Clinical impact of a multimodal pain management protocol for loop ileostomy reversal

Jeong Sub Kim; Chul Seung Lee; Jung Hoon Bae; Seung Rim Han; Do Sang Lee; In Kyu Lee; Yoon Suk Lee; In Kyeong Kim

doi:10.3393/ac.2022.01137.0162

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Original Article ERAS Clinical impact of a multimodal pain management protocol for loop ileostomy reversal: Jeong Sub Kim¹, Chul Seung Lee¹, Jung Hoon Bae², Seung Rim Han², Do Sang Lee², In Kyu Lee², Yoon Suk Lee², In Kyeong Kim²; Annals of Coloproctology 2024;40(3):210-216.
DOI: https://doi.org/10.3393/ac.2022.01137.0162
Published online: June 19, 2024

¹Department of Colorectal Surgery, Hansol Hospital, Seoul, Korea

²Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Correspondence to: In Kyeong Kim, MD Division of Colorectal surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Email: gamjadori8819@gmail.com

• Received: December 13, 2022 • Revised: January 23, 2023 • Accepted: February 1, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
Graphical abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
ARTICLE INFORMATION
REFERENCES

See letter "Multimodal analgesia for postoperative pain: pursuing liberation from pain, not redemption" in Volume 40 on page 189.

Abstract

Purpose
As introduced, multimodal pain management bundle for ileostomy reversal may be considered to reduce postoperative pain and hospital stay. The aim of this study was to evaluate clinical efficacy of perioperative multimodal pain bundle for ileostomy.
Methods
Medical records of patients who underwent ileostomy reversal after rectal cancer surgery from April 2017 to March 2020 were analyzed. Sixty-seven patients received multimodal pain bundle protocol with ileostomy reversal (group A) and 41 patients underwent closure of ileostomy with conventional pain management (group B).
Results
Baseline characteristics, including age, sex, body mass index, American Society of Anesthesiologists classification, diabetes mellitus, and smoking history, were not significantly different between the groups. The pain score on postoperative day 1 was significant lower in group A (visual analog scale, 2.6±1.3 vs. 3.2±1.2; P=0.013). Overall consumption of opioid in group A was significant less than group B (9.7±9.5 vs. 21.2±8.8, P<0.001). Hospital stay was significantly shorter in group A (2.3±1.5 days vs. 4.1±1.5 days, P<0.001). There were no significant differences between the groups in postoperative complication rate.
Conclusion
Multimodal pain protocol for ileostomy reversal could reduce postoperative pain, usage of opioid and hospital stay compared to conventional pain management.
Keywords: Abdominal pain; Pain management; Postoperative pain; Ileostomy

Graphical abstract

INTRODUCTION

Patients with ileostomy reversal tend to feel more pain than those without ileostomy in colorectal cancer surgery. It is difficult for them to ambulate early after surgery, which leads to postoperative ileus easily. Moreover, the closure of loop ileostomy can be associated with additional short-term postoperative morbidity in 2% to 33% of the patients [1]. Various efforts have been made to reduce complications, and standardized management for ileostomy reversal reduced hospital stay and complication rates [2]. Recent meta-analysis research found that purse-string skin closure was associated with significantly decreased rates of surgical site infection (SSI) in patients undergoing loop ileostomy reversal [3].

Enhanced Recovery After Surgery (ERAS) program has been regarded as the remarkable strategy of colorectal surgical cares for patients. It leads to decreased morbidity, shorter hospital days, and lower stress responses [4–6]. However, there are limited data exists for multimodal pain management bundle for ERAS designed specifically for ileostomy closure.

The purpose of this study was to determine whether multimodal pain management program effectively reduces postoperative pain after ileostomy reversal and further decrease usage of opioid during hospital stays within the setting of postoperative multimodal pain control.

METHODS

Ethics statement

This study was approved by the Institutional Review Board of The Catholic University of Korea (No. KC21RISI0537). The requirement for informed consent was waived due to the retrospective nature of the study.

Study design

This study was a single-center retrospective study. Electronic medical records of patients who underwent ileostomy reversal after rectal cancer were anlalyzed from April 2017 to March 2020 in Seoul St. Mary’s Hospital (Seoul, Korea). Our institution started a multimodal pain bundle for ileostomy reversal from August 2019 in trend of ERAS protocols.

