Acta chir belg, 2005, 105, 53-58

Acute Rehabilitation Program after Laparoscopic Colectomy using Intravenous Lidocaine

A. Kaba*, B. J. Detroz**, S. R. Laurent**, M. L. Lamy*, J. L. Joris* *Department of Anaesthesia and Intensive Care Medicine, **Department of Abdominal Surgery and Transplantation, CHU de Lige, Domaine du Sart-Tilman, Lige, Belgium.

Key words. Colectomy ; fast track ; laparoscopy ; intravenous lidocaine. Abstract. Background : The concept of postoperative acute rehabilitation was introduced to accelerate postoperative recovery and improve outcome. We investigated whether intravenous lidocaine infusion, which decreases postoperative pain and speeds the return of bowel function, can be used instead of epidural analgesia in an acute rehabilitation protocol for patients undergoing laparoscopic colectomy. Methods : Twenty eight consecutive patients scheduled for laparoscopic colectomy were prospectively included in this case series study. Segmental colectomy was performed only for benign pathology. Intraoperative opioid use was restricted. After a bolus injection of lidocaine 1.5 mgkg-1, an infusion (2 mgkg-1h-1, IV) was started before pneumoperitoneum. Balanced analgesia was used to reduce postoperative opioid consumption. Patients were allowed to drink 6 h postoperatively. The day after surgery, patients were allowed to eat a normal breakfast. Enforced mobilisation and ambulation were required from the patients. Our goal was to discharge patients within 3 days after surgery. Postoperative pain was measured. Time to first flatus, defecation, and hospital discharge were recorded. Results : Mean postoperative pain at rest and mobilisation remained below 30 mm on a 100 mm visual analogue scale. Time to first flatus, defecation, and hospital discharge were 29 13 h, 38 13 h, and 3.0 1.0 days, respectively. Conclusion : Acute rehabilitation after laparoscopic colectomy using IV lidocaine gives similar outcomes to those reported using epidural analgesia.

Introduction Several factors contribute to postoperative morbidity, length of hospital stay, and convalescence (1). Our understanding of perioperative pathophysiology and care has greatly improved over the last decade. This improved knowledge lead to the development of programs to accelerate postoperative recovery, or fast-track surgery (1-8). These acute rehabilitation programs combine preoperative information and optimisation of patients, attenuation of surgical stress, dynamic pain relief, enforced mobilisation, and early oral (enteral) nutrition. In addition, traditional practise of surgical care has been revised to encompass up-to-date recommendations for tubes, drains, and rehabilitation (9, 10). This multimodal approach to enhance postoperative recovery has been mainly developed and used for abdominal surgeries, particularly colonic surgery (7, 8, 11-14). Effective postoperative dynamic pain relief plays a key role in this approach. Epidural analgesia using local anaesthetic seems particularly appropriate after abdominal surgery since it reduces surgical stress (15), provides excellent dynamic pain relief allowing enforced mobilization (16, 17), and improves gastrointestinal function (18, 19). Epidural analgesia was therefore included in the multimodal approach for both open and laparo-

scopic colonic resection (11, 13, 20). However the benefits of epidural analgesia for minimally invasive laparoscopic colectomy, reported in non-randomised studies, have been questioned (21, 22). Intravenous lidocaine which is analgesic (23, 24), antihyperalgesic (24, 25), antiinflammatory (26), and speeds the return of bowel function after surgery (23), appears interesting to facilitate an acute rehabilitation program after colonic surgery, but has never been tested. We therefore hypothesised that the use of intravenous lidocaine would provide results similar to those reported with epidural analgesia after laparoscopic colectomy. Methods After approval of our Institution Ethics Committee and patient written informed consent, 28 consecutive ASA physical status I-III patients scheduled for elective

Manuscript submitted in the category original articles ; reprints will not be available from the author. Presented in part at the 2002 Annual Meeting of the European Society of Anaesthesiologists in Nice, France. Supported in part by a Clinical Research Grant granted to Dr. A. Kaba by the CHU of Lige.

