The Impact of Intrathecal Analgesia with Diamorphine on Postoperative Recovery in Elective Robotic-Assisted Colorectal Surgery: A Retrospective Cohort Study 

The Impact of Intrathecal Analgesia with Diamorphine on Postoperative Recovery in Elective Robotic-Assisted Colorectal Surgery: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of Intrathecal Analgesia with Diamorphine on Postoperative Recovery in Elective Robotic-Assisted Colorectal Surgery: A Retrospective Cohort Study Shubham Jain, Aravindhdoss Devadoss, Natalie Claridge, Ian Driver, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7563056/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Oct, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Enhanced recovery after surgery (ERAS) protocols emphasizes multimodal interventions to accelerate recovery. Minimally invasive elective robotic-assisted colorectal surgery is an ideal candidate for ERAS protocols. This study evaluates the role of intrathecal analgesia with diamorphine in optimizing postoperative outcomes, focusing on pain control, length of stay (LOS), and complications. Methods: A retrospective cohort study was conducted on 246 patients undergoing elective robotic-assisted colorectal surgeries between July 2021 and November 2024 at two hospitals in a single Trust (Hospitals A and B). Patients were grouped based on analgesia type: Intrathecal Analgesia with Diamorphine (IA) [Intervention] and non-intrathecal analgesia (nIA) [Control] groups. Primary outcomes included LOS, postoperative pain scores and opioid consumption. Secondary outcomes were postoperative ileus (POI) and time to first bowel movement. Results: Intrathecal Analgesia with Diamorphine was used in 61.8% (Hospital A) and 0% (Hospital B) of cases. Patients receiving IA in Hospital A compared to nIA in Hospital A and Hospital B respectively had significantly shorter LOS (5.3 days vs. 6.1 days and 7.0 days, p<0.001), reduced opioid requirements (88% reduction, p<0.00001), and a lower incidence of POI (3.6% vs. 13.2% and 14.7%, p=0.02). Time to bowel function recovery was also faster in IA group (2.6 days vs. 3.0 days in other groups, p=0.03). Conclusions: Intrathecal analgesia with diamorphine significantly enhances recovery in elective robotic-assisted colorectal surgery, aligning with ERAS objectives. Its integration into routine practice could optimize patient outcomes, reduce complications, and improve resource utilization. Further prospective studies are needed to confirm these findings. Robotic surgery Colorectal surgery Postoperative recovery ERAS Intrathecal Analgesia Diamorphine Figures Figure 1 Figure 2 What does this paper add to the literature? This paper investigates the place of intrathecal diamorphine in patients undergoing major robotic colorectal surgery, with an emphasis on reducing early postoperative pain, reducing morphine requirements and thus reducing the incidence of postoperative ileus. The results suggest a significant benefit, which has not been evidenced before in robotic assisted procedures. Introduction Colorectal surgery remains a cornerstone in the treatment of a variety of colorectal conditions, such as cancer, inflammatory bowel disease, and diverticulitis. Postoperative morbidity represents a significant risk. With advancements in surgical techniques, minimally invasive methods, such as laparoscopic and robotic-assisted surgeries, have become increasingly common. Robotic-assisted colorectal surgery, with its precision and reduced tissue trauma, reduced blood loss and shorter recovery times, offers promising benefits over traditional open surgery and is increasingly being incorporated into clinical practice [ 1 – 4 ]. Despite these advances, postoperative recovery remains a complex challenge, with pain management and prevention of complications like postoperative ileus (POI) being of paramount importance. Enhanced Recovery After Surgery (ERAS) protocols aim to optimize postoperative outcomes by implementing evidence-based interventions, including multimodal analgesia, minimisation of perioperative stress, early mobilization, and proper nutritional support [ 5 , 6 ]. One intervention that continues to gain significant attention in colorectal surgery is the use of intrathecal analgesia with diamorphine (IA). This technique has been shown to reduce postoperative pain and opioid consumption. It has also been linked to a reduction in the incidence of postoperative ileus - a common complication following major abdominal surgeries [ 7 – 10 ]. While the benefits of IA are well-documented in laparoscopic surgery, its role in robotic-assisted and open colorectal surgeries remains less clear [ 11 – 14 ]. The aim of this study is to evaluate the effects of intrathecal analgesia with diamorphine on key postoperative outcomes in patients undergoing elective robotic-assisted colorectal surgery. The focus is on postoperative pain scores, opioid consumption, the incidence of POI, and recovery metrics, including length of stay (LOS) and time to first bowel movement. We hypothesized that intrathecal analgesia would reduce opioid consumption, accelerate recovery, and minimize complications, aligning with the goals of ERAS protocols. Methods Study Design and Population This retrospective cohort study was conducted in a single trust including 246 patients who underwent elective robotic-assisted colorectal surgery at two separate hospital sites (Hospitals A and B) between July 2021 and November 2024. Patients were included if they had undergone elective robotic-assisted colorectal surgery for benign or malignant conditions. Patients were excluded if they had contraindications to IA (e.g., allergy, infection at the site of injection, or pre-existing spinal deformities), or if they required emergency surgery. The cohort was divided into two groups based on the type of analgesia received: the intrathecal analgesia with Diamorphine group (IA) [Intervention] and the non-intrathecal analgesia group (nIA) [Control]. Both patient groups received General anaesthesia in addition to the analgesia method. This study was registered with the clinical outcome audit team for the trust (Registration number SGA24-102) and approved. Owing to the retrospective nature of the study, individual patient participant consent was waived off and ethical approval was given based on the clinical outcome audit team registration. Anaesthesia Protocols In the IA group, patients received a single-shot spinal anaesthetic with 5 mg of plain bupivacaine, combined with 0.3-0.5 mg of intrathecal diamorphine. The solution was increased to 4-4.5ml with sterile saline to aid adequate spread of the diamorphine within the intrathecal space. The procedure was performed by an experienced anaesthetist, prior to the patient receiving a general anaesthetic. In both groups, a standard general anaesthetic was administered, with anaesthetic agents being decided by the case anaesthetist. The majority of patients received total intravenous anaesthesia (TIVA), using a combination of Propofol and Remifentanil. The provision of intraoperative multimodal analgesia was