From 2017 to August 2019, conventional management of ileostomy reversal was implemented. Patients who underwent surgery from August 2019 to March 2020 were assigned to a multimodal pain control group. Therefore, 67 patients received multimodal pain bundle protocol with ileostomy reversal (group A) and 41 patients underwent closure of ileostomy with conventional pain management (group B).

We informed patients of discharge criteria and methods used for postoperative pain control, such as oral or intravenous medication. Criteria for discharge in our institution included the followings: stable vital signs without fever (<37.8 ºC), tolerance of diet, ability to walk unassisted, and a tolerable visual analog scale (VAS) score of <3. The surgeon provided pain education to the patient, including information concerning the pain severity and type, and management for pain control when they were admitted to the hospital. However, evaluation of the postoperative outcome was performed by an ERAS specialist nurse, not a participating surgeon.

Table 1 shows the details of the characteristics of this study comparing multimodal versus standardized conventional management. In multimodal pain management, preoperative medications included multimodal analgesics such as gabapentin, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs). It was taken orally 2 hours before surgery. For intraoperative pain control, transversus abdominis plane (TAP) block was performed before closure of wound. Other pain control such as patient-controlled analgesic and postoperative oral analgesia according to VAS score were equally applied in both groups. A VAS score of 4 or higher was managed with appropriate pain control as needed.

Surgical procedure

Ileostomy reversal had been performed for patients who had undergone laparoscopic low anterior resection with loop ileostomy for rectal cancer. Intravenous 2nd generation cephalosporin had been administered to all patients prior to the induction of anesthesia. The patient was placed in supine position under general anesthesia. Elliptical skin incision was done around ileostomy. Ileostomy was mobilized and retracted from the abdominal wall. The proximal and distal ileum of ileostomy was performed with side-to-side anastomosis using an endo-gastrointestinal anastomosis device and reinforced with Lembert sutures.

Surgical TAP block was performed before the closure of wound for intraoperative pain control. TAP is the fascial layer between the internal oblique muscle and the transversus abdominis muscle. For ultrasoundguided TAP block, 0.75% ropivacaine was infiltrated as 10 mL on the lateral sides of the ileostomy site (Fig. 1). In multimodal pain control group (group A), they got additional ultrasound-guided TAP block. Wound was closed with purse-string fashion. The patient was allowed to drink water 4 hours after surgery and eat soft diet one day after surgery (Fig. 2).

Statistical analysis

Statistical analysis was performed using IBM SPSS ver. 24.0 (IBM Corp). A Student t-test or Pearson chi-square test and Fisher exact test were used for between-group comparisons, as appropriate for the data type and distribution. For categorical data, Fisher exact test was employed, and for continuous data, Mann-Whitney U-test. P-values of <0.05 were considered statistically significant.

RESULTS

Including age, sex and comorbidities, basic characteristics had no differences between groups A and B (Table 2). The mean operation time was longer in group A (64.7±24.1 minutes vs. 53.3±21.7 minutes, P=0.015). The median daily pain score, 1 day after surgery and 2 days, after surgery were significant lower in group A (POD 1 VAS score: 2.6±1.3 vs. 3.2±1.2, P=0.013; POD 2 VAS score: 2.9±0.7 vs. 2.2±0.9, P<0.001). Postoperative consumption of pethidine in group A was significant less than group B (12.3±48.1 mg vs. 39.0±69.1 mg, P<0.001). Consumption of oxycodone had no differences between 2 groups. However, overall consumption of opioid converted to morphine milligram equivalents in group A was significantly lower than group B (9.7±9.5 vs. 21.2±8.8, P<0.001). Postoperative length of hospital stay was significantly shorter in group A (2.3±1.5 days vs. 4.1±1.5 days, P<0.001). Postoperative complication rate and readmission within 30 days after surgery showed no significant differences between 2 groups. None of the patients had severe postoperative complications (Clavien-Dindo classification ≥IIIa) or underwent reoperation (Table 3).

DISCUSSION

In our analysis, while applying the multimodal pain protocol, postoperative pain scores were lower compared to conventional management. The demand for opioid-related drugs such as pethidine was also significantly reduced. Hence, with multimodal pain control, the length of hospital stay was shortened due to early ambulation and quick postoperative recovery. It contributed to the recent trend of ERAS protocol in colorectal surgery. However, the mean operation time was approximately 10 minutes longer in the multimodal pain control group. This is estimated the time required for ultrasound-guided TAP block. Just 10 minutes of effort can have a positive effect on the overall short-term outcome after surgery.

