Patients' perioperative experiences of an opioid-free versus opioid-based care pathway for laparoscopic bariatric surgery: A qualitative study.

Background: Despite recent evidence supporting the adoption of opioid-free anaesthetic and analgesic alternatives in the perioperative context, opioid-based regimens remain standard of care. There is limited knowledge about the patients' perioperative experiences of bariatric surgery, with no study yet investigating their experiences within an opioid-free care pathway. Objective: We aimed to describe similarities and differences in patients' perioperative experiences of undergoing bariatric surgery with either an opioid-free or opioid-based care pathway. Design: A qualitative interview study. Setting: A strategic sample of patients enrolled in an ongoing randomized controlled trial investigating the effects of opioid-free anaesthesia for bariatric surgery were recruited. In the randomized controlled trial, participants were randomized to either opioid-based anaesthesia or opioid-free anaesthesia, including transcutaneous electrical nerve stimulation as primary postoperative pain management. Participants: Twenty patients were interviewed 3 months after surgery: 10 participants in the opioid-free group versus 10 in the opioid-based group. Methods: Semi-structured interviews were conducted between December 2020 and February 2022 and analysed with qualitative content analysis. Results: The analysis yielded four categories and 12 subcategories. In Category 1, participants shared diverse emotions before surgery, including anticipation of a healthier life, but also apprehensions and feelings of failure. In Category 2, describing liminality of general anaesthesia, there were similar descriptions of struggling to remember the anaesthesia induction and struggling to surface when recovering from anaesthesia. However, some participants in the opioid-free group shared descriptions of struggling to keep control, describing accentuated memories of the anaesthesia induction. Category 3, managing your pain, showed similar experiences and strategies but different narrations of pain management, with the opioid-free group stating that transcutaneous electrical nerve stimulation works but not when it really hurts, and the opioid-based group describing confidence in but awareness of opioids. Throughout the overall perioperative time period, participants acknowledged Category 4, a patient-professional presence, stating that preparations boost the feeling of confidence before surgery and that they felt confidence in a vulnerable situation although vulnerability challenges communication. Conclusions: We highlighted the overall similarities in perioperative experiences of patients undergoing bariatric surgery. However, the differences in experiences during opioid-free anaesthesia induction need to be addressed in further implementation and research studies investigating strategies to reduce the sense of loss of control. More research is needed to facilitate the implementation of opioid-free treatment strategies into clinical practice and improve the patient care experience.

High-frequency, high-intensity transcutaneous electrical nerve stimulation compared with opioids for pain relief after gynecological surgery: a systematic review and meta-analysis.

OBJECTIVES: Opioids are important for postoperative analgesia but their use can be associated with numerous side effects. Transcutaneous electrical nerve stimulation (TENS) has been used for acute pain treatment and has dose-dependent analgesic effects, and therefore presents an alternative to intravenous (iv) opioids for postoperative pain relief. The aim of this meta-analysis was to compare high-frequency, high-intensity (HFHI or intense) TENS to iv opioids with regard to postoperative pain intensity, recovery time in the Post Anesthesia Care Unit (PACU) and opioid consumption after elective gynecological surgery. METHODS: We searched Medline, Embase, Web of Science, Cochrane, Amed and Cinahl for RCTs and quasi-experimental studies (2010-2022), and WHO and ClinicalTrials.gov for ongoing/unpublished studies. Meta-analysis and subsequent Trial Sequential Analysis (TSA) was performed for all stated outcomes. Quality of evidence was assessed according to GRADE. RESULTS: Only three RCTs met the inclusion criteria (362 participants). The surgical procedures involved surgical abortion, gynecologic laparoscopy and hysteroscopy. The applied TENS frequency was 80 Hz and intensity 40-60 mA. There was no difference in pain intensity according to Visual Analogue Scale (VAS) at discharge from PACU between the TENS and opioid group (MD VAS -0.15, 95 % CI -0.38 to 0.09) (moderate level of evidence). Time in PACU was significantly shorter in the TENS group (MD -15.2, 95 % -22.75 to -7.67), and this finding was manifested by TSA (high-level of evidence). Opioid consumption in PACU was lower in the TENS group (MD Morphine equivalents per patient mg -3.42, 95 % -4.67 to -2.17) (high-level of evidence). CONCLUSIONS: There was no detectable difference in postoperative pain relief between HFHI TENS and iv opioids after gynecological surgery. Moreover, HFHI TENS decreases recovery time and opioid consumption in PACU. HFHI TENS may be considered an opioid-sparing alternative for postoperative pain relief after gynecological surgery. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021231048.

