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Licensed Unlicensed Requires Authentication Published by De Gruyter November 3, 2020

Effectiveness of ESPITO analgesia in enhancing recovery in patients undergoing open radical cystectomy when compared to a contemporaneous cohort receiving standard analgesia: an observational study

G. Niraj, Zubair Tariq, Ashani Ratnayake, Benjamin. L Jackson, Mehar Ahson, Yehia Kamel and Vipul Kaushik



Bowel dysfunction is a major complication following open surgery for invasive cancer of the bladder that results in significant discomfort; complications and can prolong the length of stay. The incidence of postoperative ileus following open radical cystectomy has been reported as 23–40%. The median length of hospital stay after this surgery in the United Kingdom is 11 days. Standard analgesic techniques include wound infusion analgesia combined with systemic morphine or thoracic epidural analgsia. Combined erector spinae plane and intrathecal opioid analgesia is a novel technique that has been reported to be an effective method of providing perioperative analgesia thereby enhancing recovery after open radical cystectomy.


We performed a prospective study on the effectiveness of the novel analgesic technique (combined erector spinae plane and intrathecal opioid analgesia) in reducing the incidence of postoperative ileus, thereby facilitating early discharge following open radical cystectomy when compared to a contemporaneous control group receiving standard analgesia. Twenty-five patients received the novel analgesia while 31 patients received standard analgesia as a part of enhanced recovery programme. Standard analgesia arm included 14 patients who recived thoracic epidural analgesia (14/31, 45%) and 17 patients who received combined wound infusion analgesia and patient controlled analgesia with morphine (17/31, 55%). Primary outcome was the incidence of postoperative ileus. Secondary outcomes included length of hospital stay, tramadol consumption and time to bowel opening.


Combined erector spinae plane and intrathecal opioid analgesia was associated with a reduced incidence of postoperative ileus (16 [4/25] vs. 65% [20/31], p<0.001), reduced time to first open bowel (4.4 ± 2.3 vs. 6.6 ± 2.3, p<0.001) and reduced median (IQR) length of hospital stay (7[6, 12] vs. 10[8, 15], p=0.007). There was no significant difference in rescue analgesia (intravenous tramadol) consumption. Complete avoidance of systemic morphine played a key role in improved outcomes.


ESPITO was successful in reducing postoperative ileus and length of hospital stay after open radical cystectomy when compared to standard analgesia within an enhanced recovery programme.

Corresponding author: G. Niraj, Department of Anaesthesia, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Leicester, UK, E-mail:

Funding source: University Hospitals of Leicester NHS Trust

Award Identifier / Grant number: 100012151


The authors would like to thank Sue Daykin, Specialist Nurse in Pain Medicine and her team who have been instrumental in setting up local anaesthetic infusion protocol as well as training the ward staff in managing patients on continuous local anaesthetic infusions.

  1. Research funding: University Hospitals of Leicester NHS Trust funded this study.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: The authors state no conflict of interest.

  4. Informed Consent: The authors state that written informed consent was obtained from all patients.

  5. Ethical approval: Ethical approval was obtained from the research ethics committee (REC, 17/YH/0380).


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Received: 2020-07-15
Accepted: 2020-09-23
Published Online: 2020-11-03
Published in Print: 2021-04-27

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