Pain Assessment and Analgesic Requirements after Sleeve Gastrectomy: A Comparison Study of Robotic versus Laparoscopic Approaches
Abstract
:1. Introduction
2. Materials and Methods
2.1. Patient Qualification for LSG and RSG
- Patient preference: After thorough explanation of both procedures, patients were given the option to choose between LSG and RSG, provided there were no contraindications.
- Surgeon assessment: The operating surgeon evaluated each patient’s specific anatomical and clinical factors. For instance, patients with extreme obesity (BMI > 60 kg/m2) or those with complex abdominal surgical history were more likely to be recommended for RSG due to the potential benefits of enhanced visualization and precision.
- Equipment availability: The allocation of patients to LSG or RSG was also influenced by the availability of the robotic system on the day of surgery.
- Contraindications: Patients with specific contraindications to pneumoperitoneum or Trendelenburg position were not considered for RSG.
- Learning curve considerations: To ensure patient safety during the initial phase of robotic surgery implementation, patients with lower BMI and fewer comorbidities were preferentially selected for RSG.
2.2. Surgical Approach and Perioperative Management
2.3. Pain Management and Assessment
2.4. TAP Block Administration
2.5. Pain Management Protocol
- Patient education on pain expectations and management strategies;
- Administration of acetaminophen 1000 mg PO;
- Administration of celecoxib 200 mg PO (if not contraindicated).
- Transversus abdominis plane (TAP) block: 20 mL of 0.25% bupivacaine bilaterally, administered under ultrasound guidance after induction of anesthesia (when applicable);
- Dexamethasone 8 mg IV at induction (for anti-emetic and analgesic properties);
- Fentanyl IV as needed, titrated to effect.
- Fentanyl IV for breakthrough pain, administered in 25–50 mcg increments as needed;
- Ondansetron 4 mg IV every 6 h as needed for nausea/vomiting.
- Acetaminophen 1000 mg PO every 6 h (not to exceed 4000 mg in 24 h);
- Ketorolac 30 mg IV every 6 h for the first 24 h, then transition to ibuprofen 600 mg PO every 6 h if needed;
- Tramadol 50–100 mg PO every 6 h as needed for moderate pain;
- Oxycodone 5–10 mg PO every 4–6 h as needed for severe pain.
- Acetaminophen 500 mg PO every 6 h as needed;
- Ibuprofen 600 mg PO every 6 h as needed;
- Oxycodone 5 mg PO every 6 h as needed for severe pain, limited to a 3-day supply.
2.6. Statistical Analysis
- Descriptive statistics: Continuous variables were summarized using mean (standard deviation) for normally distributed data and median (range) for non-normally distributed data. Categorical variables were presented as numbers and percentages.
- Pain score analysis: Due to substantial positive skew in the pain score distribution, scores were log-transformed to reduce skew. Mixed-effects models were employed to account for the repeated-measures nature of the data (multiple pain assessments per patient).
- Time series modeling: Time was divided into period groupings aligned with scheduled pain assessments (e.g., immediately post-procedure, 2 h post, 4 h post, etc.). A proxy series was specified at the repeated-measures level to account for a non-parametric time trend.
- Medication analysis: For each time period T pain medications administered after the prior pain assessment (T minus 1) but before the current assessment T were captured at the repeated-measures level with indicator variables. Pre-procedure and intraoperative pain medications were captured with surrogate series and were allowed to moderate the repeated-measures level intercept.
- Comparative analysis: “Approach by time-period” interaction variables were specified to examine differences between LSG and RSG at each time period. The approach difference immediately post-procedure served as the reference when testing these interaction effects.
- Interactions with associated p-values greater than 0.30 were removed from the model, producing the reduced model presented in this manuscript.
- Additional calculations: The number of medications administered, mean dosages, and number of administrations of a given medication were calculated. Specific focus was given to intraoperative fentanyl and postoperative opioids, ketorolac, acetaminophen, and tramadol.
- Significance level: A p-value <0.05 was considered statistically significant for all analyses.
- Software: All analyses were performed using R (version 2.13 or higher, The R Foundation for Statistical Computing, Vienna, Austria).
