Perioperative medicine: Overview

Abstract
Background: Postoperative pain following video-assisted thoracoscopic surgery (VATS) remains a significant challenge. While epidural analgesia is still the gold standard, other types of regional analgesia are gaining popularity because of perceived less risk of complications. The efficacy of systemic opioids as an alternative to epidural analgesia has not been thoroughly explored. This systematic review and meta-analysis aims to evaluate and compare the efficacy of systemic opioids versus epidural analgesia in managing postoperative pain after VATS.

Methods: We will conduct a systematic review and meta-analysis in accordance with the Cochrane Handbook and the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) checklist. A comprehensive search will be conducted in MEDLINE, EMBASE, and the Cochrane Library supplemented with Scopus citation searches, search for gray literature using Google Scholar and a search for ongoing studies. We will include studies based on the PICO methodology without restrictions regarding study type. Two independent reviewers will screen studies, extract data, and assess study quality using the Cochrane Risk of Bias tools. The primary outcomes will be postoperative pain intensity at rest and during activity at 24, 48, and 72 h. Secondary outcomes will include use of "rescue" opioids, hospital length of stay, and adverse events. If feasible, a meta-analysis will be done, otherwise we will perform a descriptive analysis.

Results: The results will provide a comparative analysis of the effectiveness of systemic opioids versus epidural analgesia in managing postoperative pain in VATS patients. Data synthesis will include pooled estimates for pain scores, opioid consumption, and adverse events, possibly with subgroup and sensitivity analyses conducted to explore heterogeneity across studies.

Conclusions: This systematic review will offer valuable insights into the optimal pain management strategy for patients undergoing VATS. The findings may guide clinical practice in selecting the most effective and safe analgesic approach, improving postoperative recovery, and patient outcomes.

Abstract
Background: Postoperative pain management is a challenge after robot-assisted cystectomy (RAC). Methadone has a long duration of action, and we therefore hypothesized that a single dose of intraoperative methadone would reduce postoperative opioid requirements and pain intensity in bladder cancer patients undergoing RAC.

Methods: We conducted a blinded randomized controlled clinical trial from July 2020 to August 2023. Patients scheduled to undergo RAC because of bladder cancer were randomized to receive intraoperative methadone (0.15 mg/kg-1) or morphine (0.15 mg kg-1) 1 h before endotracheal extubation. The primary outcome was opioid requirements after 24 h. Secondary outcomes were opioid requirements after 3 h, pain intensity at rest and during coughing, postoperative nausea and vomiting (PONV), sedation, hypoxemia, hypoventilation, time spent in the post-anesthetic care unit, and patient satisfaction.

Results: A total of 114 patients were randomized. Data from 99 patients (14 females, 85 males; mean age 69.8 ± 8.9 years) were available for analysis; 52 received methadone and 47 received morphine. Opioid consumption was similar between the methadone group and morphine group at 3 h (median, mg, 45 (IQR 30 to 75) vs. 45 (IQR 15 to 82.5) p = .97) and at 24 h (median, mg, 125 (IQR 75 to 198.5) versus 105 (IQR 72 to 157.5), p = .29). Pain intensity was significantly lower in the morphine group at 48 h compared with the methadone group. Patient satisfaction at 24 h was increased in the methadone group compared with the morphine group (median, (IQR), NRS; 9 (IQR 7 to 10) versus 7 (IQR 4 to 9), p = .020). There were no differences between treatment groups in terms of time spent in the post-anesthetic care unit and the occurrence of opioid-related side effects.

Conclusion: A single dose of intraoperative methadone does not reduce postoperative opioid requirements compared with a single dose of morphine in bladder cancer patients undergoing RAC.