BACKGROUND:Epidural analgesia is the gold standard for postoperative pain therapy following laparotomies. However, its appropriateness for pain management after laparoscopic abdominal surgeries remains uncertain. METHODS:This systematic review with meta-analysis of randomized controlled trials (RCTs) was conducted according to the guidelines of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement; the quality of evidence was assessed with Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Included were trials with adults undergoing laparoscopic abdominal surgery where epidural analgesia was compared to other approaches. Primary outcomes were pain intensity at rest and during movement 24 hours after surgery and the number of patients with any adverse events related to epidural analgesia. RESULTS:Of 738 screened publications, a total of 41 studies were included in qualitative analysis, 34 studies in quantitative analysis. Fifteen studies compared epidural analgesia with patient-controlled intravenous analgesia (PCIA) with opioids, 10 epidural analgesia with non-patient-controlled opioids, and three epidural analgesia with epidural saline (placebo). Twenty-four hours after surgery epidural analgesia compared to PCIA may slightly reduce pain intensity at rest (n = 10; mean difference [MD]: -0.86 points; 95% confidence interval [CI]: -1.27 to -0.45; 95% prediction interval: -2.06 to 0.34; low-certainty evidence) and may reduce pain during movement even clinically relevant (n = 5; MD: -1.49 points; 95% CI: -2.11 to -0.87; low-certainty evidence). Nonetheless, there are concerns about frequent hypotension due to epidural analgesia (n = 5; relative risk [RR]: 10.1; 95% CI: 2.74-36.6; moderate-certainty evidence) while the impact due to pruritus (n = 4; RR: 0.97; 95% CI: 0.09-10.4; very low-certainty evidence) remains uncertain. Evidence for other comparisons remains limited due to sparse data. CONCLUSIONS:Preliminary evidence indicates that epidural analgesia has the potential to slightly reduce early postoperative pain intensity after laparoscopic abdominal surgery compared to PCIA. However, its use may be associated with a frequent incidence of hypotension.

BACKGROUND:Interprofessional teaching courses are generally considered useful but have rarely been implemented in German medical education curricula to date. OBJECTIVE:The aim of this pilot study was to determine whether the newly planned teaching course "interprofessional late shift" improves students' attitudes towards interprofessional work and whether this can be further optimized by a short intervention at the beginning of the course. MATERIAL AND METHODS:The quantitative assessment involved students completing the "international socialization and valuing scale-9" (ISVS-9), the "University of the West of England Interprofessional Questionnaire German" (UWE-IP-D) (only the "communication and teamwork" dimension) and the scale for general self-efficacy expectations (SWE) before and after the course. In addition, a brief assessment of the personality was carried out before the event using the Big Five Inventory-10. RESULTS:This pilot study was conducted over two semesters. Questionnaires were completed by 30 students. The ISVS‑9 total scores increased in both groups (p = 0.011); however, a significant difference in the increase between the intervention and control groups could not be determined (p = 0.98). The total scores of the UWE-IP‑D decreased significantly (p = 0.002), which indicates an improvement in communication skills. Analyses of the influence of the personality showed a significant correlation between the increase in self-efficacy, neuroticism (p = 0.018) and agreeableness (p = 0.044). CONCLUSION:The results of the pilot study clearly show that the newly planned teaching course "interprofesional late shift" could be an effective tool for enhancing medical students' appreciation of interprofessional collaboration; however, the appreciation could not be additionally improved by a short intervention at the beginning of the course.

