REGIONAL ANAESTHESIA. Editor s key points. M. Wongyingsinn 1 *, G. Baldini 1, B. Stein 2, P. Charlebois 2, S. Liberman 2 and F.

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1 British Journal of Anaesthesia 108 (5): (2012) Advance Access publication 8 March doi: /bja/aes028 REGIONAL ANAESTHESIA analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial M. Wongyingsinn 1 *, G. Baldini 1, B. Stein 2, P. Charlebois 2, S. Liberman 2 and F. Carli 1 1 Department of Anaesthesia and 2 Department of Surgery, McGill University Health Centre (MUHC), 1650 Cedar Avenue, Room D10-144, Montreal, QC, Canada H3G 1A4 * Corresponding author. minkcheerful@hotmail.com, mingkwan.wongyingsinn@mail.mcgill.ca Editor s key points There are relatively few studies on the impact of regional analgesia on postoperative outcome after abdominal surgery. analgesia was compared with patient-controlled analgesia alone in patients undergoing laparoscopic colonic resection. analgesia provided better analgesia in the first 24 h, but had no impact on long-term outcome. This study adds to the evidence of the impact of analgesic regime on postoperative long-term outcome. Background. This study was undertaken to determine the impact of an intrathecal mixture of bupivacaine and morphine, when compared with systemic morphine, on the quality of postoperative analgesia and other outcomes in the context of the enhanced recovery after surgery (ERAS) programme for laparoscopic colonic resection. Methods. Fifty patients undergoing general anaesthesia were randomly allocated to receive either a spinal mixture of bupivacaine and morphine followed by oral oxycodone (spinal group) or patient-controlled analgesia (PCA group). The primary outcome was consumption of opioids during the first three postoperative days. Secondary outcomes were pain scores, return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay. Results. Postoperative opioid consumption in the spinal group was significantly less over the first three postoperative days (P,0.001). The quality of analgesia at rest in the first 24 h was better in the spinal group (P,0.005). Excessive sedation and respiratory depression were reported in two elderly patients with spinal analgesia. There were no differences between the two groups in other outcomes (return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay). Conclusions. When ERAS programme is used for laparoscopic colonic resection, an intrathecal mixture of bupivacaine and morphine was associated with less postoperative opioid consumption, but has no other advantages over systemic opioids. Keywords: anaesthetic techniques, subarachnoid; analgesia, patient-controlled; analgesia, postoperative Accepted for publication: 23 December 2011 Optimal analgesia is an essential component of the enhanced recovery after surgery (ERAS) programme as it would facilitate earlier out-of-bed mobilization and earlier oral intake, thus leading to shorter length of hospital stay, and accelerated convalescence. 1 4 While epidural analgesia has been shown to be an important component of the ERAS programme in open colon resection, the application of this analgesic technique in laparoscopic colon surgery remains controversial. 5 9 The use of patient-controlled analgesia (PCA) with morphine has been shown to provide adequate pain relief in the context of either conventional or ERAS programme; however, superior analgesia and earlier convalescence were achieved with epidural The study in 2002 assessing two analgesic regimens after laparoscopic colonic resection revealed that an intrathecal mixture of local anaesthetics and opioids provided superior postoperative analgesia compared with intrathecal local anaesthetics alone. 4 However, the authors did not provide information on perioperative care used and on the outcome of bowel function. 4 In a recent study, the combination of laparoscopy, ERAS programme, and intrathecal injection of bupivacaine and diamorphine showed a very short length of hospital stay (23 h), but no information was provided on analgesia beyond 24 h. 12 With this in mind, this prospective randomized trial was designed to establish whether an intrathecal mixture of & The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please journals.permissions@oup.com