decided by the case anaesthetist. Local anaesthetic infiltration and Transversus abdominis planes blocks were undertaken by the surgeons for postoperative pain control. Outcome Measures The primary outcome measures were: Length of Stay (LOS): The total number of days spent in the hospital post-surgery. Pain Scores and opioid consumption: Pain was assessed in the postoperative recovery area by the recovery nurse caring for the patient. It was graded on a 4-point scale with zero being no pain and three being severe pain at rest. This scale was chosen to make the assessment easy after acceptance as standard at the local centers. The opioid consumption assessed the intravenous morphine (or equivalent) administered in the recovery room to achieve adequate comfort prior to the patient being discharged to the ward. The secondary outcome measures were: Postoperative Ileus (POI): Diagnosed based on clinical signs and symptoms, including abdominal distension, nausea, vomiting, and failure to pass flatus or stool within 72 hours post-surgery. Time to Bowel Function Recovery: Defined as the time (in days) to the first bowel movement following surgery. Statistical Analysis Statistical analysis was performed using SPSS version 27 (IBM Corp., Armonk, NY). Numerical variables were compared using the Kruskal-Wallis test, while categorical variables were compared using Chi-squared tests. Logistic regression models were used to assess the effect of spinal analgesia on the incidence of POI, adjusting for potential confounders such as age, comorbidities, and surgical complexity. The effect sizes (Cohen’s d) and 95% confidence intervals (CIs) were calculated to evaluate the clinical significance of the results. Results Patient Demographics and Baseline Characteristics A total of 246 patients who underwent elective robotic-assisted colorectal surgery (including a case mix of complete mesocolic excisions, segmental excisions for splenic flexure tumours, and low- and ultralow- anterior resections) at Hospital A and Hospital B between July 2021 and November 2024 were included in this retrospective cohort study. The case mix was complex due to availability of a single robotic surgeon to perform more complex colorectal cancer surgeries after the introduction of robotic surgery at the trust. Of these, 110 patients received intrathecal analgesia with diamorphine, while 136 patients received non-intrathecal analgesia alone. The overall mean age was 68 ± 11.68 years. There were no significant differences between the groups in terms of mean age; average body mass index (BMI); smoking habits; comorbidities such as diabetes mellitus, hypertension, and cardiovascular disease; and average preoperative haemoglobin (Hb) levels (Table 1). Table 1: Baseline demographic characteristics of the patient populations. Intrathecal Analgesia (n=110) Non-Intrathecal analgesia (n=136) Hospital A (n=110) Hospital A (n=68) Hospital B (n=68) Mean Age (in years) 66.4 69.6 68.6 Smoking History Smoker 10 7 9 Non-smoker 57 24 42 Ex-smoker 43 37 17 Average BMI 27.5 28.9 26.3 Comorbidities DM 15 11 5 COPD 4 8 5 IHD 2 5 6 Neoadjuvant treatments Pre-op R/CR/C 7 17 29 Average Pre-op Hb 134 130 130 ASA Grade 1 43 17 11 2 35 32 42 3 32 18 15 4 0 1 0 5 0 0 0 Type of Surgery Robotic 109 63 66 Lap 0 0 0 Open 1 1 0 Robotic to open 0 0 0 Lap to Open 0 4 2 Both groups had a similar distribution of surgical procedures, including segmental or total colectomy, colorectal cancer resection, and ileal pouch-anal anastomosis. The baseline characteristics of the two cohorts were well-matched, indicating that any observed differences in outcomes are attributable to the type of analgesia rather than inherent patient or surgical factors. PRIMARY OUTCOMES: (Table 2) Length of Stay (LOS) The mean length of hospital stay (LOS) was significantly shorter for patients who received intrathecal analgesia with diamorphine compared to those who received non-intrathecal analgesia alone. The average LOS for IA patients were 5.3 ± 1.2 days, compared to 6.1 ± 1.4 days and 7.0 ± 1.6 days for Hospital A and Hospital B patients receiving nIA (p<0.001). This finding suggests that intrathecal analgesia with diamorphine may promote faster recovery, potentially due to reduced opioid consumption, enhanced bowel function recovery, and a reduced incidence of postoperative complications. Postoperative Pain and Opioid Consumption Postoperative pain levels were significantly lower in patients who received intrathecal analgesia with diamorphine. The median pain score in the postoperative recovery room, as assessed on a scale of 0-3, was statistically lower with IA, compared to nIA (p<0.001). Patients in the intrathecal group are also statistically less likely to require any morphine - 96.8% reduction in the dose of total morphine required in theatre and recovery (12.5mg in nIA group compared to 0.4mg in IA), 97.9% reduction in average morphine dose required in recovery (4.7mg in nIA vs 0.1mg in IA) and a 82.2% reduction in the chance of requiring morphine in recovery when given IA (p<0.00001). (Figure 1) SECONDARY OUTCOMES: (Table 2) Postoperative Ileus (POI) Incidence The incidence of postoperative ileus (POI) was significantly lower in patients who received intrathecal analgesia. Only 4.5% of IA patients developed POI, compared to 13.2% in Hospital A and 14.7% in Hospital B patients (p=0.02) who received nIA. Logistic regression analysis, adjusting for age, comorbidities, and surgical complexity, revealed that intrathecal analgesia with diamorphine was an independent protective factor for the development of POI (odds ratio 0.24; 95% confidence interval 0.08–0.72). (Figure 2) Time to Bowel Function Recovery The time to first bowel movement was significantly shorter in the IA group. On average, patients who received diamorphine intrathecally had their first bowel movement at 2.6 ± 0.7 days post-surgery, compared to 3.0 ± 0.9 days in the nIA group (p=0.03). Table 2: Outcome measures comparing intrathecal analgesia and non-intrathecal analgesia groups. Intrathecal Analgesia (n=110) Non-Intrathecal analgesia (n=136) p-Value Hospital A (n=110) Hospital A (n=68) Hospital B (n=68) LOS AVG DAYS 5.3 6.1 7 <0.001 1ST QRT 3 3 3 3RD QRT 6 6 8.3 IQR 3 3 5.3 Pain scores 0 89 23 12 <0.00001 1 13 20 28 2 7 21 23 3 0 3 2 Postoperative ileus 5 9 10 0.02 Time to bowels open AV DAYS 2.6 2.7 2.9 0.03 1ST QRT 2 2 1 3RD QRT 3 3 4 IQR 1 1 3 Discussion The results of this study underscore the positive impact of intrathecal analgesia with diamorphine on enhancing postoperative recovery after elective robotic-assisted colorectal surgery. Specifically, IA significantly reduced opioid consumption, minimized postoperative pain, and reduced the incidence of postoperative ileus (POI), which is a common and debilitating complication following colorectal surgery [ 10 ]. These findings align with the broader body of evidence suggesting that regional anaesthesia, particularly spinal analgesia, is beneficial in enhancing recovery, promoting gastrointestinal motility, and reducing opioid-related adverse effects [ 6 , 14 , 15 ]. The mechanism by which intrathecal