Total opioid-free general anaesthesia can improve postoperative outcomes after surgery, without evidence of adverse effects on patient safety and pain management: A systematic review and meta-analysis.

BACKGROUND: Opioid-based treatment is used to manage stress responses during surgery and postoperative pain. However, opioids have both acute and long-term side effects, calling for opioid-free anaesthetic strategies. This meta-analysis compares adverse events, postoperative recovery, discharge time from post-anaesthesia care unit, and postoperative pain, nausea, vomiting, and opioid consumption between strict opioid-free and opioid-based general anaesthesia. METHODS: We conducted a systematic review and meta-analysis. We searched PubMed, Embase, Cinahl, Cochrane Library, selected reference lists, and Google Scholar. We included randomised controlled trials (RCTs) published between January 2000 and February 2021 with at least one opioid-free study arm, i.e. no opioids administered preoperatively, during anaesthesia induction, before skin closure, or before emergence from anaesthesia. RESULTS: The study comprised 1934 patients from 26 RCTs. Common interventions included laparoscopic gynaecological surgery, upper gastrointestinal surgery, and breast surgery. There is firm evidence that opioid-free anaesthesia significantly reduced adverse postoperative events (OR 0.32, 95% CI 0.22 to 0.46, I2  = 56%, p < 0.00001), mainly driven by decreased nausea (OR 0.27, (0.17 to 0.42), p < 0.00001) and vomiting (OR 0.22 (0.11 to 0.41), p < 0.00001). Postoperative opioid consumption was significantly lower in the opioid-free group (-6.00 mg (-8.52 to -3.48), p < 0.00001). There was no significant difference in length of post-anaesthesia care unit stay and overall postoperative pain between groups. CONCLUSIONS: Opioid-free anaesthesia can improve postoperative outcomes in several surgical settings without evidence of adverse effects on patient safety and pain management. There is a need for more evidence-based non-opioid anaesthetic protocols for different types of surgery as well as postoperative phases.

Opioid consumption in patients undergoing Roux-en-Y bariatric surgery compared with population controls with and without obesity.

BACKGROUND: Patients with obesity are prescribed more opioids than the general population. OBJECTIVES: To compare opioid consumption in patients with obesity who underwent Roux-en-Y bariatric surgery (RYGB) with population controls with and without obesity, not undergoing bariatric surgery, and to identify characteristics associated with opioid use. SETTING: This study included all patients with a principal diagnosis of obesity, aged 18-72 years, with a RYGB surgical code in the Swedish Patient Register between 2007 and 2013. METHODS: RYGB patients (n = 23,898) were age- and sex-matched with 1 control patient with obesity (n = 23,898) and 2 population controls without obesity (n = 46,064). Participants were classified as nonconsumers and consumers based on their opioid dispensations during the 12 months before baseline. Opioid consumption was assessed for 24 months. RESULTS: Nonconsumers. Within 24 months, a significantly higher proportion of RYGB patients (16.6%) started using opioids compared with the controls with obesity (14.3%, P < .0001) and population controls (5.4%, P < .0001). RYGB patients and controls with obesity had higher median daily intake of opioid morphine equivalent (MEQ) (2.8 mg/d) than population controls (2.5 mg/d, P < .0001). Consumers. Within 24 months, the proportion of RYGB patients and controls with obesity that was using opioids were similar (53.1% and 53.4%), but higher compared to population controls (38.0%, P < .0001). The median daily opioid MEQ was higher among RYGB patients than in population controls (10.5 versus 7.8 mg/d, P < .0001). RYGB patients, overall, had higher incidence of bowel surgery and cholecystectomy compared with controls with obesity and population controls, leading to prolonged opioid use in this group. Opioid consumption in general was associated with chronic pain and psychiatric disorder, which were more common in patients with obesity than in the population controls. CONCLUSION: RYGB surgery increased the risk of prolonged opioid use in patients with obesity who were nonconsumers before surgery but had no effect on overall opioid use among prior consumers. RYGB-associated complications requiring surgery influenced opioid use for both nonconsumers and consumers. Regular reassessments of pain mechanisms and specific treatment owing to type of pain could prevent unnecessary opioid use in this patient group.

