Evidence-based postoperative pain management after laparoscopic colorectal surgery.
OBJECTIVE
The aim of this systematic review was to evaluate the available literature on the management of pain after laparoscopic colorectal surgery.


METHODS
Randomized studies, published in English between January 1995 and July 2011, assessing analgesic and anaesthetic interventions in adults undergoing laparoscopic colorectal surgery, and reporting pain scores, were retrieved from the Embase and MEDLINE databases. The efficacy and adverse effects of the analgesic techniques was assessed. The recommendations were based on procedure-specific evidence from a systematic review and supplementary transferable evidence from other relevant procedures.


RESULTS
Of the 170 randomized studies identified, 12 studies were included. Overall, all approaches including ketorolac, methylprednisolone, intraperitoneal instillation of ropivacaine, intravenous lidocaine infusion, intrathecal morphine and epidural analgesia improved pain relief, reduced opioid requirements and improved bowel function. However, there were significant differences in the study designs and the variables evaluated, precluding quantitative analysis. The L'Abbé plots of the data from the epidural analgesia studies included in this review indicate that the pain scores in the nonepidural groups, although higher than those in the epidural groups, were within an acceptable level (i.e. < 4/10).


CONCLUSIONS
Infiltration of surgical incisions with local anaesthetic at the end of surgery, systemic steroids, conventional nonsteroidal anti-inflammatory drugs or cyclooxygenase-2-selective inhibitors in combination with paracetamol with opioid used as rescue are recommended. Intravenous lidocaine infusion is recommended, but not as the first line of therapy. However, neuraxial blocks (i.e. epidural analgesia and spinal morphine) are not necessary based on high risk:benefit ratio.
Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, Texas 75390-9068, USA. girish.joshi@utsouthwestern.edu
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D000700:Analgesics / Q000008:administration & dosage* / Q000009:adverse effects; D003107:Colorectal Surgery / Q000295:instrumentation / Q000379:methods; D019317:Evidence-Based Medicine; D006801:Humans; D010535:Laparoscopy; D010149:Postoperative Pain / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic
D000700:Analgesics