Comparison of Analgesic Effects of Intraperitoneal Lornoxicam and Ropivacaine Administration in Laparoscopic Cholecystectomy

Abstract

Objectives: In this randomized prospective study, we investigated the effects of lornoxicam vs. ropivacaine for the management of postoperative pain in patients undergoing elective laparoscopic cholecystectomy. Patients and Methods: Patients were randomized into three groups and received 150 mg (80 mL) ropivacaine or 16 mg lornoxicam (80 mL) or placebo (80 mL saline) via multi-regional intraperitoneal instillation and port sites infiltration. Patient-controlled analgesia (PCA) device was used. Tramadol 50 mg tolerable dose, 5 mg/hour basal infusion, bolus dose 20 mg, locked 30 min, 4 hour limit were applied as 200 mg. Postoperative pain was assessed with 100-mm visual analog scale (VAS) at rest, while coughing, and during mobilization. Pain scores were recorded in the post-anesthesia care unit, and at 2, 4, 8, 12,18 and 24 h after the surgery. Results: At 24 h, VAS scores at rest and while coughing were found significantly lower in ropivacaine and lornoxicam group when compared with control group (p=0.047). The percentage of patients needing tramadol was significantly lower with ropivacaine and lornoxicam compared with control (p<0.001, p=0.018). There was no statistically significant difference between ropivacaine and lornoxicam group. Conclusion: Multi-regional, intraperitoneal instillation and port site infiltration of ropivacaine and lornoxicam during laparoscopic cholecystectomy reduces the postoperative pain. Amaç: Prospektif randomize olarak yapılan bu çalışmada laparoskopik kolesistektomi sonrası ağrı tedavisinde lornoksikam ve ropivakainin etkisi araştırılmıştır. Hastalar ve Yöntemler: Çalışmaya dahil edilen 45 hasta üç gruba randomize edildi. Hastalara 150 mg (80 mL) ropivakain, 16 mg lornoksikam (80 mL) ve plasebo (80 mL saline) intraperitoneal olarak püskürtüldü ve port bölgelerine infiltre edildi. Ameliyat bitiminde hasta kontrollü analjezi cihazı ile tramadol 50 mg yükleme dozu, 5 mg bazal infüzyon, bolus doz 20 mg, kilitli kalma süresi 30 dk, 4 saatlik limit 200 mg olarak planlandı. Hastaların ağrısı görsel analog skala (VAS) ile 0-100 olacak şekilde istirahat, öksürük sonrası ve mobilizasyon sırasında değerlendirildi. Ağrı skorları ilk saatte anestezi derlenme odasında ve 2., 4., 8., 12., 18., 24. saatlerde serviste değerlendirildi. Bulgular: Ropivakain ve lornoksikam grubunda istirahat ve öksürük sonrası VAS değerleri kontrol grubuna göre daha düşük bulundu (p=0.047). Tramadol tüketimi açısından, ropivakain ve lornoksikam grupları arasında fark bulunmazken (p>0.05), kontrol grubuna göre bu iki grupta anlamlı düşük olarak bulundu (p<0.001, p=0.018). Ropivakain ve lornoksikam grubu arasında ise istatistiksel olarak anlamlı fark bulunmadı. Sonuç: Ropivakain ve lornoksikamın port bölgelerine, intraperitoneal çoklu bölgeye laparoskopik kolesistektomi sonrası infiltrasyonu ameliyat sonrası ağrı tedavisinde etkin olarak bulunmuştur.

Keywords

• Laparoscopic cholecystectomy; ropivacaine; lornoxicam; postoperative pain

Laparoskopik Kolesistektomi Sonrası Ağrı Tedavisinde İntraperitoneal Uygulanan Lornoksikam ve Ropivakainin Etkisinin Karşılaştırılması

