|Year : 2018 | Volume
| Issue : 7 | Page : 1583-1588
Effect of preintravenous injection of parecoxib, combined with transversus abdominis plane block in strategy of enhanced recovery after radical resection of colorectal cancer
Jiangbo Zheng, Zhaoming Feng, Junfeng Zhu
Department of Anesthesiology, Jinshan Branch Hospital of Shanghai Sixth People's Hospital, Shanghai, China
|Date of Web Publication||19-Dec-2018|
Department of Anesthesiology, Jinshan Branch Hospital of Shanghai Sixth People's Hospital, No. 147 Health Road, Jinshan District, Shanghai 201599
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study was to investigate the effect of preintravenous injection of parecoxib, combined with transversus abdominis plane (TAP) block and postoperative patient-controlled intravenous analgesia (PCIA) pump, in strategy of enhanced recovery after surgery for patients with radical resection of colorectal cancer.
Materials and Methods: In this prospective study, 80 patients that underwent radical resection for colorectal cancer were randomly divided into four groups: (1) the parecoxib group, with preintravenous injection of parecoxib and postoperative PCIA after surgery; (2) the TAP group, with TAP block and postoperative PCIA; (3) the parecoxib + TAP group, with parecoxib combined with TAP block and postoperative PCIA; and (4) the control group, with only postoperative PCIA and preinjection of normal saline. The visual analog score was used to measure the pain. The mean operative time, PCIA pressing time, time for first out-of-bed activity, first anus exhaust time, hospital stay duration, and complications were recorded.
Results: Operative time of the TAP group and parecoxib + TAP group was significantly longer than that of the parecoxib group and control group. The first out-of-bed activity time, first anus exhaust time, and hospital stay time of the parecoxib + TAP group were significantly shorter than those of the other groups, while the control group was all significantly higher than the other groups. Complication rates in all strategy groups were significantly lower than in the control group; however, no significant difference was found among the strategy groups.
Conclusion: The combination of parecoxib, TAP, and PCIA pump could significantly reduce patient postoperative pain and enhance recovery.
Keywords: Colorectal cancer, enhanced recovery after surgery, parecoxib
|How to cite this article:|
Zheng J, Feng Z, Zhu J. Effect of preintravenous injection of parecoxib, combined with transversus abdominis plane block in strategy of enhanced recovery after radical resection of colorectal cancer. J Can Res Ther 2018;14:1583-8
|How to cite this URL:|
Zheng J, Feng Z, Zhu J. Effect of preintravenous injection of parecoxib, combined with transversus abdominis plane block in strategy of enhanced recovery after radical resection of colorectal cancer. J Can Res Ther [serial online] 2018 [cited 2019 Dec 13];14:1583-8. Available from: http://www.cancerjournal.net/text.asp?2018/14/7/1583/247716
| > Introduction|| |
Globally, colorectal cancer is the third most common cancer and fourth leading cause for cancer-related death, with more than 1–2 million newly diagnosed cases and more than 600,000 deaths every year., During the past decades, prognosis of colorectal cancer has been significantly improved with the development of improved medical technology and biomolecular pathology. However, in low-income countries, the 5-year survival rate of colorectal cancer patients is still <50%.,
Until now, surgery remains the main approach for the treatment of colorectal cancer. Although perioperative care focuses on postoperative pain management, severe postoperative pain, in most cases, is a challenge after colonic surgery. In recent years, the development of enhanced recovery after surgery (ERAS) has been reported to enhance postoperative recovery in many surgeries, including colorectal surgery, with shorter hospital stays, earlier recovery of bowel function, and reduced hospital costs., To achieve ERAS, pain control with multimodal analgesia is the key component and largely includes the use of nonsteroidal anti-inflammatory drugs, acetaminophen, cyclooxygenase-2 (COX-2) inhibitors, local anesthetics, and the use of transversus abdominis plane (TAP) block, which blocks the neurovascular plane between the internal oblique and transversus abdominis muscles of the anterior abdominal wall to form regional analgesia.
Parecoxib, a highly selective COX-2 inhibitor, has recently reported to be used in control of postoperative pain. However, few studies focus on the effect of parecoxib on postoperative pain management after surgery for colorectal cancer, and no studies have reported the effect of parecoxib combined with TAP block in pain management. In the present prospective study, we investigated the effect of preintravenous injection of parecoxib, combined with TAP block and postoperative patient-controlled intravenous analgesia (PCIA) pump, in strategy of enhanced recovery for surgery of colorectal cancer. This study may provide new understanding for application of parecoxib and a new approach for enhanced recovery from surgery for colorectal cancer.
| > Materials and Methods|| |
The present prospective randomized controlled study included 80 cases that were diagnosed with colorectal cancer and needed radical resection in our hospital from January 2016 to November 2017. All patients were adults (18–76) and were diagnosed with an American Society of Anesthesiologists (ASA) Score of I or II; the diagnosis was confirmed by histological and pathological analysis. No distant metastasis was observed by computed tomography or magnetic resonance imaging in any patient. The following patients were excluded from the study: Patients with distant metastasis; severe cardiac, lung, liver, renal or other system diseases; other cancers; history of ulceration of digestive tract, anaphylaxis of steroidal anti-inflammatory drugs, and alcoholism; and surgery-related complications such as anastomotic fistula. All patients received laparoscopic colorectal operations. The present study was approved by the ethic committee of Shanghai Sixth People's Hospital.
