Top

Published in:

01-06-2013 | Original Article

A Nationwide Analysis of the Use and Outcomes of Epidural Analgesia in Open Colorectal Surgery

Authors: Wissam J. Halabi, Mehraneh D. Jafari, Vinh Q. Nguyen, Joseph C. Carmichael, Steven Mills, Michael J. Stamos, Alessio Pigazzi

Published in: Journal of Gastrointestinal Surgery | Issue 6/2013

Abstract

Introduction

Epidural analgesia has demonstrated superiority over conventional analgesia in controlling pain following open colorectal resections. Controversy exists regarding cost-effectiveness and postoperative outcomes.

Methods

The Nationwide Inpatient Sample (2002–2010) was retrospectively reviewed for elective open colorectal surgeries performed for benign and malignant conditions with or without the use of epidural analgesia. Multivariate regression analysis was used to compare outcomes between epidural and conventional analgesia.

Results

A total 888,135 patients underwent open colorectal resections. Epidural analgesia was only used in 39,345 (4.4 %) cases. Epidurals were more likely to be used in teaching hospitals and rectal cancer cases. On multivariate analysis, in colonic cases, epidural analgesia lowered hospital charges by US$4,450 (p < 0.001) but was associated with longer length of stay by 0.16 day (p < 0.05) and a higher incidence of ileus (OR = 1.17; p < 0.01). In rectal cases, epidural analgesia was again associated with lower hospital charges by US$4,340 (p < 0.001) but had no effect on ileus and length of stay. The remaining outcomes such as mortality, respiratory failure, pneumonia, anastomotic leak, urinary tract infection, and retention were unaffected by the use of epidurals.

Conclusion

Epidural analgesia in open colorectal surgery is safe but does not add major clinical benefits over conventional analgesia. It appears however to lower hospital charges.

Carli F, Trudel JL, Belliveau P. The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial. Diseases of the colon and rectum. Aug 2001;44(8):1083-1089.

Kong SK, Onsiong SM, Chiu WK, Li MK. Use of intrathecal morphine for postoperative pain relief after elective laparoscopic colorectal surgery. Anaesthesia. Dec 2002;57(12):1168-1173.

Bredtmann RD, Herden HN, Teichmann W, et al. Epidural analgesia in colonic surgery: results of a randomized prospective study. The British journal of surgery. Jun 1990;77(6):638-642.

Wu CT, Jao SW, Borel CO, et al. The effect of epidural clonidine on perioperative cytokine response, postoperative pain, and bowel function in patients undergoing colorectal surgery. Anesthesia and analgesia. Aug 2004;99(2):502-509, table of contents.

Moselli NM, Baricocchi E, Ribero D, Sottile A, Suita L, Debernardi F. Intraoperative epidural analgesia prevents the early proinflammatory response to surgical trauma. Results from a prospective randomized clinical trial of intraoperative epidural versus general analgesia. Annals of surgical oncology. Oct 2011;18(10):2722-2731.

Johansson K, Ahn H, Lindhagen J, Tryselius U. Effect of epidural anaesthesia on intestinal blood flow. The British journal of surgery. Jan 1988;75(1):73-76.

Wu CL, Rowlingson AJ, Herbert R, Richman JM, Andrews RA, Fleisher LA. Correlation of postoperative epidural analgesia on morbidity and mortality after colectomy in Medicare patients. Journal of clinical anesthesia. Dec 2006;18(8):594-599.

Popping DM, Elia N, Marret E, Remy C, Tramer MR. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Archives of surgery. Oct 2008;143(10):990-999; discussion 1000.

Kang CY, Halabi WJ, Luo R, Pigazzi A, Nguyen NT, Stamos MJ. Laparoscopic colorectal surgery: a better look into the latest trends. Archives of surgery. Aug 2012;147(8):724-731.

10.

HCUP (2012) Healthcare cost and utilization project—Nationwide Inpatient Sample

11.

van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Medical care. Jun 2009;47(6):626-633.

12.

Marret E, Remy C, Bonnet F. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. The British journal of surgery. Jun 2007;94(6):665-673.

13.

Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P. Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology. Sep 2002;97(3):540-549.

14.

Lehman JF, Wiseman JS. The effect of epidural analgesia on the return of peristalsis and the length of stay after elective colonic surgery. The American surgeon. Nov 1995;61(11):1009-1012.

15.

Kuruba R, Fayard N, Snyder D. Epidural analgesia and laparoscopic technique do not reduce incidence of prolonged ileus in elective colon resections. American journal of surgery. Nov 2012;204(5):613-618.

16.

Warschkow R, Steffen T, Luthi A, et al. Epidural analgesia in open resection of colorectal cancer: is there a clinical benefit? a retrospective study on 1,470 patients. J Gastrointest Surg. Aug 2011;15(8):1386-1393.

17.

Liu SS, Carpenter RL, Mackey DC, et al. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology. Oct 1995;83(4):757-765.

18.

Gendall KA, Kennedy RR, Watson AJ, Frizelle FA. The effect of epidural analgesia on postoperative outcome after colorectal surgery. Colorectal Dis. Sep 2007;9(7):584-598; discussion 598-600.

19.