3. Results
3.1. Patients’ Characteristics and Demographics
3.2. Pain Management
3.3. Pain Assessment
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- American Society for Metabolic and Bariatric Surgery (ASMBS). Estimate of Bariatric Surgery Numbers. Available online: https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers/ (accessed on 5 July 2024).
- Fazl Alizadeh, R.; Li, S.; Inaba, C.S.; Dinicu, A.I.; Hinojosa, M.W.; Smith, B.R.; Stamos, M.J.; Nguyen, N.T. Robotic versus laparoscopic sleeve gastrectomy: A MBSAQIP analysis. Surg. Endosc. 2019, 33, 917–922. [Google Scholar] [CrossRef]
- Vilallonga, R.; Fort, J.M.; Caubet, E.; Gonzalez, O.; Armengol, M. Robotic sleeve gastrectomy versus laparoscopic sleeve gastrectomy: A comparative study with 200 patients. Obes. Surg. 2013, 23, 1501–1507. [Google Scholar] [CrossRef] [PubMed]
- Gamboa, J.S.B. Pain Management in Weight Loss Surgery: Aiming for Multimodal Approach. Adv. Obes. Weight. Manag. Control 2016, 5, 232–237. [Google Scholar] [CrossRef]
- Argoff, C. Mechanisms of pain transmission and pharmacologic management. Curr. Med. Res. Opin. 2011, 27, 2019–2031. [Google Scholar] [CrossRef] [PubMed]
- Post-operative pain. Nurs. Stand. 2016, 30, 17.
- Iamaroon, A.; Tangwiwat, S.; Nivatpumin, P.; Lertwacha, T.; Rungmongkolsab, P.; Pangthipampai, P. Risk Factors for Moderate to Severe Pain during the First 24 Hours after Laparoscopic Bariatric Surgery while Receiving Intravenous Patient-Controlled Analgesia. Anesthesiol. Res. Pract. 2019, 2019, 6593736. [Google Scholar] [CrossRef] [PubMed]
- Saleh, T.; Ford, J.; Kindel, T.; Higgins, R.; Lak, K.; Gould, J.; Tan, W.H. Inpatient opioid use and pain control after robotic versus laparoscopic sleeve gastrectomy. Surgery 2024, 175, 599–604. [Google Scholar] [CrossRef] [PubMed]
- Macfater, H.; Xia, W.; Srinivasa, S.; Hill, A.G.; Van De Velde, M.; Joshi, G.P.; PROSPECT Collaborators. Evidence-Based Management of Postoperative Pain in Adults Undergoing Laparoscopic Sleeve Gastrectomy. World J. Surg. 2019, 43, 1571–1580. [Google Scholar] [CrossRef] [PubMed]
- Tan, S.; Lee, E.; Lee, S.; Sakaria, S.; Roh, J. Morphine Equianalgesic Dose Chart in the Emergency Department. J. Educ. Teach. Emerg. Med. 2022, 7, L1–L20. [Google Scholar] [CrossRef] [PubMed]
- Iohom, G. Clinical Assessment of Postoperative Pain. In Postoperative Pain Management: An Evidence-Based Guide to Practice; WB Saunders: Philadelphia, PA, USA, 2006; pp. 102–108. [Google Scholar]
- Serin, S.O.; Işıklar, A.; Karaören, G.; El-Khatib, M.F.; Caldeira, V.; Esquinas, A. Atelectasis in bariatric surgery: Review analysis and key practical recommendations. Turk. J. Anaesthesiol. Reanim. 2019, 47, 431–438. [Google Scholar] [CrossRef] [PubMed]
- Shetty, S.; Parthasarathy, S. Obesity Hypoventilation Syndrome. Curr. Pulmonol. Rep. 2015, 4, 42. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