Interprofessionelle Lehrveranstaltungen werden generell als sinnvoll erachtet, sind aber bisher selten curriculare Formate in der medizinischen Ausbildung. Ziele dieser Pilotstudie waren es zu erfassen, ob die neu geplante Lehrveranstaltung „interprofessionelle Spätschicht“ die Einstellung der Studierenden in Bezug auf interprofessionelles Arbeiten verbessert, und ob dies nochmals durch eine kurze Intervention zu Veranstaltungsbeginn optimiert werden kann. Die quantitative Begleitung sah vor, dass Studierende vor und nach der Veranstaltung die Fragebogen „International Socialization and Valuing Scale – 9“ (ISVS-9), „University of the West of England Interprofessional Questionnaire German“ (UWE-IP-D) (nur Dimension „Kommunikation und Teamarbeit“) sowie die Skala zur allgemeinen Selbstwirksamkeitserwartung (SWE) ausfüllten. Zudem erfolgte eine kurze Einschätzung der Persönlichkeit vor der Veranstaltung mittels des Big Five Inventory-10. Diese Pilotstudie wurde über zwei Semester durchgeführt. Die Fragebögen lagen von 30 Studierenden vor. Die ISVS-9-Summenwerte stiegen in beiden Gruppen an (p = 0,011). Ein signifikanter Unterschied im Anstieg zwischen Interventions- und Kontrollgruppe konnte allerdings nicht festgestellt werden (p = 0,98). Die UWE-Summenwerte gingen signifikant zurück (p = 0,002), was eine Verbesserung der kommunikativen Fähigkeiten bedeutet. Die Analyse zum Einfluss der Persönlichkeit zeigte einen signifikanten Zusammenhang zwischen dem Anstieg von Selbstwirksamkeit, Neurotizismus (p = 0,018) sowie Verträglichkeit (p = 0,044). Die Ergebnisse der Pilotstudie machen deutlich, dass die neu geplante Lehrveranstaltung „interprofessionelle Spätschicht“ ein wirkungsvolles Instrument sein könnte, die Wertschätzung interprofessioneller Zusammenarbeit von Medizinstudierenden zu stärken. Allerdings konnte die Wertschätzung durch eine kurze Schulung zu Beginn nicht zusätzlich verbessert werden.

BACKGROUND:Aim of the present study was to investigate the postoperative pain outcome following the implementation of a superficial parasternal intercostal plane (SPIP) block in children undergoing cardiac surgery with a sternotomy. METHODS:We conducted a retrospective cohort study in children undergoing extracardiac Fontan operation or a secundum atrial septal defect closure receiving a SPIP in addition to standard pain treatment versus standard pain treatment only. The primary outcome was the worst pain intensity within 24 hours (median (interquartile range)). RESULTS:Mean age of the study groups (54 patients each) was 3.22 years (±0.95), respectively 4.26 years (±2.76) in the control group. There was no statistically significant reduction in worst pain intensity 24 hours after surgery in children treated with a SPIP block (3(1-5)) compared to control group (4(2-5)) (p1-tailed = 0.16, d = 0.19). However, 4 and 12 hours after surgery there were significant improvements in median pain intensity in children treated with a SPIP block (p1-tailed = 0.04). CONCLUSIONS:This study showed that implementation of a SPIP block might further improve postoperative pain management following cardiac surgery in children. However, due to lower baseline pain intensity in the control group primary outcome failed significantly. Therefore, further trials are urgently requested.

CONTEXT:Palliative care aims to improve the quality of life in patients with progressive diseases such as cancer. Effective cancer pain management is a major challenge of palliative treatment. Empirical data on the prevalence of cancer pain, the efficiency of pain treatment and influencing factors are scarce. OBJECTIVES:Here, we investigated pain in cancer patients treated on inpatient palliative care wards in Germany. METHODS:N = 4779 data sets provided by the German Palliative Care Registry from yearly evaluation periods between 2015 and 2020 were included. Pain ratings were assessed by professionals through a checklist of symptoms and problems (HOPE-SP-CL). RESULTS:More than half of the included patients suffered from moderate/severe pain at the beginning of inpatient palliative care and in 71% of these patients, pain relief was achieved at the end of inpatient treatment. Pain intensity, depression and ECOG performance status at admission were weak predictors of later pain relief. The highest pain intensity at the beginning and least pain relief were found in patients with bone and cartilage cancer. The highest percentage of adequate pain control (81%) was seen in 2020. CONCLUSION:Data from the German Palliative Care Registry confirmed that although increasingly better addressed over the years, insufficiently controlled cancer pain remains a challenge for palliative care units. Patient-specific (e.g. psychological comorbidity) and cancer-related (e.g. bone or cartilage cancer) risk factors for poor pain treatment underline the need for individualized multimodal pain management including psychological support.

BACKGROUND:Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects.OBJECTIVES:To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques.SEARCH METHODS:We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022.SELECTION CRITERIA:Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded.DATA COLLECTION AND ANALYSIS:Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects.MAIN RESULTS:We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome.AUTHORS' CONCLUSIONS:ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.

