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Open colorectal surgery - An update of the systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations Axel R. Sauter(*) On behalf of the PROSPECT Working group of the European Society of Regional Anaesthesia Pain therapy (ESRA) (*) Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway and Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland Background Despite advancements in surgical techniques, open colectomy remains commonplace and is often associated with significant postoperative pain. 1 In 2016, the PROcedure SPECific POSToperative Pain Management (PROSPECT) group published recommendations based on a systematic review.2 The group aimed to update these recommendations by evaluating recent evidence and formulating new guidance for optimal pain control following open colectomy, in line with the PROSPECT approach. Methods A systematic review was conducted using the established PROSPECT methodology. Randomised controlled trials and systematic reviews published in English between 2016 and 2022 were examined. The studies investigated the impact of analgesic, anaesthetic or surgical strategies on postoperative pain following open colectomy. The primary outcome of interest was pain intensity. Results The original 2016 review included 93 studies. Of the 842 additional records examined, 13 new studies met the inclusion criteria and were analysed. Effective intra- and postoperative strategies included the use of paracetamol and epidural analgesia. Where epidural analgesia is contraindicated or impracticable, suitable alternatives include intravenous lidocaine, a bilateral transversus abdominis plane (TAP) block or a continuous pre-peritoneal infusion postoperatively. Safety must be emphasised: the simultaneous use of local anaesthetics via multiple routes should be avoided, and careful dosing with appropriate monitoring is critical to minimise toxicity. For colonic procedures, administrating cyclo-oxygenase-2 (COX-2) inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs) during the intraoperative and postoperative periods is also recommended.Conclusion The updated review identified an evidence-based analgesic regimen for patients undergoing open colorectal surgery. 3 References Gerbershagen HJ, Aduckathil S, van Wijck AJ, Peelen LM, Kalkman CJ, Meissner W. Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology 2013;118:934–44. Joshi GP, Bonnet F, Kehlet H. Evidence-based postoperative pain management after laparoscopic colorectal surgery. Colorectal Dis. 2013;15:146–55. Uten T, Chesnais M, van de Velde M, Raeder J, Beloeil H. Pain management after open colorectal surgery: an update of the systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol. 2024;41:363–6.