Clin Colon Rectal Surg 2019; 32(02): 121-128
DOI: 10.1055/s-0038-1676477
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Pain Management in Enhanced Recovery after Surgery (ERAS) Protocols

J. Creswell Simpson
1   Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Xiaodong Bao
1   Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
Aalok Agarwala
1   Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
› Author Affiliations
Further Information

Publication History

Publication Date:
28 February 2019 (online)


Pain control is an integral part of Enhanced Recovery after Surgery (ERAS) protocols for colorectal surgery. While opioid therapy remains the mainstay of therapy for postsurgical pain, opioids have undesired side effects including delayed recovery of bowel function, respiratory depression, and postoperative nausea and vomiting. A variety of nonopioid systemic medical therapies as well as regional and neuraxial techniques have been described as improving pain control while reducing opioid use. Multimodal and preemptive analgesia as part of an ERAS protocol facilitates early mobility and early return of bowel function and decreases postoperative morbidity. In this review, we examine several multimodal therapies and their impact on postoperative analgesia, opioid use, and recovery for patients undergoing colorectal surgery.

  • References

  • 1 Barletta JF, Asgeirsson T, Senagore AJ. Influence of intravenous opioid dose on postoperative ileus. Ann Pharmacother 2011; 45 (7-8): 916-923
  • 2 Kranke P, Jokinen J, Pace NL. , et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev 2015; 7 (07) CD009642
  • 3 Raju DP, Hakendorf P, Costa M, Wattchow DA. Efficacy and safety of low-dose celecoxib in reducing post-operative paralytic ileus after major abdominal surgery. ANZ J Surg 2015; 85 (12) 946-950
  • 4 Shariat Moharari R, Motalebi M, Najafi A. , et al. Magnesium can decrease postoperative physiological ileus and postoperative pain in major non laparoscopic gastrointestinal surgeries: a randomized controlled trial. Anesth Pain Med 2013; 4 (01) e12750
  • 5 Pöpping DM, Elia N, Van Aken HK. , et al. Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg 2014; 259 (06) 1056-1067
  • 6 Asgeirsson T, El-Badawi KI, Mahmood A, Barletta J, Luchtefeld M, Senagore AJ. Postoperative ileus: it costs more than you expect. J Am Coll Surg 2010; 210 (02) 228-231
  • 7 Vather R, Bissett IP. Risk factors for the development of prolonged post-operative ileus following elective colorectal surgery. Int J Colorectal Dis 2013; 28 (10) 1385-1391
  • 8 Lee LA, Caplan RA, Stephens LS. , et al. Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology 2015; 122 (03) 659-665
  • 9 Apfel CC, Heidrich FM, Jukar-Rao S. , et al. Evidence-based analysis of risk factors for postoperative nausea and vomiting. Br J Anaesth 2012; 109 (05) 742-753
  • 10 Apfel CC, Korttila K, Abdalla M. , et al; IMPACT Investigators. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004; 350 (24) 2441-2451
  • 11 Vigneault L, Turgeon AF, Côté D. , et al. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth 2011; 58 (01) 22-37
  • 12 Achuthan S, Singh I, Varthya SB, Srinivasan A, Chakrabarti A, Hota D. Gabapentin prophylaxis for postoperative nausea and vomiting in abdominal surgeries: a quantitative analysis of evidence from randomized controlled clinical trials. Br J Anaesth 2015; 114 (04) 588-597
  • 13 Laskowski K, Stirling A, McKay WP, Lim HJ. A systematic review of intravenous ketamine for postoperative analgesia. Can J Anaesth 2011; 58 (10) 911-923
