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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 188-191

Reduction of early postoperative pain with laparoscopic sleeve gastrectomy with local bupivacaine: a randomized placebo-controlled study


Department of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Sharkia Governorate, Egypt

Date of Submission15-Jan-2018
Date of Acceptance03-Dec-2018
Date of Web Publication12-Jun-2019

Correspondence Address:
Mohamed El Sayed
Department of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Sharkia Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_4_18

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  Abstract 

Introduction Local bupivacaine provides safe, effective, and low-cost anesthesia with good postoperative analgesia. Our aim was to confirm the postoperative analgesic efficacy and safety of bupivacaine for local infiltration in pain relief in laparoscopic sleeve gastrectomy.
Patient and methods This prospective, double-blind study was conducted on 70 patients of age 18–50 years, posted for laparoscopic sleeve gastrectomy and randomly allocated into two groups of 35 patients each. Control group (group C) received an injection of 40 ml saline 0.9%: 30 ml intraperitoneal plus 10 ml normal saline injection local infiltration in the three port sites. Group P received 40 ml of bupivacaine: 30 ml intraperitoneal plus 10 ml local infiltration at the port site. Assessment of pain scores visual analog scale in the 24 h after surgery, first need for rescue analgesia, and incidence of various complications were recorded.
Results The timing of the first analgesic request in the control group was 102.5±10.3 min, and in group D was 328.8±32.4 min, which is statistically significant (P<0.000), with no adverse effects.
Conclusion Bupivacaine (intraperitoneal and local infiltration) leads to prolonged postoperative analgesia after sleeve gastrectomy without adverse effects.

Keywords: bupivacaine, postoperative analgesia, sleeve gastrectomy


How to cite this article:
El Sayed M, Abdelsamad A. Reduction of early postoperative pain with laparoscopic sleeve gastrectomy with local bupivacaine: a randomized placebo-controlled study. Res Opin Anesth Intensive Care 2019;6:188-91

How to cite this URL:
El Sayed M, Abdelsamad A. Reduction of early postoperative pain with laparoscopic sleeve gastrectomy with local bupivacaine: a randomized placebo-controlled study. Res Opin Anesth Intensive Care [serial online] 2019 [cited 2019 Oct 15];6:188-91. Available from: http://www.roaic.eg.net/text.asp?2019/6/2/188/260145


  Introduction Top


Laparoscopic approaches to surgery have increased over the past several years. Reasons for their popularity are improvement in postoperative pain and healing time as compared with other open techniques, which can result in earlier recovery and discharge from the hospital [1]. Postoperative bariatric surgery pain has three sources: parietal pain, 50–70% of the total pain from incision in the abdominal wall owing to ports; visceral pain, 10–20% from gastrointestinal serosa; and the pain from pneumoperitoneum, 20–30% leading to diaphragmatic irritation and referred to left shoulder [2]. Local anesthetics (LAs) have been used subcutaneously into the portsite, into the periportal fascia, and muscle and parietal peritoneum to provide pain relief in laparoscopic surgery. The injection of LA at the incision site blocks Aδ and C fibers and prevents the transmission of pain impulses from the surgical incision site to the brain. Most of studies have used longer acting LA like bupivacaine, with variable doses and concentrations [3]. Intraperitoneal LA has decreased abdominal and shoulder pain, and also over the visceral peritoneum through the trocar site or into the surgical bed after excision of the organ or under the diaphragm. The reason for the injection of subdiaphragmatic LA is to decrease the shoulder pain [4]. Postoperative pain control in the obese population prevents appearance of atelectasia and other lung complications, and also increases mobility of the patient, leading to a less thromboembolic risk [5].

In our study, we try to assess the postoperative analgesic efficacy and safety of bupivacaine for intraperitoneal and local infiltration in laparoscopic sleeve gastrectomy.


  Patients and methods Top


This prospective, randomized, double-blind, placebo-controlled trial was conducted at Zagazig University Hospital, between January 2015 and January 2016, after approval of the hospital’s ethical committee, and a written informed consent was obtained from each patient. This study was carried upon 70 patients of age 18–40 years with BMI of 30–40 without any systemic disease, posted for laparoscopic sleeve gastrectomy, of both sexes. Exclusion criteria were systemic disease, age less than 18 or more than 60 years, and patients using any opioids or sedatives in the week before. Patients were enrolled in this study randomly by a computer-generated table into two groups (35 patients each). Group C (control group) received 40 ml saline (0.9%) at the beginning of surgery and 10 ml normal saline local infiltration in four port sites, and 30 ml intraperitoneal injection. Group P received 40 ml of bupivacaine (0.25%) divided into 10 ml local infiltration at the port sites and 30 ml intraperitoneally.