analgesia with diamorphine may reduce POI remains a topic of interest. One possible explanation is that intrathecal analgesia attenuates the sympathetic response to surgery, which plays a role in inhibiting gastrointestinal motility [ 6 ]. The opioid-sparing effect of IA also mitigates the common side effects of opioids like delayed gastric emptying and ileus which is particularly significant in colorectal surgery [ 16 ]. This aligns with other studies by Wongyingsinn et al and Shereef et al demonstrating the benefits of regional anaesthesia in reducing POI and improving gastrointestinal recovery in colorectal surgery [ 17 , 18 ]. While the intrathecal analgesia group showed a trend toward faster bowel function recovery, larger sample sizes and more precise measures of bowel recovery are necessary to establish clear associations. Our findings also support previous research showing the benefits of spinal analgesia in colorectal surgery. For instance, a study by Tanaka et al. (2019) demonstrated that intrathecal analgesia with diamorphine reduced the incidence of POI and facilitated faster recovery [ 8 ]. Moreover, Krombholz et al. (2025) found that intrathecal analgesia improved postoperative pain control and reduced opioid use, aligning with the results of this study [ 15 ]. In addition to its impact on bowel recovery and opioid consumption, intrathecal analgesia has other potential benefits in the context of colorectal surgery. For instance, studies have shown that IA may reduce the incidence of postoperative nausea and vomiting (PONV), a common complication following abdominal surgery [ 19 ]. This effect may be especially beneficial given the opioid-sparing benefits of intrathecal analgesia, as opioids are a common cause of PONV. Furthermore, IA is associated with fewer hemodynamic fluctuations compared to nIA, which may improve cardiovascular stability, particularly in high-risk patients [ 20 ]. The reductions in LOS and time to recovery of bowel function in the intrathecal analgesia group, along with the reduced opioid use and lower incidence of POI, all point to a more rapid and less complicated postoperative recovery. These benefits are consistent with the principles of ERAS protocols, which aim to enhance recovery through multimodal interventions like early mobilization, optimised fluid management and multimodal analgesia [ 6 ]. Whilst our study demonstrated a positive impact on LOS in the intrathecal analgesia group, LOS depends on many factors such as the complexity of the surgery, patient comorbidities, and the use of additional ERAS components [ 14 , 15 ], which are not evaluated here as independent factors. This study’s strengths lie in its real-world setting and focus on a diverse range of colorectal surgeries. However, it is important to acknowledge the limitations inherent in retrospective studies, such as the potential for unintentional selection bias and variability in perioperative practices across the two institutions. Prospective, randomized controlled trials are needed to validate these findings and explore the long-term benefits of intrathecal analgesia with diamorphine in elective robotic-assisted colorectal surgery [ 21 ]. This study demonstrates the significant benefits of intrathecal analgesia with diamorphine in improving postoperative recovery of elective robotic-assisted colorectal surgeries. The main findings include reduced opioid consumption, decreased incidence of POI, faster recovery of bowel function, and shortened hospital stays. These results align with the goals of ERAS protocols, which emphasize reducing surgical stress and optimizing recovery. Conclusion Intrathecal analgesia with diamorphine significantly enhances recovery in elective robotic-assisted colorectal surgeries, by providing improved pain control with reduced opioid consumption, and a quicker recovery of the bowel function leading to a lower incidence of postoperative ileus. This supports ERAS protocols and improves surgical outcomes. Standardizing its use across different colorectal surgical techniques could optimize patient care and resource utilization. Declarations Declaration of Interest: The authors declare that they have no financial or other interest. All authors read and approved the final manuscript. Sources of Funding: None Data Availability Statement: Data available on request. Acknowledgements: None Ethics Approval Statement: This study was registered with the clinical outcome audit team for the trust (Registration number SGA24-102) and approved. Patient Consent Statement: Patient consent was not needed as this was a retrospective study done. Permission to reproduce material from other sources: No material here is used from other studies. Clinical Trials Registration: This study was not part of any clinical trial. Type of article being submitted: Original Article Author Contribution Shubham JainWriting - original draft, Validation, Visualization, review & editing, Conceptualization, Methodology, SupervisionAravindhdoss DevadossWriting - review & editing, Visualization, Validation, original draftNatalie ClaridgeInvestigation, Conceptualization, Project administration, Writing - review & editing, Visualization, Validation, Data curationIan DriverConceptualization, Investigation, Methodology, Validation, Visualization, Writing - review & editing, Software, Formal analysisArshad MalikConceptualization, Investigation, Writing - original draft, Methodology, Validation, Visualization, review & editing, Project administration, Supervision, Resources References Wang X, Cao G, Mao W, Lao W, He C. Robot-assisted versus laparoscopic surgery for rectal cancer: a systematic review and meta-analysis. 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Spinal versus non-spinal anaesthesia for elective colorectal surgery: a systematic review and meta-analysis. Colorectal Dis. 2018;20(4):317-326. Grape S, El-Boghdadly K, Jaques C, Albrecht E. Efficacy and safety of intrathecal diamorphine: a systematic review and meta-analysis with meta-regression and trial sequential analysis. Anaesthesia. 2024;79(10):1081-1090. doi:10.1111/anae.16359 Tanaka A, Matsumoto K, Sugiyama M, Hirose T, et al. Comparison of spinal and non-spinal anaesthesia for colorectal cancer surgery: a retrospective cohort study. Surg Today. 2019;49(2):112-118. El-Boghdadly K, Jack JM, Heaney A, et al. Role of regional anesthesia and analgesia in enhanced recovery after colorectal surgery: a systematic review of randomized controlled trials. Reg Anesth Pain Med. 2022;47(5):282-292. doi:10.1136/rapm-2021-103312 Shrestha A, Sivarajan P, Gautam S, Sharma M, et al. Effect of spinal anaesthesia on postoperative ileus in abdominal surgeries: a systematic review and meta-analysis. J Clin Anesth. 2022;75:110435. Lindberg M, Franklin O, Svensson J, Franklin KA. Postoperative pain after colorectal surgery. Int J Colorectal Dis. 2020;35(7):1265-1272. doi:10.1007/s00384-020-03580-4 Kawka M, Fong Y, Gall TMH. Laparoscopic versus robotic abdominal and pelvic surgery: a systematic review of randomised controlled trials. Surg Endosc. 