2 SA for laparoscopic colon resection BJA bupivacaine and morphine provides a difference in postoperative consumption of opioids and quality of postoperative pain control during the first three postoperative days compared with systemic morphine in a group of patients undergoing laparoscopic colonic resection and using the ERAS programme. Recovery of bowel function, duration of hospital stay, perioperative complications, and readmission rate were also evaluated. Methods The research protocol was approved by the Research Ethics Boards of the McGill University Health Centre (Gen06-023) and registered with ClinicalTrials.gov (NCT ). The study was conducted between October 2010 and April 2011 at the McGill University Health Centre, Montreal, Quebec, Canada. All patients undergoing elective laparoscopic colon resection and aged more than 18 yr were enrolled in the study. A written informed consent was obtained from all subjects. Criteria for exclusion were: rectal resection, ASA.III, contraindication to spinal analgesia including infection at the site of injection and coagulopathy, chronic use of opioid, liver or renal impairment, and inability to communicate in either French or English. All patients were assessed in the preoperative clinic and a booklet on the ERAS programme. In addition, patients were instructed on how to use the numerical rating scale (NRS) for pain and gradedfrom0(nopain)to10(worstpain)andthepcadevice. A diary was also given to record daily pain intensity, nausea and vomiting, and oral intake of fluids and solids. The patients were also told to expect to leave the hospital by the third postoperative day if they met the discharge criteria (passage of formed stool, being mobile, full diet, and minimal pain). Anaesthesia The patients did not receive premedication. Anaesthesia was induced with propofol 2 mg kg 21 and fentanyl 1.5 mg kg 21. Rocuronium 0.6 mg kg 21 was given to facilitate orotracheal intubation. Anaesthesia was maintained with desflurane in a mixture of air 40% and oxygen 60%. End-tidal concentration of desflurane was adjusted to keep the bispectral index within Supplemental doses of 50 mg of fentanyl were administered if intraoperative heart rate and arterial pressure were.20% of baseline. Hypotension, systolic arterial pressure,20% of baseline values, was treated with phenylephrine. Intraoperative normothermia (temperature.368c) was maintained by positioning a thermal blanket over the exposed parts of the body. During surgery, all patients received an i.v. infusion of sodium chloride 0.9% set at a rate of 4 ml kg 21 h 21 and 500 ml of plasma expander. Prophylaxis of postoperative nausea and vomiting was achieved with dexamethasone 8 mg and droperidol mg administered after induction of anaesthesia. Study protocol On the morning of surgery and before the induction of anaesthesia, patients were randomly assigned, using a computer-generated number in brown sealed envelopes, to receive either spinal analgesia (spinal group) or i.v. PCA (PCA group). The randomization was in a block of five. Patients in the spinal group were positioned in the sitting position and a Whitacre 25 G needle was inserted at L3 4 intervertebral space and then isobaric bupivacaine 0.5% (10 mg) together with preservative-free morphine was injected. The dose of morphine was based on patient s age, with 200 mg in patients aged 75 yr and 150 mg in patients aged.75 yr. The sensory block (T4 and below dermatomes) to cold and pinprick was tested before induction of general anaesthesia. For postoperative analgesia, oral oxycodone 5 10 mg was prescribed every 3 h for the first 48 h as a breakthrough medication, if NRS pain at rest was more than 3. In the PCA group, patients received i.v. morphine delivered via a PCA pump, which was set up in the post-anaesthesia care unit (PACU) to deliver 1 mg every 7 min with no background infusion. Patients were instructed to use the PCA if the NRS pain at rest exceeded 3. PCA was discontinued 48 h after surgery, and oral oxycodone 5 10 mg was then provided every 