The Clinical Efficacy and Safety of Enhanced Recovery After Surgery for Cesarean Section: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Background: Enhanced recovery after surgery (ERAS) has been adopted in some maternity units and studied extensively in cesarean section (CS) in the last years, showing encouraging results in clinic practice. However, the present evidence assessing the effectiveness of ERAS for CS remains weak, and there is a paucity in the published literature, especially in improving maternal outcomes. Our study aimed to systematically evaluate the clinical efficacy and safety of ERAS protocols for CS.Methods: A systematic literature search using Embase, PubMed, and the Cochrane Library was carried out up to October 2020. The appropriate randomized controlled trials (RCTs) and observational studies applying ERAS for patients undergoing CS were included in this study, comparing the effect of ERAS protocols with conventional care on length of hospital stay (LOS), readmission rate, incidence of postoperative complications, postoperative pain score, postoperative opioid use, and cost of hospitalization. All statistical analyses were conducted with the RevMan 5.3 software.Results: Ten studies (four RCTs and six observational studies) involving 16,391 patients were included. ERAS was associated with a decreased LOS (WMD −7.47 h, 95% CI: −8.36 to −6.59 h, p < 0.00001) and lower incidence of postoperative complications (RR: 0.50, 95% CI: 0.37 to 0.68, p < 0.00001). Moreover, pooled analysis showed that postoperative pain score (WMD: −1.23, 95% CI: −1.32 to −1.15, p < 0.00001), opioid use (SMD: −0.46, 95% CI: −0.58 to −0.34, p < 0.00001), and hospital cost (SMD:−0.54, 95% CI: −0.63 to −0.45, p < 0.00001) were significantly lower in the ERAS group than in the conventional care group. No significant difference was observed with regard to readmission rate (RR: 0.86, 95% CI: 0.48 to 1.54, p = 0.62).Conclusions: The available evidence suggested that ERAS applying to CS significantly reduced postoperative complications, lowered the postoperative pain score and opioid use, shortened the hospital stay, and potentially reduced hospital cost without compromising readmission rates. Therefore, protocols implementing ERAS in CS appear to be effective and safe. However, the results should be interpreted with caution owing to the limited number and methodological quality of included studies; hence, future large, well-designed, and better methodological quality studies are needed to enhance the body of evidence.

Thermal injury in tonsils and its relation to postoperative pain—a histopathological and clinical study

Objectives The aim of this study was to compare thermal injury and depth of necrosis of using different monopolar power settings in partial tonsillectomy and correlate the results with the postoperative pain score. Results The study included a total of 15 patients with mean of age of 5.7 ± 2.57 years. The mean depth of injury was significantly higher for the 25 W side (0.973 ± 0.613) versus the 15 W side (0.553 ± 0.218) (p = 0.023). The postoperative pain score showed no significant differences between both sides. Conclusion The histopathologic depth of thermal injury is significantly higher with the 25 W monopolar microdissection in comparison to the 15 W; however, it does not seem to correlate with the postoperative pain level. Apparently, power settings of 25 W can be safely used for pediatric intracapsular tonsillectomies, without added postoperative morbidity despite the deeper tissue injury observed in the tonsil.

A Comparison of Analgesic Effect between Preoperative and Postoperative Transversus Abdominis Plane (TAP) Blocks for Different Durations of Laparoscopic Gynecological Surgery

Aim. This study aims to compare the postoperative analgesia between preoperative and postoperative ultrasound-guided transversus abdominis plane (TAP) blocks for different durations of laparoscopic gynecological surgery. Methods. A total of 120 patients, ASA I-III, 18–65 years of age, were divided randomly into 2 groups: preoperative TAP group (pre-TAP group) and postoperative TAP group (post-TAP group). Patients in the pre-TAP group (n = 60) and post-TAP group (n = 60) received bilateral TAP blocks of 0.375% ropivacaine, 40 mL, preoperatively and postoperatively, respectively. Duration of surgery, postoperative pain score, consumption of analgesics, and postoperative nausea and vomiting (PONV) during the first 24 h postoperatively were recorded. Results. For all the patients in the two groups, similar analgesia was obtained with no statistical difference. The same results were found in duration of surgery <180 min. Meanwhile, patients undergoing surgery >180 min in the post-TAP group obtained lower postoperative pain score, lower analgesics consumption, and higher satisfaction score than those in the pre-TAP group. Conclusion. Postoperative TAP block could offer better postoperative analgesia than preoperative TAP block for patients undergoing surgery >180 min. No difference was found in analgesia effect between preoperative TAP block and postoperative TAP block for patients undergoing surgery <180 min.

