AL) following colorectal surgery can be difficult to diagnose owing to varying clinical presentations. This systematic review aimed to assess biomarkers as potential diagnostic tests for preclinical detection of AL. METHODS: A comprehensive literature review was conducted according to PRISMA guidelines. All published studies evaluating biomarkers, both systemic and peritoneal, in the context of AL following colorectal surgery were included. Studies were sought in three electronic databases (MEDLINE, PubMed and Embase) from January 1990 to June 2016. RESULTS: Thirty-six studies evaluated 51 different biomarkers in the context of AL after colorectal surgery. Biomarkers included markers of ischaemia and inflammation, and microbiological markers, and were measured in both peritoneal drain fluid and the systemic circulation. The most commonly evaluated peritoneal drain fluid biomarkers were interleukin (IL) 6, IL-10 and tumour necrosis factor. Significantly raised drain levels in the early postoperative period were reported to be associated with the development of AL. C-reactive protein, procalcitonin and leucocytes were the most commonly evaluated systemic biomarkers with significant negative and positive predictive values. Associated area under the curve values ranged from 0·508 to 0·960. CONCLUSION: Peritoneal drain fluid and systemic biomarkers are poor predictors of AL after colorectal surgery. Combinations of these biomarkers showed improvement in predictive accuracy.