APPENDIX 1. Literature search 1
Pubmed 2
839 results:
3
((("Digestive System Surgical Procedures"[Mesh] OR "Abdomen/surgery"[Mesh] OR "Liver/surgery"[Mesh] OR "Laparotomy"[Mesh] OR 4
abdominal surger*[tiab] OR liver surger*[tiab] OR colorectal surger*[tiab] OR pancreatic surger*[tiab] OR cholecystectom*[tiab] OR 5
laparotom*[tiab] OR hepatectom*[tiab] OR colectom*[tiab] OR pancreatectom*[tiab]) AND ("Anesthetics, Local"[Mesh] OR continuous[tiab]
6
OR wound infiltrat*[tiab] OR wound infusion*[tiab] OR infiltration*[tiab] OR infusion*[tiab] OR perfusion*[tiab] OR wound catheter*[tiab]
7
OR local anaesthe*[tiab] OR local anesthe*[tiab] OR elastomeric pump*[tiab] OR ON-Q[tiab] OR transversus abdominis plane[tiab]) AND 8
("Analgesia, Epidural"[Mesh] OR "Analgesia, Patient-Controlled"[Mesh] OR "Placebos"[Mesh] OR "Sodium Chloride"[Mesh] OR 9
epidural[tiab] OR patient-controlled analges*[tiab] OR placebo [tiab] OR saline[tiab]) AND ("Postoperative Complications"[Mesh] OR "Pain, 10
Postoperative"[Mesh] OR postoperative pain[tiab] OR postoperative complication*[tiab] OR pain score*[tiab] OR pain[tiab] OR postoperative 11
analges*[tiab] OR analg*[tiab]))) AND (("Randomized Controlled Trial" [Publication Type] OR "Random Allocation"[Mesh] OR 12
(random*[tiab] AND trial*[tiab]))) 13
14
EMBASE (Ovid) 15
1547 results:
16
Database(s): Embase Classic+Embase 1947 to 2017 March 31 17
# Searches Results
1
(exp abdominal surgery/ or exp liver surgery/ or exp colorectal surgery/ or exp pancreas surgery/ or cholecystectomy/ or laparotomy/
or (abdominal surger* or liver surger* or colorectal surger* or pancreatic surger* or cholecystectom* or laparotom* or hepatectom*
or colectom* or pancreatectom*).ti,ab,kw.) and (exp local anesthetic agent/ or local anesthesia/ or exp infusion/ or exp perfusion/ or transversus abdominis plane block/ or (continuous or wound infiltrat* or wound infusion* or infiltration* or infusion* or perfusion*
or wound catheter* or local anaesthetic* or local anesthetic* or elastomeric pump* or ON-Q or transversus abdominis
plane).ti,ab,kw.) and (exp epidural anesthesia/ or patient controlled analgesia/ or placebo/ or sodium chloride/ or (epidural or patient- controlled analges* or placebo or saline).ti,ab,kw.) and (exp postoperative complication/ or postoperative pain/ or postoperative analgesia/ or (postoperative pain or postoperative complication* or pain score* or pain or postoperative analges* or analg*).ti,ab,kw.) and (randomized controlled trial/ or randomization/ or (random* and trial*).ti,ab,kw.)