Öz

Amaç: Prospektif randomize olarak yapılan bu çalışmada laparoskopik kolesistektomi sonrası ağrı tedavisinde lornoksikam ve ropivakainin etkisi araştırılmıştır. Hastalar ve Yöntemler: Çalışmaya dahil edilen 45 hasta üç gruba randomize edildi. Hastalara 150 mg (80 mL) ropivakain, 16 mg lornoksikam (80 mL) ve plasebo (80 mL saline) intraperitoneal olarak püskürtüldü ve port bölgelerine infiltre edildi. Ameliyat bitiminde hasta kontrollü analjezi cihazı ile tramadol 50 mg yükleme dozu, 5 mg bazal infüzyon, bolus doz 20 mg, kilitli kalma süresi 30 dk, 4 saatlik limit 200 mg olarak planlandı. Hastaların ağrısı görsel analog skala (VAS) ile 0-100 olacak şekilde istirahat, öksürük sonrası ve mobilizasyon sırasında değerlendirildi. Ağrı skorları ilk saatte anestezi derlenme odasında ve 2., 4., 8., 12., 18., 24. saatlerde serviste değerlendirildi. Bulgular: Ropivakain ve lornoksikam grubunda istirahat ve öksürük sonrası VAS değerleri kontrol grubuna göre daha düşük bulundu (p=0.047). Tramadol tüketimi açısından, ropivakain ve lornoksikam grupları arasında fark bulunmazken (p > 0.05), kontrol grubuna göre bu iki grupta anlamlı düşük olarak bulundu (p < 0.001, p=0.018). Ropivakain ve lornoksikam grubu arasında ise istatistiksel olarak anlamlı fark bulunmadı. Sonuç: Ropivakain ve lornoksikamın port bölgelerine, intraperitoneal çoklu bölgeye laparoskopik kolesistektomi sonrası infiltrasyonu ameliyat sonrası ağrı tedavisinde etkin olarak bulunmuştur.

Anahtar Kelimeler

• Laparoskopik kolesistektomi, ropivakain, lornoksikam, ameliyat sonrası ağrı

Kaynakça

1. Joris J, Cigarini I, Legrand M, Jacquet N, De Groote D, Franchimont P, et al. Metabolic and respiratory changes after cholecystectomy performed via laparotomy or lapa- roscopy. Br J Anaesth 1992;69:341-5.
2. Downs SH, Black NA, Devlin HB, Royston CMS, Russell RCG. A systematic review of the effectiveness and safe- ty of laparoscopic cholecystectomy. Ann R Coll Surg 1996;78:241-323.
3. Putensen-Himmer G, Putensen C, Lammer H, Lingnau W, Aigner F, Benzer H. Comparison of postoperative respira- tory function after laparoscopy or open laparotomy for cholecystectomy. Anesthesiology 1992;77:675-80.
4. Ure BM, Troidl H, Spangenberger W, Dietrich A, Lefering R, Neugebauer E. Pain after laparoscopic cholecystectomy. Intensity and localization of pain and analysis of predictors in preoperative symptoms and intraoperative events. Surg Endosc 1994;8:90-6.
5. Joris J, Thiry E, Paris P, Weerts J, Lamy M. Pain after lapa- roscopic cholecystectomy: characteristics and effect of intra- peritoneal bupivacaine. Anesth Analg 1995;81:379-84.
6. Mİiniche S, Jİrgensen H, Wetterslev J, Dahl JB. Local anes- thetic infiltration for postoperative pain relief after lapa- roscopy: a qualitative and quantitative systematic review of intraperitoneal, port-site infiltration and mesosalpinx block. Anesth Analg 2000;90:899-912.
7. Saunders CJ, Leary BF, Wolfe BM. Is outpatient laparo- scopic cholecystectomy wise? Surg Endosc 1995;9:1263-8.
8. Berggren U, Gordh T, Grama D, Haglund U, Rastad J, Arvidsson D. Laparoscopic versus open cholecystectomy: hospitalization, sick leave, analgesia and trauma responses. Br J Surg 1994;81:1362-5.