- Jamal, M.H.; Corcelles, R.; Shimizu, H.; Kroh, M.; Safdie, F.M.; Rosenthal, R.; Brethauer, S.A.; Schauer, P.R. Thromboembolic events in bariatric surgery: A large multi-institutional referral center experience. Surg. Endosc. 2015, 29, 376–380. [Google Scholar] [CrossRef]
- Huang, N.; Cunningham, F.; Laurito, C.E.; Chen, C. Can we do better with postoperative pain management? Am. J. Surg. 2001, 182, 440–448. [Google Scholar] [CrossRef]
- Hoehn, R.S.; Seitz, A.P.; Singer, K.E.; Thompson, J.R.; Watkins, B.M. Enhanced Recovery Protocol for Laparoscopic Sleeve Gastrectomy: Are Narcotics Necessary? J. Gastrointest. Surg. 2019, 23, 1541–1546. [Google Scholar] [CrossRef] [PubMed]
- Weingarten, T.N.; Sprung, J. Review of Postoperative Respiratory Depression: From Recovery Room to General Care Unit. Anesthesiology 2022, 137, 735–741. [Google Scholar] [CrossRef]
- Cleveland, E.M.; Peirce, G.S.; Freemyer, J.D.; Schriver, J.P.; Ahnfeldt, E.P.; Rice, W.V. Prospective randomized double-blind controlled trial of continuous local anesthetic infusion to reduce narcotic use in laparoscopic sleeve gastrectomy. Surg. Obes. Relat. Dis. 2015, 11, 1152–1156. [Google Scholar] [CrossRef] [PubMed]
- Coley, K.C.; Williams, B.A.; DaPos, S.V.; Chen, C.; Smith, R.B. Retrospective evaluation of unanticipated admissions and readmissions after same day surgery and associated costs. J. Clin. Anesth. 2002, 14, 349–353. [Google Scholar] [CrossRef]
- Song, K.; Melroy, M.J.; Whipple, O.C. Optimizing multimodal analgesia with intravenous acetaminophen and opioids in postoperative bariatric patients. Pharmacotherapy 2014, 34, 14S–21S. [Google Scholar] [CrossRef] [PubMed]
- Schug, S.A.; Bruce, J. Risk stratification for the development of chronic postsurgical pain. PAIN Rep. 2017, 2, e627. [Google Scholar] [CrossRef] [PubMed]
- Alper, N.; Bassiri-Tehrani, B.; Teixeira, J. Post-Operative Pain Outcomes in Robotic Sleeve Gastrectomy. Surg. Obes. Relat. Dis. 2017, 13, S195. [Google Scholar] [CrossRef]
- Pepper, V.K.; Rager, T.M.; Diefenbach, K.A.; Raval, M.V.; Teich, S.; Michalsky, M.P. Robotic vs. Laparoscopic Sleeve Gastrectomy in Adolescents; Reality or Hype. Obes. Surg. 2016, 26, 1912–1917. [Google Scholar] [CrossRef] [PubMed]
- Magouliotis, D.E.; Tasiopoulou, V.S.; Sioka, E.; Zacharoulis, D. Robotic versus Laparoscopic Sleeve Gastrectomy for Morbid Obesity: A Systematic Review and Meta-analysis. Obes. Surg. 2017, 27, 245–253. [Google Scholar] [CrossRef] [PubMed]
- Shoqirat, N.; Mahasneh, D.; Al-Khawaldeh, O.; Singh, C. Postoperative Patients in Jordan: Pain Prevalence, Characteristics, Beliefs, and Satisfaction. Pain Manag. Nurs. 2019, 20, 239–244. [Google Scholar] [CrossRef]
