The Effect of Low Pressure Pneumoperitoneum During Laparoscopic Colorectal Surgery on Early Quality of Recovery
- Conditions
- SurgeryNeuromuscular BlockadePneumoperitoneum
- Interventions
- Procedure: Low pressure pneumoperitoneum
- Registration Number
- NCT03608436
- Lead Sponsor
- Radboud University Medical Center
- Brief Summary
Randomised controlled trial comparing the effect of low pressure pneumoperitoneum with deep neuromuscular block versus normal pressure pneumoperitoneum with moderate neuromuscular block during laparoscopic colorectal surgery on early quality of recovery.
- Detailed Description
Rationale: the laparoscopic approach reduced trauma as compared to open surgery, however, the pressure used to create a PNP with sufficient surgical workspace still leads to significant tissue injury. Prior studies show that the use of low-pressure pneumoperitoneum (PNP) during laparoscopic surgery reduced postoperative pain scores, cumulative opioid consumption and improved bowel function recovery. Deep neuromuscular blockade (NMB) as compared to moderate NMB decreases the amount of intra-abdominal pressure required to achieve similar surgical conditions and enables the use of low-pressure PNP without compromising the quality of the surgical field and patient safety. Therefore, the use of deep NMB with low-pressure PNP could be a significant addition to the conventional Enhanced Recovery After Surgery (ERAS) protocols.
Objective: to establish the relationship between the use of low pressure pneumoperitoneum with deep neuromuscular blockade and the early quality of recovery after laparoscopic colorectal surgery.
Study design: a multi-center, blinded, randomized controlled clinical trial.
Study population: adult individuals scheduled for laparoscopic colorectal surgery with a primary colonic anastomosis.
Intervention: participants will be randomly assigned in a 1:1 fashion to either the experimental group (group A): low pressure PNP (8 mmHg) with deep NMB (PTC 1-2) or the control group (group B): normal pressure PNP (12 mmHg) with moderate NMB (TOF count 1-2).
Primary endpoint: Quality of recovery score (QoR-40) 24 hours after surgery.
Secondary endpoints: QoR-40 score (day 3 and 7 after surgery), McGill pain- and RAND-36 score (1 day before and 3 months after surgery), pain scores, PONV, analgesia use, length of hospital stay, postoperative complications, surgical conditions and time to reach discharge criteria.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 178
- Scheduled for laparoscopic colorectal surgery with a primary anastomosis
- Obtained informed consent
- Age over 18 years
- Insufficient control of the Dutch language to read the patient information and to fill out the questionnaires
- Primary colostomy
- Neo-adjuvant chemotherapy
- Chronic use of analgesics or psychotropic drugs
- Use of NSAIDs shorter than 5 days before surgery
- Known or suspected allergy to rocuronium of sugammadex
- Neuromuscular disease
- Indication for rapid sequence induction
- Severe liver- or renal disease (creatinine clearance <30ml/min)
- BMI >35 kg/m²
- Deficiency of vitamin K dependent clotting factors or coagulopathy
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Low pressure PNP, deep NMB Low pressure pneumoperitoneum Low pressure pneumoperitoneum of 8 mmHg with deep neuromuscular block (post tetanic count of 1-2) reached by titration with continuous infusion of Rocuronium bromide. Normal pressure PNP, moderate NMB Rocuronium Bromide Normal pressure pneumoperitoneum of 12 mmHg with moderate neuromuscular block (TOF count of 1-2) reached by titration with bolus or continuous infusion of a low dose of Rocuronium bromide. Low pressure PNP, deep NMB Rocuronium Bromide Low pressure pneumoperitoneum of 8 mmHg with deep neuromuscular block (post tetanic count of 1-2) reached by titration with continuous infusion of Rocuronium bromide.
- Primary Outcome Measures
Name Time Method Total score on the Quality of Recovery-40 questionnaire 24 hours after surgery The QoR-40 is a validated assessment tool for measuring a patient's self-assessed quality of recovery after surgery. It consists of 40 questions measuring 5 dimensions: patient support, comfort, emotions, physical independence and pain. Each item is rated on a scale of 1 to 5, giving a minimal score of 40 and a maximum score of 200.
- Secondary Outcome Measures
Name Time Method Intraoperative complications During surgery Complications during surgery graded according to the Clavien-Dindo classification
RAND-36 general health questionnaire Upon admission and 3 months after surgery Validated patient-reported survey of health
Post-operative nausea and vomiting (PONV) 1, 8, 24 and 72 hours after surgery NRS 0-10
Total score on the Quality of Recovery-40 questionnaire Day 3 and day 7 after surgery The QoR-40 is a validated assessment tool for measuring a patient's self-assessed quality of recovery after surgery. It consists of 40 questions measuring 5 dimensions: patient support, comfort, emotions, physical independence and pain. Each item is rated on a scale of 1 to 5, giving a minimal score of 40 and a maximum score of 200.
Cumulative use of analgesics and anti-emetics 1, 8, 24 and 72 hours after surgery Total dose of opiates, other analgesics and anti-emetic drugs
Length of hospital stay From date of admission until date of discharge from the hospital (usually several days), assessed up to 3 months. Total number of days from admission to discharge after surgery (not including readmission)
McGill pain Questionnaire Upon admission and 3 months after surgery Validated questionnaire for the assessment of quality and intensity of pain
Pain scores 1, 8, 24, and 72 hours after surgery Pain at rest and pain upon movement (NRS 0-10), is pain acceptable yes or no, referred shoulder pain yes or no?
Surgical conditions Intraoperative: after introduction of the trocars and every 15 minutes until the end of the pneumoperitoneum. Rating of the surgical conditions with the Leiden Surgical Rating Scale (L-SRS). The L-SRS is scored by the surgeon and ranges from 1-5 for quality of the surgical field. A score of 5 means optimal conditions: a wide laparoscopic field with no patient movements or muscle contractions, 1 means extremely poor conditions: the surgeon is unable to obtain a visible laparoscopic field because of inadequate muscle relaxation.
Time to reach discharge criteria From date of surgery until date of actual discharge from the hospital (usually several days), assessed up to 3 months. Number of days to reach the following criteria after surgery: adequate pain control with oral medication, passage of flatus or defecation, intake of solid food tolerated, patient is mobilized and independent and patient accepts discharge.
Postoperative complications Up to 3 months after surgery Postoperative complications
Trial Locations
- Locations (3)
Canisius Wilhelmina Hospital
🇳🇱Nijmegen, Gelderland, Netherlands
Martini general hospital
🇳🇱Groningen, Netherlands
Maxima Medisch Centrum
🇳🇱Veldhoven, Netherlands