Intraperitoneal ropivacaine reduces time interval to initiation of chemotherapy after surgery for advanced ovarian cancer: randomised controlled double-blind pilot study.

BACKGROUND: Advanced-stage ovarian cancer has a poor prognosis; surgical resection with the intent to leave no residual tumour followed by adjuvant chemotherapy is the standard treatment. Local anaesthetics (LA) have anti-inflammatory and analgesic effects. We hypothesised that intraperitoneal LA (IPLA) would lead to improved postoperative recovery, better pain relief, and earlier start of chemotherapy. METHODS: This was a prospective, randomised, double-blind, placebo-controlled pilot study in 40 women undergoing open abdominal cytoreductive surgery. Patients were randomised to receive either intraperitoneal ropivacaine (Group IPLA) or saline (Group Placebo) perioperatively. Except for study drug, patients were treated similarly. Intraoperatively, ropivacaine 2 mg ml-1 or 0.9% saline was injected thrice intraperitoneally, and after operation via a catheter and analgesic pump into the peritoneal cavity for 72 h. Postoperative pain, time to recovery, home discharge, time to start of chemotherapy, and postoperative complications were recorded. RESULTS: No complications from LA administration were recorded. Pain intensity and rescue analgesic consumption were similar between groups. Time to initiation of chemotherapy was significantly shorter in Group IPLA (median 21 [inter-quartile range 21-29] vs 29 [inter-quartile range 21-40] days; P=0.021). Other parameters including time to home readiness, home discharge and incidence, and complexity of postoperative complications were similar between the groups. CONCLUSIONS: Intraperitoneal ropivacaine during and for 72 h after operation after cytoreductive surgery for ovarian cancer is safe and reduces the time interval to initiation of chemotherapy. Larger studies are warranted to confirm these initial findings. CLINICAL TRIAL REGISTRATION: NCT02256228.

Effects of a home-based exercise program on the insulin-like growth factor axis in patients operated for colorectal cancer in Sweden: Results from the randomised controlled trial PHYSSURG-C.

OBJECTIVES: We report results from a subgroup within the ongoing PHYSSURG-C trial with the aim to examine effects of exercise on IGF-1 and IGFBP-3 in patients undergoing colorectal cancer surgery. DESIGN: Randomised controlled trial. SETTING: A Swedish university hospital. PARTICIPANTS: Between 2015 and 2016, 217 patients were enrolled (I = 106, C = 111), with 122 patients that had given blood samples at baseline and at least at one follow-up (I = 51, C = 71). Patients 20 year or older with colorectal cancer were eligible. Exclusion criteria were emergency surgery, local surgery, language problems or inability to perform intervention. INTERVENTIONS: Patients were computer-randomised to either a daily home-based aerobic exercise intervention (I), or to usual care (C). The intervention lasted two weeks before surgery and four weeks after discharge from hospital and consisted of medium-intensity aerobic exercise and inspiratory muscle training. Circulating concentrations of IGF-1 and IGFBP-3 were determined by blinded personnel at baseline, time of surgery and 4-6 weeks postoperatively. PRIMARY AND SECONDARY OUTCOME MEASURES: The outcome of this subpopulation report was change in IGF-1/IGFBP-3 ratio, IGF-1 and IGFBP-3 concentrations from baseline to surgery, and 4-6 weeks postoperatively. RESULTS: The IGF-1/IGFBP-3 ratio increased from baseline to surgery by 11% in I and 8% in C with no difference between groups (I vs. C: 1.04, 95%CI: 0.97-1.11; p = 1.000). Postoperative change was 5% in I and 3% in C with no difference between groups (I vs. C:1.03, 95%CI: 0.96-1.10; p = 1.000). Results concerning IGF-1 and IGFBP-3 also showed statistically significant dynamics over time with no difference between groups. No adverse events were reported. CONCLUSIONS: The home-based exercise program in our trial did not have any effect on IGF-1, or IGFBP-3. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov with identifier NCT02299596. This work was funded externally.

Roux Limb Motility in Gastric Bypass Patients with Chronic Abdominal Pain-Is There an Association to Prescribed Opioids?