- Dang, J.T.; Szeto, V.G.; Elnahas, A.; Ellsmere, J.; Okrainec, A.; Neville, A.; Malik, S.; Yorke, E.; Hong, D.; Biertho, L.; et al. Canadian consensus statement: Enhanced recovery after surgery in bariatric surgery. Surg. Endosc. 2020, 34, 1366–1375. [Google Scholar] [CrossRef] [PubMed]
LSG (n = 435) | RSG (n = 49) | p-Value | |
---|---|---|---|
Patient Factors | |||
Age (median, range) | 29 (18–63) | 33 (18–70) | 0.06 |
Female (N, %) | 239 (54.9) | 28 (57.1) | 0.77 |
Initial BMI (mean, SD) | 45.0 (±7.4) | 43.3 (±5.3) | 0.11 |
Functional status | |||
Independent | 435 (100) | 49 (100) | - |
Smoker (N, %) | 92 (21.1) | 17 (34.6) | 0.03 |
ASA category | 0.45 | ||
ASA 1–2 | 128 (29.4) | 18 (36.7) | |
ASA 3 | 305 (70.1) | 31 (63.3) | |
ASA 4–5 | 2 (0.5) | 0 (0.0) | |
Comorbidities (N, %) | |||
Diabetes | 107 (24.5) | 5 (10.2) | 0.02 |
OSA | 135 (31.0) | 15 (30.6) | 0.95 |
HTN | 134 (30.8) | 14 (28.5) | 0.87 |
GERD | 132 (30.3) | 7 (14.2) | 0.01 |
COPD | 3 (0.6) | 0 (0.0) | 0.56 |
DLD | 183 (42.0) | 22 (44.8) | 0.75 |
Chronic steroids | 23 (5.2) | 0 (0.0) | 0.14 |
Renal insufficiency | 19 (4.3) | 2 (4.0) | 0.92 |
Dialysis | 4 (0.9) | 0 (0.0) | 0.50 |
Prior VTE | 6 (1.3) | 1 (2.0) | 0.71 |
Therapeutic anticoagulation | 15 (3.4) | 0 (0.0) | 0.37 |
Prior MI | 15 (3.4) | 1 (2.0) | 0.60 |
LSG | RSG | p-Value | |
---|---|---|---|
Mean operative time (minutes) | 89.9 ± 30.5 | 122.5 ± 27.1 | <0.001 |
Transverse abdominis plane (TAP) block performed (%) | 53 (12.2%) | 13 (27%) | 0.005 |
Use of fentanyl IV (%) | 219 (50.5%) | 29 (60.4%) | 0.404 |
Mean fentanyl dose (mcg) | 50 | 50 | - |
Morphine Equivalent Daily Dose (mg/day) | 2880 | 2880 | - |
Use of acetaminophen 1000 mg (%) | 254 (58.5%) | 36 (75%) | 0.188 |
Use of other analgesic medications (%) | 199 (45.7%) | 6 (12.7%) | <0.001 |
Medication | Mean Dose LSG Cohort | # of Pts LSG | Mean Dose RSG Cohort | # of Pts RSG | Time Period |
---|---|---|---|---|---|
Fentanyl IV | 50 mcg | 305 (70.3%) | 50 mcg | 33 (68.8%) | 48 h |
MEDD using fentanyl IV | 2880 mg/day | 305 (70.3%) | 2880 mg/day | 33 (68.8%) | 24 h |
Morphine IV | 9.45 mg | 226 (52.1%) | 10 mg | 21 (43.8%) | 48 h |
MEDD using fentanyl IV combined with Morphine IV | 2889.45 mg/day | - | 2890 mg/day | - | 24 h |
Medication | Mean Dose in LSG Cohort | Mean Dose in RSG Cohort | Mean # of Doses LSG | Mean # of Doses RSG |
---|---|---|---|---|
Ketorolac IV | 30 mg | 30 mg | 6.74 ± 2.20 | 7.55 ± 1.01 |
Acetaminophen IV | 994.1 mg | 994.7 mg | 5.97 ± 1.57 | 6.04 ± 0.99 |
Medication | Mean # of Doses LSG | # of Patients in LSG (%) | Mean # of Doses RSG | # of Patients in RSG (%) |
---|---|---|---|---|
Tramadol 100 mg = 10 MEDD | 2.64 ± 1.78 | 235 (54.1%) | 1.82 ± 1.03 | 24 (50%) |
Tramadol 50 mg = 5 MEDD | 2.40 ± 1.52 | 5 (1.2%) | 0 | 0 (0%) |
Score | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | N/A | |
% | % | % | % | % | % | % | % | % | % | % | % | |
Immediately after surgery | ||||||||||||