3 h as a breakthrough medication. All patients received oral acetaminophen and naproxen daily for up to five postoperative days. Surgical care The ERAS programme for colon surgery was implemented at the MUHC in The following elements of ERAS programme were applied: patients education, selected bowel preparation, clear fluids up to 2 h before surgery, no premedication, intraoperative warming, small surgical incision, laparoscopy, absence of a nasogastric tube and drains, postoperative laxatives, postoperative nausea and vomiting prophylaxis, early oral diet and mobilization, and multimodal analgesia. All operations were performed by three laparoscopy-trained colorectal surgeons. Patients undergoing right hemicolectomy received no bowel preparation, whereas those undergoing left-sided resection received GoLYTELY w the day before surgery. Cefazoline 2 g and metronidazole 500 mg were administered i.v. 30 min before surgical incision. Antiembolic stockings were applied, and a urinary catheter was inserted in the bladder. The laparoscopic approach to surgical resection was previously described. 13 Postoperative care Once analgesia was optimized in the PACU, patients were transferred to the surgical ward where patients started oral fluids and sat on the chair. Nausea and vomiting were treated initially with i.v. dimenhydrinate, and ondansetron if necessary. Feeding with free fluids and semisolid food started the morning after surgery. There were no dietary restrictions. As part of the ERAS programme, patients were instructed to chew a gum three times a day, and to drink milk of magnesia daily. The bladder catheter was removed the morning after surgery if the haemodynamic conditions were stable and urine output was satisfactory. The ERAS 851

3 BJA Wongyingsinn et al. programme written orders were followed by the nursing team. The patients were assessed twice daily by the surgical team. Outcome measures Once patients were discharged home, the perioperative care data were extracted from the patients diaries and medical records by the research assistant, who is a bachelor student of biology and has no basic knowledge of the anaesthetic techniques used. The primary outcome measured was postoperative consumption of opioids during the first three postoperative days. For those who received PCA, the daily amount of morphine during the first 48 h and the amount of oral oxycodone consumed were recorded. For those in the spinal group, the daily amount of oral oxycodone was also measured. All i.v. and oral opioids consumptions were converted to morphine equivalent consumption which oral oxycodone 7.5 mg is equivalent to 5 mg of i.v. morphine. 14 The secondary outcome measure was the quality of postoperative pain control, as assessed by NRS at rest, on walking and on coughing at 24, 48, and 72 h after surgery. Intermediate outcomes included time to return of bowel function (passage of flatus and passage of formed stools), time to tolerate free fluids and full diet, readiness to discharge, duration of hospital stay, perioperative complications, and readmission rate. Duration of hospital stay was counted from the day of operation to the day of discharge. Respiratory depression is defined as a respiratory rate,10 bpm, oversedation is defined as difficult to rouse or unrousable, and respiratory distress is defined as a rapid, shallow breathing with hypoxaemia. Statistical analysis The sample size was calculated to detect morphine consumption in the first 24 h and based on the published study in major colorectal surgery. 