BACKGROUND/AIM: A number of patients continue to suffer from chronic abdominal pain of unknown origin, which may also lead to a prolonged use of opioid analgesics. Symptoms of abdominal pain, nausea and vomiting in this patient group resemble the characteristics of the Roux stasis Syndrome. The aim was to elucidate relationships between chronic abdominal pain, Roux limb motor activity and opioid analgesics. METHODS: Roux limb high-resolution manometry and ratings of abdominal pain and quality of life were analysed in 15 gastric bypass patients reporting abdominal pain of unknown origin. Effect of acute opiate administration (morphine i.v.) on fasting Roux limb motor activity was assessed in asymptomatic and morphine-naïve gastric bypass patients (n = 9) and compared with an untreated control group (n = 11). RESULTS: In the symptomatic patient group, we found disturbed Roux limb motor patterns in 10 out of 15 examinations, but no signs of Roux stasis syndrome. A high prevalence of prescribed opioid analgesics as well as a high number of reoperations in this group. The worst quality of life and the highest number of pain-killing medications were observed among the patients with distal pacemaker activity in Roux limb. In the morphine-naïve and asymptomatic patients, morphine increased the muscular tone in the Roux limb during phase III-like motor activity. A majority of the RYGBP patients with chronic abdominal pain had a disturbed Roux limb fasting motility, and there was a high prevalence of prescribed opioid analgesics. In opiate-naïve RYGBP patients, acute morphine intravenously increased the muscular tone of the Roux limb.

Does intraperitoneal ropivacaine reduce postoperative inflammation? A prospective, double-blind, placebo-controlled pilot study.

BACKGROUND: Postoperative inflammation is a common consequence of surgery and the ensuing stress response. Local anesthetics have anti-inflammatory properties. The primary aim of this study was to evaluate if LA administrated intraperitoneally perioperatively might inhibit expression of inflammatory cytokines. METHODS: This was a, randomized, double blind, placebo-controlled study (ClinicalTrial.gov reg no: NCT02256228) in patients undergoing surgery for ovarian cancer. Patients were randomized to receive: intraperitoneal ropivacaine (Group IPLA) or saline (Group P) perioperatively. Except for study drug, patients were treated similarly. At the end of surgery, a multi-port catheter was inserted intraperitoneally, and ropivacaine 2 mg/mL or 0.9% saline, 10 mL was injected intermittently every other hour during 72 hours postoperatively. Systemic expression of cytokines and plasma ropivacaine were determined before and 6, 24, and 48 hours after surgery. Stress response was measured by serum glucose, cortisol, and insulin. RESULTS: Forty patients were recruited, 20 in each group. There was no statistical significant difference in systemic cytokine between the groups at any time point. Serum cortisol was significantly lower in the IPLA group at 6 hours, median 103 nmol/L (IQR 53-250) compared to placebo, median 440 nmol/L (IQR 115-885), P = 0.023. Serum glucose and insulin were similar between the groups. Total and free serum concentrations of ropivacaine were well below toxic concentrations. CONCLUSION: In this small study, perioperative intraperitoneal ropivacaine did not reduce the systemic inflammatory response associated with major abdominal surgery. Total and free ropivacaine concentrations were below known toxic concentrations in humans.

The effect of pre- and post-operative physical activity on recovery after colorectal cancer surgery (PHYSSURG-C): study protocol for a randomised controlled trial.

BACKGROUND: Surgery for colorectal cancer is associated with a high risk of post-operative adverse events, re-operations and a prolonged post-operative recovery. Previously, the effect of prehabilitation (pre-operative physical activity) has been studied for different types of surgery, including colorectal surgery. However, the trials on colorectal surgery have been of limited methodological quality and size. The aim of this trial is to compare the effect of a combined pre- and post-operative intervention of moderate aerobic physical activity and inspiratory muscle training (IMT) with standard care on post-operative recovery after surgery for colorectal cancer. METHODS/DESIGN: We are conducting a randomised, controlled, parallel-group, open-label, multi-centre trial with physical recovery within 4 weeks after cancer surgery as the primary endpoint. Some 640 patients planned for surgery for colorectal cancer will be enrolled. The intervention consists of pre- and post-operative physical activity with increased daily aerobic activity of moderate intensity as well as IMT. In the control group, patients will be advised to continue their normal daily exercise routine. The primary outcome is patient-reported physical recovery 4 weeks post-operatively. Secondary outcomes are length of sick leave, complication rate and severity, length of hospital stay, re-admittances, re-operations, post-operative mental recovery, quality of life and mortality, as well as changes in insulin-like growth factor 1 and insulin-like growth factor-binding protein 3, perception of pain and a health economic analysis. DISCUSSION: An increase in moderate-intensity aerobic physical activity is a safe, cheap and feasible intervention that would be possible to implement in standard care for patients with colorectal cancer. If shown to be effective, this lifestyle intervention could be a clinical parallel to pre-operative smoke cessation that has already been implemented with good clinical results. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02299596 . Registered on 17 November 2014.

