Evidence-based postoperative pain management after laparoscopic colorectal surgery

doi:10.1111/j.1463-1318.2012.03062.x Systematic review Evidence-based postoperative pain management after laparoscopic colorectal surgery G. P. Josh...
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doi:10.1111/j.1463-1318.2012.03062.x

Systematic review

Evidence-based postoperative pain management after laparoscopic colorectal surgery G. P. Joshi*, F. Bonnet† and H. Kehlet‡ on behalf of the PROSPECT collaboration1 *Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, Texas, USA, †Department d’ Anesthesie Reanimation, Hopital Tenon, Assistance Publique Hoˆpitaux de Paris, Universite´ Pierre et Marie Curie, Paris VI, Paris, France and ‡Section for Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Copenhagen University, Copenhagen, Denmark Received 16 January 2012; accepted 3 March 2012; Accepted Article online 30 April 2012

Abstract Aim The aim of this systematic review was to evaluate the available literature on the management of pain after laparoscopic colorectal surgery. Method 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

Introduction Colorectal surgery using the laparoscopic approach has gained wide acceptance because it is associated with reduced pain and ⁄ or analgesic consumption, lower morbidity including reduced wound infection, a faster recovery and a shorter hospital stay, without compromising surgical outcome [1]. However, most of the recommendations concerning postoperative pain management for the laparoscopic approach are based on studies Correspondence to: Girish P. Joshi, MBBS, MD, FFARCSI, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, Texas, 75390-9068, USA. E-mail: [email protected] 1 PROSPECT collaboration members are listed in the Appendix.

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bowel function. However, there were significant differences in the study designs and the variables evaluated, precluding quantitative analysis. The L’Abbe´ 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). Conclusion 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. Keywords Laparoscopic colorectal surgery, pain, analgesia, systematic review, evidence-based medicine

performed in open surgical procedures [2]. Consequently, optimal pain therapy for patients undergoing laparoscopic colorectal surgery remains controversial. A recent systematic review of postoperative analgesia after laparoscopic colorectal surgery has stated that ‘the use of spinal anesthesia postoperatively may offer many advantages with lower complication rate, lack of unilateral block and lack of prolonged motor block’ [3]. This statement clearly does not take into account the potential complications of spinal (intrathecal) analgesia, such as nausea, vomiting, pruritus, urinary retention and respiratory depression [4]. Importantly, the authors did not take into consideration the use of multimodal analgesia techniques that have been shown to be optimal for laparoscopic surgical procedures.

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The PROSPECT (procedure-specific postoperative pain management) Working Group is a collaboration of surgeons ⁄ surgical scientists and anaesthesiologists working together to formulate evidence-based recommendations for postoperative pain management that are specific for different surgical procedures [5–11]. The recommendations are based on procedure-specific evidence from a systematic review, supplementary transferable evidence from other relevant procedures and clinical practice information. Importantly, this approach takes into consideration the efficiency and the adverse effects of an analgesic technique. The aim of the present systematic review was to evaluate the available literature on the management of pain after laparoscopic colorectal surgery. Postoperative pain (pain scores and supplemental analgesic requirements) was the primary focus, but other recovery outcomes, including adverse effects, were also assessed where reported, and the limitations of the data were reviewed.

Method A systematic review of the literature concerning analgesia after laparoscopic colorectal surgery was conducted. The search was performed from 1995 to July 2011 using MEDLINE and Embase, according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines [12]. Search terms related to pain and interventions for colorectal surgery: pain OR postoperative pain OR analgesi* OR anaesthe* OR anesthe* OR VAS OR ‘visual analog*’ OR VRS OR mcgill OR epidural OR neuraxial OR intrathecal OR paravertebral OR spinal OR infiltration OR NSAID OR COX-2 OR paracetamol OR acetaminophen OR gabapentin OR pregabalin OR clonidine OR opioid OR ketamine OR corticosteroid OR EMLA OR colon resection OR colectomy OR colorectal surgery OR colonic surgery. The search was limited to randomized controlled studies or trials, clinical studies or trials, English language, and human(s). Study inclusion criteria