  • 14 Fassoulaki A, Melemeni A, Tsaroucha A, Paraskeva A. Perioperative pregabalin for acute and chronic pain after abdominal hysterectomy or myomectomy: a randomised controlled trial. Eur J Anaesthesiol 2012; 29 (11) 531-536
  • 15 Apfel CC, Turan A, Souza K, Pergolizzi J, Hornuss C. Intravenous acetaminophen reduces postoperative nausea and vomiting: a systematic review and meta-analysis. Pain 2013; 154 (05) 677-689
  • 16 Johns N, O'Neill S, Ventham NT, Barron F, Brady RR, Daniel T. Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a systematic review and meta-analysis. Colorectal Dis 2012; 14 (10) e635-e642
  • 17 Tan M, Law LS, Gan TJ. Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways. Can J Anaesth 2015; 62 (02) 203-218
  • 18 Pandazi A, Kapota E, Matsota P, Paraskevopoulou P, Dervenis C, Kostopanagiotou G. Preincisional versus postincisional administration of parecoxib in colorectal surgery: effect on postoperative pain control and cytokine response. A randomized clinical trial. World J Surg 2010; 34 (10) 2463-2469
  • 19 Lassen K, Soop M, Nygren J. , et al; Enhanced Recovery After Surgery (ERAS) Group. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009; 144 (10) 961-969
  • 20 Maund E, McDaid C, Rice S, Wright K, Jenkins B, Woolacott N. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. Br J Anaesth 2011; 106 (03) 292-297
  • 21 Ong CKS, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010; 110 (04) 1170-1179
  • 22 Politi JR, Davis II RL, Matrka AK. Randomized prospective trial comparing the use of intravenous versus oral acetaminophen in total joint arthroplasty. J Arthroplasty 2017; 32 (04) 1125-1127
  • 23 Fenlon S, Collyer J, Giles J. , et al. Oral vs intravenous paracetamol for lower third molar extractions under general anaesthesia: is oral administration inferior?. Br J Anaesth 2013; 110 (03) 432-437
  • 24 Singla NK, Parulan C, Samson R. , et al. Plasma and cerebrospinal fluid pharmacokinetic parameters after single-dose administration of intravenous, oral, or rectal acetaminophen. Pain Pract 2012; 12 (07) 523-532
  • 25 Kuo CP, Jao SW, Chen KM. , et al. Comparison of the effects of thoracic epidural analgesia and i.v. infusion with lidocaine on cytokine response, postoperative pain and bowel function in patients undergoing colonic surgery. Br J Anaesth 2006; 97 (05) 640-646
  • 26 Grady MV, Mascha E, Sessler DI, Kurz A. The effect of perioperative intravenous lidocaine and ketamine on recovery after abdominal hysterectomy. Anesth Analg 2012; 115 (05) 1078-1084
  • 27 Turan A, Karamanlioğlu B, Memiş D, Usar P, Pamukçu Z, Türe M. The analgesic effects of gabapentin after total abdominal hysterectomy. Anesth Analg 2004; 98 (05) 1370-1373
  • 28 Sen H, Sizlan A, Yanarates O. , et al. A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesth Analg 2009; 109 (05) 1645-1650
  • 29 Cavalcante AN, Sprung J, Schroeder DR, Weingarten TN. Multimodal analgesic therapy with gabapentin and its association with postoperative respiratory depression. Anesth Analg 2017; 125 (01) 141-146
  • 30 Chen J-Y, Ko T-L, Wen Y-R. , et al. Opioid-sparing effects of ketorolac and its correlation with the recovery of postoperative bowel function in colorectal surgery patients: a prospective randomized double-blinded study. Clin J Pain 2009; 25 (06) 485-489
  • 31 Gan TJ, Joshi GP, Zhao SZ, Hanna DB, Cheung RY, Chen C. Presurgical intravenous parecoxib sodium and follow-up oral valdecoxib for pain management after laparoscopic cholecystectomy surgery reduces opioid requirements and opioid-related adverse effects. Acta Anaesthesiol Scand 2004; 48 (09) 1194-1207