9. Mraović B, Jurisić T, Kogler-Majeric V, Sustic A. Intraperitoneal bupivacaine for analgesia after laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1997;41:193-6.
10. Pasqualucci A, de Angelis V, Contardo R, Colò F, Terrosu G, Donini A, et al. Preemptive analgesia: intraperitoneal local anesthetic in laparoscopic cholecystectomy. A randomized, double-blind, placebo-controlled study. Anesthesiology 1996;85:11-20.
11. Chundrigar T, Hedges AR, Morris R, Stamatakis JD. Intraperitoneal bupivacaine for effective pain relief after laparoscopic cholecystectomy. Ann R Coll Surg Engl
12. Scheinin B, Kellokumpu I, Lindgren L, Haglund C, Rosenberg PH. Effect of intraperitoneal bupivacaine on pain after laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1995;39:195-8.
13. Szem JW, Hydo L, Barie PS. A double-blinded evaluation of intraperitoneal bupivacaine vs saline for the reduction of postoperative pain and nausea after laparoscopic cholecys- tectomy. Surg Endosc 1996;10:44-8.
14. Helvacioglu A, Weis R. Operative laparoscopy and postop- erative pain relief. Fertil Steril 1992;57:548-52.
15. Narchi P, Benhamou D, Fernandez H. Intraperitoneal local anaesthetic for shoulder pain after day-case laparoscopy. Lancet 1991;338:1569-70.
16. Callesen T, Hjort D, Mogensen T, Schouenborg L, Nielsen D, Reventlid H, et al. Combined field block and i.p. instilla- tion of ropivacaine for pain management after laparoscopic sterilization. Br J Anaesth 1999;82:586-90.
17. Narchi P, Benhamou D, Bouaziz H, Fernandez H, Mazoit JX. Serum concentrations of local anaesthetics following intraperitoneal administration during laparoscopy. Eur J Clin Pharmacol 1992;42:223-5.
18. Benhamou D, Narchi P, Mazoit JX, Fernandez H. Postoperative pain after local anesthetics for laparoscopic sterilization. Obstet Gynecol 1994;84:877-80.
19. Litwin DE, Girotti MJ, Poulin EC, Mamazza J, Nagy AG. Laparoscopic cholecystectomy: trans-Canada experience with 2201 cases. Can J Surg 1992;35:291-6.
20. Alkhamesi NA, Ridgway PF, Ramwell A, McCullough PW, Peck DH, Darzi AW. Peritoneal nebulizer: a novel technique for delivering intraperitoneal therapeutics in laparoscopic surgery to prevent locoregional recurrence. Surg Endosc 2005;19:1142-6.
21. McGinn FP, Miles AJ, Uglow M, Ozmen M, Terzi C, Humby M. Randomized trial of laparoscopic cholecystectomy and mini-cholecystectomy. Br J Surg 1995;82:1374-7.
22. Zubaroğlu E, Çalışkan K, Keskin A, Serim Ç, Seratlı O, Özgüven R. Laparoskopik ve açık kolesistektominin postoperatif ağrı yönünden karşılaştırılması. Ağrı Dergisi 1997;9:24-9.
23. Mİiniche S, Mikkelsen S, Wetterslev J, Dahl JB. A qualita- tive systematic review of incisional local anaesthesia for postoperative pain relief after abdominal operations. Br J Anaesth 1998;81:377-83.
24. Wills VL, Hunt DR. Pain after laparoscopic cholecystec- tomy. Br J Surg 2000;87:273-84.
25. Kehlet H, Gray AW, Bonnet F, Camu F, Fischer HB, McCloy RF, et al. A procedure-specific systematic review and consensus recommendations for postoperative anal- gesia following laparoscopic cholecystectomy. Surg Endosc 2005;19:1396-415.
26. Alexander JI. Pain after laparoscopy. Br J Anaesth 1997;79:369-78.
27. Bisgaard T, Klarskov B, Trap R, Kehlet H, Rosenberg J. Pain after microlaparoscopic cholecystectomy. A randomized double-blind controlled study. Surg Endosc 2000;14:340-4.
28. Callesen T, Hjort D, Mogensen T, Schouenborg L, Nielsen D, Reventlid H, et al. Combined field block and i.p. instilla- tion of ropivacaine for pain management after laparoscopic sterilization. Br J Anaesth 1999;82:586-90.
29. Elhakim M, Elkott M, Ali NM, Tahoun HM. Intraperitoneal lidocaine for postoperative pain after laparoscopy. Acta Anaesthesiol Scand 2000;44:280-4.
30. Lee IO, Kim SH, Kong MH, Lee MK, Kim NS, Choi YS, et al. Pain after laparoscopic cholecystectomy: the effect and timing of incisional and intraperitoneal bupivacaine. Can J Anaesth 2001;48:545-50.
31. Labaille T, Mazoit JX, Paqueron X, Franco D, Benhamou D. The clinical efficacy and pharmacokinetics of intraperito- neal ropivacaine for laparoscopic cholecystectomy. Anesth Analg 2002;94:100-5.
32. Kehlet H. Effect of postoperative pain treatment on out- come-current status and future strategies. Langenbecks Arch Surg 2004;389:244-9.