All patients in our study had general anesthesia using propofol, fentanyl, rocuronium, and isoflurane. Postoperatively, the pain severity score was recorded by using visual analog pain scale between 0 and 10 (0=no pain; 10=most severe pain), initially every 2 h for the first 24 h. Diclofenac (75 mg/kg) was given intramuscularly as a rescue analgesia when visual analog pain scale of at least 3 and repeated after 12 h if needed. Additional breakthrough mepridine was given intramuscularly 50 mg/dose each time, if necessary. Time to the first analgesic request, diclofenac consumption (mg), and the number of patients who needed additional breakthrough mepridine in each group were recorded. The associated adverse effects such as nausea, vomiting, hypotension, bradycardia, respiratory depression, shivering, and sedation were recorded.

Statistical analysis

To calculate the sample size, we started a pilot study for 1 month. We found that 40% of patients in the control arm needed additional mepridine in comparison with 12% in bupivacaine arm at a power analysis of β error of 0.8 and α error of 0.05, which showed that 35 patients per study group were needed. Continuous variables were expressed as the mean±SD and the categorical variables were expressed as a number (%). Continuous variables were checked for normality by using Shapiro–Wilk test. Independent Student’s t-test was used to compare two groups of normally distributed data, whereas Mann–Whitney U-test was used for non-normally distributed data. Percentage of categorical variables were compared using the χ2-test. All tests were two sided. P-value less than 0.05 was considered statistically significant. All data were analyzed using statistical package for social science for Windows, version 18.0 (SPSS Inc., Chicago, Illinois, USA) and MedCalc for Windows, version 13 (MedCalc Software bvba, Ostend, Belgium).


  Results Top


[Table 1] shows no statistically significant difference in the demographic data and duration of surgery of the studied groups.
Table 1 Demographic data of studied groups

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[Table 2] shows the time to the first analgesic request, in control group is 102.5 ± 10.3 minutes and group-P is 328.8 ± 32.4 minutes, which is statistically significant (p < 0.000) as shown in figure (1). Diclofenac consumption in control group is 155.14+ 8.34 mg and p group-P is 53.23 + 11.32 mg, which is statistically significant as shown in figure (2). Number of patients who needed additional Mepridine in control group is 20 (57%) and in dexmedetomidine group-D is 0 (0.05%) which is statistically significant (p < 0.000).
Table 2 Analgesic use

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[Table 3] shows the side effects in the studied groups. Nausea and vomiting were detected in 3 patients (8.5%) of group C, 2 patient and (5.7%) in group P. Statistically, the incidences of nausea and vomiting of the 2 studied groups were comparable. Shoulder pain was detected in 20 patients (57.1%) in group C and 10 patients (22.5%) in group P which is a statistically significant difference (p < 0.000).
Table 3 Adverse effects

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  Discussion Top


In laparoscopic surgeries, because of gas insufflations and increased intraperitoneal pressure, peritoneal inflammation and neuronal affection with a linear relationship between abdominal cavity compliance and severity of postoperative pain [6]. Intraperitoneal LA agents have become an important tool in controlling postoperative pain, nausea, and vomiting and reducing hospital stay [7] ([Table 1],[Table 2],[Table 3]).

Intraperitoneal instillation of 0.25% bupivacaine provides effective analgesia. In addition to this, according to our study, the duration of postoperative pain relief is better in group P (328.8±32.4 min) versus in group C (102.5±10.3 min), and this difference is statistically significant (P=0.000). Our results came along with previous studies that applied LA or placebo in a randomized trial [8],[9],[10]. IN contrast, Tam et al. [11] found that postoperative pain was the same after first 4 h. The LA regimen significantly reduced incisional pain during the first 3 h postoperatively. Our study shows prolonged time of analgesia owing to long-acting bupivacaine. Rehan et al. [12] were in agreement with our study. They found that infiltration of 0.25% bupivacaine at the port sites and intraperitoneally decreased the postoperative pain in first 24 h. It also significantly reduced the analgesic requirements in the postoperative period in the first 24 h [12]. The results of the work of Bhardwaj et al. [13] demonstrated that intraperitoneal use of bupivacaine with adrenaline produces less postoperative analgesic requirements. Our results regarding the dose of diclofenac required in the postoperative period was higher in group C than group P, which correlates with the study done by Ahmed et al. [14].