  • 32 Wattchow DA, De Fontgalland D, Bampton PA, Leach PL, McLaughlin K, Costa M. Clinical trial: the impact of cyclooxygenase inhibitors on gastrointestinal recovery after major surgery - a randomized double blind controlled trial of celecoxib or diclofenac vs. placebo. Aliment Pharmacol Ther 2009; 30 (10) 987-998
  • 33 Gorissen KJ, Benning D, Berghmans T. , et al. Risk of anastomotic leakage with non-steroidal anti-inflammatory drugs in colorectal surgery. Br J Surg 2012; 99 (05) 721-727
  • 34 Zakine J, Samarcq D, Lorne E. , et al. Postoperative ketamine administration decreases morphine consumption in major abdominal surgery: a prospective, randomized, double-blind, controlled study. Anesth Analg 2008; 106 (06) 1856-1861
  • 35 Dale O, Somogyi AA, Li Y, Sullivan T, Shavit Y. Does intraoperative ketamine attenuate inflammatory reactivity following surgery? A systematic review and meta-analysis. Anesth Analg 2012; 115 (04) 934-943
  • 36 Remérand F, Le Tendre C, Baud A. , et al. The early and delayed analgesic effects of ketamine after total hip arthroplasty: a prospective, randomized, controlled, double-blind study. Anesth Analg 2009; 109 (06) 1963-1971
  • 37 Koinig H, Wallner T, Marhofer P, Andel H, Hörauf K, Mayer N. Magnesium sulfate reduces intra- and postoperative analgesic requirements. Anesth Analg 1998; 87 (01) 206-210
  • 38 Waldron NH, Jones CA, Gan TJ, Allen TK, Habib AS. Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis. Br J Anaesth 2013; 110 (02) 191-200
  • 39 Bolac CS, Wallace AH, Broadwater G, Havrilesky LJ, Habib AS. The impact of postoperative nausea and vomiting prophylaxis with dexamethasone on postoperative wound complications in patients undergoing laparotomy for endometrial cancer. Anesth Analg 2013; 116 (05) 1041-1047
  • 40 Kurz A, Fleischmann E, Sessler DI, Buggy DJ, Apfel C, Akça O. ; Factorial Trial Investigators. Effects of supplemental oxygen and dexamethasone on surgical site infection: a factorial randomized trial. Br J Anaesth 2015; 115 (03) 434-443
  • 41 Tufanogullari B, White PF, Peixoto MP. , et al. Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables. Anesth Analg 2008; 106 (06) 1741-1748
  • 42 Blaudszun G, Lysakowski C, Elia N, Tramèr MR. Effect of perioperative systemic α2 agonists on postoperative morphine consumption and pain intensity: systematic review and meta-analysis of randomized controlled trials. Anesthesiology 2012; 116 (06) 1312-1322
  • 43 Collard V, Mistraletti G, Taqi A. , et al. Intraoperative esmolol infusion in the absence of opioids spares postoperative fentanyl in patients undergoing ambulatory laparoscopic cholecystectomy. Anesth Analg 2007; 105 (05) 1255-1262
  • 44 Chia YY, Chan MH, Ko NH, Liu K. Role of β-blockade in anaesthesia and postoperative pain management after hysterectomy. Br J Anaesth 2004; 93 (06) 799-805
  • 45 Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan Jr JA, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA 2003; 290 (18) 2455-2463
  • 46 Marret E, Remy C, Bonnet F. ; Postoperative Pain Forum Group. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. Br J Surg 2007; 94 (06) 665-673
  • 47 Guay J, Nishimori M, Kopp SL. Epidural local anesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting, and pain after abdominal surgery: a Cochrane review. Anesth Analg 2016; 123 (06) 1591-1602
  • 48 Ahmed J, Lim M, Khan S, McNaught C, Macfie J. Predictors of length of stay in patients having elective colorectal surgery within an enhanced recovery protocol. Int J Surg 2010; 8 (08) 628-632