To decrease the postoperative pain, we used celecoxib, acetaminophen, and gabapentin as combined perioperative analgesics. NSAIDs and acetaminophen have good analgesic effects associated with reduction of some opioid-related side effects such as postoperative nausea, vomiting, and sedation [7–9]. Although NSAIDs increase the risk of surgical bleeding, cyclooxygenase-2 inhibitors such as celecoxib did not report on presence or absence of surgical bleeding [7]. In addition, preoperative celecoxib had clear advantages over placebo in terms of postoperative pain reduction, analgesic consumption, and patient satisfaction [8].

As part of our multimodal perioperative pain therapy, we also developed an ultrasound-guided surgical TAP block method. Several studies have previously confirmed the effectiveness and safety of the TAP block, which has been employed throughout numerous procedures including colorectal surgery [10–13]. Ropivacaine is a drug with a longer duration, more selective blocking of sensory nerves, and fewer side effects such as cardiovascular and central nervous system [14].

Postoperative complication rates were not significantly different between the 2 groups. Postoperative ileus was not significantly different, but the incidence was less frequent in multimodal pain control group. It seems that reduction of postoperative pain through appropriate pain control management could help the patient to walk early after surgery. Through the multimodal pain treatments, postoperative opioid consumption such as pethidine was reduced in our data. Opioid-induced bowel dysfunction or paradoxical abdominal pain were decreased. In addition, in our ERAS protocols, patients are discharged the next day after a 1-day diet after surgery. Other studies showed that ileostomy reversals had still a mean length of stay of 5 days [15–17]. It is important that patients are educated about the overall ERAS program and discharge criteria. The incidence of pain attributable to vague anxiety may be reduced by including the expected degree of pain among the discharge criteria described in the educational contents, which consecutively reduce eventual delays in discharge. When pain was reduced through multimodal pain control without other complications, patient was discharged, and the length of hospital stay was shortened.

Therefore, the length of hospital stay was shorter, and the readmission rate may seem relatively high. In cases of readmission, there were 5 ileus cases and 2 diarrhea cases in the multimodal pain control group, compared to 2 ileus cases and 1 hematochezia case in the conventional group. All patients recovered through conservative treatment. Most cases of postoperative complication and readmission were ileus due to restore the continuity of resting distal bowel. Therefore, more attention should be paid to dietary education after surgery.

In our study, all patients underwent wound closure with purse-string closure and SSI did not occur. Many studies reported that the pursestring closure compared to conventional linear closure is an effective method and had a lower risk of wound infection [18, 19]. Lee et al. [20] reported that purse-string closure was significantly lower in stoma site infection (2% vs. 15%, P=0.01). This would be thought to lower infection with spontaneous drainage through a hole. Moreover, wound irrigation was performed with only wet gauze after fascia closure. It was associated with a reduced incidence of superficial or deep SSI and decreasing the length of hospital stay [21].

This study had several limitations. First, the number of patients was small in this single-center retrospective analysis. Large-scale multicenter studies or randomized controlled trials should be carried out in order to confirm our findings. Second, we did not analyze the pain score hourly, nor compare quality of life between the 2 groups. Nevertheless, this study revealed a clear correlation between preoperative pain management and shortened hospital length of stay.

In conclusion, multimodal pain protocol for ileostomy reversal could reduce postoperative pain, usage of opioid, and the length of hospital stay compared to conventional pain management. In trend of ERAS protocol, it could be effective pain control bundle for ileostomy reversal.

ARTICLE INFORMATION

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: CSL, YSL, JHB, SRH, DSL; Data curation: IKK, CSL; Formal analysis: JSK, IKK, CSL; Investigation: CSL; Methodology: IKK, CSL; Project administration: IKL, YSL, JHB, SRH, DSL; Visualization: IKL, YSL; Writing–original draft: JSK, IKK, CSL; Writing–review & editing: JHB, SRH, DSL, IKL, YSL. All authors read and approved the final manuscript.

Fig. 1.