9 Twenty-three patients in each group were sufficient to demonstrate a 50% reduction in postoperative morphine consumption during the first 24 h between two techniques with a type-1 error of 0.05 and a power of 80%. The number was increased to 25 patients to include 10% dropouts. All data were collected in a private computer database. Categorical variables were analysed using the x 2 test. Continuous variables are presented as mean and standard deviation (SD) or median and inter-quartile range (IQR) and were compared between the groups using either unpaired Student s t-test or the Mann Whitney U-test. A P-value of,0.05 was regarded as a significant difference. All statistical analyses were performed using SPSS version 18 for Windows (SPSS Inc., Chicago, IL, USA). Results Fifty-five patients were assessed in the preoperative clinic. The consort diagram showed the flow of participants through each stage of a randomized trial (Fig. 1). The patient characteristics and clinical data were presented in Analysis Allocation Enrolment Table 1. The success rate of spinal insertion was 100%. There were significant differences between the two groups in terms of duration of surgery, intraoperative fentanyl consumption, and the amount of crystalloid used (P¼0.01). The incidence of intraoperative hypotension requiring vasopressors was similar in both groups (Table 1). Primary outcome During the first postoperative 24 h, the median amount of morphine consumption in the spinal group was 8 (IQR 3 15) mg compared with 37 (IQR 23 47) mg in the PCA group, P, The median consumptions from 24 to 48 h in the spinal and PCA groups were, respectively, 0 (IQR 0 10) and 5 (IQR 1 15) mg, P¼0.08. From 48 to 72 h, morphine consumption in the spinal group was 0 (IQR 0 3) mg and in the PCA group was 13 (IQR 0 16 mg), P¼ The median cumulative morphine equivalent consumptions over the first 48 h were 13 (IQR 3 28) mg in the spinal group vs 43 (IQR 27 62) mg in the PCA group (P,0.001) and over the 72 h were 13 (IQR 4 35) mg in the spinal group and 56 (IQR 38 73) mg in the PCA group (P,0.001). In the PCA group, all patients were successfully transitioned to oral oxycodone 48 h after operation. In the first postoperative 72 h, three patients (13%) in the spinal group did not require supplement opioids, while all patients in the PCA group used PCA morphine as a rescue for pain (P¼0.07). Secondary outcomes Assessed for eligibility, n=55 Randomized, n=50 Primary exclusion, n=5 Not meeting inclusion criteria, n=2 Refused to participate, n=3 Allocated to spinal group, n=25 Allocated to PCA group, n=25 Secondary exclusion, n=1 Converted to laparotomy, n=1 Analysed, n=24 Analysed, n=25 Fig 1 CONSORT flow diagram. PCA, patient-controlled analgesia. Pain at rest during the first postoperative 24 h was significantly lower in the spinal group. Thereafter, no significant difference was shown between the groups (Table 2). During this time, the number of patients reporting no pain (NRS¼0) was greater in the spinal group (P¼0.002) (Fig. 2). There was no difference in time to return of bowel function (flatus and bowel movement) and dietary intake between the two groups. Similarly, readiness to discharge and duration of hospital stay were the same in the two groups (Table 2). Although 39 patients (80%) in total fulfilled the discharge criteria by postoperative day 3, only

4 SA for laparoscopic colon resection BJA Table 1 Patient characteristics, clinical data, postoperative complications, and readmission of two studied groups. Data are presented as mean (SD) or median (IQR). PCA, patient-controlled analgesia; BMI, body mass index; IBD, inflammatory bowel disease (n524) PCA (n525) P-value Age (range, yr) 65 (39 85) 65 (34 83) Sex (male, female) 11, 13 11, 14 BMI (kg m 22 ) 25 (5) 26 (5) ASA physical status I, II, III 5, 17, 2 6, 15, 4 Diagnosis (patients) Cancer, polyps, diverticular disease, IBD 12, 7, 5, 0 15, 6, 1, 3 Co-morbidity (patients) Hypertension 5 (20%) 4 (16%) Diabetes mellitus 3 (12%) 2 (8%) Anaemia 2 (8%) 1 (4%) Coronary artery disease 1 (4%) 2 (8%) Chronic obstructive pulmonary disease 1 (4%) 1 (4%) Atrial fibrillation 1 (4%) 1 (4%) Hypercholesterolaemia 1 (4%) 0 (0%) Type of surgery (patients) Right, left hemicolectomy 16, 8 10, 15 Duration of surgery (min) 137 ( ) 180 ( ) 0.03 Fentanyl consumption (mg) 250 ( ) 250 ( ) 0.01 Estimated blood loss (ml) 200 ( ) 235 ( ) 0.81 I.V. fluid replacement (litre) 1.2 ( ) 1.5 ( ) 0.03 Hypotension (patients) 11 (46%) 7 (28%) 0.20 Postoperative complications (patients) Respiratory depression 1 (4%) 0 (0%) 1.00 Oversedation 1 (4%) 0 (0%) 1.00 Nausea 5 (21%) 6 (24%) 1.00 Vomit 5 (21%) 5 (20%) 1.00 Pruritus 2 (8%) 0 (0%) 0.26 Ileus 1 (4%) 2 (8%) 1.00 Anaemia requiring blood transfusion 1 (4%) 1 (4%) 1.00 