Comparative Analgesic Efficacies of Ropivacaine and Bupivacaine for Postoperative Rectus Sheath Block in Paediatric Abdominal Surgery: A Meta-Analysis of Randomized Controlled Trial and Retrospective Cohort Studies

Background. The optimal dose and concentration of analgesic efficacy of ropivacaine (RPV) and bupivacaine (BPV) for postoperative pain relief in paediatric abdominal surgery patients is still unclear. Therefore, this meta-analysis compared the efficacy of these analgesics, their administered modes (ultrasound-guided RSB versus LAI) for postoperative pain relief, and side effects. Methods. Three databases, PubMed, Embase, and Cochrane Database of Systematic Reviews, were exhaustively searched with predefined keywords. Eight randomized clinical trials and retrospective studies were selected. Analgesic effect, postoperative pain score, level of side effect, applied dose, and concentration of drug were analysed. Results. Drug dose ranged from 0.5–2.5 mL/kg of 0.2 to 0.5% concentrations. Male participant for RSB and LAI treatment groups varied from 40–62% and 25–83%, respectively. Mean age of RSB and LAI groups ranged from 3.8–11.65 years and 4.3–11.27 years, respectively. Our meta-analysis revealed that RSB could reduce total opioid use postoperatively (WMD = −0.02, 95% CI: −0.02, −0.02), with I2 value of 15%. We found that the RPV (0.25%, 2.5 ml/kg) was optimal in suppressing the pain. Its lower concentration (0.2%) was ineffective, whereas higher one (0.375%) seems to increase risk of systemic toxicity. Similarly, BPV (0.25%, 2.5 mg/kg) efficaciously reduced the pain score, while its lower concentration was ineffective. The combined postoperative pain score in the RPV-treated group was found to be significantly reduced ( p < 0.01 ) with I2 value of 85% indicating high heterogeneity. Conclusion. Both RPV and BPV were significantly effective in reducing postoperative pain score. It appears that RSB could be a preferred choice to deliver analgesia, due to reduced opiate dose requirement and improved clinical safety without significant postoperative adverse events.

Multidisciplinary Cooperation Alleviates Postoperative Pain after Elective Craniotomies: A Prospective Randomized Controlled Study of Neurosurgical Enhanced Recovery After Surgery (ERAS) program

Objective: To prospectively evaluate the efficacy of neurosurgical enhanced recovery after surgery (ERAS) protocol on the management of postoperative pain after elective craniotomies. Methods: This randomised controlled trial was conducted in the neurosurgical center of Tangdu Hospital (Fourth Military Medical University, Xi’an, China). A total of 129 patients undergoing craniotomies between October 2016 and July 2017 were enrolled in a randomized clinical trial comparing ERAS protocol and conventional care. The primary outcome was the postoperative pain score assessed by a verbal numerical rating scale (NRS). Results: Patients in the ERAS group had a significant reduction in postoperative pain score on POD 1 compared to patients in the control group (mean NRS 3.12 vs. 4.44, OR 0.0968, 95% CI 0.3299 to 2.317, p = 0.010). More patients (n = 44, 68.8%) in the ERAS group experienced mild pain (NRS: 1 to 3) on POD1 compared with patients (n = 23, 35.4%) in the control group (p < 0.05). A significant reduction in pain score was observed on POD 2 and POD 3 in the ERAS group compared with that in the control group (POD2: mean NRS 2.85 vs. 4.32, OR 0.2628, 95% CI 0.5619 to 2.379, p=0.002. POD3: mean NRS 2.32 vs. 4.03, OR 0.1468, 95% CI 0.9537 to 2.458, p < 0.001, respectively). In addition, the median postoperative length of hospital stay was significantly decreased with the incorporation of ERAS protocol compared to the controls (ERAS: 4 days, control: 7 days, P<0.001). Conclusion: Implementation of the neurosurgical ERAS protocol for elective craniotomy patients have significant benefits in alleviating postoperative pain and enhancing recovery after surgery compared to the conventional care. Further evaluation of this protocol in larger, multi-center studies is warranted.