Intraoperative transversus abdominis plane (TAP) block during ropivacaine infiltration. (A) Ultrasound-guided TAP block. Injection was located between the internal oblique (IO) muscle and the transversus abdominis muscle plane; 0.75 % ropivacaine was infiltrated as 10 mL on the lateral side of the ileostomy site. (B) Wound site during ropivacaine infiltration. EO, external oblique muscle.

Fig. 2.

Multimodal analgesic approaches for Enhanced Recovery After Surgery (ERAS) protocols. PO, per oral; TAP, transversus abdominis plane; IV, intravenous; PCA, patient-controlled analgesia; PRN, as needed; IM, intramuscular.

Table 1.

Characteristics of study data

Characteristic	Multimodal pain management	Standardized management
Perioperative care	Per standardized with multimodal analgesic management	Per standardized management
Antimicrobial prophylaxis	Single dose cefoxitin 1 g was given at induction
Patient-controlled analgesia system	All patients until the morning after surgery
Liquid diet	4 hr after surgery
Ambulation	After surgery
Soft diet	1st day after surgery
Multimodal analgesic approach	Yes	No
Oral analgesia	Before and after surgery	First day after surgery
Surgical and ultrasound-guided TAP block	Yes	No
Operative period	August 2019–March 2020	April 2017–August 2019
No. of patients	67	41
Wound closure	Purse-string skin closure
Inclusion criteria	Rectal cancer, elective surgery
Exclusion criteria	Combined operation with other organs

TAP, transversus abdominis plane.

Table 2.

Comparison of baseline characteristics of the groups A and B

Characteristic	Group A (n=67)	Group B (n=41)	P-value
Age (yr)	59.0±12.9	61.3±12.8	0.375
Male sex	38 (56.7)	27 (65.9)	0.347
Body mass index (kg/m²)	22.3±4.2	23.7±3.2	0.068
ASA classification			0.486
I	10 (14.9)	4 (9.8)
II	53 (79.1)	36 (87.8)
III	4 (6.0)	1 (2.4)
Diabetes mellitus	3 (4.5)	11 (26.8)	0.172
Smoking	3 (4.5)	7 (17.1)	0.739

Values are presented as mean±standard deviation or number (%). Group A, multimodal pain management group. Group B, conventional management group.

ASA, American Society of Anesthesiologists.

Table 3.

Perioperative outcome with groups A and B

Outcome	Group A (n=67)	Group B (n=41)	P-value
Operative time (min)	64.7±24.1	53.3±21.7	0.015
Postoperative opioid consumption
Pethidine (mg)	12.3±48.1	39.0±69.1	<0.001
Oxycodone (mg)	0.2±1.1	0.3±1.2	0.812
Morphine milligram equivalents	9.7±9.5	21.2±8.8	<0.001
Median daily pain score (VAS)
Postoperative day 1	2.6±1.3	3.2±1.2	0.013
Postoperative day 2	2.9±0.7	2.2±0.9	<0.001
Postoperative hospital stay (day)	2.3±1.5	4.1±1.5	<0.001
Postoperative complication	7 (10.4)	6 (14.7)	0.552
Ileus	6 (9.0)	5 (12.2)	0.589
Bleeding	1 (1.5)	1 (2.4)	0.723
Surgical site infection	0 (0)	0 (0)	0.506
Severe complication^a	0 (0)	0 (0)	-
Reoperation	0 (0)	0 (0)	-
Readmission within 30 days	7 (10.4)	3 (7.3)	0.739
Morality within 30 days	0 (0)	0 (0)	-

Values are presented as mean±standard deviation or number (%). Group A, multimodal pain management group. Group B, conventional management group.

VAS, visual analog scale.

^a Clavien-Dindo classification ≥IIIa (requiring surgical, endoscopic, or radiological intervention not under radiological intervention).