1686
2 limit 1 to english language 1547
18
Cochrane Library
19
Cochrane Central Register of Controlled Trials (CENTRAL): 1542 trials 20
http://onlinelibrary.wiley.com/cochranelibrary/search/advanced/shared/searches/1291176237344767625
21
ID Search Hits
22
#1 MeSH descriptor: [Digestive System Surgical Procedures] explode all trees 14340 23 #2 MeSH descriptor: [Abdomen] explode all trees and with qualifier(s): [Surgery - SU] 1598 24
#3 MeSH descriptor: [Liver] explode all trees and with qualifier(s): [Surgery - SU] 130 25
#4 MeSH descriptor: [Laparotomy] explode all trees 804 26
#5 abdominal surger* or liver surger* or colorectal surger* or pancreatic surger* or cholecystectom* or laparotom* or hepatectom* or colectom* or 27 pancreatectom*:ti,ab,kw (Word variations have been searched) 19056
28
#6 #1 or #2 or #3 or #4 or #5 29332 29
#7 MeSH descriptor: [Anesthetics, Local] explode all trees 6977 30
#8 continuous or wound infiltrat* or wound infusion* or infiltration* or infusion* or perfusion* or wound catheter* or local anaesthetic* or local anesthetic* or 31 elastomeric pump* or ON-Q or transversus abdominis plane:ti,ab,kw (Word variations have been searched) 82229
32 #9 #7 or #8 82229 33
#10 MeSH descriptor: [Analgesia, Epidural] explode all trees 1934 34
#11 MeSH descriptor: [Analgesia, Patient-Controlled] explode all trees 1849 35 #12 MeSH descriptor: [Placebos] explode all trees 23193
36 #13 MeSH descriptor: [Sodium Chloride] explode all trees 2382 37
#14 epidural or patient-controlled analges* or placebo or saline:ti,ab,kw (Word variations have been searched) 215073 38
#15 #10 or #11 or #12 or #13 or #14 215829 39
#16 MeSH descriptor: [Postoperative Complications] explode all trees 33645 40 #17 MeSH descriptor: [Pain, Postoperative] explode all trees 11427
41
#18 postoperative pain or postoperative complication* or pain score* or pain or postoperative analges* or analg*:ti,ab,kw (Word variations have been searched) 42
134523 43
#19 #16 or #17 or #18 139635
44 #20 #6 and #9 and #15 and #19 in Trials 1542
45 46
APPENDIX Table 2. Overview of included studies 46
Referenc e
Total number
of patients
Type of surgery
Open surgery
or laparosc
opy
ERAS Incision Analgesia type
N per
group Age (years) Location of wound catheter
Drugs administered Rescue analgesia
Additional drugs
Almeida
2011 38
Elective abdomi
nal surgery
Open Non ERAS
Midline or transverse incision
CWI 19 49.9 ± 13 Sub-
cutaneous
Ropivacaine 0.2% 5 ml/h (first 10-ml
bolus); patient- administered bolus
of 2 ml at 15-min intervals
IV tramadol and morphine
Paracetamol 1 g every 6 h,
regular NSAIDs
Control:
thoracolumb
ar epidural 19 55.7 ± 10.7
Continuous 40 ml 0.75% ropivacaine, 250 μg fentanyl, 33 ml 0.9% saline at 2
ml/h; patient- administered bolus
of 2 ml at 15-min intervals
Ansaloni
2007 96 Append
ectomy Open Non
ERAS McBurney
incision CWI 48 27.10 ± 10.90 Pre-
peritoneal
Ropivacaine 500 mg (first 10 mL of 0.2%
ropivacaine 20 mg bolus) 5 ml/h 48
hours
30 mg
ketorolac IV NR
Control:
CWI with saline
48 28.92 ± 9.95
Baig
2006 70
Colorec tal
surgery Open Non
ERAS Midline
incision CWI 35 55.7 ± 17.7 Sub-
cutaneous Bupivacaine 0.5%
300 ml 72 hours
PCA with morphine (meperidine in case of allergy).
Initial infusion rate: 1 mg/hour,
increased to 3 mg/hour if pain
control was insufficient.
NR
Control:
CWI with saline
35 58.8 ± 16.3
Beaussier
2007 42
Colorec tal cancer surgery
Open Non ERAS
Periumbilica l midline
incision
CWI 21 58 ± 10 Pre-
peritoneal
Ropivacaine 0.2%
480 ml 10 ml/h 48 hours
PCA with intravenous infusion 1 mg morphine with a 7-min lockout
time.
Nonopioid iv analgesics (ketoprofen 50
mg 3 daily, or acetaminophen
1 g 4 daily in case of contraindicatio
n to NSAID) Control:
CWI with
saline 21 62 ± 9
Bertoglio
2012 106
Colorec tal cancer surgery
Open Non ERAS
Midline (91%) Paramedian
(6%) Transverse
(3%)
CWI 53 65.70 ± 7.82 Pre-
peritoneal
Ropivacaine 10 ml/h (first 10ml bolus) 48
hours
IV morphine for a period of 72 hours with PCA 1 mg/dose
with a 10- minute lockout
time without background infusion.