Randomized controlled trials (RCTs) in the English language assessing analgesic and anaesthetic interventions in adult laparoscopic colorectal surgery and reporting pain on a linear analogue, verbal or numerical rating scale, were included. Quality of included studies

The following criteria were used to assess the quality of eligible studies (Table 1):

1 Statistical analyses and patient follow-up assessment: indicates whether statistical analyses were reported and whether patient follow-up was greater or less than 80%. 2 Allocation concealment assessment: indicates whether there was adequate prevention of foreknowledge of treatment assignment by those involved in recruitment (A = adequate, B = unclear, C = inadequate, D = not used). 3 Numerical scores (total 1–5) for study quality: assigned using the method proposed by Jadad [13] to indicate whether a study reported appropriate randomization, double-blinding and statements of possible withdrawals. 4 Additional study quality assessment: including an assessment of how closely the study report met the requirements of the PRISMA guidelines [12]. Analyses of outcome

Summary information for each included study was extracted and recorded in data tables. This information included pain scores, supplementary analgesic use, time to first analgesic request, functional outcome and adverse effects. It was assumed that the postoperative pain scores were assessed at rest, unless otherwise specified in the study report. Studies were stratified according to the class of analgesic and the mode of delivery (systemic, neuraxial or local). The effectiveness of each intervention for each outcome was evaluated qualitatively, by assessing the number of studies showing a significant difference between treatment arms. Other sources of information to formulate recommendations

Evidence from the systematic review was supplemented by data from studies in other procedures with similar pain profiles (e.g. other abdominal procedures performed under a laparoscopic approach, including gynaecological procedures), where relevant (transferable evidence), and included to support the procedure-specific evidence where this was insufficient to formulate the recommendation. Details of the transferable evidence used in this review are available on the PROSPECT website (http:// www.postoppain.org). Studies that reported data pooled from patients undergoing mixed surgical procedures were excluded from the procedure-specific systematic review, but were used as additional transferable evidence where appropriate. Current clinical practice information was taken into account, in addition to procedure-specific and transferable evidence, to ensure that the recommendations have clinical validity. The recommendations were formulated by the PROSPECT Working Group, using the Delphi

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148

Statistics reported and > 80% follow-up

Statistics not reported or questionable or < 80% follow-up

NA

RCT

RCT

Clinical practice information (expert opinion)

NA, not applicable; RCT, randomized controlled trial.

NA

Systematic review with homogeneous results

Study type

Statistical analyses and patient follow-up assessment

Study quality assessments

B

AND ⁄ OR

NA

A OR B OR B

AND

NA

Allocation concealment

Yes

1–2

Yes

NA

3–5

1–2

NA

NA

1–5

NA

Jadad scores

Additional assessment of overall study quality required to judge LoE

Table 1 Relationship between quality and source of evidence, levels of evidence (LoE) and grades of recommendation.

4

2

1

1

LoE

D

B (or extrapolation from one procedure-specific LoE 1 study)

A (based on two or more studies or a single large, well-designed study)

A

Procedure-specific

C

B

B

Transferable

Grade of recommendation (based on overall LoE, considering balance of clinical practice information and evidence)

Pain after laparoscopic colorectal surgery G. P. Joshi et al.

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method to draft recommendations [14], followed by round-table discussion and then further Delphi rounds to achieve final consensus [15]. The recommendations for optimal pain relief are graded A–D according to the overall level of evidence (LoE), as determined by the quality of studies included, consistency of evidence and source of evidence, including transferable evidence (Table 1). Statistical analysis

Meta-analysis could not be performed because there were a limited number of studies of homogeneous design that reported similar outcome measures. The majority of the procedure-specific evidence was, therefore, assessed only qualitatively.

Results The PRISMA guidelines were followed for the description of this study (Fig. 1) (the detailed results regarding excluded trials are available on the PROSPECT website, http://www.postoppain.org). The quality of studies and level of evidence are presented in Table 2. Of the included trials, colonic surgery was performed in nine [16–25] while colorectal surgery was performed in three [21,26,27]. Also, five studies included hand-assisted or hybrid procedures [16,18,20,22,26]. In one study, ketorolac 30 mg IV (intravenous) every 6 h for 30 h (n = 22 in each group), compared with

Table 2 Quality assessment and level of evidence assigned to the randomised laparoscopic colorectal surgery trials included in this review.