REFERENCES

1. Kaidar-Person O, Person B, Wexner SD. Complications of construction and closure of temporary loop ileostomy. J Am Coll Surg 2005;201:759–73.Article PubMed
2. Joh YG, Lindsetmo RO, Stulberg J, Obias V, Champagne B, Delaney CP. Standardized postoperative pathway: accelerating recovery after ileostomy closure. Dis Colon Rectum 2008;51:1786–9.Article PubMed
3. Gachabayov M, Lee H, Chudner A, Dyatlov A, Zhang N, Bergamaschi R. Purse-string vs. linear skin closure at loop ileostomy reversal: a systematic review and meta-analysis. Tech Coloproctol 2019;23:207–20.Article PubMed PDF
4. Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations: 2018. World J Surg 2019;43:659–95.Article PubMed PDF
5. Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, et al. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2017;60:761–84.Article PubMed
6. Felling DR, Jackson MW, Ferraro J, Battaglia MA, Albright JJ, Wu J, et al. Liposomal bupivacaine transversus abdominis plane block versus epidural analgesia in a colon and rectal surgery enhanced recovery pathway: a randomized clinical trial. Dis Colon Rectum 2018;61:1196–204.Article PubMed
7. Elia N, Lysakowski C, Tramèr MR. Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone?: metaanalyses of randomized trials. Anesthesiology 2005;103:1296–304.Article PubMed
8. Straube S, Derry S, McQuay HJ, Moore RA. Effect of preoperative Cox-II-selective NSAIDs (coxibs) on postoperative outcomes: a systematic review of randomized studies. Acta Anaesthesiol Scand 2005;49:601–13.Article PubMed
9. Apfel CC, Turan A, Souza K, Pergolizzi J, Hornuss C. Intravenous acetaminophen reduces postoperative nausea and vomiting: a systematic review and meta-analysis. Pain 2013;154:677–89.Article PubMed
10. Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Anesth Analg 2008;107:2056–60.Article PubMed
11. McDonnell JG, O’Donnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesth Analg 2007;104:193–7.Article PubMed
12. Guerra L, Philip S, Lax EA, Smithson L, Pearlman R, Damadi A. Transversus abdominis plane blocks in laparoscopic colorectal surgery: better pain control and patient outcomes with liposomal bupivacaine than bupivacaine. Am Surg 2019;85:1013–6.Article PubMed PDF
13. Lee CS, Park SJ, Hong SH, Shim JW, Chae MS, Han SR, et al. Clinical effect of multimodal perioperative pain management protocol for minimally invasive colorectal cancer surgery: propensity score matching study. Asian J Surg 2021;44:471–5.Article PubMed
14. Rouholamin S, Ghahiri A, Dehghan Khalili B. The efficacy of ropivacaine 0.5% in transversus abdominis plane block to relieve the postoperative pain of female laparoscopic surgery grade II. Adv Biomed Res 2022;11:12. Article PubMed PMC
15. Wong KS, Remzi FH, Gorgun E, Arrigain S, Church JM, Preen M, et al. Loop ileostomy closure after restorative proctocolectomy: outcome in 1,504 patients. Dis Colon Rectum 2005;48:243–50.Article PubMed
16. Luglio G, Pendlimari R, Holubar SD, Cima RR, Nelson H. Loop ileostomy reversal after colon and rectal surgery: a single institutional 5-year experience in 944 patients. Arch Surg 2011;146:1191–6.Article PubMed
17. Archer V, Cloutier Z, Berg A, McKechnie T, Wiercioch W, Eskicioglu C. Short-stay compared to long-stay admissions for loop ileostomy reversals: a systematic review and meta-analysis. Int J Colorectal Dis 2022;37:2113–24.Article PubMed PDF
18. Li LT, Brahmbhatt R, Hicks SC, Davila JA, Berger DH, Liang MK. Prevalence of surgical site infection at the stoma site following four skin closure techniques: a retrospective cohort study. Dig Surg 2014;31:73–8.Article PubMed PDF
19. Hsieh MC, Kuo LT, Chi CC, Huang WS, Chin CC. Pursestring closure versus conventional primary closure following stoma reversal to reduce surgical site infection rate: a meta-analysis of randomized controlled trials. Dis Colon Rectum 2015;58:808–15.Article PubMed
20. Lee JT, Marquez TT, Clerc D, Gie O, Demartines N, Madoff RD, et al. Pursestring closure of the stoma site leads to fewer wound infections: results from a multicenter randomized controlled trial. Dis Colon Rectum 2014;57:1282–9.Article PubMed
21. Al-Sawat A, Mun JY, Yoon SH, Lee CS. Wound irrigation using wet gauze may reduce surgical site infection following laparoscopic appendectomy. Front Surg 2022;9:813738. Article PubMed PMC