High-resolution solid-state manometry of the upper and lower esophageal sphincters during anesthesia induction: a comparison between obese and non-obese patients.

BACKGROUND: The prevalence of obesity has increased dramatically in recent decades. The gastrointestinal changes associated with obesity have clinical significance for the anesthesiologist in the perioperative period. The lower esophageal sphincter and the upper esophageal sphincter play a central role in preventing regurgitation and aspiration. The effects of increased intra-abdominal pressure during anesthesia on the lower esophageal sphincter and the upper esophageal sphincter in obese patients are unknown. In the present study we evaluated, with high-resolution solid-state manometry, the upper esophageal sphincter, lower esophageal sphincter, and barrier pressure (BrP) (lower esophageal pressure--gastric pressure) in obese patients during anesthesia induction and compared them with pressures in non-obese patients. METHODS: We studied 28 patients, ages 18 to 72 years, 14 with a body mass index > or = 35 kg/m(2), who were undergoing laparoscopic gastric bypass, and 14 with a body mass index < or = 30 kg/m(2), who were undergoing laparoscopic cholecystectomy, using high-resolution solid-state manometry. RESULTS: Upper esophageal sphincter pressure decreased during anesthesia induction in both groups. Lower esophageal sphincter pressure decreased in both groups during anesthesia induction, and it was significantly lower in obese patients than in non-obese patients. The BrP decreased in both groups and was significantly lower in the obese group than in the non-obese group. The BrP remained positive at all times in both groups. CONCLUSION: Lower esophageal sphincter and BrPs decreased in both obese and non-obese patients during anesthesia induction, but were significantly lower in obese patients. Although the BrP was significantly lower, it remained positive in all patients.

The effect of anesthetic technique on early postoperative gastric emptying: comparison of propofol-remifentanil and opioid-free sevoflurane anesthesia.

PURPOSE: A postoperative decrease in the gastric emptying (GE) rate may delay the early start of oral feeding and alter the bioavailability of orally administered drugs. The aim of this study was to compare the effect on early gastric emptying between two anesthetic techniques. METHODS: Fifty patients (age, 19-69 years) undergoing day-case laparoscopic cholecystectomy were randomly assigned to received either total intravenous anesthesia with propofol/remifentanil/rocuronium (TIVA; n = 25) or inhalational opioid-free anesthesia with sevoflurane/rocuronium (mask induction; GAS; n = 25). Postoperative gastric emptying was evaluated by the acetaminophen method. After arrival in the recovery unit, acetaminophen (paracetamol) 1.5 g was given through a nasogastric tube, and blood samples were drawn during a 2-h period. The area under the serum-acetaminophen concentration curve from 0-60 min (AUC60), the maximal concentration (Cmax), and the time to reach C-max (Tmax) were calculated. RESULTS: Twelve patients were excluded due to surgical complications (e.g., conversion to open surgery) and difficulty in drawing blood samples (TIVA, n = 7; GAS, n = 5). Gastric emptying parameters were (mean +/- SD): TIVA, AUC60, 2458 +/- 2775 min.micromol.l(-1); Cmax, 71 +/- 61 micromol.l(-1); and Tmax, 81 +/- 37 min; and GAS, AUC60, 2059 +/- 2633 min.micromol.l(-1); Cmax, 53 +/- 53 micromol.l(-1); and Tmax, 83 +/- 41 min. There were no significant differences between groups. CONCLUSION: There was no major difference in early postoperative gastric emptying between inhalation anesthesia with sevoflurane versus total intravenous anesthesia with propofol-remifentanil. Both groups showed a pattern of delayed gastric emptying, and the variability in gastric emptying was high. Perioperative factors other than anesthetic technique may have more influence on gastric emptying.