Study [reference]

Quality score (Allocation concealment: A–D; randomization, blinding and withdrawal score)

Quality score (Jadad score)

Level of evidence

Schlachta [16] Vignali [17] Kaba [18] Park [19] Sammour [20] Kong [21] Neudecker [22] Senagore [23] Taqi [24] Turunen [25] Wonggyingsinn [26] Zingg [27]

A A A B A B B B B B A B

5 5 5 2 5 5 1 3 2 3 4 5

1 1 1 2 1 1 2 1 2 2 1 3

placebo, reduced pain scores during walking on days 1 (P < 0.001), 2 (P < 0.05) and 3 (P < 0.001), but not on day 4 [16]. In addition, ketorolac significantly reduced postoperative morphine requirements (33 ± 31 mg vs 63 ± 41 mg, P = 0.011). The time to first flatus (median 2.0 days vs 3.0 days, P < 0.001) and full diet (median 2.5 days vs 3.0 days, P = 0.033) were also significantly

Potentially relevant abstracts identified and screened for retrieval (literature search not limited to RCTs), n = 1477 Articles excluded based on title review, n = 1309 Articles retrieved for more detailed evaluation, n = 168

Potentially appropriate RCTs to be included in qualitative systematic review, n = 25

Figure 1 PRISMA (preferred reporting items for systematic reviews and metaanalyses) diagram showing identification of included references (RCT, randomized controlled trial).

Articles excluded based on abstract evaluation, n = 143 - Pain scores not reported, n = 33 - Not RCT, n = 23 - Lack of a defined subgroup or analysis, n = 16 - Abdominal procedure not defined, n = 2 - Open or hand-assisted approach, n = 67 - Other, n = 2

RCTs excluded from qualitative systematic review; studies comparing surgical techniques, n =13 RCTs included in qualitative systematic review, n = 12

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reduced. There was no difference between the groups for pain scores at rest, while pain scores on coughing were similar on days 1–3, but were higher in the ketorolac group on day 4 (P < 0.001). There were no differences in the length of hospital stay or the incidence of anastomotic leakage. A randomized, placebo-controlled study evaluated the benefits of methylprednisolone 30 mg ⁄ kg IV, given 60–90 min before surgery in patients undergoing laparoscopic colonic surgery (n = 13) [17]. All patients received thoracic epidural analgesia with 6–10 ml of 0.75% ropivacaine followed by 50% of the loading bolus every 90–120 min (0.5 mg ⁄ kg ⁄ h), intraoperatively. Postoperatively, patients received epidural infusion of 0.25% ropivacaine (4–6 ml ⁄ h) and ketorolac 100 mg IV every 8 h for the first 3 days. In the methylprednisolone group, pain at rest was less on postoperative day (POD) 1, P = 0.001, and POD 2, P = 0.02. Reduction in pulmonary function (forced vital capacity and forced expiratory volume in the first minute) on POD 1 and POD 2 were less pronounced in the methylprednisolone group. There were no differences in morbidity or anastomotic leakage. In another study, lidocaine infusion (1.5 mg ⁄ kg bolus followed by 2 mg ⁄ kg ⁄ h infusion intraoperatively and 1.33 mg ⁄ kg ⁄ h for 24 h postoperatively, n = 20 in each group) was superior to placebo for reducing postoperative pain scores during mobilization (P = 0.020) and on coughing (P = 0.010) in the first 48 h after surgery [18]. Abdominal discomfort scores were significantly lower with lidocaine infusion (P < 0.0001). However, the pain scores at rest in the two groups were comparable. Lidocaine infusion significantly reduced intraoperative opioid requirements (P < 0.001) as well as reduced postoperative opioid consumption from 0 to 2 h (P = 0.002) and 20–24 h (P = 0.001) after surgery, but not from 2 to 6 h (P = 0.46) or 6–20 h (P = 0.06); overall opioid use from 0 to 24 h was significantly lower in the lidocaine group by 64% (P = 0.005). Lidocaine infusion reduced the time to first flatus and first bowel movement (both P = 0.001) as well as reduced the length of hospital stay (P = 0.001). Incidence of postoperative nausea or vomiting (PONV) was similar in both the groups. Yet another study compared lidocaine infusion (1.5 mg ⁄ kg bolus followed by 2 mg ⁄ kg ⁄ h infusion intraoperatively and 1 mg ⁄ kg ⁄ h postoperatively, n = 27) with thoracic epidural analgesia (bupivacaine 2.5 mg ⁄ ml, 5–10 ml bolus followed by intraoperative infusion at 5–10 ml ⁄ h as well as infusion of bupivacaine 1 mg ⁄ ml with morphine 0.02 mg ⁄ ml with the rate adjusted to pain for 48 h postoperatively, n = 24) [26]. Pain scores were lower in the thoracic epidural group at 24 h and 48 h in the subgroup undergoing rectal surgery

