Laparoskopik Kolesistektomi Sonrası Ağrı Tedavisinde İntraperitoneal Uygulanan Lornoksikam ve Ropivakainin Etkisinin Karşılaştırılması

Trakya Univ Tip Fak Derg 2010;27(2):142-149 • doi: 10.5174/tutfd.2008.01046.2 Original Article / Klinik Çalışma - Araştırma Comparison of Analgesic Effects of Intraperitoneal Lornoxicam and Ropivacaine Administration in Laparoscopic Cholecystectomy Laparoskopik Kolesistektomi Sonrası Ağrı Tedavisinde İntraperitoneal Uygulanan Lornoksikam ve Ropivakainin Etkisinin Karşılaştırılması Ceyhun MEMEDOV, Öner MENTEŞ, Abdurrahman ŞİMŞEK, Can KEÇE, Gökhan YAĞCI, Ali HARLAK, Ahmet COŞAR,1 Turgut TUFAN Departments of General Surgery and 1Anesthesiology, Gülhane Military Medical School, Ankara Submitted / Başvuru tarihi: 25.09.2008 Accepted / Kabul tarihi: 04.12.2008 Objectives: In this randomized prospective study, we investigated the effects of lornoxicam vs. ropivacaine for the management of postoperative pain in patients undergoing elective laparoscopic cholecystectomy. Amaç: Prospektif randomize olarak yapılan bu çalışmada laparoskopik kolesistektomi sonrası ağrı tedavisinde lornoksikam ve ropivakainin etkisi araştırılmıştır. Results: At 24 h, VAS scores at rest and while coughing were found significantly lower in ropivacaine and lornoxicam group when compared with control group (p=0.047). The percentage of patients needing tramadol was significantly lower with ropivacaine and lornoxicam compared with control (p<0.001, p=0.018). There was no statistically significant difference between ropivacaine and lornoxicam group. Bulgular: Ropivakain ve lornoksikam grubunda istirahat ve öksürük sonrası VAS değerleri kontrol grubuna göre daha düşük bulundu (p=0.047). Tramadol tüketimi açısından, ropivakain ve lornoksikam grupları arasında fark bulunmazken (p>0.05), kontrol grubuna göre bu iki grupta anlamlı düşük olarak bulundu (p<0.001, p=0.018). Ropivakain ve lornoksikam grubu arasında ise istatistiksel olarak anlamlı fark bulunmadı. Hastalar ve Yöntemler: Çalışmaya dahil edilen 45 hasta üç gruba randomize edildi. Hastalara 150 mg (80 mL) ropivakain, 16 mg lornoksikam (80 mL) ve plasebo (80 mL saline) intraperitoneal olarak püskürtüldü ve port bölgelerine infiltre edildi. Ameliyat bitiminde hasta kontrollü analjezi cihazı ile tramadol 50 mg yükleme dozu, 5 mg bazal infüzyon, bolus doz 20 mg, kilitli kalma süresi 30 dk, 4 saatlik limit 200 mg olarak planlandı. Hastaların ağrısı görsel analog skala (VAS) ile 0-100 olacak şekilde istirahat, öksürük sonrası ve mobilizasyon sırasında değerlendirildi. Ağrı skorları ilk saatte anestezi derlenme odasında ve 2., 4., 8., 12., 18., 24. saatlerde serviste değerlendirildi. Patients and Methods: Patients were randomized into three groups and received 150 mg (80 mL) ropivacaine or 16 mg lornoxicam (80 mL) or placebo (80 mL saline) via multi-regional intraperitoneal instillation and port sites infiltration. Patient-controlled analgesia (PCA) device was used. Tramadol 50 mg tolerable dose, 5 mg/hour basal infusion, bolus dose 20 mg, locked 30 min, 4 hour limit were applied as 200 mg. Postoperative pain was assessed with 100-mm visual analog scale (VAS) at rest, while coughing, and during mobilization. Pain scores were recorded in the post-anesthesia care unit, and at 2, 4, 8, 12,18 and 24 h after the surgery. Sonuç: Ropivakain ve lornoksikamın port bölgelerine, intraperitoneal çoklu bölgeye laparoskopik kolesistektomi sonrası infiltrasyonu ameliyat sonrası ağrı tedavisinde etkin olarak bulunmuştur. Conclusion: Multi-regional, intraperitoneal instillation and port site infiltration of ropivacaine and lornoxicam during laparoscopic cholecystectomy reduces the postoperative pain. Key words: Laparoscopic cholecystectomy; ropivacaine; lornoxicam; postoperative pain. Anahtar sözcükler: Laparoskopik kolesistektomi; ropivakain; lornoksikam; ameliyat sonrası ağrı. Correspondence (İletişim adresi): Dr. Öner Menteş. Gülhane Askeri Tıp Akademisi Genel Cerrahi Anabilim Dalı, 06018 Ankara. Tel: 0312 - 304 50 15 Fax (Faks): 0312 - 304 51 02 e-mail (e-posta): © Trakya Üniversitesi Tıp Fakültesi Dergisi. Ekin Tıbbi Yayıncılık tarafından basılmıştır. Her hakkı saklıdır. © Medical Journal of Trakya University. Published by Ekin Medical Publishing. All rights reserved. 142 Comparison of Analgesic Effects of Intraperitoneal Lornoxicam and Ropivacaine Administration in Laparoscopic Cholecystectomy Laparoscopic cholecystectomy (LC) has become a gold standard and preferred surgical technique for gall bladder pathologies because of an improved postoperative course compared with open surgery.[1,2] Although LC results in less postoperative pain and/or reduced analgesic consumption, better cosmetic results, and a shorter hospital stay compared with open cholecystectomy, however, it is not a pain-free procedure.[2,3] Early postoperative pain is the most prevalent and dominant complaint that requires strong analgesia including opiates after elective laparoscopic cholecystectomy.[4] For that reason, many efforts have been made to improve postoperative analgesia after LC, but postoperative pain, however, does not completely disappear and several studies have shown that visceral pain is the major component.[5,6] Nonetheless, post-cholecystectomy pain may be moderate or even severe for some patients during the first 24 postoperative hours, and has frequently been treated with nonsteroid anti-inflammatory drugs (NSAIDs) or opioid treatment.[7,8] when they had postoperative complications, which could increase postoperative pain. Thus, only those who were likely to have a simple laparoscopic cholecystectomy were included. Before the end of the surgery, metoclopramide (10 mg) was given intravenously to all patients to reduce the incidence of nausea and vomiting. No patient underwent the placement of intraperitoneal drain. Patients were divided into three randomized groups with 15 patients in each group. In the control group, at the end of the surgical process, 80 mL of saline was instillated under direct vision by the surgeon into the gallbladder bed after partial retrograde release of the gallbladder, right and left subdiaphragmatic area and instillation to the visceral peritoneum at the end of the procedure. The remaining 20 ml salin was injected into the four port access in which one port was injected 5 ml’s. For the patients in the 2nd (ropivacaine) group, at the end of the surgical process, 80 ml ropivacaine (Naropin® 7.5 mg/ml 20 ml was diluted with 80 ml saline totally 100 ml solution) was instillated into the gallbladder bed, right and left subdiaphragmatic area and the visceral peritoneal surface respectively, then the remaining 20 ml was infiltrated around the port trocar sites in 5 ml’s. Local anesthetic infiltration is often used to improve pain relief after laparoscopic cholecystectomy.[5,9-13] The postoperative analgesic effect of intraperitoneal administration of local anesthesia after laparoscopic gynecologic surgery has proved to be effective and safe but there is lack of consensus regarding the dose, concentration, site, and manner of administration.[14 (...truncated)