Effect of liposomal bupivacaine on opioid requirements and length of stay in colorectal enhanced recovery pathways: A systematic review and network meta‐analysis

Abstract

Aim: Reducing postoperative opioid consumption is a key aim of enhanced recovery after colorectal surgery protocols. Potential solutions include anaesthetic techniques such as local infiltration of anaesthetic agents or transversus abdominis plane (TAP) blocks. This study aimed to assess the efficacy of liposomal bupivacaine (LB) for colorectal resections, across a variety of anaesthetic techniques. Methods: PubMed, Scopus and Embase databases were searched for relevant studies assessing LB, administered by any anaesthetic technique. The primary outcome was postoperative morphine consumed (milligrams) and the secondary outcome was length of stay (days). A Bayesian network meta-analysis comparing LB versus non-LB analgesia was performed alongside meta-regression for different surgical approaches. Results: Twelve trials were included, with a total of 2512 patients. LB-based wound infiltration was most likely to reduce length of stay followed by TAP block with LB (sum under the cumulative ranking [SUCRA] 85.55 and 70.26, respectively). TAP block with LB was most likely to reduce morphine requirements, followed by wound infiltration with LB (SUCRA 83.94 and 75.73, respectively). Compared to standard analgesia, LB-based wound infiltration reduced morphine usage (mean difference 36.64 mg, 95% credibility interval 15.64-59.20) and length of stay (mean difference 1.79 days, 95% credibility interval 0.59-3.81). On meta-regression, the findings held for minimally invasive surgery only. Conclusion: Although LB-based interventions were associated with reduced postoperative morphine requirements and length of stay in this network meta-analysis, the confidence in these estimates was graded as very low. Further well-executed trials are required before LB can be recommended as a first-line agent.

The use of liposomal bupivacaine in fracture surgery: a review

“…Two studies compared liposomal bupivacaine to saline injection or no injection at all and found no difference in pain scores on postoperative days 1–4 [ 30 , 32 ]. Chen et al also found no difference in pain scores on postoperative days 1–4 when comparing supraclavicular nerve block with and without the addition of liposomal bupivacaine [ 33 ].…”

“…In addition to these studies on the use of liposomal bupivacaine in total knee arthroplasty, there is also an abundance of data, including meta-analyses and systematic reviews, on the use of liposomal bupivacaine in total hip arthroplasty and total shoulder arthroplasty [ 27 – 31 ]. Some of these studies, as well as many studies in the general surgery, and anesthesia literature fail to identify much, if any, difference between the use of standard bupivacaine and liposomal bupivacaine [ 32 – 34 ].…”

Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

“…195 Data remain controversial regarding the purported extended duration of benefit with long-acting local anesthetics such as liposomal bupivacaine in reducing postoperative opioid consumption. 196–199…”

“…195 Data remain controversial regarding the purported extended duration of benefit with long-acting local anesthetics such as liposomal bupivacaine in reducing postoperative opioid consumption. [196][197][198][199] Another option, spinal analgesia with intrathecal morphine administration, can be used in the perioperative setting. Studies and meta-analyses have shown that intrathecal morphine is more effective than intravenous opioids in laparoscopic surgery and is associated with lower pain scores.…”

Single-shot liposomal bupivacaine in place of rectus sheath catheters to provide non-opiate analgesia after laparotomy: a quality improvement project to reduce the need for ongoing nursing input

“…Additionally, there is evidence to support the use of LB in abdominal surgery when given as a transversus abdominis plane block 13–15. Specific to colorectal resections, but not discriminatory in the mode of its delivery, two systematic reviews with meta-analysis associate the use of LB with reduced postoperative morphine requirements and shorter lengths of stay 16 17. To our knowledge, there are no studies that directly compare the efficacy of LB to bupivacaine delivered via RSCs.…”