Tachycardia 1 (4%) 1 (4%) 1.00 Anastomotic abscess 1 (4%) 0 (0%) 1.00 Fever 1 (4%) 0 (0%) 1.00 Respiratory distress 1 (4%) 0 (0%) 1.00 Readmissions (patients) 1.00 Anastomotic leak 0 (0%) 1 (4%) 1.00 Anterior abdominal wall abscess 1 (4%) 0 (0%) 1.00 patients (65%) in each group were discharged within 3 days after operation (Fig. 3). The reasons for leaving the hospital after postoperative day 3 are presented in Table 3. Postoperative complications Two patients in the spinal groups stayed overnight in the postoperative care unit (PACU); one patient (age 75 yr) was oversedated and the other (age 81 yr) required ventilatory support for 8 h because of respiratory depression. They were transferred the following day to the postoperative ward and the postoperative course was uneventful. There were no differences between the two groups in the incidence of postoperative nausea and vomiting, pruritus, and ileus. Two patients had postoperative anaemia requiring blood transfusion; one patient in the spinal group had low preoperative haemoglobin (6 g litre 21 ) and intraoperative blood loss 400 ml, another patient in the PCA group had postoperative bleeding problem because of prophylaxis anticoagulants. One anastomotic abscess occurred in the spinal group, while the patient was still in hospital, and received a conservative treatment. One patient in each group had tachycardia, which was successfully managed with i.v. fluid resuscitation. One patient in the spinal group developed postoperative fever and had spontaneous recovery. One patient in the spinal group had postoperative respiratory distress which was improved with oxygen therapy. Two patients (4%) developed complications after discharge from the hospital and were readmitted; one patient in the 853

5 BJA Wongyingsinn et al. Table 2 Outcomes. Data are presented as median (IQR) or mean (SD). PCA, patient-controlled analgesia (n524) PCA (n525) P-value Number of patients 15 Patient-controlled analgesia (PCA) Pain at rest At 24 h 0 (0 1.5) 2 (1 4) At 48 h 0 (0 2) 1 (0 4) 0.15 At 72 h 0 (0 3) 0 (0 2.5) 0.87 Pain on walking At 24 h 2 (0 3) 2 (1 4) 0.12 At 48 h 0 (0 3)) 1 (0 4) 0.28 At 72 h 0 (0 3) 0 (0 2.5) 0.97 Pain on coughing At 24 h 3 ( ) 5 (2 5) 0.49 At 48 h 2 (0 3.5) 2 (1 5.5) 0.13 At 72 h 0 (0 4) 1 (0 3.5) 0.98 Time to first flatus (h) 37 (18) 30 (19) 0.18 Time to first bowel 56 (17) 56 (19) 0.92 movement (h) Time to first drink (h) 5 (5) 7 (5) 0.20 Time to first full diet (h) 42 (16) 38 (20) 0.33 Readiness to discharge 3 (3 3) 3 (3 4) 0.92 (days) Hospital stay (days) 3 (3 4) 3 (3 4) 0.59 Number of patients spinal group with anterior abdominal wall abscess which was treated with ultrasound-guided abscess drainage, and the other patient in the PCA group with anastomotic leak which required ultrasound-guided intra-abdominal drainage (Table 1). Discussion P=0.002 No pain (NRS 0) P=0.30 Mild pain (NRS 1 3) Patient-controlled analgesia (PCA) Pain levels P=0.05 Moderate pain (NRS 4 6) P=0.16 Severe pain (NRS 7 10) Fig 2 Distribution of pain intensity at rest at postoperative 24 h according to group assignment. NRS, numerical rating scale for pain. The numbers of patients in each category were compared between two study groups using the x 2 test. The results of this study indicate that, in the context of the ERAS programme, an intrathecal mixture of bupivacaine and morphine significantly decreased postoperative morphine consumption after laparoscopic colon surgery in the >5 Duration of hospital stay (days) Fig 3 Distribution of duration of hospital stay. first 72 h compared with systemic opioid. However, spinal analgesia did not influence the duration of hospital stay, time to return of bowel function and postoperative complications. Laparoscopic approach to colorectal resection has been shown to reduce length of hospital stay by 1.7 days and incidence of wound complications. 15 However, the benefits of laparoscopy on long-term outcomes are still being debated. In the quest to optimize surgical care, the ERAS programme was designed by combining a series of evidence-based interventions, which target physiological stresses related to surgery. A recent meta-analysis comparing ERAS programme with traditional care in open colorectal surgery demonstrated the superiority of the ERAS programme, resulting in significantly decreased length of stay by 2.6 days and rate of morbid events. 