Treatment and analgesia strategies
Patients were randomly divided into four groups, with 20 cases in each group according to a computer-generated randomization list run by the hospital pharmacist: (1) the parecoxib group, with preintravenous injection of parecoxib and postoperative PCIA pump after surgery; (2) the TAP group, with TAP block and postoperative PCIA; (3) the parecoxib + TAP, with parecoxib combined with TAP block and postoperative PCIA; and (4) the control group, with only postoperative PCIA and preinjection of normal saline of equal volume to parecoxib. The surgery strategy for all patients was followed the identical protocol and the surgery was conducted by the same team. Briefly, common sense of perioperative treatment and suggestions for promoting rehabilitation were introduced to all patients to abate nervousness. Oral cathartic was administered to patients 1 night before surgery and mechanical bowel preparation was conducted if necessary. Liquid fasting was performed 2 h before surgery. During surgery, broad-spectrum antibiotics were administered once, preventively, and the catheter was not set or removed 24–28 h after surgery. The patients were encouraged to do out-of-bed activities and gradually enhance the frequency.
For analgesia strategies, the pretreatment of parecoxib was performed by preintravenous injection with 100 ml normal saline with 40 mg parecoxib. TAP block was performed by bilateral TAP blocks method under ultrasonography guidance after intubation as described elsewhere., The entire experiment and surgery, including TAP blocking, were conducted by the same team according to the same protocols, and TAP blocking was performed by the same anesthesiologist. Briefly, musculoaponeurotic layers of the lateral abdominal wall were cleared, detected by an ultrasonography probe (SonoSite, Bothell, WA, US), and a 100 mm Stimuplex® needle (B Braun, Melsungen, Germany) was used to achieve TAP using in-plane technology from the inside to the outside. 0.375% ropivacaine (20 ml) was infiltrated on each side. The success of TAP and TAP blocking level was mainly determined by needling the patients' skin; when skin pain disappeared, the procedure was considered successful. The constitution of drugs in PCIA pump (automatic electronic drug injection pump ZZB-II type, Jiangsu AI Peng Medical Equipment Co., Ltd., China) was dexmedetomidine hydrochloride 0.05 μg/kg/h + butorphanol tartrate 6 mg + sufentanil citrate 0.02 μg/kg/h + 0.9% physiological saline (100 ml).
Demographic data, including age, gender, and body mass index (BMI), and clinical data including ASA stage, and operative time were collected. The visual analog score (VAS) was used to measure pain condition at 4, 12, 24, 36, and 48 h after surgery. Measurement of VAS scores was conducted by two different physicians, both of whom were blinded. The PCIA pressing time within 48 h, time for first out-of-bed activity, first anus exhaust time, hospital stay duration, and complications were recorded.
The measurement data were expressed as mean ± standard deviation and counting materials were compared using Chi-square test. Comparison among three or more groups was conducted using one-way analysis of variance followed by Tukey post hoc test. Statistical significance was set at P < 0.05. All calculations were made using SPSS 18.0 (IBM, USA).
| > Results|| |
Basis clinical information for all patients
As shown in [Table 1], the present study selected a total of 80 cases, with a mean age of 60.64 ± 8.35 years, male: female 48:32. The study design is shown in [Figure 1]. There was no significant difference between groups for age, gender, BMI, ASA stage, as well as for bleeding, infusion, and urine amounts during operation. However, mean operative time of the TAP group and parecoxib + TAP group was significantly longer than that of the parecoxib group and control group, P < 0.05, which might be due to the procedures of TAP.
