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Acta chir belg, 2005, 105, 53-58

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 pro-

grams to accelerate postoperative recovery, or fast-track

surgery (1-8). These acute rehabilitation programs com-

bine 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 recommenda-

tions 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 abdomi-

nal surgery since it reduces surgical stress (15), provides

excellent dynamic pain relief allowing enforced mobili-

zation (16, 17), and improves gastrointestinal func-

tion (18, 19). Epidural analgesia was therefore included

in the multimodal approach for both open and laparo-

scopic colonic resection (11, 13, 20). However the ben-

efits of epidural analgesia for minimally invasive

laparoscopic colectomy, reported in non-randomised

studies, have been questioned (21, 22). Intravenous lido-

caine 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 hypo-

thesised 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

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 postoperativerecovery and improve outcome. We investigated whether intravenous lidocaine infusion, which decreases postoperativepain and speeds the return of bowel function, can be used instead of epidural analgesia in an acute rehabilitation proto-col for patients undergoing laparoscopic colectomy.Methods : Twenty eight consecutive patients scheduled for laparoscopic colectomy were prospectively included in thiscase series study. Segmental colectomy was performed only for benign pathology. Intraoperative opioid use wasrestricted. After a bolus injection of lidocaine 1.5 mgkg-1, an infusion (2 mgkg-1h-1, IV) was started before pneu-moperitoneum. Balanced analgesia was used to reduce postoperative opioid consumption. Patients were allowed todrink 6 h postoperatively. The day after surgery, patients were allowed to eat a normal breakfast. Enforced mobilisa-tion 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 thosereported using epidural analgesia.

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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54 A. Kaba et al.

laparoscopic colectomy were included in this acute reha-

bilitation program. All patients received precise oral and

written information about our program and the impor-

tance of their contribution in the early postoperativenutrition and enforced mobilisation. No colectomy was

carried-out for colonic cancer. Fifteen patients under-

went 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 angiodyspla-

sia. The primary goal of our program was to discharge

patients from the hospital on or before the third postop-

erative day.

Anaesthesia and postoperative analgesia

Our protocol restricted the use of intra- and postopera-

tive 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-atracuri-

um (0.2 mgkg-1). Immediately after induction of anaes-

thesia, a bolus injection of 1.5 mgkg-1 lidocaine was

given followed by an infusion of 2 mgkg-1h-1. The lido-

caine 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 adminis-

tered to reduce postoperative hyperalgesia.

Postoperative analgesia was provided by the combina-

tion of propacetamol, a precursor of paracetamol (Pro-

Dafalgan UPSA Medica, Belgium ; 2g of propaceta-

mol = 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-inflam-matory 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 provid-

ed 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 standardfive-trocar or four-trocar technique. For right colecto-

my, after intracorporeal dissection of the ascending

colon and the Bauhin valve, the specimen was exterior-

ized 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-sig-

moid junction. The recto-sigmoid junction was cut using

a stapler. The sigmoid colon was retrieved through a 5-

6 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 anastomo-

sis 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 hos-

pital 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 post-

operatively, 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 cal-

culated. Time to first flatus, defecation, and hospital dis-

charge were recorded.Data are presented as mean SD.

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Intravenous Lidocaine and Laparoscopic Colectomy 55

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 aver-

aged 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. Moreprecisely, nine patients left the hospital on postoperative

day 2, 15 on postoperative day 3, and three on postoper-

ative 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 indepen-

dent when discharged from the hospital. Except the 85-

year-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 fast-

ing, she was again able to eat normally and left the hos-

pital. No other readmission and no other morbidityoccurred during the postoperative 30-days follow-up.

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

Fig. 1Self-reported pain scores at 2 and 6 hours after surgery and at9 am, 1 pm, and 6 pm on the first and second day after surgery.Reports were taken with the patients at rest, during mobilisa-tion from the supine to the sitting position, and while cough-ing. Pain was reported on a 100-mm visual analogue scale with0 mm being no pain and 100 mm being the worst pain imagin-able.