ZusammenfassungIm Rahmen der kompetenzbasierten Facharztausbildung wurden bereits Kernkompetenzen im Sinne von Entrustable Professional Activities (EPA) in der Anästhesiologie definiert. Appunterstützte formative Assessments und Feedbacks könnten die Umstellung zu einer kompetenzbasierten Lehre erleichtern.Die Studierenden der Humanmedizin des Wintersemesters 2022/23, die den curricularen Kurs Notfallmedizin 2 der Universitätsklinik Münster besuchten, erhielten entweder im Anschluss an ein Szenariotraining mithilfe einer App ein systematisches oder unsystematisches Feedback.Insgesamt wurden 104 Studierende (50 in der Experimental-, 54 in der Kontrollgruppe) eingeschlossen. Die Evaluationsergebnisse unterschieden sich nicht zwischen beiden Gruppen (p = 0,225). Die Experimental- (14,12 min [± 4,37]) im Vergleich zur Kontrollgruppe (11,15 min [± 3,32]) erhielt im Mittel ein 2,97 min längeres Feedback (p < 0,001). Der Vergleich der Ergebnisse der Selbsteinschätzung des Supervisionslevels zu den Zeitpunkten vor (p = 0,051) und nach dem Kurs (p = 0,134) zeigten keine signifikanten Unterschiede. Für den Vergleich zwischen der Selbst- (durch den Studierenden nach seiner Teamleiterrolle) und Fremdeinschätzung (durch den/die Dozent*in) nach dem Fallbeispiel bestanden keine signifikanten Unterschiede (p = 0,480).Die vorliegende Observationsstudie hat gezeigt, dass ein appbasiertes formatives Feedback implementiert werden kann. Allerdings hatte dies keine Auswirkungen auf die Evaluationsergebnisse der Studierenden bzw. Selbst- und Fremdeinschätzungen zum Supervisionsbedarf.

Study objective: Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear. Design: Systematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment. Setting: Postoperative pain treatment. Patients: Adult patients undergoing visceral cancer surgery. Interventions: Any kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques. Measurements: Primary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus. Main results: 59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): -1.35 to -0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: -2.34 to -1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: -1.20 to -0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: -1.34 to -0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA. Conclusions: Following visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery.

Postoperative pain management following laparoscopic, non-oncological visceral surgery in adults is challenging. Regional anaesthesia could be a promising component in multimodal pain management. We performed a systematic review and meta-analysis with GRADE assessment. Primary outcomes were postoperative acute pain intensity at rest/during movement after 24 h, the number of patients with block-related adverse events and the number of patients with postoperative paralytic ileus. 82 trials were included. Peripheral regional anaesthesia combined with general anaesthesia versus general anaesthesia may result in a slight reduction of pain intensity at rest at 24 h (mean difference (MD) − 0.72 points; 95

Background In Germany relevant competences for anesthesiology residents were defined as entrustable professional activities. App supported formative assessment and feedback might improve education in students. Methods All fifth year medical students undergoing specific emergency medicine training in October 2022 were included. One half was educated using 360 degree App for systematic feedback and formative assessment, while the other ones received regular feedback. Results We finally included the data of 104 medical students (50 within the experimental group, 54 within the control group). There was no difference in the results of the evaluation (p = 0.225). The experimental (14.12 min [+/- 4.37]) compared to the control group (11.15 min [+/- 3.32]) received a longer feedback (2.97 min, p < 0.001). The mean duration of the systematic EPA based feedback was 5.62 min (+/- 1.6 min). The results of the self-assessment before (p = 0.051) and after (p = 0.134) scenario training were not different. The same was true for the comparison of self- and objective assessments regarding the need for supervision (p = 0.480). Conclusion The present observational prospective trial showed that implementation of an App based formative assessment and feedback is possible. However, this was not associated with differences in evaluation, self- and objective assessments.