Pain conditions of different groups of patients by visual analog scores
To determine recovery and pain control effect of different analgesia strategies, the VAS scores were collected and analyzed. As shown in [Table 2] and [Figure 2], results show that at all-time points, scores in control group were all significantly higher than those of the other 3 groups, P < 0.05, indicating that all analgesia strategies were effective on pain control. No significant difference was found between the parecoxib group and TAP group; however, scores in the parecoxib + TAP group were significantly lower than all other groups at all-time points except for 48 h, P < 0.05, suggesting that the combination of pretreatment with parecoxib and TAB block resulted in the optimal pain control strategy in this study.
|Figure 2: Pain condition of different groups by visual analogue scores. aP < 0.05, compared to Parecoxib; bP < 0.05, compared to transversus abdominis plane; cP < 0.05, compared to Parecoxib + transversus abdominis plane group; dP < 0.05, compared to control|
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Clinical outcomes of patient-controlled intravenous analgesia pressing times within 48 h, first out-of-bed activity time, first anus exhaust time, and hospital stay time
To further analyze the recovery situation for the different groups, the PCIA pressing times within 48 h, first out-of-bed activity time, first anus exhaust time, and hospital stay time were compared. As shown in [Table 3], mean PCIA pressing times were the lowest in the parecoxib + TAP group and the highest in the control group compared with other groups, P < 0.05, which were consistent with the VAS results above. Moreover, the first out-of-bed activity time, first anus exhaust time, and hospital stay time of the parecoxib + TAP group were all significantly shorter than the other groups, while the control group was all significantly higher compared with other groups, P < 0.05. No significant difference was observed between the parecoxib and TAP groups. Together, these results suggest that all three strategies benefited postoperative recovery, with the combination of parecoxib and TAP demonstrating the advantageous strategy.
|Table 3: Clinical outcomes of patient-controlled intravenous analgesia pressing times within 48 h, first out-of-bed activity time, first anus exhaust time, hospital stay time, and total costs|
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Finally, we investigated the postoperative complication rate in the four groups of patients. Results showed that total postoperative complication rates in all strategy groups. Including pretreatment with parecoxib, TAP, and the parecoxib + TAP combination was all significantly lower compared with the control group, P < 0.05. However, no significant difference was found among the three treatment groups [Table 4].
| > Discussion|| |
Although postoperative pain management is the key component of perioperative care, there are still many patients suffering from moderate-to-severe pain after surgery and trauma. With the development of recent recovery strategies, it was demonstrated that ERAS was beneficial for postoperative recovery, thus attracting the medical community. Parecoxib is a novel COX-2 selective inhibitor which was recently demonstrated to have greater anti-tumor potency than previous COX-2 inhibitors. Notably, parecoxib was found to be effective in pain control both pre- and post-operatively. The TAP block, involving the injection of a local anesthetic between the internal oblique and transversus tap, is a new applied technique for operative pain management. It was reported that this form of blockade could lead to a reduction in postoperative opiate use for analgesia and an improvement in respiratory and gut function.
Previously, few studies focused on effect of parecoxib on pain management and ERAS in colorectal cancer surgery. To the best of our knowledge, no study has reported the effect of the combination of parecoxib and TAP. In this study, we demonstrated that the combination of pretreatment of parecoxib and TAP significantly improved the pain condition as well as enhance the postoperative recovery of patients that underwent radical resection for colorectal cancer.
Three different analgesia strategies including pretreatment of parecoxib, TAP, and the combination of both were compared; a PCIA pump was used in all groups. First, we found that the operative time of the TAP and combination groups was significantly longer than other groups, which might be due to the TAP procedure. Ris et al. investigated the effect of TAP block on patient-controlled analgesia for laparoscopic high anterior resection and found that the TAP group had similar operative times compared with non-TAP groups. However, in a double-blind randomized clinical trial study for TAP blockade in laparoscopic colorectal surgery, it was found that operative time in TAP group was significantly longer than controls.
The VAS scores and PICA pressing times were then used to compare the pain control effects among the groups. Results showed that all strategies significantly reduced the degree of pain, enhanced postoperative recovery, and reduced the complication rate, with the combination of both pretreatment of parecoxib and TAP demonstrating the best results. Ris et al. demonstrated that TAP block improved analgesia, reduced opioid requirement, and expedited recovery of bowel function for patient that underwent laparoscopic high anterior resection. Keller et al. reviewed 200 consecutive cases of laparoscopic colorectal surgery and found that the TAP used as an ERAS facilitated a shorter length of stay and reoperation rates, indicating that TAP blocks might be an efficient, cost-effective method for improving laparoscopic colorectal surgery results. In a comparison study between pre- and post-treatment of parecoxib, Pandazi et al. found that pretreatment of parecoxib reduced postoperative morphine consumption without affecting morphine-related adverse effects, and attenuated IL-6 production 24 h after surgery for colorectal cancer. All studies and our present study showed that both treatment of parecoxib and TAP were effective to enhance postoperative recovery for colorectal cancer patients.
| > Conclusion|| |
We conducted a prospective study to investigate the effect of preintravenous injection of parecoxib combined with TAP block and postoperative PCIA pump in a strategy of enhanced recovery after radical resection of colorectal cancer. Results showed that the combination of parecoxib, TAP, and the use of a PCIA pump significantly reduced postoperative pain and enhanced recovery. These results might provide new understanding for the application of parecoxib and a new approach for enhanced recovery from surgery for colorectal cancer.