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(P = 0.023 and 0.008, respectively), but not colonic surgery. There were no differences in gut function recovery or the duration of hospital stay. A randomized placebo-controlled study (n = 20 in each of the three groups) compared the efficacy of ropivacaine (1 mg ⁄ kg) with saline instillation at the initiation or at the end of pneumoperitoneum [19]. Pain scores were lower in the ropivacaine instillation groups but only for a limited time period (< 4 h). Postoperative fentanyl consumption was also reduced mainly during the first 4 h, particularly in the group that received ropivacaine instillation at the initiation of pneumoperitoneum. Also, the time to regular diet was shorter in the patients who received ropivacaine after insufflation and before deflation, but there was no difference in time to bowel movement in the ropivacaine groups. Another randomized trial compared peritoneal insufflation of carbon dioxide warmed at 37C and humidified (98%) (n = 35) with insufflation of dry and cold gas (n = 39) [20]. Pain scores at rest and on movement were decreased in the warmed and humidified gas group, only on POD 1 (P = 0.01 and 0.018, respectively). However, opioid requirements and inflammatory response (i.e. plasma cytokine levels) in the two groups were similar. Spinal morphine 0.2 mg as a part of spinal anaesthesia (hyperbaric bupivacaine 0.5% 3 ml) (n = 18) was compared with spinal anaesthesia alone (n = 17); both patient groups received general anaesthesia [21]. Spinal morphine reduced cumulative pain scores at rest or during coughing from 0 to 48 h (P = 0.035 and P = 0.01, respectively). Also, spinal morphine reduced supplementary intravenous morphine consumption over 48 h (P = 0.003). The incidence of nausea and vomiting in the two groups was comparable. However, the need for antiemetics was higher in the spinal morphine group. Five studies evaluated the efficacy of thoracic epidural analgesia compared with conventional analgesic techniques including intravenous patient controlled analgesia (IV-PCA) with opioids [22–25,27]. Four studies were randomized trials [22–25], while one was a subanalysis of a randomized trial [27]. One study reported no difference in pain scores between thoracic epidural and IV-PCA morphine [22], but the opioid consumption was lower on days 1 and 2 (P = 0.04). There was no difference in time to first bowel movement [22]. In contrast another study reported significantly lower pain scores in the epidural group at 6 h (P = 0.001) and 18 h (P = 0.003), but not thereafter [23]. However, there were no differences in supplemental opioid requirements [23]. Another study found that thoracic epidural analgesia reduced pain at rest (P = 0.0005) as well as on coughing (P = 0.0002) and walking (P = 0.0002) on days 1 and 2, but not on days 3 and 4 [24]. In addition, vomiting was less on days 1