IV ketorolac 30 mg 3 times
daily or paracetamol 1 g 4 times daily
Control:
epidural (T8-L1)
53 64.51 ± 6.66 Ropivacaine 10 ml/h (first 10ml bolus) 48
hours
Boulind
2012 41
Colorec tal surgery
Laparos
copy ERAS CWI 17 68 ± 12 Pre-
peritoneal
Levobupivacaine 0.125 mg/ml 2 ml/h
48 hours IV morphine
Paracetamol 1 g every 6 h,
400 mg ibuprofen
every 8 h Control:
epidural (T9–10 or T10–11) + sham CWI
14 74 ± 8
Levobupivacaine 0,125 mg/ml and 100 μl per 50 ml fentanyl at 4 ml/h
Chan
2010 48
Liver resectio
n Open Non
ERAS
Right subcostal
incision (with or without upper midline extension)
CWI 22 51.8 ± 7.8 Pre-
peritoneal
Ropivacaine 0.25%
4 ml/h 68 hours
PCA morphine with a 1-mg bolus, 5-min lock-out and 4-
h dose-limit of 0.3 mg/kg.
NR
Control:
CWI with
saline 22 52.1 ± 8.3
Cheong
2001 70
Colorec tal surgery
Open Non ERAS
Left iliac fossa skin crease incision
CWI 35 61 (41-82) Sub-
cutaneous Bupivacaine 0.5% 2 ml/h 60 hours
CWI:
subcutaneous morphine
NR
Control: IV
PCA 35 64 (15-83) Intermittent IV
morphine infusion 1±3 mg/h 60 hours
Chester
1989 30
Cholecy stectom
y Open Non
ERAS
Right upper transverse abdominal incision
CWI 15 50 (24-71) Pre-
peritoneal
Bupivacaine 4 ml/h 24 hours
IV pethidine (0.2mg/kg) on demand via the
PCAD.
NR
Control:
CWI with
saline 15 50 (24-71)
Clevelan
d 2015 82
Sleeve gastrect omy
Laparos copy
Non
ERAS CWI 39 35.9 Pre-
peritoneal
Ropivacaine 0.2%
7ml/h
Hydromorphon e PCA at a rate of 0.2 mg every 10 minutes (removed on postoperative
day 1)
IV narcotics
Control:
CWI with saline
43 33.9
Fassoula
ki 2016 102 Cholecy stectom
y
Laparos
copy Non
ERAS CWI 50 51 ± 11.2 Sub-
cutaneous Ropivacaine 0.75%
2ml/h 24 hours
Paracetamol 400 mg or codeine 10 mg
Tramadol in PACU
Control:
CWI with saline
52 48 ± 12.5
Fustran
2015 60
Colorec tal surgery
Laparoto my/lapar oscopy CWI: 17 (52%)/1 6 (48%).
Control:
17 (50%)/1 7 (50%)
Non
ERAS CWI 29 64 (41-80) Pre-
peritoneal
Ropivacaine 0.38%
5 ml/h in laparotomy patients,
2 ml/h in laparoscopy patients
48 hours
PCA with 0.5 mg dose of morphine with a 5 min lockout
time for 48 h.
Dexketoprofen 50 mg and acetaminophen
1 g IV three times per day during the 48-h
trial period
Control:
CWI with
saline 31 64.5 (18-78)
Ganapath
y 2015 50 Laparot
omy Open Non
ERAS
Midline
incision CWI 26 61.7 ± 10.8 Pre-
peritoneal
Ropivacaine 0.35%
4-5 ml/h 72 hours
IV PCA with hydromorphone
0.2-0.3 mg lockout time 6
min and no basal infusion
Naproxen 500 mg twice daily, gabapentin 300 mg twice daily
and paracetamol 650 mg every 6
h Control:
epidural (T7 -T8 or T8-
T9)
24 58.0 ± 12.2
Bupivacaine 0.1%
with hydromorphone 10
mg/ml started preoperatively 8
ml/h 72 hours
3-ml boluses every 20min
Hughes
2015 93
Liver resectio
n Open ERAS
Right subcostal
incision CWI 49 62.8 ± 12.1 Pre-
peritoneal
Levobupivacaine 0.375% 4ml/h 48 hours + nerve block
40 ml 0.125%
levobupivacaine
NR NR
Control:
epidural (T8–T9)
44 62.6 ± 11.1 Levobupivacaine
0.1% with 2 μg/ml fentanyl
Jouve
2013 50
Colorec tal surgery
Open ERAS
Periumbilica l midline
incision
CWI + sham
epidural 26 68 ± 9 Pre-
peritoneal Ropivacaine 0.2%
10 ml/h 48 hours
IV PCA with 1mg/ml morphine and
0.05mg/ml droperidol 1- mg with a 7- min lockout
time.
Acetaminophe n (1 g every 6
h) and ketoprofen (50
mg every 6 h) for 48 h
Control:
epidural (T9–11 left T8–10 right) + sham CWI
24 63 ± 12
PCA 0.2%
ropivacaine and 0.25 μg/ml sufentanil 5 ml/h, boluses of 5 ml 15- min lockout time
EA and CWI were removed
48 h after surgery, and boluses of 1-
mg IV morphine were allowed in each
group as a rescue medication
Kahokehr
2011 60
Colorec tal surgery
Open + 2/2 laparosc
opy
ERAS
Midline or transverse
incision CWI 30 68.5 (31-84) Intra-
peritoneal Ropivacaine 0.2% 4 ml/h 68 hours
Continuous epidural infusion of
0.2%
ropivacaine + 2 mcg/mL fentanyl 4-10
ml/h for 48 hours. Oral opiates:
tramadol as first line, morphine or oxycodone as
second line.
Break through pain was controlled with
nurse administered
Paracetamol (4 g/day) and
NSAID tenoxicam 20 mg twice daily.
IV morphine or fentanyl.
Control:
CWI with saline
30 70 (22-88)
Khorgam i 2013 60
Elective abdomi
nal surgery
(<2 hours)
Open Non
ERAS Midline
incision CWI 30 43 ± 17 Supra-
fascial
Bupivacaine 0.25%
1 ml per centimetre of incision length trough each catheter
every 6h for 48 hours
PCA: IV bolus of 1 mg morphine no more frequently
than every 8 min, on patient
demand.
NR
CWI 30 41 ± 15 Inter-fascial
Lee 2016 43
Colorec tal cancer surgery
Laparos copy
Non
ERAS CWI 20 53.4 ± 8.7 Sub-facial Ropivacaine 0.5% 4
ml/h 72 hours (first 10ml bolus)
Bolus of fentanyl IV PCA 15 μg/ml with a lockout
time.
Meperidine 0.5 mg/kg for
rescue analgesia if VAS > 40 mm
even after IV PCA bolus.
Antiemetic drugs (metocloprami
de, palonosetron,
granisetron)
Control: IV
PCA 22 55.3 ± 8.7
Fentanyl 15 μg/l 0.5 ml/h (and bolus 1ml with a lockout time
of 15 min)
Mungroo
p 2016 102
Hepato- pancreat
o- biliary surgery
Open ERAS
Subcostal or midline incision
CWI 55 NR Pre-
peritoneal
Bupivacaine 0.125%
12 ml/h 72 hours (and 2 boluses of 30
ml bupivacaine 0.25%)
Morphine or piritramide
patient- controlled analgesia, non-
opioids, and continuous infusion of esketamine.
Paracetamol (1 g four times a
day) and dipyrone (maximum of 4
g per day) or naproxen (250
mg twice daily).
Control:
epidural (T7-T10)
47 NR
Option 1: PCA with Bupivacaine 0.125%
and sufentanil 1μg/ml 6mL/h and bolus of 2mL and a lockout time of 20
min. 4 h max. 1.2 mg bupivacaine per
kg. Option 2:
continuous with bupivacaine 0.125%
and sufentanil 0.5 μg/mL started at 0.1
mL/kg per h. Both bupivacaine 0·25%
and sufentanil 1 μg/mL before
incision.
Niraj
2011 58
Hepato- pancreat
o- biliary surgery
+ nefrecto
my
Open Non ERAS
Extended right subcostal incision or
rooftop (chevron) incision or transverse incision
CWI 27 64 ± 12 Pre-
peritoneal
Bupivacaine 0.375%
8-hourly bolus injections through each TAP catheter
72 hours
A bolus of 10 ml bupivacaine 0.25% into one
or both catheters. Re- siting catheters if unsuccessful.
Still unsuccessful --
> TAP
Intravenous tramadol 50–
100 mg 6- hourly, as required.
Paracetamol 1 g 6-hourly
catheters were removed and
epidural analgesia
started.
Control:
epidural (T7-T9)
31 64 ± 11
PCEA with a background infusion
of bupivacaine 0.125% and 2 μg/ml
fentanyl 6ml/h increased in 2 ml/h increments up to 12 ml/h. Bolus: 2 ml
with a lockout period of 30 min.
7.5-ml bolus of bupivacaine
0.25%. 2 boluses over 60
min unsuccessful --
> (PCA) with morphine and an epidural infusion of
plain bupivacaine
0.125%
Niraj
2014 61 Colorec
tal surgery
Laparos
copy ERAS
Surgical incision was
limited to T10 dermatome
CWI 30 66.7 ± 12.6 Pre-
peritoneal
Levobupivacaine 0.25% 48 hours and
2.5 mg/kg levobupivacaine 0.375% was used
for the four- quadrant blocks at the end of surgery.
Inadequate pain control despite
boluses of bupivacaine -->
PCA with morphine.
Intravenous tramadol 100 mg 6 hourly.
Paracetamol 1 g every 6 h, diclofenac 150
mg/day 1 as required.
Control:
epidural
(T9-T11) 31 64.4 ± 16.2
PCEA with a background infusion
of bupivacaine 0.125% and 2 μg/ml
fentany : 8 ml/h increased in 2 ml/h increments up to 12 ml/h. Bolus: 2 ml
with a lockout period of 30 min.
Polglase
2007 310
Colorec tal
surgery Open Non ERAS
Midline
incision CWI 143 66.9 ± 14 Sub-
cutaneous
Ropivacaine 0.54%
4 ml/h 72 hours
Morphine infusion (1mg h/1) and PCA (1mg bolus/5-
min lockout).
Tramadol 50mg six hourly
Paracetamol 1g six hourly.
Parecoxib 40 mg IV daily for
the first three days (first 139 patients) or
intravenously. ketorolac 30 or 15mg IM 12
hourly.
Control:
CWI with saline
167 64.5 ± 12.5
Rao Kadam
2013
41
Colorec tal, upper gastroin
testinal and urologic
al
Open Non ERAS
Midline
incision CWI 22 63.8 ± 10.1 Pre-
peritoneal
Ropivacaine 0.2%
16 ml/h 72 hours and a bolus dose of 20 ml of ropivacaine
0.375% bilaterally
PCA with fentanyl (bolus
10 to 40 μg, lockout time five minutes, no background
infusion)
Paracetamol 1.0 g (orally or
intravenous)
Control:
epidural (T7-T9)
19 60.9 ± 13.2
Ropivacaine 0.2% 5 - 15 ml/h and a bolus of 8-15 ml of
ropivacaine 0.2%
Revie
2012 64 Liver
resectio n
Open ERAS Right
subcostal incision
CWI + sham
epidural 33 60 (39-84) Pre- peritoneal
Levobupivacaine 0.375% 4 ml/h 48 hours and PCA with
opiate
Oxycodone 10 mg as required
for breakthrough
pain relief.
Paracetamol 1g 4/day, buprofen 400 mg three times per day (unless contraindicated
, in which case tramadol 100 mg four times per day was
used) Control:
epidural (T7-T8) + sham CWI
31 60 (23-85)
Bupivacaine 0.1%
and 2 mcg/ml fentanyl 7-10 ml/h
Sherwint
er 2008 29
Laparos copic adjustab
le gastric banding
Laparos copy
Non
ERAS CWI 14 45.6 ± 9.7 Intra-
peritoneal
Bupivacaine 0.375%
2 ml/h 48 hours
IV morphine as needed
IV ketorolac every 6 h
Control:
CWI with saline
15 42.0 ± 11.8
Sistla
2017 94
Elective midline laparoto my
Open Non ERAS
Midline
incision CWI 47 53.3 ± 13.4 Pre-
peritoneal
Bupivacaine 0.25%
6ml/h 48 hours
PCA with morphine 1 mg/mL (1 mL bolus, lockout period 15 min, total dose limit 20 mg in 4 h,
and no continuous
infusion)
NR
Control:
CWI with saline
47 54.4 ± 11.4
Wahba
2014 44
Upper abdomi nal surgery
Open Non
ERAS NR CWI 22 66.4 ± 4.8 Pre-
peritoneal
Bupivacaine 0.25%
15 ml every 8 h on each side for 48 hours and first 20 ml
of 0.25 % bupivacaine was
injected in increments in the
catheter on each side
PCA with morphine (1
mg bolus/
lockout interval 10 min)
NR
Control:
epidural (T9-T10)
22 66.3 ± 5.4
Bupivacaine 0.125%
continuous 6-8 ml/h and first 10 ml of
0.125 % bupivacaine was
injected in increments in the
catheter Wang
2010 55
Colorec tal surgery
Open Non
ERAS Midline
incision CWI 28 64.6 (58.6-
70.7) Pre-
peritoneal Ropivacaine 0.2% 4
ml/h 67.5 hours PCA with
morphine NR
Control:
CWI with saline
27 70.3 (64.5- 76.1)
Zheng
2016 75 Gastrect
omy Open Non
ERAS
Midline
incision CWI 25 61.96 ± 12.72 Pre-
peritoneal
Ropivacaine 0.3% 5 ml/h 48 hours
2 mg bolus of morphine intravenous
(VAS≥4)
40 mg of parecoxib every 12 h
PCIA 25 63.56 ± 10.21
0.5 mg/mL morphine with a size of 200 mL that delivered a bolus of 2 mg with a 5 min
lockout time
Epidural
(T7-T8) 25 62.40 ± 9.69
Test dose of 4 ml 2% lidocaine. PCA
for 48h, 0.1%
ropivacaine and 20 μg/mL morphine at 6-8 mL/h. A bolus
infusion of 3-4 mL/h with a lock
time of 15 min.
47
APPENDIX Table 3. Satisfaction with pain treatment
Intervention Active control P value Outcome
CWI pre-peritoneal vs. active control
Bertoglio (2012) 24/53 (45%) 4/53 (8%) Total number of
excellent scores on satisfaction Niraj (2014) 19/32 (59%) 10/31 (32%)
Total number of excellent scores on satisfaction Niraj (2011) 9/27 (33%) 11/31 (35%)
Total number of excellent scores on satisfaction Total 52/112 (46%) 25/115 (22%) P < 0.001
CWI pre-peritoneal vs. placebo
Ansaloni (2007) 16/48 (33.3%) 7/48 (14.6%)
Total number of excellent scores on satisfaction Total 16/48 (33.3%) 7/48 (14.6%) P = 0.054
APPENDIX Table 4. Urinary retention and length of urinary catheter use
Intervention Control Significance Outcome
CWI pre-peritoneal vs. active control
Hughes (2015) 2 / 49 patients 5 / 44 patients P = 0.249 Patients with urinary retention
Mungroop (2016) 5.6 ± 6.2 days 5.8 ± 4.5 days P = 0.024 Length of urinary catheter use (mean±
SD) Niraj (2014) 44 (35–48 [12–72])
hours 72 (48–72) hours P = 0.002 Length of urinary catheter use (median (IQR))
CWI subcutaneous vs. active control
Almeida (2011) 0/19 patients 1/19 patients P = 0.331 Patients with urinary retention
CWI pre-peritoneal vs. placebo
Cleveland (2015) 2 / 39 patients 1 / 43 patients P = 0.46 Patients with urinary retention