This study was funded by Jinshan District Medical and Health Science and Technology Innovation Fund Project (2017-3-27).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Brenner H, Kloor M, Pox CP. Colorectal cancer. Lancet 2014;383:1490-502.
Zhang Y, Zhang S, Xia W, Dong Z. Association of cytotoxic T-lymphocyte antigen 4 rs231775 gene polymorphism with colorectal cancer risk. J Cancer Res Therap 2018;14:526-32.
The Lancet. Toward better control of colorectal cancer. Lancet 2014;383:1437.
Misale S, Yaeger R, Hobor S, Scala E, Janakiraman M, Liska D, et al.
Emergence of KRAS mutations and acquired resistance to anti-EGFR therapy in colorectal cancer. Nature 2012;486:532-6.
Watanabe T, Itabashi M, Shimada Y, Tanaka S, Ito Y, Ajioka Y, et al.
Japanese society for cancer of the colon and rectum (JSCCR) guidelines 2014 for treatment of colorectal cancer. Int J Clin Oncol 2015;20:207-39.
Yamada T, Hayashi T, Cho H, Yoshikawa T, Taniguchi H, Fukushima R, et al.
Usefulness of enhanced recovery after surgery protocol as compared with conventional perioperative care in gastric surgery. Gastric Cancer 2012;15:34-41.
Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: A meta-analysis of randomized controlled trials in colorectal surgery. Surgery 2011;149:830-40.
Slieker JC, Clerc D, Hahnloser D, Demartines N, Hübner M. Prospective evaluation of discharge trends after colorectal surgery within an enhanced recovery after surgery pathway. Dig Surg 2017;34:298-304.
Bhangu A, Singh P, Fitzgerald JE, Slesser A, Tekkis P. Postoperative nonsteroidal anti-inflammatory drugs and risk of anastomotic leak: Meta-analysis of clinical and experimental studies. World J Surg 2014;38:2247-57.
Nagata J, Watanabe J, Sawatsubashi Y, Akiyama M, Arase K, Minagawa N, et al.
A novel transperitoneal abdominal wall nerve block for postoperative pain in laparoscopic colorectal surgery. Asian J Surg 2018;41:417-21.
Naik BI, Tsang S, Knisely A, Yerra S, Durieux ME. Retrospective case-control non-inferiority analysis of intravenous lidocaine in a colorectal surgery enhanced recovery program. BMC Anesthesiol 2017;17:16.
Favuzza J, Delaney CP. Outcomes of discharge after elective laparoscopic colorectal surgery with transversus abdominis plane blocks and enhanced recovery pathway. J Am Coll Surg 2013;217:503-6.
Albrecht E, Kirkham KR, Endersby RV, Chan VW, Jackson T, Okrainec A, et al.
Ultrasound-guided transversus abdominis plane (TAP) block for laparoscopic gastric-bypass surgery: A prospective randomized controlled double-blinded trial. Obes Surg 2013;23:1309-14.
Williams DL, Pemberton E, Leslie K. Effect of intravenous parecoxib on post-craniotomy pain. Br J Anaesth 2011;107:398-403.
Ris F, Findlay JM, Hompes R, Rashid A, Warwick J, Cunningham C, et al.
Addition of transversus abdominis plane block to patient controlled analgesia for laparoscopic high anterior resection improves analgesia, reduces opioid requirement and expedites recovery of bowel function. Ann R Coll Surg Engl 2014;96:579-85.
Pandazi A, Kapota E, Matsota P, Paraskevopoulou P, Dervenis C, Kostopanagiotou G, et al.
Preincisional versus postincisional administration of parecoxib in colorectal surgery: Effect on postoperative pain control and cytokine response. A randomized clinical trial. World J Surg 2010;34:2463-9.
Favuzza J, Delaney CP. Laparoscopic-guided transversus abdominis plane block for colorectal surgery. Dis Colon Rectum 2013;56:389-91.
Joshi GP, Bonnet F, Kehlet H; PROSPECT collaboration. Evidence-based postoperative pain management after laparoscopic colorectal surgery. Colorectal Dis 2013;15:146-55.
Xiong W, Li WH, Jiang YX, Liu S, Ai YQ, Liu R, et al
. Parecoxib: An enhancer of radiation therapy for colorectal cancer. Asian Pac J Cancer Prev 2015;16:627-33.
Smith SR, Draganic B, Pockney P, Holz P, Holmes R, Mcmanus B, et al.
Transversus abdominis plane blockade in laparoscopic colorectal surgery: A double-blind randomized clinical trial. Int J Colorectal Dis 2015;30:1237-45.
Keller DS, Ermlich BO, Delaney CP. Demonstrating the benefits of transversus abdominis plane blocks on patient outcomes in laparoscopic colorectal surgery: Review of 200 consecutive cases. J Am Coll Surg 2014;219:1143-8.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]