33. Abdel-Raouf M, Amer H. Postoperative analgesic effects of intraperitoneal NMDA receptor antagonists (ketamine and magnesium) in patients undergoing laparoscopic cholecys- tectomy. Egypt J Anaesth 2004:20;107-11.
34. Raetzell M, Maier C, Schröder D, Wulf H. Intraperitoneal application of bupivacaine during laparoscopic cholecys- tectomy--risk or benefit? Anesth Analg 1995;81:967-72.
35. Razek EA. Intraperitoneal levobupivacaine for analge- sia after laparoscopic cholecystectomy. Egypt J Anaesth 2003;19:249-54.
36. Ghezzi F, Cromi A, Bergamini V, Raffaelli R, Crotti S, Segredini R, et al. Preemptive port site local anesthesia in gynecologic laparoscopy: a randomized, controlled trial. J Minim Invasive Gynecol 2005;12:210-5.
37. Narchi P, Benhamou D, Bouaziz H, Fernandez H, Mazoit JX. Serum concentrations of local anaesthetics following intraperitoneal administration during laparoscopy. Eur J Clin Pharmacol 1992;42:223-5.
38. Karadeniz Ü, Erdemli E, Ünver S, Yaşıtlı H, Ayoğlu H. Laparoskopik kolesistektomi sonrası postoperatif ağrı tedavisinde intraperitoneal bupivakain enjeksiyonu ve infüzyonu. Anestezi Dergisi 2003;11:226-30.
39. Inan A, Sen M, Dener C. Local anesthesia use for laparo- scopic cholecystectomy. World J Surg 2004;28:741-4.
40. Raetzell M, Maier C, Schröder D, Wulf H. Intraperitoneal application of bupivacaine during laparoscopic cholecys- tectomy--risk or benefit? Anesth Analg 1995;81:967-72.
41. Radhofer-Welte S, Rabasseda X. Lornoxicam, a new potent NSAID with an improved tolerability profile. Drugs Today [Barc] 2000;36:55-76.
42. Balfour JA, Fitton A, Barradell LB. Lornoxicam. A review of its pharmacology and therapeutic potential in the man- agement of painful and inflammatory conditions. Drugs 1996;51:639-57.
43. Staunstrup H, Ovesen J, Larsen UT, Elbaek K, Larsen U, Krİner K. Efficacy and tolerability of lornoxicam ver- sus tramadol in postoperative pain. J Clin Pharmacol 1999;39:834-41.
44. Nİrholt SE, Sindet-Pedersen S, Larsen U, Bang U, Ingerslev J, Nielsen O, et al. Pain control after dental surgery: a dou- ble-blind, randomised trial of lornoxicam versus morphine. Pain 1996;67:335-43.
45. Rosenow DE, van Krieken F, Stolke D, Kursten FW. Intravenous administration of lornoxicam, a new NSAID, and pethidine for postoperative pain. A placebo-controlled pilot study. Clin Drug Invest 1996;11:11-9.
46. Ilias W, Jansen M. Pain control after hysterectomy: an observer-blind, randomised trial of lornoxicam versus tra- madol. Br J Clin Pract 1996;50:197-202.
47. Trampitsch E, Pipam W, Moertl M, Sadjak A, Dorn C, Sittl R, et al. Preemptive randomized, double-blind study with lornoxicam in gynecological surgery. [Article in German] Schmerz 2003;17:4-10. [Abstract]
48. Moller R, Covino BG. Cardiac electrophysiologic proper- ties of bupivacaine and lidocaine compared with those of ropivacaine, a new amide local anesthetic. Anesthesiology
49. Feldman HS, Arthur GR, Covino BG. Comparative sys- temic toxicity of convulsant and supraconvulsant doses of intravenous ropivacaine, bupivacaine, and lidocaine in the conscious dog. Anesth Analg 1989;69:794-801.
50. Scott DB, Lee A, Fagan D, Bowler GM, Bloomfield P, Lundh R. Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 1989;69:563-9.
51. Martinsson T, Oda T, Fernvik E, Roempke K, Dalsgaard CJ, Svensjö E. Ropivacaine inhibits leukocyte rolling, adhe- sion and CD11b/CD18 expression. J Pharmacol Exp Ther 1997;283:59-65.
52. Karamanlioglu B, Turan A, Memis D, Kaya G, Ozata S, Ture M. Infiltration with ropivacaine plus lornoxicam reduces postoperative pain and opioid consumption. Can J Anaesth 2005;52:1047-53.
53. Dobbs FF, Kumar V, Alexander JI, Hull MG. Pain after lapa- roscopy related to posture and ring versus clip sterilization. Br J Obstet Gynaecol 1987;94:262-6.
54. Helvacioglu A, Weis R. Operative laparoscopy and postop- erative pain relief. Fertil Steril 1992;57:548-52.
55. Louizos AA, Hadzilia SJ, Leandros E, Kouroukli IK, Georgiou LG, Bramis JP. Postoperative pain relief after laparoscopic cholecystectomy: a placebo-controlled double- blind randomized trial of preincisional infiltration and intraperitoneal instillation of levobupivacaine 0.25%. Surg Endosc 2005;19:1503-6.