2023;37(9):6672-6681. doi:10.1007/s00464-023-10275-8 Barud M, Turek B, Dąbrowski W, Siwicka D. Anesthesia for robot-assisted surgery: a review. Anaesthesiol Intensive Ther. 2025;57(1):99-107. doi:10.5114/ait/203168 de Boer HD, Scott MJ, Fawcett WJ. Anaesthesia role in enhanced recovery after surgery: a revolution in care outcomes. Curr Opin Anaesthesiol. 2023;36(2):202-207. doi:10.1097/ACO.0000000000001248 Krombholz E, Wirsching A, Seidl A, Frey MC, Obrecht I, Hasler-Gehrer S, et al. Spinal anesthesia decreases pain and total hospitalization costs but not ileus after colon surgery: a prospective study. Br J Surg. 2025 May;112(Suppl_7):znaf092.056. Wilson F, Jones CN. Analgesia for open abdominal surgery. Dig Med Res. 2019;2:23. 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(5):850-856. doi:10.1093/bja/aes028 Shereef A, Raftery D, Sneddon F, et al. Prolonged ileus after colorectal surgery, a systematic review. J Clin Med. 2023;12(18):5769. doi:10.3390/jcm12185769 Huh H. Postoperative nausea and vomiting in spinal anesthesia. Korean J Anesthesiol. 2023;76(2):87-88. doi:10.4097/kja.23157 Tang Y, Ge Y. Effects of combining epidural with general anesthesia on postoperative sleep and pain in elderly patients undergoing gastrointestinal tumor surgery: a prospective randomized trial. BMC Anesthesiol. 2025;25(1):398. doi:10.1186/s12871-025-03266-w Pirie K, Traer E, Finniss D, Myles PS, Riedel B. Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions. Br J Anaesth. 2022;129(3):378-393. doi:10.1016/j.bja.2022.05.029 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Oct, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 27 Sep, 2025 Reviewers agreed at journal 27 Sep, 2025 Reviews received at journal 27 Sep, 2025 Reviewers agreed at journal 26 Sep, 2025 Reviewers agreed at journal 26 Sep, 2025 Reviewers invited by journal 19 Sep, 2025 Editor assigned by journal 09 Sep, 2025 Submission checks completed at journal 08 Sep, 2025 First submitted to journal 08 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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01:01:55","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":41609,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7563056/v1/a3da011f6339b911672c3864.png"},{"id":92680010,"identity":"8969ae09-9e62-4d93-ab70-fa2eff66c238","added_by":"auto","created_at":"2025-10-03 01:01:55","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7285,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7563056/v1/20cb79ce48fa989e552f038f.png"},{"id":92680013,"identity":"ab330c5c-d1af-4c7a-93cc-5ca4b619da6a","added_by":"auto","created_at":"2025-10-03 01:01:55","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72623,"visible":true,"origin":"","legend":"","description":"","filename":"8b41c28f331949338b0474b255db11091structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7563056/v1/bf50af4a474c73513b7ecbe1.xml"},{"id":92680014,"identity":"0c0d7287-769c-4975-8faa-ee7f795dbfd0","added_by":"auto","created_at":"2025-10-03 01:01:55","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":81087,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7563056/v1/d01c8bbcf06187e18d4e5ed6.html"},{"id":92680005,"identity":"852318a0-7cd5-43ab-ba9c-1c950c7df7fd","added_by":"auto","created_at":"2025-10-03 01:01:55","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":229945,"visible":true,"origin":"","legend":"\u003cp\u003ePain scores in recovery and opioid consumption. The intrathecal analgesia group required significantly less opioid analgesia (88% less opioids) compared to the non-intrathecal analgesia group (p\u0026lt;0.00001).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7563056/v1/633a8f0fbdd611dd5cf09ba8.jpeg"},{"id":92681608,"identity":"554e6f21-bd1c-48ac-8f01-9abaa28ed1d9","added_by":"auto","created_at":"2025-10-03 01:09:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13871,"visible":true,"origin":"","legend":"\u003cp\u003eIncidence of postoperative ileus (POI) in intrathecal versus non-intrathecal analgesia groups. Intrathecal analgesia with Diamorphine was associated with a significantly lower incidence of POI (4.5% vs. 13.2% and 14.7%, p=0.02).\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7563056/v1/0c5b9bfad60ca5fd28105aa0.png"},{"id":93956157,"identity":"7fd8d4dc-b4b2-48f7-afc7-b2649cd57d4b","added_by":"auto","created_at":"2025-10-20 16:11:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1006249,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7563056/v1/81a66146-e5db-4bb0-93f4-0c65e281146c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of Intrathecal Analgesia with Diamorphine on Postoperative Recovery in Elective Robotic-Assisted Colorectal Surgery: A Retrospective Cohort Study ","fulltext":[{"header":"What does this paper add to the literature?","content":"\u003cp\u003eThis paper investigates the place of intrathecal diamorphine in patients undergoing major robotic colorectal surgery, with an emphasis on reducing early postoperative pain, reducing morphine requirements and thus reducing the incidence of postoperative ileus. The results suggest a significant benefit, which has not been evidenced before in robotic assisted procedures.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eColorectal surgery remains a cornerstone in the treatment of a variety of colorectal conditions, such as cancer, inflammatory bowel disease, and diverticulitis. Postoperative morbidity represents a significant risk. With advancements in surgical techniques, minimally invasive methods, such as laparoscopic and robotic-assisted surgeries, have become increasingly common. Robotic-assisted colorectal surgery, with its precision and reduced tissue trauma, reduced blood loss and shorter recovery times, offers promising benefits over traditional open surgery and is increasingly being incorporated into clinical practice [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite these advances, postoperative recovery remains a complex challenge, with pain management and prevention of complications like postoperative ileus (POI) being of paramount importance.\u003c/p\u003e\u003cp\u003eEnhanced Recovery After Surgery (ERAS) protocols aim to optimize postoperative outcomes by implementing evidence-based interventions, including multimodal analgesia, minimisation of perioperative stress, early mobilization, and proper nutritional support [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. One intervention that continues to gain significant attention in colorectal surgery is the use of intrathecal analgesia with diamorphine (IA). This technique has been shown to reduce postoperative pain and opioid consumption. It has also been linked to a reduction in the incidence of postoperative ileus - a common complication following major abdominal surgeries [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While the benefits of IA are well-documented in laparoscopic surgery, its role in robotic-assisted and open colorectal surgeries remains less clear [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe aim of this study is to evaluate the effects of intrathecal analgesia with diamorphine on key postoperative outcomes in patients undergoing elective robotic-assisted colorectal surgery. The focus is on postoperative pain scores, opioid consumption, the incidence of POI, and recovery metrics, including length of stay (LOS) and time to first bowel movement. We hypothesized that intrathecal analgesia would reduce opioid consumption, accelerate recovery, and minimize complications, aligning with the goals of ERAS protocols.