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Intraperitoneal Local Anesthetic Instillation and Postoperative Infusion Improves Functional Recovery Following Colectomy: A Randomized Controlled Trial

Duffield, Jaime A., B.M.B.S., Ph.D.1; Thomas, Michelle L., Ph.D., F.R.A.C.S.1,2; Moore, James W., M.D., F.R.A.C.S.1,2; Hunter, R. Andrew, M.B.B.S., F.R.A.C.S.2,3; Wood, Carolyn, M.B.B.S., F.A.N.Z.C.A.4; Gentili, Sheridan, B.Sc.(Hons.), G.Dip.Biostat., Ph.D.5; Lewis, Mark, M.D., F.R.C.S., F.R.A.C.S.1,2

doi: 10.1097/DCR.0000000000001177
Original Contributions: Benign
Denotes Associated Video Abstract
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BACKGROUND: Intraperitoneal local anesthetic is an analgesic technique for inclusion in the polypharmacy approach to postoperative pain management in enhanced recovery after surgery programs. Previously, augmentation of epidural analgesia with intraperitoneal local anesthetic was shown to improve functional postoperative recovery following colectomy.

OBJECTIVE: This study determines whether intraperitoneal local anesthetic improves postoperative recovery in patients undergoing colectomy, in the absence of epidural analgesia, with standardized enhanced recovery after surgery perioperative care.

DESIGN: This is a multisite, double-blinded, randomized, placebo-controlled trial (ClinicalTrials.gov Identifier NCT02449720).

SETTINGS: This study was conducted at 3 hospital sites in South Australia.

PATIENTS: Eighty-six adults undergoing colectomy were stratified by approach (35 open; 51 laparoscopic), then randomly assigned to intraperitoneal local anesthetic (n = 44) and control (n = 42) groups.

INTERVENTIONS: Patients in the intraperitoneal local anesthetic group received an intraoperative intraperitoneal ropivacaine 100-mg bolus both pre- and postdissection and 20 mg/h continuous postoperative infusion for 48 hours. Patients in the control group received a normal saline equivalent.

MAIN OUTCOME MEASURES: Functional postoperative recovery was assessed by using the surgical recovery scale for 45 days; postoperative pain was assessed by using a visual analog scale; and opioid consumption, use of rescue ketamine, recovery of bowel function, time to readiness for discharge, and perioperative complications were recorded.

RESULTS: The intraperitoneal local anesthetic group reported improved surgical recovery scale scores at day 1 and 7, lower pain scores, required less rescue ketamine, and passed flatus earlier than the control group (p < 0.05). The improvement in surgical recovery scale at day 7 and pain scores remained when laparoscopic colectomy was considered separately. Opioid consumption and time to readiness for discharge were equivalent.

LIMITATIONS: This study was powered to detect a difference in surgical recovery scale, but not the other domains of recovery, when the intraperitoneal local anesthetic group was compared with control.

CONCLUSIONS: We conclude that instillation and infusion of intraperitoneal ropivacaine for patients undergoing colectomy, including by the laparoscopic approach, decreases postoperative pain and improves functional postoperative recovery. We recommend routine inclusion of intraperitoneal local anesthetic into the multimodal analgesia component of enhanced recovery after surgery programs for laparoscopic colectomy. See Video Abstract at http://links.lww.com/DCR/A698.

1 School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia

2 Colorectal Surgical Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia

3 Colorectal Surgical Society of Australia and New Zealand, Hawthorn, Victoria, Australia

4 Department of Anaesthesia, Hyperbaric and Pain Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia

5 Teaching and Innovation Unit, University of South Australia, Adelaide, South Australia, Australia

Funding/Support: Dr Duffield was supported by the Covidien Colorectal Research Scholarship granted by the School of Medicine, The University of Adelaide. There are no further sources of funding to disclose.

Financial Disclosures: None reported.

Ethical Considerations: This study was approved by the Investigational Drugs Subcommittee (IDSC) and the Human Research Ethics Committee (HREC) of the Royal Adelaide Hospital on March 19, 2015, and assigned identifiers: HREC/15/RAH/45 Protocol Record 150219. The requirements of the Research Governance Unit were adhered to SSA/15/RAH/164 (MyIP 6436). This study was approved by the HREC of St Andrew’s Hospital on July 13, 2015, and allocated Identifier: Project Number 91, and by the HREC of Calvary Health Care Adelaide on 28 October 2015 and allocated Identifier: 15-CHREC-F009. Registration at ClinicalTrials.gov register was prospective ClinicalTrials.gov Identifier: NCT02449720. WHO Universal Trial Number (UTN) Identifier: U1111-1170–6367. This study was conducted in accordance with the ethical principles that have their origin from the declaration of Helsinki and are consistent with ICH/GCP. This study complies with the National Health & Medical Research Council (NHMRC) National Statement on Ethical Conduct in Research Involving Humans.

Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, WA, June 10 to 14, 2017.

Correspondence: Jaime Duffield, B.M.B.S., Ph.D., C/O Colorectal Surgical Unit, Level 5E 333–334, Royal Adelaide Hospital, 12 Port Rd, Adelaide, South Australia 5000. E-mail: jaime.duffield@sa.gov.au.

© 2018 The American Society of Colon and Rectal Surgeons