An important task in obstetrics is to offer patients adequate pain management after vaginal delivery (VD) and after cesarean section (CS). The aim of the present analysis was to assess pain intensity at the day after childbirth, after 3 and 6 months in women after VD and after CS. Additionally, it was planned to identify determinants of maternal satisfaction with acute pain therapy following VD and CS. This secondary analysis of a single-center prospective cohort study included 210 parturients. The women gave birth in the University Hospital of Wuerzburg. They completed a survey before childbirth (P), on the first day (D1), 3 and 6 months after VD and CS. The survey included questions about the expected pain, the experienced pain, the birth, the pain afterwards and also psychological questionnaires. In addition, information was collected from the patient records. Women with planned CS received spinal anesthesia. A secondary CS was performed with an epidural, spinal or general anesthesia. Pain therapy on the ward was standardized. The primary outcomes were acute and chronic pain intensity at rest, during movement, determinants of satisfaction with pain therapy and the wish to have received more pain medication during and after VD and CS (D1). A total of 175 women completed the survey at all time points and were available for the analysis (drop-out 16.8

STUDY OBJECTIVE:Assessment of the efficacy and safety of perioperative intravenous ketamine in reducing incidence and severity of chronic postsurgical pain. STUDY DESIGN:A systematic review and meta-analysis of randomized controlled trials (RCTs). DATA SOURCES:The following data sources were systematically searched: MEDLINE, CENTRAL, and EMBASE (till 02/2021). PATIENTS:Adult patients undergoing any surgery. INTERVENTIONS:Perioperative use of intravenous ketamine as an additive analgesic drug compared to placebo, no active control treatment, and other additive drugs. MEASUREMENTS:Primary outcomes were number of patients with chronic postsurgical pain after 6 months and ketamine related adverse effects. Secondary outcomes were chronic postsurgical pain incidence after 3 and 12 months, chronic postsurgical neuropathic pain incidence, chronic postsurgical moderate to severe pain incidence, intensity of chronic postsurgical pain at rest, and during movement, oral morphine consumption after 3, 6, and 12 months and incidence of opioid-related adverse effects. MAIN RESULTS:Thirty-six RCTs were included with a total of 3572 patients. Ketamine compared to placebo may result in no difference in the number of patients with chronic postsurgical pain after 6 months (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.71-1.05; I2  = 34%; 16 studies; low-certainty evidence). Ketamine may reduce the incidence of chronic postsurgical neuropathic pain after 3 months in comparison to placebo (RR 0.78, 95% CI 0.62-0.99, I2  = 31%, seven trials, low-certainty evidence). Ketamine compared to placebo may increase the risk for postoperative nystagmus (RR 9.04, 95% CI 1.15-70.90, I2 30%, two trials, low-certainty evidence) and postoperative visual disturbances (RR 2.29, 95% CI 1.05-4.99, I2 10%, seven trials, low-certainty evidence). CONCLUSIONS:There is low-certainty evidence that perioperative ketamine has no effect on chronic postsurgical pain in adult patients. Low-certainty evidence suggests that ketamine compared to placebo may reduce incidence of chronic postsurgical neuropathic pain after 3 months. Questions like ideal dosing, treatment duration and more patient-related outcome measures remain unanswered, which warrants further studies. PROTOCOL REGISTRATION:Prospero CRD42021223625, 07.01.2021.

OBJECTIVEThe aim of this systematic review was to investigate postoperative pain outcomes and adverse events after peripheral regional anesthesia (PRA) compared to no regional anesthesia (RA), placebo, or neuraxial anesthesia in children and adults undergoing cardiac surgery.DESIGNA systematic review and meta-analysis with an assessment of the risk of bias (Cochrane RoB 1) and certainty of evidence (Grading of Recommendations, Assessment, Development, and Evaluation).SETTINGRandomized controlled trials (RCTs).PARTICIPANTSAdults and children undergoing heart surgery.INTERVENTIONSAny kind of PRA compared to no RA or placebo or neuraxial anesthesia.MEASUREMENTS AND MAIN RESULTSIn total, 33 RCTs (2,044 patients) were included-24 of these had a high risk of bias, and 28 were performed in adults. Compared to no RA, PRA may reduce pain intensity at rest 24 hours after surgery (mean difference [MD] -0.81 points, 95% CI -1.51 to -0.10; I2 = 92%; very low certainty evidence). Peripheral regional anesthesia, compared to placebo, may reduce pain intensity at rest (MD -1.36 points, 95% CI -1.59 to -1.13; I2 = 54%; very low certainty evidence) and during movement (MD -1.00 points, 95% CI -1.34 to -0.67; I² = 72%; very low certainty evidence) 24 hours after surgery. No data after pediatric cardiac surgery could be meta-analyzed due to the low number of included trials.CONCLUSIONSCompared to no RA or placebo, PRA may reduce pain intensity at rest and during movement. However, these results should be interpreted cautiously because the certainty of evidence is only very low.