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(P = 0.033) and 2 (P = 0.005). However, fatigue scores were lower on day 3. Also, the times to first flatus (P = 0.0061) and first bowel movement (P = 0.0027) as well as times to return of liquid diet (P = 0.0442) and first bowel movement (P = 0.0436) were significantly lower in the epidural group [24]. A comparison between thoracic epidural with IV-PCA morphine with all patients receiving oral paracetamol (0.5–1 g every 6 h) and metamizol as rescue [27] revealed that pain (P = 0.004) and opioid consumption (P < 0.001) were lower in the epidural group. Also, the times to recovery of gastrointestinal function (i.e. first flatus passed, first defaecation and first solid food tolerated) were significantly lower (P = 0.025). Another study compared epidural analgesia combined with a multimodal analgesic technique consisting of ketoprofen 100 mg, paracetamol 1 g preoperatively as well as postoperatively plus oxycodone as rescue with a multimodal analgesic technique alone [25]. Epidural analgesia reduced pain on coughing (P = 0.001) and ambulation for 48 h, but not at rest. Opioid consumption was also reduced for 24 h (P = 0.009). Patients in the epidural group had less fatigue on the day of surgery, but oral intake, mobilization and length of stay were similar [25]. The L’Abbe´ plots of the data from the studies included in this review indicated 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) (Fig. 2).

Mean VAS pain score, mm (Non-epidural group)

100

80

60 3

2

4

40 1 20

0 0

5

20 40 60 80 100 Mean VAS pain scores, mm (Epidural group)

Figure 2 Effect of epidural analgesia on visual analogue scale (VAS) pain scores in laparoscopic colorectal resection patients 24 h postoperatively. Mean data are plotted from individual studies. Larger circles indicate studies with greater numbers of patients. Statistical significance of individual study results is indicated where available. 1, Senagore 2003 [23] (during ambulation), not significant; 2, Taqi 2007 [24] (at rest), P = 0.0005; 3, Turunen 2009 [25] (on coughing), not reported; 4, Zingg 2009 [27] (at rest) P = 0.004; 5, Wongyingsinn 2011 [26] (at rest), P = 0.556.

Discussion The approach used in this systematic review provides the basis for clinically relevant recommendations for pain management in patients undergoing laparoscopic colorectal surgery. The choice of an intervention was determined by a balance of its analgesic efficacy as well as the associated risks, as emphasized by the grading of recommendations assessment, development and evaluation (GRADE) system [28]. Epidural analgesia has been shown to provide excellent pain relief with improved gastrointestinal function after ‘open’ colorectal surgery [2]; however, its role in laparoscopic surgery has been questioned [29] because of reduced pain associated with the laparoscopic approach [30]. Our results also revealed that pain scores in patients receiving multimodal analgesia were within an acceptable range (i.e. < 4 ⁄ 10) (Fig. 2). A recent RCT published after the completion of this systematic review compared the efficacy of epidural analgesia, intrathecal analgesia and IV-PCA with morphine after colorectal surgery using enhanced recovery protocols [31]. Epidural analgesia did not improve return of bowel function and length of stay. Also, pulmonary function and quality of life were similar in all groups. Given the lack of superiority of epidural analgesia over other analgesic techniques in patients undergoing laparoscopic colorectal surgery and the potential risk of adverse effects (e.g. minor complications such as hypotension and urinary retention and major complications such as epidural haematoma or abscess) [32,33], routine use of epidural analgesia cannot be recommended (grade D, LoE 4). Nevertheless, epidural analgesia might be considered in high-risk pulmonary patients (grade D, LoE 4) as it has been shown to prevent postoperative pulmonary complications [34]. Of note, it appears that the relative benefit of epidural analgesia with regard to reduction in postoperative pulmonary complications has decreased over the last three decades, probably due to reduced baseline risk from respiratory physiotherapy, avoidance of nasogastric tubes, prophylactic antibiotics and early mobilization [34]. Another controversial neuraxial technique is the use of spinal morphine. A recent RCT reported that recovery characteristics after laparoscopic colorectal surgery were comparable after spinal analgesia and IV-PCA [31]. Although the pain scores in the IV-PCA group were higher than the intrathecal analgesia group, these differences were observed only in the early postoperative period [31]. Unfortunately, the IV-PCA group did not receive multimodal analgesia such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase (COX)-2 specific inhibitors, which may

