Perioperative pain management for appendicectomy: A systematic review and Procedure-specific Postoperative Pain Management recommendations

Freys, Jacob C.; Bigalke, Stephan M.; Mertes, Moritz; Lobo, Dileep N.; Pogatzki-Zahn, Esther M.; Freys, Stephan M.; The PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy (ESRA)

Abstract

BACKGROUND
Despite being a commonly performed surgical procedure, pain management for appendicectomy is often neglected because of insufficient evidence on the most effective treatment options.

OBJECTIVE
To provide evidence-based recommendations by assessing the available literature for optimal pain management after appendicectomy.

DESIGN AND DATA SOURCES
This systematic review-based guideline was conducted according to the PROSPECT methodology. Relevant randomised controlled trials, systematic reviews and meta-analyses in the English language from January 1999 to October 2022 were retrieved from MEDLINE, Embase and Cochrane Databases using PRISMA search protocols.

ELIGIBILITY CRITERIA
We included studies on adults and children. If articles reported combined data from different surgeries, they had to include specific information about appendicectomies. Studies needed to measure pain intensity using a visual analogue scale (VAS) or a numerical rating scale (NRS). Studies that did not report the precise appendicectomy technique were excluded.

RESULTS
Out of 1388 studies, 94 met the inclusion criteria. Based on evidence and consensus, the PROSPECT members agreed that basic analgesics [paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs)] should be administered perioperatively for open and laparoscopic appendicectomies. A laparoscopic approach is preferred because of lower pain scores. Additional recommendations for laparoscopic appendicectomies include a three-port laparoscopic approach and the instillation of intraperitoneal local anaesthetic. For open appendicectomy, a preoperative unilateral transverse abdominis plane (TAP) block is recommended. If not possible, preincisional infiltration with local anaesthetics is an alternative. Opioids should only be used as rescue analgesia. Limited evidence exists for TAP block in laparoscopic appendicectomy, analgesic adjuvants for TAP block, continuous wound infiltration after open appendicectomy and preoperative ketamine and dexamethasone. Recommendations apply to children and adults.

CONCLUSION
This review identified an optimal analgesic regimen for open and laparoscopic appendicectomy. Further randomised controlled trials should evaluate the use of regional analgesia and wound infiltrations with adequate baseline analgesia, especially during the recommended conventional three-port approach.

Citation

Freys, J. C., Bigalke, S. M., Mertes, M., Lobo, D. N., Pogatzki-Zahn, E. M., Freys, S. M., & The PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy (ESRA). (2024). Perioperative pain management for appendicectomy: A systematic review and Procedure-specific Postoperative Pain Management recommendations. European Journal of Anaesthesiology, 41(3), 174-187. https://doi.org/10.1097/eja.0000000000001953

• Journal Article Type: Article
• Acceptance Date: Nov 3, 2023
• Online Publication Date: Jan 15, 2024
• Publication Date: 2024-03
• Deposit Date: Jan 16, 2024
• Publicly Available Date: Jan 16, 2025
• Journal: European Journal of Anaesthesiology
• Print ISSN: 0265-0215
• Electronic ISSN: 1365-2346
• Publisher: Lippincott, Williams & Wilkins
• Peer Reviewed: Peer Reviewed
• Volume: 41
• Issue: 3
• Pages: 174-187
• DOI: https://doi.org/10.1097/eja.0000000000001953
• Public URL: https://nottingham-repository.worktribe.com/output/29831424
• Publisher URL: https://journals.lww.com/ejanaesthesiology/fulltext/2024/03000/perioperative_pain_management_for_appendicectomy_.3.aspx