Bartha E, Carlsson P, Kalman S. Evaluation of costs and effects of epidural analgesia and patient-controlled intravenous analgesia after major abdominal surgery. British journal of anaesthesia. Jan 2006;96(1):111-117.

20.

Shapiro A, Zohar E, Hoppenstein D, Ifrach N, Jedeikin R, Fredman B. A comparison of three techniques for acute postoperative pain control following major abdominal surgery. Journal of clinical anesthesia. Aug 2003;15(5):345-350.

21.

de Leon-Casasola OA, Parker BM, Lema MJ, Groth RI, Orsini-Fuentes J. Epidural analgesia versus intravenous patient-controlled analgesia. Differences in the postoperative course of cancer patients. Regional anesthesia. Sep-Oct 1994;19(5):307-315.

22.

Neudecker J, Schwenk W, Junghans T, Pietsch S, Bohm B, Muller JM. Randomized controlled trial to examine the influence of thoracic epidural analgesia on postoperative ileus after laparoscopic sigmoid resection. The British journal of surgery. Oct 1999;86(10):1292-1295.

23.

Turunen P, Carpelan-Holmstrom M, Kairaluoma P, et al. Epidural analgesia diminished pain but did not otherwise improve enhanced recovery after laparoscopic sigmoidectomy: a prospective randomized study. Surg Endosc. Jan 2009;23(1):31-37.

24.

Levy BF, Scott MJ, Fawcett W, Fry C, Rockall TA. Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. The British journal of surgery. Aug 2011;98(8):1068-1078.

25.

Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. British journal of anaesthesia. Oct 2002;89(4):622-632.

26.

Zingg U, Miskovic D, Hamel CT, Erni L, Oertli D, Metzger U. Influence of thoracic epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal resection: benefit with epidural analgesiaSurg Endosc. Feb 2009;23(2):276-282.

27.

Senagore AJ, Whalley D, Delaney CP, Mekhail N, Duepree HJ, Fazio VW. Epidural anesthesia-analgesia shortens length of stay after laparoscopic segmental colectomy for benign pathology. Surgery. Jun 2001;129(6):672-676.

28.

Takasaki M, Takahashi T. Respiratory function during cervical and thoracic extradural analgesia in patients with normal lungs. British journal of anaesthesia. Dec 1980;52(12):1271-1276.

29.

Paulsen EK, Porter MG, Helmer SD, Linhardt PW, Kliewer ML. Thoracic epidural versus patient-controlled analgesia in elective bowel resections. American journal of surgery. Dec 2001;182(6):570-577.

30.

Senagore AJ, Delaney CP, Mekhail N, Dugan A, Fazio VW. Randomized clinical trial comparing epidural anaesthesia and patient-controlled analgesia after laparoscopic segmental colectomy. The British journal of surgery. Oct 2003;90(10):1195-1199.

31.

Sala C, Garcia-Granero E, Molina MJ, Garcia JV, Lledo S. Effect of epidural anesthesia on colorectal anastomosis: a tonometric assessment. Diseases of the colon and rectum. Aug 1997;40(8):958-961.

32.

Bigler D, Hjortso NC, Kehlet H. Disruption of colonic anastomosis during continuous epidural analgesia. An early postoperative complication. Anaesthesia. Mar 1985;40(3):278-280.

33.

Ryan P, Schweitzer SA, Woods RJ. Effect of epidural and general anaesthesia compared with general anaesthesia alone in large bowel anastomoses. A prospective study. Eur J Surg. Jan 1992;158(1):45-49.

34.

Lai R, Lu Y, Li Q, Guo J, Chen G, Zeng W (2012) Risk factors for anastomotic leakage following anterior resection for colorectal cancer: the effect of epidural analgesia on occurrence. International journal of colorectal disease. 2012. doi: 10.1007/s00384-012-1585-5

35.

Holte K, Kehlet H. Epidural analgesia and risk of anastomotic leakage. Reg Anesth Pain Med. Mar-Apr 2001;26(2):111-117.

36.

Cook TM, Counsell D, Wildsmith JA. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. British journal of anaesthesia. Feb 2009;102(2):179-190.

Title: A Nationwide Analysis of the Use and Outcomes of Epidural Analgesia in Open Colorectal Surgery
Authors: Wissam J. Halabi
Mehraneh D. Jafari
Vinh Q. Nguyen
Joseph C. Carmichael
Steven Mills
Michael J. Stamos
Alessio Pigazzi
Publication date: 01-06-2013
Publisher: Springer-Verlag
Published in: Journal of Gastrointestinal Surgery / Issue 6/2013
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-013-2195-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

A Nationwide Analysis of the Use and Outcomes of Epidural Analgesia in Open Colorectal Surgery

Abstract

Introduction

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 6/2013

Management of Esophageal Perforation in 120 Consecutive Patients: Clinical Impact of a Structured Treatment Algorithm

A Note on the Jadad Score as an Efficient Tool for Measuring Trial Quality

Fistula-in-ano: When to Cut, Tie, Plug, or Sew

Porcelain Gallbladder: A Benign Process or Concern for Malignancy?

Combined Portal Vein Resection for Hilar Cholangiocarcinoma: A Meta-analysis of Comparative Studies

Outcome Comparisons Among the Hangzhou, Chengdu, and UCSF Criteria for Hepatocellular Carcinoma Liver Transplantation after Successful Downstaging Therapies