16 Based on these results, a multimodal intervention like the ERAS programme could provide better results than laparoscopy alone In reality, the two approaches are still used separately; while laparoscopy for colonic resection is rapidly adopted by many surgeons, surgical care in many units still remains very traditional Recently, a randomized study has demonstrated a significant advantage by implementing the ERAS programme together with laparoscopy The 33 h difference in overall time to recovery was due to better tolerance of early dietary intake in the group receiving the two interventions. 25 Similarly, the number of complications was less when laparoscopy and ERAS programme were implemented together. 25 The use of spinal analgesia for open and laparoscopic colorectal resection has been shown to provide a superior quality of pain relief compared with systemic morphine Similarly, in the present investigation, opioid consumption was consistently less in the spinal group during the first three postoperative days, with 13% of patients in this group not requesting oral opioids. Also, the number of patients having no pain on postoperative day 1 was significantly more in the spinal group (63% vs 48%). Furthermore, the number of patients reporting moderate pain was significantly less (4% vs 24%) and no patient reported severe pain (0% vs 8%). injection of opioids presents several advantages over systemic injection and epidural blockade, including 854

6 SA for laparoscopic colon resection BJA Table 3 Reasons for hospital discharge beyond postoperative day 3. BMI, body mass index; LOS, length of hospital stay after the operation; IBD, inflammatory bowel disease Age Sex BMI ASA Diagnosis Ready to D/C LOS Reason for delayed D/C Right hemicolectomy 75 F 26 2 Polyps 3 4 Social reason Right hemicolectomy 83 F 17 2 Polyps 3 4 Social reason Left hemicolectomy 59 M 24 1 Diverticular disease 4 4 Fever Right hemicolectomy 61 F 23 1 Polyps 6 6 Anaemia requiring blood transfusion Right hemicolectomy 80 M 25 2 Cancer 6 6 Tachycardia Right hemicolectomy 80 F 30 2 Cancer 6 6 Respiratory distress Right hemicolectomy 69 F 23 2 Cancer 7 7 Anastomotic abscess Right hemicolectomy 71 F 19 2 Cancer 9 9 Ileus PCA Right hemicolectomy 70 F 22 2 Cancer 3 4 Social reason Left hemicolectomy 54 F 21 2 IBD 3 4 Social reason Left hemicolectomy 76 F 27 3 Cancer 3 4 Social reason Left hemicolectomy 85 F 20 2 Cancer 3 4 Delay bowel movement Left hemicolectomy 51 M 25 1 Colo-vesicle fistula 3 4 Delay bowel movement Left hemicolectomy 67 F 25 3 Cancer 4 4 Tachycardia Left hemicolectomy 55 F 26 1 Cancer 5 5 Ileus Transverse colectomy 67 F 21 3 Cancer 6 6 Bleeding from prophylaxis anticoagulant Right hemicolectomy 47 F 20 1 IBD 6 6 Ileus less invasiveness, small dosage of opioids required to achieve the same analgesia, and lower failure rate as demonstrated in the randomized controlled trial comparing epidural, spinal, and PCA. 27 Despite the lower opioid consumption in the spinal group and better postoperative pain relief at rest on the first postoperative day in the spinal group, no other benefits could be accounted in this study. Return of bowel function, time to reach the criteria for discharge, number of postoperative complications, and length of hospital stay were in fact similar in both groups. This contrasts with the contention that better analgesia would accelerate postoperative outcome, thus leading to less complications. Explanation of negative finding could be attempted, although one cannot imply that the quality of analgesia was directly related to postoperative complications. It is likely that the effectiveness of the integrated interventions as part of the ERAS programme would overcome the impact that each modality could have on the short- and long-term outcomes which characterize the recovery process. In view of the limited published material on spinal analgesia for colon surgery, it was decided to consider postoperative