Rosenblatt et al. [15] reported major cardiovascular and neurological toxicity after use of three times the LA concentration treated successfully. Cardiac arrhythmias or circulatory collapse or disturbed conscious level and coma we did not face any type of adverse effect in our study.

Limitations of this study are as follows:
  1. Subjective experience of pain was difficult to quantify objectively.
  2. Systemic absorption and peak plasma levels of LA following blocks in bariatric patients have not been analyzed.



  Conclusion Top


Bupivacaine (intraperitoneal and local infiltration) leads to prolonged postoperative analgesia with sleeve gastrectomy without any adverse effects.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mitra S, Khandelwal P, Roberts K, Kumar S, Vadivelu N. Pain relief in laparoscopic cholecystectomy − a review of the current options. Pain Pract 2012; 12:485–496.  Back to cited text no. 1
    
2.
Ruiz-Tovar J, Muñoz JL, Gonzalez J, Zubiaga L, García A, Jimenez M et al. Postoperative pain after laparoscopic sleeve gastrectomy:comparison of three analgesic schemes (isolated intravenousanalgesia, epidural analgesia associated with intravenous analgesia and port-sites infiltration with bupivacaine associated with intravenous analgesia). Surg Endosc 2017; 31:231–236.  Back to cited text no. 2
    
3.
Einarsson JI, Sun J, Orav J, Young AE. Local analgesia in laparoscopy: a randomized trial. Obstet Gynecol 2004; 104:1335–1339.  Back to cited text no. 3
    
4.
Papadima A, Lagoudianakis EE, Antonakis P, Filis K, Makri I, Markogiannakis H et al. Repeated intraperitoneal instillation of levobupivacaine for the management of pain after laparoscopic cholecystectomy. Surgery 2009; 146:475–482.  Back to cited text no. 4
    
5.
Charghi R, Backman S, Christou N et al. Patient controlled iv analgesia is an acceptable pain management strategy in morbidly obese patients undergoing gastric bypass surgery. A retrospective comparison with epidural analgesia. Can J Anaesth 2009; 52: 672–678.  Back to cited text no. 5
    
6.
Tobias JD. Pain management following laparoscopy: can we do better? Saudi J Anaesth 2013; 7:3–4.  Back to cited text no. 6
    
7.
Kahokehr A, Sammour T, Soop M, Hill AG. Intraperitoneal local anaesthetic in abdominal surgery: a systematic review. ANZ J Surg 2011; 81:237–245.  Back to cited text no. 7
    
8.
Bisgaard T, Klarskov B, Kristiansen VB, Callesen T. Multi-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized, double-blinded, placebo-controlled study. Anesth Analg 1999; 89:1017–1024.  Back to cited text no. 8
    
9.
Lee IO, Kim SH, Kong MH et al. Pain after laparoscopic cholecystectomy: the effect and timing of incisional and intraperitoneal bupivacaine. Can J Anaesth 2001; 48:545–550.  Back to cited text no. 9
    
10.
Jimenez Fuertes M, Costa Navarro D. Outpatient laparoscopic cholecystectomy and pain control: a series of 100 cases. Cir Esp 2015; 93:181–186.  Back to cited text no. 10
    
11.
Tam T, Harkins G, Wegrzyniak L, Ehrgood S, Kunselman A, Davies M. Infiltration of bupivacaine local anesthetic to trocar insertion sites after laparoscopy: a randomized, double-blind, stratified, and controlled trial. J Minim Invasive Gynecol 2014; 21:1015–1021.  Back to cited text no. 11
    
12.
Rehan AG, Ali Z. Post-operative pain after laparoscopic cholecystectomy: role of port site and intra-peritoneal infiltration of injection bupivacaine. Ann Punjab Med Coll 2010; 4:2751–2754.  Back to cited text no. 12
    
13.
Bhardwaj N, Sharma V, Chari P. Intraperitoneal bupivacaine instillation for postoperative pain relief after laparoscopic cholecystectomy. Indian J Anaesth 2002; 46:49–52.  Back to cited text no. 13
    
14.
Ahmed B, Elmawgoud AA, Dosa R. Antinociceptive effect of (α-2 adrenoceptor agonist) dexmedetomidine vs meperidine, topically, after laproscopic gynecologic surgery. J Med Sci 2008; 8:400–404.  Back to cited text no. 14
    
15.
Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology 2006; 105:217–218.  Back to cited text no. 15
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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