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have improved pain relief. A systematic review of studies evaluating spinal morphine found that it reduced the pain scores after abdominal surgery as well as reducing opioid requirements for up to 24 h [4]. However, the incidence of pruritus and respiratory depression were increased. Other potential complications include urinary retention and PONV. Therefore, spinal anaesthesia ⁄ morphine is not recommended in laparoscopic colorectal surgery (grade D, LoE 4). Lidocaine infusion during and after open abdominal surgery has been shown to reduce postoperative pain and opioid requirements, as well as improve bowel function and reduce the length of hospital stay [35–37]. No significant local anaesthetic toxicity has been reported in the published systematic reviews [35–37]. Therefore, intravenous lidocaine infusion could be recommended in patients in whom other analgesic therapies are not adequate or appropriate. However, large randomized clinical trials are necessary before lidocaine infusion is recommended for routine use (grade B, LoE 2), because the optimal dose and duration of lidocaine infusion remain unknown. Intraperitoneal instillation of long-acting local anaesthetics has been shown to reduce the intensity of postlaparoscopic pain [6,38–40]. A study published after completion of this systematic review reported reduced pain and opioid requirements as well as improved early surgical recovery after instillation and infusion of intraperitoneal ropivacaine in patients undergoing laparoscopic colectomy using enhanced recovery protocols [41]. However, this study was confounded by the use of epidural analgesia. Because the concentration and dose of the local anaesthetic as well as optimal timing of administration remains unknown, intraperitoneal local anaesthetic instillation cannot be recommended at this time (grade D, LoE 4). Because opioid-related adverse effects may delay recovery, nonopioid analgesics, e.g. acetaminophen (paracetamol) and conventional NSAIDs or COX-2 specific inhibitors, should be used when possible (grade B) based on transferable evidence (LoE 1) showing analgesic benefit [42–45]. Acetaminophen is ineffective as a single therapy for treatment of pain of moderate to severe intensity; therefore, it is best used in combination with conventional NSAIDs or COX-2 selective inhibitors [45], which may be supplemented with weak opioids for lowto-moderate intensity postoperative pain, and with strong opioids for moderate-to-high intensity postoperative pain (grade B). These drugs should be administered at the appropriate time (preoperatively or intraoperatively) to provide sufficient analgesia in the early recovery period, as well as continued in the postoperative period (transferable evidence, LoE 1). There is not enough evidence at this

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time to recommend one conventional NSAID or COX-2 selective inhibitor in preference to another. The use of these medications should depend upon assessment of individual patient risks (grade B). Recent studies have suggested a potential risk of postoperative anastomotic leakage in patients receiving NSAIDs [46,47]. However, this concern needs further exploration. Another concern with conventional (or nonselective) NSAIDs is the potential risk of bleeding. A recent systematic review found an increased risk of surgical bleeding in patients receiving nonselective NSAIDs on the basis of six of the 38 trials included [43]. Parenteral glucocorticoids (e.g. methyprednisolone and dexamethasone) have been shown to reduce postoperative pain as well as length of hospital stay after abdominal surgery with no evidence of increased complications including after colorectal surgery [48,49]. Therefore, glucocorticoids may be considered as a part of multimodal analgesic technique for laparoscopic colorectal surgery (grade B, LoE 1). Infiltration of the surgical wound with local anaesthetic can provide excellent analgesia that outlasts the duration of action of the local anaesthetic [6,50], and therefore is recommended (grade B) for laparoscopic colorectal resection (LoE 1). This review has identified several areas for future research where current data are insufficient or conflicting. The role of transversus abdominis plane (TAP) block, which involves administration of local anaesthetic between the layers of internal oblique and transversus abdominis muscles, needs to be evaluated [51,52]. A prospective observational trial, not included in this review, has evaluated the analgesic efficacy of TAP block in patients undergoing laparoscopic colorectal surgery, and observed a reduction in cumulative morphine consumption, but with no differences in duration of hospital stay [53]. An analysis of an electronic database of patients undergoing laparoscopic colorectal surgery revealed that both intravenous acetaminophen (n = 138) alone as well as intravenous acetaminophen with TAP blocks (n = 50) aided accelerated recovery [54]. Future studies also need to evaluate the risk:benefit ratio of continuous local anaesthetic wound infusion in comparison with singleshot TAP block combined with multimodal analgesia. There is a need for adequately powered trials evaluating analgesic approaches including multimodal analgesic techniques that would include combinations of acetaminophen and NSAID ⁄ COX-2 selective inhibitor (preferably started preoperatively or intraoperatively), and regional anaesthetic techniques, with oral opioids administered as rescue postoperatively. Similarly, ketamine [55] and alpha-2-delta ligands [56,57], that have documented benefits in other procedures, need to be further evaluated in well-designed trials. Also, future trials should include