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laparoscopic colectomy were included in this acute rehabilitation program. All patients received precise oral and written information about our program and the importance of their contribution in the early postoperative nutrition and enforced mobilisation. No colectomy was carried-out for colonic cancer. Fifteen patients underwent colectomy for diverticulitis ; three of them had an entero-vaginal fistula, one had an entero-vesical fistula, and one an entero-cutaneous fistula. Seven patients were operated on for benign villous polyp, five suffered from inflammatory bowel disease, and one had angiodysplasia. The primary goal of our program was to discharge patients from the hospital on or before the third postoperative day. Anaesthesia and postoperative analgesia Our protocol restricted the use of intra- and postoperative opioids. After 6 h fasting, all patients were given 50 mg hydroxyzine and 0.5 mg alprazolam by mouth 2 h before surgery. In the operating theatre, an intravenous infusion of 8 mlkg-1h-1 Ringers Lactate solution was started. General anaesthesia was induced with propofol (2 mgkg-1), sufentanil (0.25 mgkg-1), and cis-atracurium (0.2 mgkg-1). Immediately after induction of anaesthesia, a bolus injection of 1.5 mgkg-1 lidocaine was given followed by an infusion of 2 mgkg-1h-1. The lidocaine infusion was stopped at the end of surgery. Anaesthesia was maintained with sevoflurane in 80% oxygen/air mixture. All patients received droperidol 0.625 mg and tropisetron 2 mg, a 5-HT3 antagonist, to prevent postoperative nausea and vomiting. At skin incision, ketamine 0.5 mgkg-1 was administered to reduce postoperative hyperalgesia. Postoperative analgesia was provided by the combination of propacetamol, a precursor of paracetamol (ProDafalgan UPSA Medica, Belgium ; 2g of propacetamol = 1g paracetamol [2 g IV 30 min before the end of surgery and then systematically every 6 h]), tramadol (2 mgkg-1 30 min before the end of surgery followed by a continuous infusion of 400 mg over a period of 24 hours), and ketoprofen, a nonsteroidal anti-inflammatory drug (100 mg IV 30 min before the end of surgery and then an infusion of 100 mg over a period of 24 hours). Patient-controlled analgesia with piritramide, a synthetic opioid, was used as rescue medication. Twenty four hours after the end of surgery, when the intravenous infusion was stopped, analgesia was provided with oral paracetamol 1 g every 6 h, ketoprofen 100 mg twice daily, and tramadol 100 mg, if necessary. Surgical procedure All procedures were performed by two experienced laparoscopic surgeons (BJD, SRL) using a standard five-trocar or four-trocar technique. For right colecto-

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my, after intracorporeal dissection of the ascending colon and the Bauhin valve, the specimen was exteriorized through a 5-6 cm minilaparotomy in the right lower abdomen. After resection of the pathologic colon, the anastomosis was hand-sewn and returned to the abdominal cavity. The minilaparotomy was then closed. In laparoscopic sigmoid colectomy, the sigmoid colon was first mobilised intracorporeally up to the recto-sigmoid junction. The recto-sigmoid junction was cut using a stapler. The sigmoid colon was retrieved through a 56 cm minilaparotomy in the left lower abdomen and then resected. The anvil of a circular stapling device was inserted extracorporeally into the descending colon. After closure of the laparotomy, the pneumoperitoneum was re-established and a trans-anal colorectal anastomosis was completed by the double-stapling technique. Gastrointestinal tubes were withdrawn at the end of surgery after aspiration of the gastric content. Erythromycin, 500 mg every 8 h, was given for 24 h as a gastrokinetic. An abdominal drain was left in contact with the anastomosis for 24 h. The bladder catheter was removed on the morning of the first postoperative day. Acute rehabilitation protocol Patients were allowed to drink water 6 h after surgery. If patients did not complain of nausea or vomiting, they were given 200 ml of nutritive supplement without residue (Clinutren 1.5 Kcal/ml, Nestl, France) one hour later. On postoperative day 1, patients had a light breakfast and lunch. If they had no food intolerance, intravenous infusion was stopped and normal diet was resumed. Patients were asked to drink three 200 ml nutritive supplements per day. Active mobilisation was done in bed 4 h after surgery. Enforced mobilisation was requested the following days : assisted ambulation, 20 m in the morning and 50 m in the afternoon on postoperative day 1, and 100 m in the morning and the afternoon on day 2. Defecation and tolerance of normal diet were required before discharge. Patients actually left the hospital when they felt ready to go home. Parameters Pain scores were obtained on a 100-mm visual analogue scale at rest, during mobilisation from the supine to the sitting position, and during coughing at 2 and 6 h postoperatively, and at 9:00 a.m., 1:00 p.m., and 6:00 p.m. on postoperative days 1 and 2. Postoperative fatigue scores and gastrointestinal comfort were also assessed on a 100-mm visual analogue scale at the same times. Caloric intakes on postoperative days 1 and 2 were calculated. Time to first flatus, defecation, and hospital discharge were recorded. Data are presented as mean SD.

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Fig. 1 Self-reported pain scores at 2 and 6 hours after surgery and at 9 am, 1 pm, and 6 pm on the first and second day after surgery. Reports were taken with the patients at rest, during mobilisation from the supine to the sitting position, and while coughing. Pain was reported on a 100-mm visual analogue scale with 0 mm being no pain and 100 mm being the worst pain imaginable.