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study was conducted in a single trust including 246 patients who underwent elective robotic-assisted colorectal surgery at two separate hospital sites (Hospitals A and B) between July 2021 and November 2024. Patients were included if they had undergone elective robotic-assisted colorectal surgery for benign or malignant conditions. Patients were excluded if they had contraindications to IA (e.g., allergy, infection at the site of injection, or pre-existing spinal deformities), or if they required emergency surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe cohort was divided into two groups based on the type of analgesia received: the intrathecal analgesia with Diamorphine group (IA) [Intervention] and the non-intrathecal analgesia group (nIA) [Control]. Both patient groups received General anaesthesia in addition to the analgesia method.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was registered with the clinical outcome audit team for the trust (Registration number SGA24-102) and approved. Owing to the retrospective nature of the study, individual patient participant consent was waived off and ethical approval was given based on the clinical outcome audit team registration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnaesthesia Protocols\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the IA group, patients received a single-shot spinal anaesthetic with 5 mg of plain bupivacaine, combined with 0.3-0.5 mg of intrathecal diamorphine. The solution was increased to 4-4.5ml with sterile saline to aid adequate spread of the diamorphine within the intrathecal space. The procedure was performed by an experienced anaesthetist, prior to the patient receiving a general anaesthetic. In both groups, a standard general anaesthetic was administered, with anaesthetic agents being decided by the case anaesthetist. The majority of patients received total intravenous anaesthesia (TIVA), using a combination of Propofol and Remifentanil. The provision of intraoperative multimodal analgesia was decided by the case anaesthetist. Local anaesthetic infiltration and Transversus abdominis planes blocks were undertaken by the surgeons for postoperative pain control.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome measures were:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eLength of Stay (LOS):\u003c/strong\u003e The total number of days spent in the hospital post-surgery.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePain Scores and opioid consumption:\u003c/strong\u003e Pain was assessed in the postoperative recovery area by the recovery nurse caring for the patient. It was graded on a 4-point scale with zero being no pain and three being severe pain at rest.\u0026nbsp;This scale was chosen to make the assessment easy after acceptance as standard at the local centers.\u0026nbsp;The opioid consumption assessed the intravenous morphine (or equivalent) administered in the recovery room to achieve adequate comfort prior to the patient being discharged to the ward.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe secondary outcome measures were:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003ePostoperative Ileus (POI):\u003c/strong\u003e Diagnosed based on clinical signs and symptoms, including abdominal distension, nausea, vomiting, and failure to pass flatus or stool within 72 hours post-surgery.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTime to Bowel Function Recovery:\u003c/strong\u003e Defined as the time (in days) to the first bowel movement following surgery.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed using SPSS version 27 (IBM Corp., Armonk, NY). Numerical variables were compared using the Kruskal-Wallis test, while categorical variables were compared using Chi-squared tests. Logistic regression models were used to assess the effect of spinal analgesia on the incidence of POI, adjusting for potential confounders such as age, comorbidities, and surgical complexity. The effect sizes (Cohen\u0026rsquo;s d) and 95% confidence intervals (CIs) were calculated to evaluate the clinical significance of the results.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient Demographics and Baseline Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 246 patients who underwent elective robotic-assisted colorectal surgery (including a case mix of complete mesocolic excisions, segmental excisions for splenic flexure tumours, and low- and ultralow- anterior resections) at Hospital A and Hospital B between July 2021 and November 2024 were included in this retrospective cohort study. The case mix was complex due to availability of a single robotic surgeon to perform more complex colorectal cancer surgeries after the introduction of robotic surgery at the trust. Of these, 110 patients received intrathecal analgesia with diamorphine, while 136 patients received non-intrathecal analgesia alone. The overall mean age was 68 \u0026plusmn; 11.68 years. There were no significant differences between the groups in terms of mean age; average body mass index (BMI); smoking habits; comorbidities such as diabetes mellitus, hypertension, and cardiovascular disease; and average preoperative haemoglobin (Hb) levels (Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1: Baseline demographic characteristics of the patient populations.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"607\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 243px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eIntrathecal Analgesia (n=110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 243px;\"\u003e\n \u003cp\u003eNon-Intrathecal analgesia (n=136)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eHospital A (n=110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003eHospital A (n=68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eHospital B (n=68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 243px;\"\u003e\n \u003cp\u003eMean Age (in years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e66.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e69.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e68.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 122px;\"\u003e\n \u003cp\u003eSmoking History\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eNon-smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eEx-smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 243px;\"\u003e\n \u003cp\u003eAverage BMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e28.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e26.