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Page 10 of 18 Tebala et al. Mini-invasive Surg 2018;2:32 I http://dx.doi.org/10.20517/2574-1225.2018.37

side effects such as constipation, ileus, nausea, urinary retention, over sedation, delirium and delayed dis-
charge. Clearly, this does not fit with the ERAS principles. The further demonstration, that non-opioid an-
[74]
algesia may be associated with less pain, reduced risk of cancer recurrence and longer survival has con-
vinced the medical community that non-opioids regimens should be considered. The European guidelines
suggest using opioids only as rescue analgesia, in particular in laparoscopic surgery. The ASER guidelines
suggest a multimodal approach with NSAIDs, paracetamol and/or gabapentin, eventually associated with
spinal/epidural analgesia and/or local anaesthetic infusion within the wound. Eventual adjuncts can be ste-
[73]
roids, ketamine and tramadol .
It has been demonstrated that the neuro-axial block is able to reduce the surgical stress by interrupting the
transmission of the nociceptive stimulus to the brainstem, thus reducing the risk of postoperative ileus [2,75] .
Epidural analgesia is also effective for the pain control in the postoperative period, even if many Authors
prefer to limit its use to laparotomic surgery where its benefits are definitely clearer than the risks. Epi-
dural anaesthesia (EA) is associated with very good pain control after colorectal surgery, both laparoscopic
and open, but the prolonged block of the sympathetic system, with consequent hypotension and need for
[76]
continuous fluid infusion, is a major concern. Although the benefits of EA are well known , the use of
single-injection intrathecal (spinal) analgesia (IA) with opioid plus or minus local anaesthesia is gaining
[77]
favor . The main advantage of IA with respect to epidural is its easiness, as it does not require any further
equipment or specific surveillance. The perceived drawback is its potential risk of complications such as
[77]
respiratory depression. This has been widely contradicted by scientific evidences . On the contrary, IA is
safe and effective, as it is able to control postoperative pain while allowing earlier functional recovery and
[78]
shorter LOS . IA is usually performed to provide additional pain control in association with paracetamol
and NSAIDs.

Peripheral analgesia can also be extremely effective. Transversus abdominis plane infiltration, wound and
peritoneal infiltration and rectus sheath block in association with systemic analgesia have all been demon-
[73]
strated to be able to reduce the use of opioid with respect to systemic analgesia only .

All non-opioid oral analgesic agents have been widely used and have been found to be able to reduce
the use of opioids. Their routine use is part of any ERAS programme. Intravenous administration of
paracetamol can achieve higher plasma concentrations with respect to the oral administration, but there is
[79]
no evidence of a clear superiority of intravenous versus oral administration in the clinical settings . The
use of NSAIDs has been recommended on the basis of good efficacy and insufficient evidence of complica-
[80]
tions . However, recent evidence suggest caution with the use of non-selective NSAIDs like diclofenac,
[81]
due to increased risk of anatomotic leak . Gabapentin and pregabalin can also be used to reduce the re-
[82]
[73]
quirement of opioids in the postoperative period , and as such their use is recommended by the ASER ,
[85]
[84]
[83]
[86]
but only at high doses. Tramadol , ketamine , magnesium and steroids have all been used for post-
operative pain control, with some efficacy, but their use has not gained wide acceptance.
Prevention of postoperative nausea and vomiting
Postoperative nausea and vomiting (PONV) are common side effects of surgery and anaesthesia and can
affect early feeding and reduce patient satisfaction. Recent guidelines suggest a multimodal and quite lib-
[23]
eral approach to PONV treatment . Avoidance of opiates and administration of oxygen can help reducing
[87]
PONV. Goll et al. demonstrated that 2 h of 80% oxygen are more effective in reducing PONV than on-
dansetron. However, postoperative ondansetron following preoperative administration of dexamethasone
[23]
is an effective combination . It is well known that intravenous anaesthesia with propofol is superior to
[23]
[88]
inhalation anaesthesia , but the role of gabapentin is not yet fully defined .