Fig. 2 Self-reported fatigue scores at 2 and 6 hours after surgery and at 9 am, 1 pm, and 6 pm on the first and second day after surgery. Fatigue was reported on a 100-mm visual analogue scale with 0 mm being no fatigue and 100 mm being the worst imaginable.

Table 1 Patient data (mean SD or number)

Parameter Age ; yr Sex ratio : F/M Weight ; kg Height ; cm ASA physical status (I,II,III) ; number of patients Right / Transverse / Left colectomy ; number of patients N = 28 54 15 21 / 7 69 13 164 8 6 / 16 / 6 6 / 1 / 21

Results Patient data are shown in table 1. Our analgesia protocol provided effective static and dynamic pain relief, as mean pain scores at rest and during mobilisation were less than 30 mm (Fig. 1). Gastro-intestinal comfort scores were high, above 90 mm during the first two postoperative days. Postoperative fatigue scores averaged 30 mm during the same period of time (Fig. 2). The duration of intravenous infusion was 23 5 h. Times to first meal, first flatus, and defecation were respectively : 18 2 h, 29 13 h, and 38 13 h. The length of hospital stay was 3.0 1.0 days. More precisely, nine patients left the hospital on postoperative

day 2, 15 on postoperative day 3, and three on postoperative day 5. The three patients who were discharged on day 5 were elderly ; they respected our program and ate an almost normal diet the day after surgery, but asked to stay over the weekend for personal convenience. One 85-year-old woman was finally discharged on day 8 after she developed a haemorrhagic gastric ulcer the third postoperative day. All patients were fully independent when discharged from the hospital. Except the 85year-old woman who was placed in a nursing home, all the other returned home. Caloric intakes were 1508 649 Kcal on day 1 and 1725 347 Kcal on day 2. One man vomited in the evening of the day of surgery, but was able to have breakfast the first postoperative day. Four women (three left colectomies, one right colectomy) complained of postoperative nausea. Fasting and intravenous infusion had to be prolonged in one of them until the morning of the second postoperative day. The three other could eat the light breakfast the day after surgery and had their intravenous infusion stopped 24 h after surgery. One patient was re-admitted for abdominal distension and discomfort ten days after surgery. After a 24-hours fasting, she was again able to eat normally and left the hospital. No other readmission and no other morbidity occurred during the postoperative 30-days follow-up.

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Discussion This study demonstrates that an acute rehabilitation program allowing patient discharge from the hospital on the third postoperative day or sooner after laparoscopic colectomy can be achieved without epidural analgesia. Indeed, 85 percent of the patients included in our rehabilitation program left the hospital the second or the third day after colonic resection. Our protocol without epidural analgesia resulted in similar length of hospital stay and comparable times for first meal and for defecation to those reported when epidural analgesia is used for 24 h postoperatively (11, 20, 22). Beside the management of postoperative analgesia, our multimodal approach was very similar to that of Kehlets group (11, 13). This included preoperative patient information, early oral nutrition, enforced active mobilisation, and ambulation. To allow early food intake, it is essential to avoid factors that contribute to postoperative ileus, to promote treatments that speed the return of bowel function (18, 19), and to prevent postoperative nausea and vomiting (27). The laparoscopic approach reduces surgical trauma and the size of the incisions in the abdominal wall. Consequently, laparoscopic colectomy results in shorter postoperative ileus than open colonic resection, although the actual reduction is less than what was previously thought (18, 2830). Moreover postoperative pain, pulmonary dysfunction, and metabolic response are significantly reduced after laparosocpy as compared with laparotomy (29, 30). In our study no patients were scheduled for resection of colonic cancer. Indeed the use of laparoscopy for cancer surgery was very controversial because of the risk of peritoneal and port-sites metastases. Recent studies however suggest that tumor recurrence and long-term survival are not adversely affected by laparoscopy as compared with laparotomy (29, 30). Perioperative opioid is an important pathophysiologic factor of postoperative ileus. All measures to reduce the need for perioperative opioid must therefore be taken (18, 19). The contribution to ileus of intraoperative short-acting opioids is probably less than that of postoperative opioids. Intraoperative opioids nevertheless contribute to spinal sensitisation responsible for postoperative hyperalgesia and subsequently increase postoperative opioid consumption (31). Kehlets group uses epidural anaesthesia to reduce intraoperative opioids. In the absence of epidural anaesthesia, we preferred inhalation anaesthesia to intravenous anaesthesia with opioids. Postoperative opioids consumption is also decreased by balanced analgesia, which combines several analgesics acting on different targets of the nociceptive pathways (32). In this study, we administered paracetamol, a nonsteroidal anti-inflammatory drug (NSAID), and ketamine. NSAIDs were reported to