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 122px;\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eCOPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eIHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 243px;\"\u003e\n \u003cp\u003eNeoadjuvant treatments Pre-op R/CR/C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 243px;\"\u003e\n \u003cp\u003eAverage Pre-op Hb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 122px;\"\u003e\n \u003cp\u003eASA Grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 122px;\"\u003e\n \u003cp\u003eType of Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eRobotic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eLap \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eOpen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eRobotic to open\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003eLap to Open\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBoth groups had a similar distribution of surgical procedures, including segmental or total colectomy, colorectal cancer resection, and ileal pouch-anal anastomosis. The baseline characteristics of the two cohorts were well-matched, indicating that any observed differences in outcomes are attributable to the type of analgesia rather than inherent patient or surgical factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePRIMARY OUTCOMES: (Table 2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLength of Stay (LOS)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean length of hospital stay (LOS) was significantly shorter for patients who received intrathecal analgesia with diamorphine compared to those who received non-intrathecal analgesia alone. The average LOS for IA patients were 5.3 \u0026plusmn; 1.2 days, compared to 6.1 \u0026plusmn; 1.4 days and 7.0 \u0026plusmn; 1.6 days for Hospital A and Hospital B patients receiving nIA (p\u0026lt;0.001). This finding suggests that intrathecal analgesia with diamorphine may promote faster recovery, potentially due to reduced opioid consumption, enhanced bowel function recovery, and a reduced incidence of postoperative complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Pain and Opioid Consumption\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative pain levels were significantly lower in patients who received intrathecal analgesia with diamorphine. The median pain score in the postoperative recovery room, as assessed on a scale of 0-3, was statistically lower with IA, compared to nIA (p\u0026lt;0.001). Patients in the intrathecal group are also statistically less likely to require any morphine - 96.8% reduction in the dose of total morphine required in theatre and recovery (12.5mg in nIA group compared to 0.4mg in IA), 97.9% reduction in average morphine dose required in recovery (4.7mg in nIA vs 0.1mg in IA) and a 82.2% reduction in the chance of requiring morphine in recovery when given IA (p\u0026lt;0.00001). (Figure 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSECONDARY OUTCOMES: (Table 2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Ileus (POI) Incidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe incidence of postoperative ileus (POI) was significantly lower in patients who received intrathecal analgesia. Only 4.5% of IA patients developed POI, compared to 13.2% in Hospital A and 14.7% in Hospital B patients (p=0.02) who received nIA. Logistic regression analysis, adjusting for age, comorbidities, and surgical complexity, revealed that intrathecal analgesia with diamorphine was an independent protective factor for the development of POI (odds ratio 0.24; 95% confidence interval 0.08\u0026ndash;0.72). (Figure 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTime to Bowel Function Recovery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe time to first bowel movement was significantly shorter in the IA group. On average, patients who received diamorphine intrathecally had their first bowel movement at 2.6 \u0026plusmn; 0.7 days post-surgery, compared to 3.0 \u0026plusmn; 0.9 days in the nIA group (p=0.03).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Outcome measures comparing intrathecal analgesia and non-intrathecal analgesia groups.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"607\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003eIntrathecal Analgesia (n=110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 203px;\"\u003e\n \u003cp\u003eNon-Intrathecal analgesia (n=136)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003ep-Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003eHospital A (n=110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003eHospital A (n=68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003eHospital B (n=68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 142px;\"\u003e\n \u003cp\u003eLOS\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003eAVG DAYS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e1ST QRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e3RD QRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 142px;\"\u003e\n \u003cp\u003ePain scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026lt;0.00001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 203px;\"\u003e\n \u003cp\u003ePostoperative ileus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 142px;\"\u003e\n \u003cp\u003eTime to bowels open\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003eAV DAYS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e1ST QRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e3RD QRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study underscore the positive impact of intrathecal analgesia with diamorphine on enhancing postoperative recovery after elective robotic-assisted colorectal surgery. Specifically, IA significantly reduced opioid consumption, minimized postoperative pain, and reduced the incidence of postoperative ileus (POI), which is a common and debilitating complication following colorectal surgery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These findings align with the broader body of evidence suggesting that regional anaesthesia, particularly spinal analgesia, is beneficial in enhancing recovery, promoting gastrointestinal motility, and reducing opioid-related adverse effects [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe mechanism by which intrathecal analgesia with diamorphine may reduce POI remains a topic of interest. One possible explanation is that intrathecal analgesia attenuates the sympathetic response to surgery, which plays a role in inhibiting gastrointestinal motility [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The opioid-sparing effect of IA also mitigates the common side effects of opioids like delayed gastric emptying and ileus which is particularly significant in colorectal surgery [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This aligns with other studies by Wongyingsinn et al and Shereef et al demonstrating the benefits of regional anaesthesia in reducing POI and improving gastrointestinal recovery in colorectal surgery [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. While the intrathecal analgesia group showed a trend toward faster bowel function recovery, larger sample sizes and more precise measures of bowel recovery are necessary to establish clear associations.