morphine consumption as a primary outcome and confirm previous published findings indicating the optimal quality of analgesia achieved with this technique. Furthermore, it was an intention to verify whether the quality of analgesia with an intrathecal mixture of local anesthetic and opioid would impact on other relevant outcomes such as mobilization out of bed and dietary intake. The length of hospital stay was not chosen as a primary outcome because it depends upon many factors, such as administrative decisions, organization of hospital care, and patient s expectation, and therefore cannot be considered as a reliable outcome. Although there were no haemodynamic side-effects in the spinal group, two elderly patients in our series required overnight observation for excessive sedation and temporary ventilatory support, indicating that caution must be exercised when intrathecal opioids, even in small doses, are used in the elderly population. In contrast to our findings, other authors have injected up to 0.3 mg of intrathecal morphine in elderly patients undergoing open colorectal surgery and did not report either respiratory depression or excessive sedation This could be explained by more intense pain stimulation caused by open surgery, thus resulting in less incidence of respiratory depression and excessive sedation. One limitation of this study is related to the study design with the spinal group receiving oral opioids instead of PCA as in the control group. In other studies where the spinal mixture of local anaesthetic and opioid was compared with either PCA or epidural, oral tramadol and morphine were also used after surgery with satisfactory results In our study, the nurses undertook hourly assessment of pain together with other vital signs, and, if the NRS pain at rest was more than 3, patients would receive oral oxycodone. This approach might be criticized since it depends on the availability of nursing, however, from the date collected, it shows that the spinal group had better pain scores and consumed less opioids during the first 24 h. Another limitation is that the study was not blinded. To limit bias, a diary was constructed so that patients would record pain intensity and aspects of bowel function recovery (time and quantity of oral intake, nausea and vomiting, time to pass flatus, and bowel movements) twice a day. Together with the record of vital signs and the medication chart, the diaries were analysed once the patient was discharged. 855

7 BJA Wongyingsinn et al. In conclusion, the present randomized study in patients undergoing laparoscopic colon surgery and in the context of the ERAS programme confirmed that an intrathecal mixture of bupivacaine and morphine followed was associated with less postoperative opioid consumption compared with systemic morphine. However, the short period (24 h) of significant analgesia and the potential risk of excessive sedation and respiratory depression in an elderly population must be taken into consideration. Acknowledgements The authors thank the personnel in the minimally invasive operating theatres and the postoperative ward, Montreal General Hospital, McGill University Health Centre, for helping to complete this study. Declaration of interest None declared. Funding This work was supported by the Department of Anaesthesia, MUHC, Montreal, Quebec, Canada. References 1 Bollish SJ, Collins CL, Kirking DM, Bartlett RH. Efficacy of patientcontrolled versus conventional analgesia for postoperative pain. Clin Pharm 1985; 4: White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F. The role of the anesthesiologist in fast-track surgery: from multimodal analgesia to perioperative medical care. Anesth Analg 2007; 104: Zafar N, Davies R, Greenslade GL, Dixon AR. The evolution of analgesia in an accelerated recovery programme for resectional laparoscopic colorectal surgery with anastomosis. Colorectal Dis 2010; 12: Kong SK, Onsiong SM, Chiu WK, Li MK. Use of intrathecal morphine for postoperative pain relief after elective laparoscopic colorectal surgery. Anaesthesia 2002; 57: Carli F, Trudel JL, Belliveau P. The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial. Dis