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shorten postoperative ileus (33, 34). This effect might be due to their sparing effect on opioid requirement, but also to a direct effect on intra-abdominal inflammation, the starting point of the inhibitory reflex responsible for postoperative ileus. We also selected tramadol, a weak opioid, because it is associated with fewer side effects on bowel motility than other opioids (36, 37). Thoracic epidural analgesia with local anaesthetic, which inhibits the spinal sympathetic nervous system, has been demonstrated repeatedly to accelerate the return of bowel function after abdominal surgery and was therefore included in acute rehabilitation programs (1, 11, 13, 18-20). Instead of epidural analgesia however, we used intravenous lidocaine, which was also shown to shorten postoperative ileus. This effect might be mediated by a direct action on the inhibitory myenteric plexus that is activated after abdominal surgery and or indirectly by the reduction of opioid requirements (23, 24). We also administered erythromycin for its gastrokinetic properties. Finally, prevention of postoperative nausea and vomiting is particularly important in case of abdominal surgery and laparoscopy. Indeed, the reported incidence of these side effects is as high as 50% (38). Prevention of postoperative nausea and vomiting, achieved with droperidol, tropisetron, a 5-HT3 antagonist, and intraoperative high oxygen administration in our proptocol (27, 39), was effective since nausea or vomiting was prospectively detected in five patients (18%). Only one patient complained of nausea responsible for delayed nutrition. Enforced mobilisation and ambulation require effective postoperative analgesia. The epidural technique with local anaesthetic provides better dynamic pain relief than epidural or systemic opioid and, therefore, facilitates acute rehabilitation (40, 41). The laparoscopic approach results in less pain and requires less postoperative opioid than open surgery (29, 30, 42). Therefore, we considered that adequate pain relief after laparoscopy could be achieved without epidural analgesia. Accordingly, our analgesic regimen was very effective since pain during mobilisation and when coughing were lower than 30-mm on a 100-mm visual analogue scale. Pain scores in our study were similar to those reported when epidural analgesia is used postoperatively (22). Postoperative dynamic pain results from hyperalgesia secondary to peripheral and spinal sensitisation following tissue trauma. In the absence of epidural analgesia, we combined NSAIDs, ketamine, and paracetamol, which all reduce peripheral or spinal sensitization (43, 44). Finally all patients were given intraoperative intravenous lidocaine. Intravenous lidocaine reduces pain at rest and during mobilisation, as well as postoperative opioid requirement. Lidocaine is anti-hyperalgesic partly by inhibition of N-methyl-D-aspartate receptors, which play a key role in spinal sensitization (25, 46).

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Moreover systemic lidocaine blocks the activation of polymorphonuclear leukocytes and thus has anti-inflammatory effects (26, 47). Intravenous lidocaine has several properties similar to epidural analgesia with local anaesthetics : It is analgesic, reduces opioid requirements, and accelerates the return of bowel function altered by abdominal surgery. All these properties are particularly welcome in an acute rehabilitation program. Intravenous lidocaine therefore appears to be an appealing alternative to epidural analgesia particularly for less invasive surgical procedures like laparoscopies. It is almost impossible to compare in a double-blind fashion intravenous lidocaine and epidural analgesia. We therefore decided to investigate prospectively whether an acute rehabilitation program using intravenous lidocaine instead of epidural analgesia would allow hospital discharge the third day after laparoscopic colectomy. Our protocol resulted in similar length of hospital stay, and comparable times for first meal and for defecation to those reported when epidural analgesia is used for 24 h postoperatively (11, 20, 22). Our patients were younger than those in Bardrams study (11), but their ages were similar to those in Senagores studies (20, 22). Intravenous lidocaine might play an important role in our rehabilitation protocol. However, its actual impact cannot be determined from this study. In conclusion, after laparoscopic colectomy, an acute rehabilitation program allows patients to tolerate their first meal within 24 h of the end of surgery and to leave the hospital the third postoperative day or sooner. Such a program does not seem to require epidural analgesia probably because of the reduced invasiveness of laparoscopy. Intravenous lidocaine, which has several properties potentially beneficial for an acute rehabilitation program, appears to offer outcomes similar to when epidural analgesia is employed for 24 hours after surgery to reduce pain. References
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Pr. J. Joris Department of Anaesthesia and Intensive Care Medicine CHU de Lige Domaine du Sart Tilman B-4000 Lige, Belgium Tel. : 32-4-3667180 Fax : 32-4-3667636 E-mail : Jean.Joris@chu.ulg.ac.be