Continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in adults

Abstract

Background: Colorectal resection through a midline laparotomy is a commonly performed surgical procedure to treat various bowel conditions. The typical postoperative hospital stay after this operation is 6 to 10 days. The main factors hindering early recovery and discharge are thought to include postoperative pain and delayed return of bowel function.Continuous infusion of a local anaesthetic into tissues surrounding the surgical incision via a multi-lumen indwelling wound catheter placed by the surgeon prior to wound closure may reduce postoperative pain, opioid consumption, the time to return of bowel function, and the length of hospital stay.

Objectives: To evaluate the efficacy and adverse events of continuous local anaesthetic wound infusion for postoperative pain after midline laparotomy for colorectal resection in adults.

Search methods: We searched the CENTRAL, MEDLINE and Embase databases to January 2019 to identify trials relevant to this review. We also searched reference lists of relevant trials and reviews for eligible trials. Additionally, we searched two clinical trials registers for ongoing trials.

Selection criteria: We considered randomised controlled trials (including non-standard designs) or quasi-randomised controlled trials comparing continuous wound infusion of a local anaesthetic versus a placebo or a sham after midline laparotomy for colorectal resection in adults. We did not compare continuous local anaesthetic wound infusion to other techniques, such as transverse abdominis plane block or thoracic epidural analgesia. We allowed non-randomised analgesic co-interventions carried out equally in the intervention and control groups.

Data collection and analysis: Two review authors independently identified trials for inclusion and assessed their quality using the Cochrane 'Risk of bias' tool. We extracted data using standardised forms, including pain at rest and on movement (10-point scale), opioid consumption via a patient-controlled analgesia (PCA) system (mg morphine equivalent), postoperative opioid-related adverse events, the time to rescue analgesia, the time to first flatus and to first bowel movement, the time to ambulation, the length of hospital stay, serious postoperative adverse events, and patient satisfaction. We quantitatively synthesised the data by meta-analysis. We summarised and graded the certainty of the evidence for critical outcomes using the GRADEpro tool and created a 'Summary of findings' table.

Main results: This review included six randomised controlled trials that enrolled a total of 564 adults undergoing elective midline laparotomy for colorectal resection comparing continuous wound infusion of a local anaesthetic to a normal saline placebo. Due to 23 post-randomisation exclusions, a total of 541 participants contributed data to the analysis of at least one outcome (local anaesthetic 268; control 273). Most participants were aged 55 to 65 years, with normal body mass index and low to moderate anaesthetic risk (American Society of Anesthesiologists class I-III). Random sequence generation, allocation concealment, and blinding were appropriately carried out in most trials. However, we had to downgrade the certainty of the evidence for most outcomes due to serious study limitations (risk of bias), inconsistency, indirectness, imprecision and reporting bias.Primary outcomesOn postoperative day 1, pain at rest (mean difference (MD) -0.59 (from 3.1), 95% confidence interval (CI) -1.12 to -0.07; 5 studies, 511 participants; high-certainty evidence), pain on movement (MD -1.1 (from 6.1), 95% CI -2.3 to -0.01; 3 studies, 407 participants; low-certainty evidence) and opioid consumption via PCA (MD -12 mg (from 41 mg), 95% CI -20 to -4; 6 studies, 528 participants; moderate-certainty evidence) were reduced in the local anaesthetic group compared to the control group.Secondary outcomesThere was a reduction in the time to first bowel movement (MD -0.67 from 4.4 days, 95% CI -1.17 to -0.17; 4 studies, 197 participants; moderate-certainty evidence) and the length of hospital stay (MD -1.2 from 7.4 days, 95% CI -2.0 to -0.3; 4 studies, 456 participants; high-certainty evidence) in the local anaesthetic group compared to the control group.There was no evidence of a difference in any serious postoperative adverse events until hospital discharge (RR 1.04, 95% CI 0.68 to 1.58; 6 studies, 541 participants; low-certainty evidence) between the two study groups.

Authors' conclusions: After elective midline laparotomy for colorectal resection, continuous wound infusion of a local anaesthetic compared to a normal saline placebo reduces postoperative pain at rest and the length of hospital stay, on the basis of high-certainty evidence. This means we are very confident that the effect estimates for these outcomes lie close to the true effects. There is moderate-certainty evidence to indicate that the intervention probably reduces opioid consumption via PCA and the time to first bowel movement. This means we are moderately confident that effect estimates for these outcomes are likely to be close to the true effects, but there is a possibility that they are substantially different. The intervention may reduce postoperative pain on movement, however, this conclusion is based on low-certainty evidence. This means our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect. There is low-certainty evidence to indicate that the intervention may have little or no effect on the rates of any serious postoperative adverse events until hospital discharge. High-quality randomised controlled trials to evaluate the intervention with a focus on important clinical and patient-centred outcomes are needed.

Conflict of interest statement

1. SL received the Doctor in Training Research Scholarship for this project from Avant Mutual Group in 2015 (USD 15,000 over 1 year). Avant Mutual Group is a medical defence organisation and provider of medical indemnity insurance, with no affiliation to any manufacturer or distributor of devices or drugs used for continuous local anaesthetic wound infusion. SL uses this intervention in clinical practice.

2. AY: none known

3. EA: none known

4. BK: none known

5. GS: none known

6. AB: none known. AB uses this intervention in clinical practice.

7. HC: none known

8. DD: none known

9. ZY: none known. ZY uses this intervention in clinical practice.

Figures

1

Study flow diagram

2

'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies

3

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study

1.1. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 1 Pain at rest: day 1 (10‐point numerical rating scale or equivalent).

1.2. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 2 Pain at rest: day 2 (10‐point numerical rating scale or equivalent).

1.3. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 3 Pain at rest: day 3 (10‐point numerical rating scale or equivalent).

1.4. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 4 Pain on movement: day 1 (10‐point numerical rating scale or equivalent).

1.5. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 5 Pain on movement: day 2 (10‐point numerical rating scale or equivalent).

1.6. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 6 Pain on movement: day 3 (10‐point numerical rating scale or equivalent).

1.7. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 7 Opioid consumption via patient controlled analgesia: day 1 (mg morphine equivalent).

1.8. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 8 Opioid consumption via patient controlled analgesia: day 2 (mg morphine equivalent).

1.9. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 9 Opioid consumption via patient controlled analgesia: day 3 (mg morphine equivalent).

1.10. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 10 Opioid consumption via patient controlled analgesia: day 4 (mg morphine equivalent).

1.11. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 11 Nausea or vomiting.

1.12. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 12 Ileus.

1.13. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 13 Pruritus.

1.14. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 14 Respiratory depression.

1.15. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 15 Time to first bowel movement (days).

1.16. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 16 Time to ambulation (days).

1.17. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 17 Length of hospital stay (days).

1.18. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 18 Any serious postoperative adverse event (composite outcome).

1.19. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 19 Pneumonia.

1.20. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 20 Laparotomy wound breakdown.

1.21. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 21 Laparotomy wound infection.

1.22. Analysis

Comparison 1 Local anaesthetic versus placebo, Outcome 22 Local anaesthetic systemic toxicity.

2.1. Analysis

Comparison 2 Subgroup analyses by local anaesthetic agent, Outcome 1 Pain at rest: day 1 (10‐point numerical rating scale or equivalent).

2.2. Analysis

Comparison 2 Subgroup analyses by local anaesthetic agent, Outcome 2 Pain on movement: day 1 (10‐point numerical rating scale or equivalent).

2.3. Analysis

Comparison 2 Subgroup analyses by local anaesthetic agent, Outcome 3 Opioid consumption via patient‐controlled analgesia: day 1 (mg morphine equivalent).

3.1. Analysis

Comparison 3 Subgroup analyses by wound infusion programme, Outcome 1 Pain at rest: day 1 (10‐point numerical rating scale or equivalent).

3.2. Analysis

Comparison 3 Subgroup analyses by wound infusion programme, Outcome 2 Pain on movement: day 1 (10‐point numerical rating scale or equivalent).

3.3. Analysis

Comparison 3 Subgroup analyses by wound infusion programme, Outcome 3 Opioid consumption via patient‐controlled analgesia: day 1 (mg morphine equivalent).

4.1. Analysis

Comparison 4 Subgroup analyses by co‐analgesic agents, Outcome 1 Pain at rest: day 1 (10‐point numerical rating scale or equivalent).

4.2. Analysis

Comparison 4 Subgroup analyses by co‐analgesic agents, Outcome 2 Pain on movement: day 1 (10‐point numerical rating scale or equivalent).

4.3. Analysis

Comparison 4 Subgroup analyses by co‐analgesic agents, Outcome 3 Opioid consumption via patient‐controlled analgesia: day 1 (mg morphine equivalent).

5.1. Analysis

Comparison 5 Sensitivity analyses excluding unpublished data, Outcome 1 Time to first bowel movement (days).

6.1. Analysis

Comparison 6 Sensitivity analyses excluding estimated or derived data, Outcome 1 Pain at rest: day 1 (10‐point numerical rating scale or equivalent).

6.2. Analysis

Comparison 6 Sensitivity analyses excluding estimated or derived data, Outcome 2 Pain at rest: day 2 (10‐point numerical rating scale or equivalent).

6.3. Analysis

Comparison 6 Sensitivity analyses excluding estimated or derived data, Outcome 3 Pain on movement: day 1 (10‐point numerical rating scale or equivalent).

6.4. Analysis

Comparison 6 Sensitivity analyses excluding estimated or derived data, Outcome 4 Pain on movement: day 2 (10‐point numerical rating scale or equivalent).

6.5. Analysis

Comparison 6 Sensitivity analyses excluding estimated or derived data, Outcome 5 Opioid consumption via patient‐controlled analgesia: day 1 (mg morphine equivalent).

6.6. Analysis

Comparison 6 Sensitivity analyses excluding estimated or derived data, Outcome 6 Opioid consumption via patient‐controlled analgesia: day 2 (mg morphine equivalent).

6.7. Analysis

Comparison 6 Sensitivity analyses excluding estimated or derived data, Outcome 7 Nausea or vomiting.

6.8. Analysis

Comparison 6 Sensitivity analyses excluding estimated or derived data, Outcome 8 Time to ambulation (days).

6.9. Analysis

Comparison 6 Sensitivity analyses excluding estimated or derived data, Outcome 9 Length of hospital stay (days).

6.10. Analysis

Comparison 6 Sensitivity analyses excluding estimated or derived data, Outcome 10 Laparotomy wound infection.

7.1. Analysis

Comparison 7 Subgroup analyses by wound catheter location, Outcome 1 Pain at rest: day 1 (10‐point numerical rating scale or equivalent).

7.2. Analysis

Comparison 7 Subgroup analyses by wound catheter location, Outcome 2 Pain on movement: day 1 (10‐point numerical rating scale or equivalent).

7.3. Analysis

Comparison 7 Subgroup analyses by wound catheter location, Outcome 3 Opioid consumption via patient‐controlled analgesia: day 1 (mg morphine equivalent).