\u003c/p\u003e\u003cp\u003eOur findings also support previous research showing the benefits of spinal analgesia in colorectal surgery. For instance, a study by Tanaka et al. (2019) demonstrated that intrathecal analgesia with diamorphine reduced the incidence of POI and facilitated faster recovery [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Moreover, Krombholz et al. (2025) found that intrathecal analgesia improved postoperative pain control and reduced opioid use, aligning with the results of this study [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition to its impact on bowel recovery and opioid consumption, intrathecal analgesia has other potential benefits in the context of colorectal surgery. For instance, studies have shown that IA may reduce the incidence of postoperative nausea and vomiting (PONV), a common complication following abdominal surgery [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This effect may be especially beneficial given the opioid-sparing benefits of intrathecal analgesia, as opioids are a common cause of PONV. Furthermore, IA is associated with fewer hemodynamic fluctuations compared to nIA, which may improve cardiovascular stability, particularly in high-risk patients [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe reductions in LOS and time to recovery of bowel function in the intrathecal analgesia group, along with the reduced opioid use and lower incidence of POI, all point to a more rapid and less complicated postoperative recovery. These benefits are consistent with the principles of ERAS protocols, which aim to enhance recovery through multimodal interventions like early mobilization, optimised fluid management and multimodal analgesia [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Whilst our study demonstrated a positive impact on LOS in the intrathecal analgesia group, LOS depends on many factors such as the complexity of the surgery, patient comorbidities, and the use of additional ERAS components [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which are not evaluated here as independent factors.\u003c/p\u003e\u003cp\u003eThis study\u0026rsquo;s strengths lie in its real-world setting and focus on a diverse range of colorectal surgeries. However, it is important to acknowledge the limitations inherent in retrospective studies, such as the potential for unintentional selection bias and variability in perioperative practices across the two institutions. Prospective, randomized controlled trials are needed to validate these findings and explore the long-term benefits of intrathecal analgesia with diamorphine in elective robotic-assisted colorectal surgery [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study demonstrates the significant benefits of intrathecal analgesia with diamorphine in improving postoperative recovery of elective robotic-assisted colorectal surgeries. The main findings include reduced opioid consumption, decreased incidence of POI, faster recovery of bowel function, and shortened hospital stays. These results align with the goals of ERAS protocols, which emphasize reducing surgical stress and optimizing recovery.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIntrathecal analgesia with diamorphine significantly enhances recovery in elective robotic-assisted colorectal surgeries, by providing improved pain control with reduced opioid consumption, and a quicker recovery of the bowel function leading to a lower incidence of postoperative ileus. This supports ERAS protocols and improves surgical outcomes. Standardizing its use across different colorectal surgical techniques could optimize patient care and resource utilization. \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of Interest:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no financial or other interest.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSources of Funding:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u0026nbsp;\u003c/strong\u003eData available on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval Statement:\u0026nbsp;\u003c/strong\u003eThis study was registered with the clinical outcome audit team for the trust (Registration number SGA24-102) and approved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Consent Statement:\u0026nbsp;\u003c/strong\u003ePatient consent was not needed as this was a retrospective study done.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePermission to reproduce material from other sources:\u0026nbsp;\u003c/strong\u003eNo material here is used from other studies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trials Registration:\u0026nbsp;\u003c/strong\u003eThis study was not part of any clinical trial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eType of article being submitted:\u0026nbsp;\u003c/strong\u003eOriginal Article\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eShubham JainWriting - original draft, Validation, Visualization, review \u0026amp; editing, Conceptualization, Methodology, SupervisionAravindhdoss DevadossWriting - review \u0026amp; editing, Visualization, Validation, original draftNatalie ClaridgeInvestigation, Conceptualization, Project administration, Writing - review \u0026amp; editing, Visualization, Validation, Data curationIan DriverConceptualization, Investigation, Methodology, Validation, Visualization, Writing - review \u0026amp; editing, Software, Formal analysisArshad MalikConceptualization, Investigation, Writing - original draft, Methodology, Validation, Visualization, review \u0026amp; editing, Project administration, Supervision, Resources\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWang X, Cao G, Mao W, Lao W, He C. Robot-assisted versus laparoscopic surgery for rectal cancer: a systematic review and meta-analysis. J Cancer Res Ther. 2020;16(5):979-989. doi:10.4103/jcrt.JCRT_533_18\u003c/li\u003e\n \u003cli\u003eGustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS\u0026reg;) Society recommendations: 2018. World J Surg. 2019;43(3):659-695.\u003c/li\u003e\n \u003cli\u003eKehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630-641.\u003c/li\u003e\n \u003cli\u003eLevy BF, Scott MJ, Fawcett WJ, Staahl C, Ljungqvist O. Enhanced recovery pathways in colorectal surgery: results from a UK database of 1,000 patients. Br J Surg. 2011;98(8):1107-1111.\u003c/li\u003e\n \u003cli\u003eFearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CHC, Lassen K, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS\u0026reg;) Society recommendations. Clin Nutr. 2012;31(5):801-816.\u003c/li\u003e\n \u003cli\u003eDoleman B, Read DJ, Faleiro RJ, Lund JN, Rex S. Spinal versus non-spinal anaesthesia for elective colorectal surgery: a systematic review and meta-analysis. Colorectal Dis. 2018;20(4):317-326.\u003c/li\u003e\n \u003cli\u003eGrape S, El-Boghdadly K, Jaques C, Albrecht E. Efficacy and safety of intrathecal diamorphine: a systematic review and meta-analysis with meta-regression and trial sequential analysis. Anaesthesia. 