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Ann Coloproctol > Volume 40(3); 2024 > Article
Kim, Lee, Bae, Han, Lee, Lee, Lee, and Kim: Clinical impact of a multimodal pain management protocol for loop ileostomy reversal

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.

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 [46]. 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 [79]. 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 [1013]. 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 [1517]. 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.

Notes

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.
ac-2022-01137-0162f1.jpg
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.
ac-2022-01137-0162f2.jpg
ac-2022-01137-0162f3.jpg
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 complicationa 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).

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