Evidence-Based Management of Postoperative Pain in Adults Undergoing Laparoscopic Sleeve Gastrectomy
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Laparoscopic sleeve gastrectomy (LSG) is a common weight loss operation that is increasingly being managed on an outpatient or overnight stay basis. The aim of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after LSG.
A systematic review utilizing preferred reporting items for systematic reviews and meta-analysis with PROcedure SPECific Postoperative Pain ManagemenT methodology was undertaken. Randomized controlled trials (RCTs) published in the English language from inception to September 2018 assessing postoperative pain using analgesic, anesthetic, and surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases.
Significant heterogeneity was identified in the 18 RCTs included in this systematic review. Gabapentinoids and transversus abdominis plane blocks reduced LSG postoperative pain. There was limited procedure-specific evidence of analgesic effects for acetaminophen, non-steroidal anti-inflammatory drugs, dexamethasone, magnesium, and tramadol in this setting. Inconsistent evidence was found in the studies investigating alpha-2-agonists. No evidence was found for intraperitoneal local anesthetic administration or single-port laparoscopy.
The literature to recommend an optimal analgesic regimen for LSG is limited. The pragmatic view supports acetaminophen and a non-steroidal anti-inflammatory drug, with opioids as rescue analgesics. Gabapentinoids should be used with caution, as they may amplify opioid-induced respiratory depression. Although transversus abdominis plane blocks reduced pain, port-site infiltration may be considered instead, as it is a simple and inexpensive approach that provides adequate somatic blockade. Further RCTs are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.
PROSPECT is supported by an unrestricted Grant from the European Society of Regional Anaesthesia and Pain Therapy (ESRA). In the past, PROSPECT had received unrestricted Grants from Pfizer Inc. New York, NY, USA and Grunenthal, Aachen, Germany.
PROSPECT working group: H. Beloeil, F. Bonnet, A Hill, G. P. Joshi, H. Kehlet, P. Lavand’homme, P. Lirk, E. Pogatzki-Zahn, N. Rawal, J. Raeder, S. Schug, M. Van de Velde.
HM, WX and SS conducted the literature search and analyzed the retrieved articles with AH; HM, WX, SS, AH and GJ wrote the manuscript, which was reviewed and edited by all the other authors who have also participated in the PROSPECT Working Group meetings using a Delphi method.
Compliance with ethical standards
Conflict of interest
Andrew Hill has received Honoraria from MSD. Philipp Lirk has no conflicts of interest to declare. Girish P. Joshi has received honoraria from Baxter and Pacira Pharmaceuticals. Francis Bonnet has received honoraria from Pfizer, The Medicine Company, Abbott France, and Nordic Pharma France. Henrik Kehlet has received honoraria from Pfizer and Grunenthal. The Anesthesiology Unit of the University of Western Australia, but not Stephan Schug privately, has received research and travel funding and speaking and consulting honoraria from bioCSL, Eli Lilly, Indivior, iX Biopharma and Pfizer. Narinder Rawal has received honoraria from Baxter and Sintetica. Marc Van de Velde received honoraria from Sintetica, Grunenthal, Vifor Pharma, MSD, Nordic Pharma, Janssen Pharmaceuticals, Heron Therapeutics and Aquettant.
- 16.Rupniewska-Ladyko A, Malec-Milewska M, Kraszewska E, Pirozynski M (2018) Gabapentin before laparoscopic sleeve gastrectomy reduces postoperative oxycodone consumption in obese patients: a randomized double-blind placebo-controlled trial. Minerva Anestesiol 84:565–571Google Scholar
- 20.Elbakry A-E, Sultan W-E, Ibrahim E (2018) A comparison between inhalational (desflurane) and total intravenous anaesthesia (propofol and dexmedetomidine) in improving postoperative recovery for morbidly obese patients undergoing laparoscopic sleeve gastrectomy: a double-blinded randomised controlled trial. J Clin Anesth 45:6–11CrossRefGoogle Scholar
- 25.Said AM, Balamoun HA (2017) Continuous transversus abdominis plane blocks via laparoscopically placed catheters for bariatric surgery. Obes Surg 07:07Google Scholar
- 28.Ruiz-Tovar J, Muñoz JL, Gonzalez J et al (2017) Postoperative pain after laparoscopic sleeve gastrectomy: comparison of three analgesic schemes (isolated intravenous analgesia, epidural analgesia associated with intravenous analgesia and port-sites infiltration with bupivacaine associated with intravenous analgesia). Surg Endosc 31:231–236CrossRefGoogle Scholar
- 32.Mechanick JI, Youdim A, Jones DB et al (2013) Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by american association of clinical endocrinologists, the obesity society, and american society for metabolic & bariatric surgery. Obesity 21(S1):S1–S27CrossRefGoogle Scholar