Table 1

Patient data (mean SD or number)

Parameter N = 28

Age ; yr 54 15

Sex ratio : F/M 21 / 7

Weight ; kg 69 13

Height ; cm 164 8

ASA physical status (I,II ,III) ; number of patients 6 / 16 / 6

Right / Transverse / Left colectomy ; number of patients 6 / 1 / 21

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56 A. Kaba et al.

Discussion

This study demonstrates that an acute rehabilitation pro-

gram allowing patient discharge from the hospital on thethird postoperative day or sooner after laparoscopic

colectomy can be achieved without epidural analgesia.

Indeed, 85 percent of the patients included in our reha-

bilitation 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 defeca-

tion 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 post-

operative nausea and vomiting (27). The laparoscopic

approach reduces surgical trauma and the size of the

incisions in the abdominal wall. Consequently, laparo-

scopic colectomy results in shorter postoperative ileus

than open colonic resection, although the actual reduc-

tion is less than what was previously thought (18, 28-

30). Moreover postoperative pain, pulmonary dysfunc-

tion, and metabolic response are significantly reducedafter 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 pathophysiolog-

ic factor of postoperative ileus. All measures to reduce

the need for perioperative opioid must therefore be

taken (18, 19). The contribution to ileus of intraopera-tive short-acting opioids is probably less than that of

postoperative opioids. Intraoperative opioids neverthe-

less contribute to spinal sensitisation responsible for

postoperative hyperalgesia and subsequently increase

postoperative opioid consumption (31). Kehlets group

uses epidural anaesthesia to reduce intraoperative opi-

oids. In the absence of epidural anaesthesia, we pre-

ferred inhalation anaesthesia to intravenous anaesthesia

with opioids. Postoperative opioids consumption is also

decreased by balanced analgesia, which combines sev-

eral analgesics acting on different targets of the noci-

ceptive pathways (32). In this study, we administered

paracetamol, a nonsteroidal anti-inflammatory drug(NSAID), and ketamine. NSAIDs were reported to

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 forpostoperative 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 pro-

grams (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 myen-

teric plexus that is activated after abdominal surgery and

or indirectly by the reduction of opioid require-

ments (23, 24). We also administered erythromycin for

its gastrokinetic properties. Finally, prevention of post-

operative 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 vom-

iting, achieved with droperidol, tropisetron, a 5-HT3antagonist, and intraoperative high oxygen administra-

tion in our proptocol (27, 39), was effective since nausea

or vomiting was prospectively detected in five patients

(18%). Only one patient complained of nausea responsi-ble for delayed nutrition.

Enforced mobilisation and ambulation require effec-

tive 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 laparoscop-

ic approach results in less pain and requires less postop-

erative opioid than open surgery (29, 30, 42). Therefore,

we considered that adequate pain relief after

laparoscopy could be achieved without epidural analge-

sia. Accordingly, our analgesic regimen was very effec-

tive since pain during mobilisation and when coughingwere 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 postoperative-

ly (22). Postoperative dynamic pain results from hyper-

algesia secondary to peripheral and spinal sensitisation

following tissue trauma. In the absence of epidural anal-

gesia, we combined NSAIDs, ketamine, and paraceta-

mol, which all reduce peripheral or spinal sensitiza-

tion (43, 44). Finally all patients were given intraopera-

tive intravenous lidocaine. Intravenous lidocaine reduces

pain at rest and during mobilisation, as well as postoper-

ative opioid requirement. Lidocaine is anti-hyperalgesic

partly by inhibition ofN-methyl-D-aspartate receptors,which play a key role in spinal sensitization (25, 46).

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Intravenous Lidocaine and Laparoscopic Colectomy 57

Moreover systemic lidocaine blocks the activation of

polymorphonuclear leukocytes and thus has anti-inflam-

matory effects (26, 47). Intravenous lidocaine has sever-

al properties similar to epidural analgesia with localanaesthetics : It is analgesic, reduces opioid require-

ments, 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 appeal-

ing 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 intra-

venous 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 leavethe 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 rehabilita-

tion program, appears to offer outcomes similar to when

epidural analgesia is employed for 24 hours after

surgery to reduce pain.

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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