Discussion
PODs, acute pain, hypotension, pain
COMPLICATIONS, GASTRIC CANCER
In this multicenter randomized trial on laparoscopic versus open gastrectomy for gastric cancer, pain scores were comparable and acceptable in both treatment arms during all PODs and at discharge (between 2 and 4 at all PODs and < 2 at discharge). Mobilization milestones were quickly reached in both treatment arms and only modestly quicker in the laparoscopic group. In the laparoscopic group, mean daily opioid consumption was significantly lower, and significantly fewer patients used oral opioids at discharge. Hence, laparoscopic gastrectomy led to adequate pain control, generally without epidural analgesia and with a clinically relevantly lower consumption of opioids, compared to open gastrectomy.The higher opioid consumptions in the open group were partly due to the majority of this group receiving epidural analgesia, through which local anesthetics and opioids are administered. Epidural administered opioids also reach the systemic circulation and were therefore converted into daily oral morphine equivalents (via recognized conversion values) and added to the daily opioid consumption.These opioid reductions are deemed especially relevant in light of the current opioid epidemic.It would be especially relevant if this would also result in reduced long-term opioid users after laparoscopic gastrectomy. Chronic opioid use often begins with treatment of acute pain, and approximately 3.3% of patients exposed to chronic use become addicted.Three trials on distal gastrectomy briefly reported on pain or analgesic consumption upon publishing the main trial results.Epidural analgesia is an invasive procedure, and complications can occur, such as hypotension and not adequately functioning epidural catheters in up to one-third of patients.An important limitation of the current study is that the trial protocol only allowed for epidural analgesia in the open group, since ERAS guidelines indicated that epidural analgesia provided superior pain control compared to intravenous analgesia in open abdominal surgery.Strengths of the current study are that it is the first randomized trial on this subject in a Western population and the first to also include total gastrectomy.In conclusion, in the current multicenter randomized trial on laparoscopic versus open gastrectomy, adequate pain management was achieved in both treatment arms. After laparoscopic gastrectomy, this was generally achieved without epidural analgesia and with significantly lower consumption of opioids, compared to open gastrectomy.