  • 49 Khan SA, Khokhar HA, Nasr ARH, Carton E, El-Masry S. Effect of epidural analgesia on bowel function in laparoscopic colorectal surgery: a systematic review and meta-analysis. Surg Endosc 2013; 27 (07) 2581-2591
  • 50 Hübner M, Blanc C, Roulin D, Winiker M, Gander S, Demartines N. Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Ann Surg 2015; 261 (04) 648-653
  • 51 Halabi WJ, Kang CY, Nguyen VQ. , et al. Epidural analgesia in laparoscopic colorectal surgery: a nationwide analysis of use and outcomes. JAMA Surg 2014; 149 (02) 130-136
  • 52 Lee JH, Park JH, Kil HK, Choi SH, Noh SH, Koo BN. Efficacy of intrathecal morphine combined with intravenous analgesia versus thoracic epidural analgesia after gastrectomy. Yonsei Med J 2014; 55 (04) 1106-1114
  • 53 Kong SK, Onsiong SM, Chiu WK, Li MK. Use of intrathecal morphine for postoperative pain relief after elective laparoscopic colorectal surgery. Anaesthesia 2002; 57 (12) 1168-1173
  • 54 Wongyingsinn M, Baldini G, Stein B, Charlebois P, Liberman S, Carli F. Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial. Br J Anaesth 2012; 108 (05) 850-856
  • 55 Virlos I, Clements D, Beynon J, Ratnalikar V, Khot U. Short-term outcomes with intrathecal versus epidural analgesia in laparoscopic colorectal surgery. Br J Surg 2010; 97 (09) 1401-1406
  • 56 Charlton S, Cyna AM, Middleton P, Griffiths JD. Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery. Cochrane Database Syst Rev 2010; 12 (12) CD007705
  • 57 Brogi E, Kazan R, Cyr S, Giunta F, Hemmerling TM. Transversus abdominal plane block for postoperative analgesia: a systematic review and meta-analysis of randomized-controlled trials. Can J Anaesth 2016; 63 (10) 1184-1196
  • 58 Walter CJ, Maxwell-Armstrong C, Pinkney TD. , et al. A randomised controlled trial of the efficacy of ultrasound-guided transversus abdominis plane (TAP) block in laparoscopic colorectal surgery. Surg Endosc 2013; 27 (07) 2366-2372
  • 59 Rashid A, Gorissen KJ, Ris F. , et al. No benefit of ultrasound guided transversus abdominis plane blocks over local anaesthetic wound infiltration in elective laparoscopic colonic surgery; results of a double blind randomized controlled trial. Colorect Dis 2016; 19 (07) 681-689
  • 60 Oh TK, Yim J, Kim J. , et al. Effects of preoperative ultrasound-guided transversus abdominis plane block on pain after laparoscopic surgery for colorectal cancer: a double-blind randomized controlled trial. Surg Endosc 2017; 31 (01) 127-134
  • 61 Pedrazzani C, Menestrina N, Moro M. , et al. Local wound infiltration plus transversus abdominis plane (TAP) block versus local wound infiltration in laparoscopic colorectal surgery and ERAS program. Surg Endosc 2016; 30 (11) 5117-5125
  • 62 Gilron I, Orr E, Tu D, Mercer CD, Bond D. A randomized, double-blind, controlled trial of perioperative administration of gabapentin, meloxicam and their combination for spontaneous and movement-evoked pain after ambulatory laparoscopic cholecystectomy. Anesth Analg 2009; 108 (02) 623-630
  • 63 Gilron I, Tu D, Dumerton-Shore D. , et al. The effect of triple vs. double nonopioid therapy on postoperative pain and functional outcome after abdominal hysterectomy: a randomised double-blind control trial. Eur J Anaesthesiol 2015; 32 (04) 269-276
  • 64 Oh ES, Li M, Fafowora TM. , et al. Preoperative risk factors for postoperative delirium following hip fracture repair: a systematic review. Int J Geriatr Psychiatry 2015; 30 (09) 900-910