Optimal analgesia during major open and laparoscopic abdominal surgery.

Optimal analgesia is a key element of enhanced recovery after surgery (ERAS), not only for humanitarian reasons but also because poorly relieved surgical pain contributes to surgical stress and impairs recovery. A multimodal analgesic approach is advised in order to provide adequate analgesia, reduce opioid consumption, reduce side effects and facilitate the achievement of ERAS milestones. For open surgery, a thoracic epidural for 48 to 72 hours, with regular acetaminophen and antiinflammatories is probably the treatment of choice. For laparoscopic surgery, intrathecal or local anesthesia in the wound combined with regular acetaminophen and antiinflammatory drugs is effective.

An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery.

BACKGROUND: Enhanced perioperative care programs have been developed in order to attenuate the impact of surgical stress on organ dysfunction, thereby accelerating hospital discharge and reducing morbidity. The implementation of a fast-track program for laparoscopic colorectal surgery is reported. METHODS: We report on a series of patients who entered a coordinated program based on preoperative patient education and counseling, a laparoscopic approach, provision of postoperative epidural analgesia, early food intake and mobilization, and structured surgical and nursing care practices. The program was introduced in September 2006 and adapted to our institutional needs. Outcome measures included length of hospital stay, return of bowel function, incidences of postoperative complications, and rate of readmission to hospital. RESULTS: Twenty-five patients were selected by the surgeons for the accelerated laparoscopic colorectal pathway. The median duration of hospital stay was 3 (95% confidence interval, 3-4) days. Sixteen patients (64%) were discharged from hospital on day 3. Nine patients failed the pathway for various reasons (social indications, poor pain relief, wound infection, anemia, urinary retention) and were discharged later (six patients on day 4, two patients on day 5, and one patient on day 6). Times to recover bowel function and to resume a full diet were all within the first 36 hr from time of surgery. There were two readmissions. CONCLUSION: This early clinical experience demonstrates the feasibility of a fast-track program for colonic surgery and the requirement for an integrated multidisciplinary approach to perioperative care.