2024;79(10):1081-1090. doi:10.1111/anae.16359\u003c/li\u003e\n \u003cli\u003eTanaka A, Matsumoto K, Sugiyama M, Hirose T, et al. Comparison of spinal and non-spinal anaesthesia for colorectal cancer surgery: a retrospective cohort study. Surg Today. 2019;49(2):112-118.\u003c/li\u003e\n \u003cli\u003eEl-Boghdadly K, Jack JM, Heaney A, et al. Role of regional anesthesia and analgesia in enhanced recovery after colorectal surgery: a systematic review of randomized controlled trials. Reg Anesth Pain Med. 2022;47(5):282-292. doi:10.1136/rapm-2021-103312\u003c/li\u003e\n \u003cli\u003eShrestha A, Sivarajan P, Gautam S, Sharma M, et al. Effect of spinal anaesthesia on postoperative ileus in abdominal surgeries: a systematic review and meta-analysis. J Clin Anesth. 2022;75:110435.\u003c/li\u003e\n \u003cli\u003eLindberg M, Franklin O, Svensson J, Franklin KA. Postoperative pain after colorectal surgery. Int J Colorectal Dis. 2020;35(7):1265-1272. doi:10.1007/s00384-020-03580-4\u003c/li\u003e\n \u003cli\u003eKawka M, Fong Y, Gall TMH. Laparoscopic versus robotic abdominal and pelvic surgery: a systematic review of randomised controlled trials. Surg Endosc. 2023;37(9):6672-6681. doi:10.1007/s00464-023-10275-8\u003c/li\u003e\n \u003cli\u003eBarud M, Turek B, Dąbrowski W, Siwicka D. Anesthesia for robot-assisted surgery: a review. Anaesthesiol Intensive Ther. 2025;57(1):99-107. doi:10.5114/ait/203168\u003c/li\u003e\n \u003cli\u003ede Boer HD, Scott MJ, Fawcett WJ. Anaesthesia role in enhanced recovery after surgery: a revolution in care outcomes. Curr Opin Anaesthesiol. 2023;36(2):202-207. doi:10.1097/ACO.0000000000001248\u003c/li\u003e\n \u003cli\u003eKrombholz E, Wirsching A, Seidl A, Frey MC, Obrecht I, Hasler-Gehrer S, et al. Spinal anesthesia decreases pain and total hospitalization costs but not ileus after colon surgery: a prospective study. Br J Surg. 2025 May;112(Suppl_7):znaf092.056.\u003c/li\u003e\n \u003cli\u003eWilson F, Jones CN. Analgesia for open abdominal surgery. Dig Med Res. 2019;2:23.\u003c/li\u003e\n \u003cli\u003eWongyingsinn 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(5):850-856. doi:10.1093/bja/aes028\u003c/li\u003e\n \u003cli\u003eShereef A, Raftery D, Sneddon F, et al. Prolonged ileus after colorectal surgery, a systematic review. J Clin Med. 2023;12(18):5769. doi:10.3390/jcm12185769\u003c/li\u003e\n \u003cli\u003eHuh H. Postoperative nausea and vomiting in spinal anesthesia. Korean J Anesthesiol. 2023;76(2):87-88. doi:10.4097/kja.23157\u003c/li\u003e\n \u003cli\u003eTang Y, Ge Y. Effects of combining epidural with general anesthesia on postoperative sleep and pain in elderly patients undergoing gastrointestinal tumor surgery: a prospective randomized trial. BMC Anesthesiol. 2025;25(1):398. doi:10.1186/s12871-025-03266-w\u003c/li\u003e\n \u003cli\u003ePirie K, Traer E, Finniss D, Myles PS, Riedel B. Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions. Br J Anaesth. 2022;129(3):378-393. doi:10.1016/j.bja.2022.05.029\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Robotic surgery, Colorectal surgery, Postoperative recovery, ERAS, Intrathecal Analgesia, Diamorphine","lastPublishedDoi":"10.21203/rs.3.rs-7563056/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7563056/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Enhanced recovery after surgery (ERAS) protocols emphasizes multimodal interventions to accelerate recovery. Minimally invasive elective robotic-assisted colorectal surgery is an ideal candidate for ERAS protocols. This study evaluates the role of intrathecal analgesia with diamorphine in optimizing postoperative outcomes, focusing on pain control, length of stay (LOS), and complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective cohort study was conducted on 246 patients undergoing elective robotic-assisted colorectal surgeries between July 2021 and November 2024 at two hospitals in a single Trust (Hospitals A and B). Patients were grouped based on analgesia type: Intrathecal Analgesia with Diamorphine (IA) [Intervention] and non-intrathecal analgesia (nIA) [Control] groups. Primary outcomes included LOS, postoperative pain scores and opioid consumption. Secondary outcomes were postoperative ileus (POI) and time to first bowel movement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Intrathecal Analgesia with Diamorphine was used in 61.8% (Hospital A) and 0% (Hospital B) of cases. Patients receiving IA in Hospital A compared to nIA in Hospital A and Hospital B respectively had significantly shorter LOS (5.3 days vs. 6.1 days and 7.0 days, p\u0026lt;0.001), reduced opioid requirements (88% reduction, p\u0026lt;0.00001), and a lower incidence of POI (3.6% vs. 13.2% and 14.7%, p=0.02). Time to bowel function recovery was also faster in IA group (2.6 days vs. 3.0 days in other groups, p=0.03).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Intrathecal analgesia with diamorphine significantly enhances recovery in elective robotic-assisted colorectal surgery, aligning with ERAS objectives. Its integration into routine practice could optimize patient outcomes, reduce complications, and improve resource utilization. Further prospective studies are needed to confirm these findings.\u003c/p\u003e","manuscriptTitle":"The Impact of Intrathecal Analgesia with Diamorphine on Postoperative Recovery in Elective Robotic-Assisted Colorectal Surgery: A Retrospective Cohort Study ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-03 01:01:50","doi":"10.21203/rs.3.rs-7563056/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-27T21:29:25+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"263931131497829881667173727376592136838","date":"2025-09-27T19:45:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-27T18:47:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26045661814905160785110998705914385066","date":"2025-09-26T18:55:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"11662518722051819368936828768004976162","date":"2025-09-26T18:53:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-19T13:49:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-09T16:04:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-09T03:53:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2025-09-08T10:20:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b9c1bd9c-77cf-4706-80e5-f9dfbb5eecee","owner":[],"postedDate":"October 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T16:07:27+00:00","versionOfRecord":{"articleIdentity":"rs-7563056","link":"https://doi.org/10.1007/s11701-025-02878-1","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2025-10-13 15:58:16","publishedOnDateReadable":"October 13th, 2025"},"versionCreatedAt":"2025-10-03 01:01:50","video":"","vorDoi":"10.1007/s11701-025-02878-1","vorDoiUrl":"https://doi.org/10.1007/s11701-025-02878-1","workflowStages":[]},"version":"v1","identity":"rs-7563056","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7563056","identity":"rs-7563056","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}