Spinal Analgesia, Colonic Resection and an Enhanced Recovery
Spinal Analgesia, Colonic Resection and an Enhanced Recovery
The results of this study indicate that, in the context of the ERAS programme, an intrathecal mixture of bupivacaine and morphine significantly decreased postoperative morphine consumption after laparoscopic colon surgery in the first 72 h compared with systemic opioid. However, spinal analgesia did not influence the duration of hospital stay, time to return of bowel function and postoperative complications.
Laparoscopic approach to colorectal resection has been shown to reduce length of hospital stay by 1.7 days and incidence of wound complications. However, the benefits of laparoscopy on long-term outcomes are still being debated. In the quest to optimize surgical care, the ERAS programme was designed by combining a series of evidence-based interventions, which target physiological stresses related to surgery. A recent meta-analysis comparing ERAS programme with traditional care in open colorectal surgery demonstrated the superiority of the ERAS programme, resulting in significantly decreased length of stay by 2.6 days and rate of morbid events.
Based on these results, a multimodal intervention like the ERAS programme could provide better results than laparoscopy alone. In reality, the two approaches are still used separately; while laparoscopy for colonic resection is rapidly adopted by many surgeons, surgical care in many units still remains very traditional. Recently, a randomized study has demonstrated a significant advantage by implementing the ERAS programme together with laparoscopy. The 33 h difference in overall time to recovery was due to better tolerance of early dietary intake in the group receiving the two interventions. Similarly, the number of complications was less when laparoscopy and ERAS programme were implemented together.
The use of spinal analgesia for open and laparoscopic colorectal resection has been shown to provide a superior quality of pain relief compared with systemic morphine. Similarly, in the present investigation, opioid consumption was consistently less in the spinal group during the first three postoperative days, with 13% of patients in this group not requesting oral opioids. Also, the number of patients having no pain on postoperative day 1 was significantly more in the spinal group (63% vs 48%). Furthermore, the number of patients reporting moderate pain was significantly less (4% vs 24%) and no patient reported severe pain (0% vs 8%).
Spinal injection of opioids presents several advantages over systemic injection and epidural blockade, including less invasiveness, small dosage of opioids required to achieve the same analgesia, and lower failure rate as demonstrated in the randomized controlled trial comparing epidural, spinal, and PCA. Despite the lower opioid consumption in the spinal group and better postoperative pain relief at rest on the first postoperative day in the spinal group, no other benefits could be accounted in this study. Return of bowel function, time to reach the criteria for discharge, number of postoperative complications, and length of hospital stay were in fact similar in both groups. This contrasts with the contention that better analgesia would accelerate postoperative outcome, thus leading to less complications. Explanation of negative finding could be attempted, although one cannot imply that the quality of analgesia was directly related to postoperative complications. It is likely that the effectiveness of the integrated interventions as part of the ERAS programme would overcome the impact that each modality could have on the short- and long-term outcomes which characterize the recovery process.
In view of the limited published material on spinal analgesia for colon surgery, it was decided to consider postoperative morphine consumption as a primary outcome and confirm previous published findings indicating the optimal quality of analgesia achieved with this technique. Furthermore, it was an intention to verify whether the quality of analgesia with an intrathecal mixture of local anesthetic and opioid would impact on other relevant outcomes such as mobilization out of bed and dietary intake. The length of hospital stay was not chosen as a primary outcome because it depends upon many factors, such as administrative decisions, organization of hospital care, and patient's expectation, and therefore cannot be considered as a reliable outcome.
Although there were no haemodynamic side-effects in the spinal group, two elderly patients in our series required overnight observation for excessive sedation and temporary ventilatory support, indicating that caution must be exercised when intrathecal opioids, even in small doses, are used in the elderly population. In contrast to our findings, other authors have injected up to 0.3 mg of intrathecal morphine in elderly patients undergoing open colorectal surgery and did not report either respiratory depression or excessive sedation. This could be explained by more intense pain stimulation caused by open surgery, thus resulting in less incidence of respiratory depression and excessive sedation.
One limitation of this study is related to the study design with the spinal group receiving oral opioids instead of PCA as in the control group. In other studies where the spinal mixture of local anaesthetic and opioid was compared with either PCA or epidural, oral tramadol and morphine were also used after surgery with satisfactory results. In our study, the nurses undertook hourly assessment of pain together with other vital signs, and, if the NRS pain at rest was more than 3, patients would receive oral oxycodone. This approach might be criticized since it depends on the availability of nursing, however, from the date collected, it shows that the spinal group had better pain scores and consumed less opioids during the first 24 h. Another limitation is that the study was not blinded. To limit bias, a diary was constructed so that patients would record pain intensity and aspects of bowel function recovery (time and quantity of oral intake, nausea and vomiting, time to pass flatus, and bowel movements) twice a day. Together with the record of vital signs and the medication chart, the diaries were analysed once the patient was discharged.
In conclusion, the present randomized study in patients undergoing laparoscopic colon surgery and in the context of the ERAS programme confirmed that an intrathecal mixture of bupivacaine and morphine followed was associated with less postoperative opioid consumption compared with systemic morphine. However, the short period (24 h) of significant analgesia and the potential risk of excessive sedation and respiratory depression in an elderly population must be taken into consideration.