Study objective: Postoperative pain management in opioid users remains challenging. The perioperative administration of ketamine might lead to favourable pain outcomes in these patients. Study design: A systematic review of randomised controlled trials (RCT) with meta-analysis and assessment of the quality of evidence by GRADE was performed. Setting: Perioperative pain treatment. Patients: Adult opioid users undergoing surgery. Interventions: Perioperative administration of ketamine. Measurements: Primary outcomes were postoperative acute pain at rest/during movement after 24 h and number of patients with ketamine-related adverse events. Main results: Nine RCTs (802 patients with at least two weeks opioid-intake) were included. There is low-quality evidence that ketamine may slightly reduce postoperative pain during movement after 24 h (mean difference:-0.79; 95% confidence interval (CI):-1.22 to-0.36). Based on a very low-quality of evidence, we are uncertain on any effect of ketamine on pain at rest after 24 h and incidences of adverse events like hallucinations and confusion within 48 h. However, perioperative ketamine reduced cumulative mean opioid consumption by 97.3 mg (95%CI:-164.8 to-29.7) after 24 h and 186.4 mg (95%CI:-347.6 to-25.2) after 48 h. The relative risks (RR) for opioid-related adverse events were significantly different for sedation within 24 h (RR: 0.54; 95%CI 0.37 to 0.78). Conclusions: There is currently limited evidence for a reduced postoperative pain intensity using perioperative ketamine in preoperative opioid-consuming patients. However, a clinically relevant opioid-sparing effect was evident associated with a reduced risk for postoperative sedation and without increased harm. Therefore, ketamine might be a useful anti-hyperalgesic adjuvant in these patients. Nevertheless, with clinical heterogeneity being considerable, it's too premature to suggest any specific ketamine protocol. Furthermore, many questions (like ideal dosing, treatment duration and more favourable patient-related outcome measures including longterm effects) remain open and need to be addressed in future studies. Protocol registration: Prospero CRD42020185497.

Background Robot-assisted minimally invasive esophagectomy (RAMIE) shows promising results regarding postoperative complications in patients with esophageal cancer. To date, no data are available regarding postoperative analgesic consumption. The aim of this work is to evaluate analgesic consumption after esophagectomy. Methods A total of 274 Ivor Lewis esophageal resections performed sequentially from January 2012 to December 2020 were evaluated. RAMIE cases (n = 51) were compared with the hybrid technique (laparoscopic abdominal phase followed by open thoracotomy, n = 59) and open abdominothoracic esophagectomy (OTE) (n = 164). Data were collected retrospectively. The primary endpoint was the overall postoperative morphine consumption, which represents a reliable indirect measurement of pain. Pain levels recorded on the first, third, and fifth postoperative days were assessed as secondary endpoints. Results A total of 274 patients were included. The postoperative opioid consumption rate for patients who underwent RAMIE (quartiles: 0.14, 0.23, 0.36 mg morphine milligram equivalents (MME)/kg body weight (bw)/day) was significantly lower than in the open group (0.19, 0.33, 0.58 mg MME/kg bw/day, p = 0.016). The overall postoperative opioid consumption for patients who underwent RAMIE was significantly lower (2.45, 3.63, 7.20 mg MME/kg bw/day; morphine milligram equivalents per kilogram body weight) compared with the open (4.85, 8.59, 14.63 MME/kg bw/day, p < 0.0001) and hybrid (4.13, 6.84, 11.36 MME/kg bw/day, p = 0.008) groups. Patients who underwent RAMIE reported lower pain scores compared with the open group on the fifth postoperative day, both at rest (p = 0.004) and while performing activities (p < 0.001). Conclusions This study shows that patients who underwent RAMIE experienced similar postoperative pain while requiring significantly lower amounts of opioids compared with patients who underwent open and hybrid surgery. Further studies are required to verify the results.

Schnabel, Alexander PhD; Brünen, Andreas MD; Rohlfing, Fabian MD; Ullrich, Simone MD; Gottschalk, Antje PhD Author Information