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Table 3 Overall recommendations for management of pain associated with laparoscopic colorectal surgery in adults. Intraoperative interventions in time to secure analgesia in the immediate postoperative period • Single dose of dexamethasone 4–8 mg OR single high-dose methylprednisolone in high-risk pulmonary patients • Intravenous COX-2 or NSAID and intravenous paracetamol (acetaminophen) • Wound infiltration with long-acting local anaesthetic at the end of surgery • Intravenous lidocaine bolus followed by continuous infusion Postoperative period High-intensity pain (VAS ‡ 50 mm) • COX-2 or NSAID + paracetamol + intravenous patientcontrolled analgesia opioid • Intravenous lidocaine infusion, if above therapy ineffective Moderate-intensity pain (VAS > 30 < 50 mm) or low-intensity pain (VAS £ 30 mm) • COX-2 or NSAID + paracetamol ± weak opioid Multimodal rehabilitation protocols NSAID, conventional nonsteroidal anti-inflammatory drug; COX-2, cyclooxygenase-2 specific inhibitors; VAS, visual analogue scale of 1–100 mm.

article. G.P.J. drafted the manuscript. All authors including the PROSPECT working group critically reviewed the manuscript and provided comments and suggestions. All authors including the members of the working group approved the final version of the manuscript.

Financial support All authors are members of the PROSPECT Working Group, which is supported by Pfizer Inc., New York, USA. The PROSPECT Working Group members have been reimbursed by Pfizer Inc. for attending PROSPECT meetings to formulate the consensus recommendations. Pfizer Inc. provided financial support for the editing assistance provided by Choice Pharma, Hitchin, UK. This paper makes no specific recommendations about the use of any medical products, drugs or equipment manufactured by Pfizer Inc. or by any of its subsidiaries. G.P.J. has received honoraria from Pfizer, Baxter and Cadence. F.B. has received honoraria from Pfizer, Abbott France, and Astra Zeneca France. H.K. has received honoraria from Pfizer.

References multimodal rehabilitation protocols (fast track or enhanced recovery programmes) as an integral part of the study design [58]. This will allow us to differentiate the effects of the analgesic intervention on perioperative outcome from those of the enhanced recovery programmes, which are becoming the standard of care. In conclusion, this study provides clinicians with supporting arguments for and against the use of various interventions for postoperative pain management in patients undergoing colorectal surgery (Table 3). The recommendations from this review may be incorporated in a clinical pathway for the perioperative care of laparoscopic colorectal surgery in an effort to improve the overall outcome and allow early discharge home, as well as early return to daily living.

Acknowledgements The authors would like to thank Iradj Reza, Ph.D. for performing the literature search and Choice Pharma, Hitchin, UK, for assistance with data compilation.

Author contributions The concept of procedure-specific pain management was conceptualized and developed by the PROSPECT working group. All authors reviewed the literature and formulated the treatment recommendations published in this

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Appendix PROSPECT collaboration: F. Bonnet, Department d’Anesthe´sie Reanimation, Hoˆpital Tenon, Assistance Publique Hoˆpitaux de Paris, Universite´ Pierre et Marie Curie, Paris, France. F. Camu, Department of Anesthesiology, Flemish Free University of Brussels Medical Center, Brussels, Belgium. H. B. J. Fischer, Department of Anaesthesiology, Alexandra Hospital, Redditch, Worcestershire, UK. G. P. Joshi, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, Texas, USA. E. A. M. Neugebauer, Institute of Research in Operative Medicine, University of Witten-Herdecke, Cologne, Germany. N. Rawal, Department of Anaesthesia and ¨ rebro, Sweden. S. Intensive Care, University Hospital, O A. Schug, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia. C. J. P. Simanski, Department of Trauma and Orthopaedic Surgery Cologne-Merheim, University of Witten-Herdecke, Cologne, Germany. H. Kehlet, Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark.

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