Discussion
The results of this study indicate that, in the context of the ERAS programme, an intrathecal mixture of bupivacaine and morphine significantly decreased postoperative morphine consumption after laparoscopic colon surgery in the first 72 h compared with systemic opioid. However, spinal analgesia did not influence the duration of hospital stay, time to return of bowel function and postoperative complications.
Laparoscopic approach to colorectal resection has been shown to reduce length of hospital stay by 1.7 days and incidence of wound complications. However, the benefits of laparoscopy on long-term outcomes are still being debated. In the quest to optimize surgical care, the ERAS programme was designed by combining a series of evidence-based interventions, which target physiological stresses related to surgery. A recent meta-analysis comparing ERAS programme with traditional care in open colorectal surgery demonstrated the superiority of the ERAS programme, resulting in significantly decreased length of stay by 2.6 days and rate of morbid events.
Based on these results, a multimodal intervention like the ERAS programme could provide better results than laparoscopy alone. In reality, the two approaches are still used separately; while laparoscopy for colonic resection is rapidly adopted by many surgeons, surgical care in many units still remains very traditional. Recently, a randomized study has demonstrated a significant advantage by implementing the ERAS programme together with laparoscopy. The 33 h difference in overall time to recovery was due to better tolerance of early dietary intake in the group receiving the two interventions. Similarly, the number of complications was less when laparoscopy and ERAS programme were implemented together.
The use of spinal analgesia for open and laparoscopic colorectal resection has been shown to provide a superior quality of pain relief compared with systemic morphine. Similarly, in the present investigation, opioid consumption was consistently less in the spinal group during the first three postoperative days, with 13% of patients in this group not requesting oral opioids. Also, the number of patients having no pain on postoperative day 1 was significantly more in the spinal group (63% vs 48%). Furthermore, the number of patients reporting moderate pain was significantly less (4% vs 24%) and no patient reported severe pain (0% vs 8%).
Spinal injection of opioids presents several advantages over systemic injection and epidural blockade, including less invasiveness, small dosage of opioids required to achieve the same analgesia, and lower failure rate as demonstrated in the randomized controlled trial comparing epidural, spinal, and PCA. Despite the lower opioid consumption in the spinal group and better postoperative pain relief at rest on the first postoperative day in the spinal group, no other benefits could be accounted in this study. Return of bowel function, time to reach the criteria for discharge, number of postoperative complications, and length of hospital stay were in fact similar in both groups. This contrasts with the contention that better analgesia would accelerate postoperative outcome, thus leading to less complications. Explanation of negative finding could be attempted, although one cannot imply that the quality of analgesia was directly related to postoperative complications. It is likely that the effectiveness of the integrated interventions as part of the ERAS programme would overcome the impact that each modality could have on the short- and long-term outcomes which characterize the recovery process.
In view of the limited published material on spinal analgesia for colon surgery, it was decided to consider postoperative morphine consumption as a primary outcome and confirm previous published findings indicating the optimal quality of analgesia achieved with this technique. Furthermore, it was an intention to verify whether the quality of analgesia with an intrathecal mixture of local anesthetic and opioid would impact on other relevant outcomes such as mobilization out of bed and dietary intake. The length of hospital stay was not chosen as a primary outcome because it depends upon many factors, such as administrative decisions, organization of hospital care, and patient's expectation, and therefore cannot be considered as a reliable outcome.
Although there were no haemodynamic side-effects in the spinal group, two elderly patients in our series required overnight observation for excessive sedation and temporary ventilatory support, indicating that caution must be exercised when intrathecal opioids, even in small doses, are used in the elderly population. In contrast to our findings, other authors have injected up to 0.3 mg of intrathecal morphine in elderly patients undergoing open colorectal surgery and did not report either respiratory depression or excessive sedation. This could be explained by more intense pain stimulation caused by open surgery, thus resulting in less incidence of respiratory depression and excessive sedation.
One limitation of this study is related to the study design with the spinal group receiving oral opioids instead of PCA as in the control group. In other studies where the spinal mixture of local anaesthetic and opioid was compared with either PCA or epidural, oral tramadol and morphine were also used after surgery with satisfactory results. In our study, the nurses undertook hourly assessment of pain together with other vital signs, and, if the NRS pain at rest was more than 3, patients would receive oral oxycodone. This approach might be criticized since it depends on the availability of nursing, however, from the date collected, it shows that the spinal group had better pain scores and consumed less opioids during the first 24 h. Another limitation is that the study was not blinded. To limit bias, a diary was constructed so that patients would record pain intensity and aspects of bowel function recovery (time and quantity of oral intake, nausea and vomiting, time to pass flatus, and bowel movements) twice a day. Together with the record of vital signs and the medication chart, the diaries were analysed once the patient was discharged.
In conclusion, the present randomized study in patients undergoing laparoscopic colon surgery and in the context of the ERAS programme confirmed that an intrathecal mixture of bupivacaine and morphine followed was associated with less postoperative opioid consumption compared with systemic morphine. However, the short period (24 h) of significant analgesia and the potential risk of excessive sedation and respiratory depression in an elderly population must be taken into consideration.