Colon Rectum 2001; 44: Senagore AJ, Whalley D, Delaney CP, Mekhail N, Duepree HJ, Fazio VW. Epidural anesthesia analgesia shortens length of stay after laparoscopic segmental colectomy for benign pathology. Surgery 2001; 129: Taqi A, Hong X, Mistraletti G, Stein B, Charlebois P, Carli F. Thoracic epidural analgesia facilitates the restoration of bowel function and dietary intake in patients undergoing laparoscopic colon resection using a traditional, nonaccelerated, perioperative care program. Surg Endosc 2007; 21: Zingg U, Miskovic D, Hamel CT, Erni L, Oertli D, Metzger U. Influence of thoracic epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal resection: benefit with epidural analgesia. Surg Endosc 2009; 23: Beaussier M, Weickmans H, Parc Y, et al. Postoperative analgesia and recovery course after major colorectal surgery in elderly patients: a randomized comparison between intrathecal morphine and intravenous PCA morphine. Reg Anesth Pain Med 2006; 31: Senagore AJ, Delaney CP, Mekhail N, Dugan A, Fazio VW. Randomized clinical trial comparing epidural anaesthesia and patientcontrolled analgesia after laparoscopic segmental colectomy. Br J Surg 2003; 90: Hong X, Mistraletti G, Zandi S, Stein B, Charlebois P, Carli F. Laparoscopy for colectomy accelerates restoration of bowel function when using patient controlled analgesia. Can J Anaesth 2006; 53: Levy BF, Scott MJ, Fawcett WJ, Rockall TA. 23-hour-stay laparoscopic colectomy. Dis Colon Rectum 2009; 52: Wongyingsinn M, Baldini G, Charlebois P, Liberman S, Stein B, Carli F. Intravenous lidocaine versus thoracic epidural analgesia: a randomized controlled trial in patients undergoing laparoscopic colorectal surgery using an enhanced recovery program. Reg Anesth Pain Med 2011; 36: McGill University Health Centre Opioid Therapy Guidelines. Montreal, Quebec, Canada: McGill University Health Centre, Tjandra JJ, Chan MK. Systematic review on the short-term outcome of laparoscopic resection for colon and rectosigmoid cancer. Colorectal Dis 2006; 8: Soop M. Multimodal rehabilitation in the laparoscopic era: still worth it? Dis Colon Rectum 2011; 54: Raue W, Haase O, Junghans T, Scharfenberg M, Muller JM, Schwenk W. Fast-track multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: a controlled prospective evaluation. Surg Endosc 2004; 18: CarliF,CharleboisP,BaldiniG,CacheroO,SteinB.Anintegratedmultidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery. Can J Anaesth 2009; 56: Lindsetmo RO, Champagne B, Delaney CP. Laparoscopic rectal resections and fast-track surgery: what can be expected? Am J Surg 2009; 197: Patel GN, Rammos CK, Patel JV, Estes NC. Further reduction of hospital stay for laparoscopic colon resection by modifications of the fast-track care plan. Am J Surg 2010; 199: Scatizzi M, Kroning KC, Boddi V, De Prizio M, Feroci F. Fast-track surgery after laparoscopic colorectal surgery: is it feasible in a general surgery unit? Surgery 2010; 147: Tsikitis VL, Holubar SD, Dozois EJ, Cima RR, Pemberton JH, Larson DW. Advantages of fast-track recovery after laparoscopic right hemicolectomy for colon cancer. Surg Endosc 2010; 24: Kumar A, Hewett PJ. Fast-track or laparoscopic colorectal surgery? ANZ J Surg 2007; 77: Slim K, Fingerhut A. Laparoscopy or fast-track surgery, or both? Surg Endosc 2009; 23: Lee TG, Kang SB, Kim DW, Hong S, Heo SC, Park KJ. Comparison of early mobilization and diet rehabilitation program with conventional care after laparoscopic colon surgery: a prospective randomized controlled trial. Dis Colon Rectum 2011; 54: Virlos I, Clements D, Beynon J, Ratnalikar V, Khot U. Short-term outcomes with intrathecal versus epidural analgesia in laparoscopic colorectal surgery. Br J Surg 2010; 97: Levy BF, Scott MJ, Fawcett W, Fry C, Rockall TA. Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. Br J Surg 2011; 98: Bailey PL, Lu JK, Pace NL, et al. Effects of intrathecal morphine on the ventilatory response to hypoxia. NEnglJMed2000; 343: Cole PJ, Craske DA, Wheatley RG. Efficacy and respiratory effects of low-dose spinal morphine for postoperative analgesia following knee arthroplasty. Br J Anaesth 2000; 85: