Continuous Infusion of Ropivacaine Shortens Recovery Time After Colorectal Cancer Surgery

Roxanne Nelson

August 24, 2007

August 24, 2007 — A continuous preperitoneal infusion of 0.2% ropivacaine ( Naropin, AstraZeneca) following open colorectal resection reduces the use of postoperative analgesia, improves relief from pain, and shortens postoperative recovery time, concludes a study in the September issue of Anesthesiology
. The technique appears to offer an effective and efficient method of managing pain following open major abdominal surgery, say the researchers, headed by Marc Beaussier, MD, from St. Antoine University Hospital, in Paris, France.

"From a theoretical point of view, administration of local anesthetics at the wound site is the most rational approach to reduce the afferent nociceptive barrage and thereby pain and stress responses with their secondary risks of organ dysfunction and morbidity," comments an accompanying editorial. However, the editorialists, Henrik Kehlet, MD, PhD, from the Juliane Marie Centre, in Copenhagen, Denmark, and Spencer S. Liu, MD, PhD, from the Hospital for Special Surgery and Weil Medical College of Cornell University, in New York, comment that while new delivery methods of local anesthetics represent an exciting and potentially valuable means of providing nonopioid analgesia directly to the periphery, they still need a more comprehensive evaluation.

"The peripheral use of continuous wound infusion of local anesthetics represents an effective analgesic technique that, due to its simplicity, may find its way to be an important instrument in our analgesic armamentarium across several major surgical procedures," they write. "Hopefully, future research will document in more detail other extra-analgesic benefits on outcomes such as reduction of postoperative organ dysfunctions; enhanced recovery when integrated into multimodal rehabilitation programs; patient safety; and quality of life and health economics."

In the current study, Dr. Beaussier and colleagues investigated whether the continuous infusion of a local anesthetic over the parietal peritoneum, delivered by a multiholed catheter in the preperitoneal position, would have an impact on postoperative morphine consumption, pain relief, and recovery following open colorectal surgery. The major goal of this study was to demonstrate the efficacy of continuous wound infiltration after abdominal laparotomy and how it can be greatly improved when the perfusion catheter is placed deep in the abdominal wall layer, rather than subcutaneously, Dr. Beaussier explained to Medscape.

"Several studies have been performed evaluating wound infiltration after abdominal surgery, with conflicting results," he said. "Catheter location was always in the subcutaneous position, and many factors may influence the effectiveness of continuous wound infiltration."

A cohort of 42 patients undergoing surgery for colorectal cancer was randomized to receive preperitoneal ropivacaine or placebo, beginning toward the end of the procedure. The patients received either a continuous wound infusion of ropivacaine 0.2% (a 10 mL bolus followed by an infusion of 10 mL/hour over 48 hours) or the same protocol with 0.9% NaCl.

The results showed that pain scores in the postoperative period, both at rest and during coughing, were significantly lower among patients who were receiving ropivacaine. The difference between the 2 groups was significant throughout the first 12 hours after surgery while at rest and throughout the first 48 hours while coughing. During their first day following surgery, 6 patients receiving ropivacaine required analgesics, compared with 11 in the control group.

Morphine usage was also considerably lower among patients receiving ropivacaine than among the control group. During the first 3 postoperative days, morphine use was 48 ± 23 mg among patients receiving ropivacaine, vs 84 ± 37 mg among the controls. Patients in the ropivacaine group also reported better sleep quality during their first 2 postoperative nights, and recovery of intestinal transit, as assessed by the time to first bowel movement, was also faster. The average hospital stay was also shorter: 115 ± 25 hours for those on ropivacaine, vs 147 ± 53 hours for patients receiving placebo.

"Our study provides evidence showing that preperitoneal perfusion has a significant and clinically pertinent impact on postoperative pain," said Dr. Beaussier. "Preperitoneal perfusion has been studied after minor surgery, in a poorly designed study, without demonstrating any benefit on outcomes."

An important parameter that needs to be taken into account is the high flow rate that was used in this trial, he pointed out. "It is certainly more appropriate than flow rates less than 5 mL/hour that were used in previous studies, although this remains to be firmly evaluated in a randomized comparative study."

Dr. Beaussier also indicated that a comparative study with epidural analgesia remains to be conducted and that epidural anesthesia is more effective in controlling pain, especially when the patient is coughing. "However, epidural analgesia cannot be implemented in all patients scheduled for colorectal cancer resection," he said.

"The major message is that, in these conditions, continuous wound infusion offers a simple and efficacious method to alleviate postoperative pain after major abdominal surgery," Dr. Beaussier said. "The benefits to the rehabilitation process may have economical consequences that remain to be studied. Certainly, further studies will bring new insights into the best flow rate to deliver, the best local anesthetic to choose, and the best type of catheter to use.

"But the multicenter design, the clinical setting, and the appropriate statistical analysis make the current results sturdy enough to be widely applied in clinical practices," he added.

This study received a grant from AstraZeneca. Dr Kehlet has received a grant from AstraZeneca Södertälje, in Sweden, to study wound infusion of local anesthetics in knee and hip replacement. Dr Liu is a consultant to Anesiva, in San Francisco, CA.

Anesthesiology. 2007; in press.

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