LSG | 41.8 | 3.9 | 6.2 | 7.1 | 5.7 | 6.7 | 6.7 | 7.4 | 4.6 | 1.6 | 1.6 | 6.7 |
RSG | 59.2 | 8.2 | 2.0 | 2.0 | 6.1 | 6.1 | 8.2 | 2.0 | 4.1 | 0 | 0 | 2.0 |
2 h after surgery | ||||||||||||
LSG | 27.1 | 6.9 | 21.4 | 13.6 | 8.3 | 6.2 | 3.4 | 2.3 | 3.2 | 0.5 | 0.7 | 6.4 |
RSG | 32.7 | 4.1 | 16.3 | 12.2 | 6.1 | 4.1 | 4.1 | 10.2 | 4.1 | 0 | 0 | 6.1 |
4 h after surgery | ||||||||||||
LSG | 31.3 | 2.3 | 11.7 | 7.6 | 6.7 | 9.0 | 6.0 | 4.4 | 4.4 | 0.5 | 0.7 | 15.6 |
RSG | 32.7 | 2.0 | 14.3 | 6.1 | 14.3 | 4.1 | 4.1 | 4.1 | 2.0 | 0 | 0 | 16.3 |
8 h after surgery | ||||||||||||
LSG | 45.5 | 2.5 | 6.7 | 7.6 | 6.2 | 6.7 | 4.1 | 3.0 | 1.1 | 0.9 | 0 | 15.6 |
RSG | 51.0 | 2.0 | 10.2 | 2.0 | 4.1 | 2.0 | 2.0 | 4.1 | 2.0 | 0 | 0 | 20.4 |
12 h after surgery | ||||||||||||
LSG | 52.9 | 1.6 | 6.7 | 7.1 | 5.5 | 3.9 | 3.9 | 2.5 | 0.9 | 0.2 | 0.2 | 14.5 |
RSG | 63.3 | 2.0 | 2.0 | 6.1 | 6.1 | 2.0 | 2.0 | 2.0 | 0 | 0 | 0 | 14.3 |
24 h after surgery | ||||||||||||
LSG | 51.7 | 2.3 | 8.7 | 5.3 | 6.4 | 5.1 | 3.7 | 1.6 | 0.7 | 0.5 | 0.7 | 13.3 |
RSG | 67.3 | 2.0 | 6.1 | 2.0 | 4.1 | 4.1 | 0 | 0 | 0 | 0 | 0 | 14.3 |
48 h after surgery | ||||||||||||
LSG | 24.8 | 0.7 | 3.9 | 3.9 | 4.4 | 2.3 | 1.4 | 0.9 | 0 | 0.2 | 0.2 | 57.2 |
RSG | 16.3 | 0 | 2.0 | 0 | 0 | 4.1 | 0 | 0 | 0 | 0 | 0 | 77.6 |
72 h after surgery | ||||||||||||
LSG | 8.0 | 0.2 | 1.1 | 0.2 | 0.2 | 0.7 | 0.2 | 0.9 | 0 | 0 | 0 | 88.3 |
RSG | 2.0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 2.0 | 95.9 |
At discharge | ||||||||||||
LSG | 64.4 | 1.8 | 8.5 | 6.2 | 8.3 | 3.2 | 2.8 | 3.0 | 0.5 | 0 | 0.2 | 1.1 |
RSG | 67.3 | 4.1 | 10.2 | 0.0 | 2.0 | 10.2 | 2.0 | 2.0 | 0 | 2.0 | 0 | 0 |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Barajas-Gamboa, J.S.; Ihsan Khan, M.S.; Mocanu, V.; Dang, J.T.; Romero-Velez, G.; Lee St-John, T.; Diaz Del Gobbo, G.; Guerron, A.D.; Pantoja, J.P.; Abril, C.; et al. Pain Assessment and Analgesic Requirements after Sleeve Gastrectomy: A Comparison Study of Robotic versus Laparoscopic Approaches. J. Clin. Med. 2024, 13, 5168. https://doi.org/10.3390/jcm13175168
Barajas-Gamboa JS, Ihsan Khan MS, Mocanu V, Dang JT, Romero-Velez G, Lee St-John T, Diaz Del Gobbo G, Guerron AD, Pantoja JP, Abril C, et al. Pain Assessment and Analgesic Requirements after Sleeve Gastrectomy: A Comparison Study of Robotic versus Laparoscopic Approaches. Journal of Clinical Medicine. 2024; 13(17):5168. https://doi.org/10.3390/jcm13175168
Chicago/Turabian StyleBarajas-Gamboa, Juan S., Mohammed Sakib Ihsan Khan, Valentin Mocanu, Jerry T. Dang, Gustavo Romero-Velez, Terrence Lee St-John, Gabriel Diaz Del Gobbo, A. Daniel Guerron, Juan Pablo Pantoja, Carlos Abril, and et al. 2024. "Pain Assessment and Analgesic Requirements after Sleeve Gastrectomy: A Comparison Study of Robotic versus Laparoscopic Approaches" Journal of Clinical Medicine 13, no. 17: 5168. https://doi.org/10.3390/jcm13175168