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Clinical impact of a multimodal pain management protocol for loop ileostomy reversal

Ann Coloproctol. 2024;40(3):210-216. Published online June 19, 2024

DOI: https://doi.org/10.3393/ac.2022.01137.0162

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Figure

Clinical impact of a multimodal pain management protocol for loop ileostomy reversal

Fig. 1. Intraoperative transversus abdominis plane (TAP) block during ropivacaine infiltration. (A) Ultrasound-guided TAP block. Injection was located between the internal oblique (IO) muscle and the transversus abdominis muscle plane; 0.75 % ropivacaine was infiltrated as 10 mL on the lateral side of the ileostomy site. (B) Wound site during ropivacaine infiltration. EO, external oblique muscle.

Fig. 2. Multimodal analgesic approaches for Enhanced Recovery After Surgery (ERAS) protocols. PO, per oral; TAP, transversus abdominis plane; IV, intravenous; PCA, patient-controlled analgesia; PRN, as needed; IM, intramuscular.

Graphical abstract

Fig. 1.

Fig. 2.

Graphical abstract

Clinical impact of a multimodal pain management protocol for loop ileostomy reversal

Characteristic	Multimodal pain management	Standardized management
Perioperative care	Per standardized with multimodal analgesic management	Per standardized management
Antimicrobial prophylaxis	Single dose cefoxitin 1 g was given at induction
Patient-controlled analgesia system	All patients until the morning after surgery
Liquid diet	4 hr after surgery
Ambulation	After surgery
Soft diet	1st day after surgery
Multimodal analgesic approach	Yes	No
Oral analgesia	Before and after surgery	First day after surgery
Surgical and ultrasound-guided TAP block	Yes	No
Operative period	August 2019–March 2020	April 2017–August 2019
No. of patients	67	41
Wound closure	Purse-string skin closure
Inclusion criteria	Rectal cancer, elective surgery
Exclusion criteria	Combined operation with other organs

Characteristic	Group A (n=67)	Group B (n=41)	P-value
Age (yr)	59.0±12.9	61.3±12.8	0.375
Male sex	38 (56.7)	27 (65.9)	0.347
Body mass index (kg/m²)	22.3±4.2	23.7±3.2	0.068
ASA classification			0.486
I	10 (14.9)	4 (9.8)
II	53 (79.1)	36 (87.8)
III	4 (6.0)	1 (2.4)
Diabetes mellitus	3 (4.5)	11 (26.8)	0.172
Smoking	3 (4.5)	7 (17.1)	0.739

Outcome	Group A (n=67)	Group B (n=41)	P-value
Operative time (min)	64.7±24.1	53.3±21.7	0.015
Postoperative opioid consumption
Pethidine (mg)	12.3±48.1	39.0±69.1	<0.001
Oxycodone (mg)	0.2±1.1	0.3±1.2	0.812
Morphine milligram equivalents	9.7±9.5	21.2±8.8	<0.001
Median daily pain score (VAS)
Postoperative day 1	2.6±1.3	3.2±1.2	0.013
Postoperative day 2	2.9±0.7	2.2±0.9	<0.001
Postoperative hospital stay (day)	2.3±1.5	4.1±1.5	<0.001
Postoperative complication	7 (10.4)	6 (14.7)	0.552
Ileus	6 (9.0)	5 (12.2)	0.589
Bleeding	1 (1.5)	1 (2.4)	0.723
Surgical site infection	0 (0)	0 (0)	0.506
Severe complication^a	0 (0)	0 (0)	-
Reoperation	0 (0)	0 (0)	-
Readmission within 30 days	7 (10.4)	3 (7.3)	0.739
Morality within 30 days	0 (0)	0 (0)	-

Table 1. Characteristics of study data

TAP, transversus abdominis plane.

Table 2. Comparison of baseline characteristics of the groups A and B

Values are presented as mean±standard deviation or number (%). Group A, multimodal pain management group. Group B, conventional management group.

ASA, American Society of Anesthesiologists.

Table 3. Perioperative outcome with groups A and B

Values are presented as mean±standard deviation or number (%). Group A, multimodal pain management group. Group B, conventional management group.

VAS, visual analog scale.

Clavien-Dindo classification ≥IIIa (requiring surgical, endoscopic, or radiological intervention not under radiological intervention).