Top

Surgical Endoscopy

Published in:

01-07-2019

Epidural analgesia in the era of enhanced recovery: time to rethink its use?

Authors: Ahmed M. Al-Mazrou, James M. Kiely, Ravi P. Kiran

Published in: Surgical Endoscopy | Issue 7/2019

Abstract

Background

Previous assessments of the impact of epidural analgesia (EA) on outcomes after colorectal surgery were related to the period before widespread implementation of the enhanced recovery after surgery (ERAS) protocols. This study evaluates the impact of EA on postoperative recovery after colectomy using recent multicenter data.

Methods

Patients who underwent elective colectomy from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) data (2014–2015) were identified. Demographics, comorbidities, diagnosis, procedure type and approach, and postoperative complications associated with EA were assessed. Impact of EA on postoperative ileus, length of stay (LOS), and prolonged LOS (defined as LOS > 75 percentile) was evaluated for all, open, and laparoscopic cases using univariable and multivariable analyses.

Results

Of 9045 elective colectomy procedures, 3081 (34.1%) received EA. Epidural analgesia was associated with greater rates of postoperative ileus (15.9% vs. 10.8%, p < 0.0001), superficial (5.5% vs. 4%, p = 0.001) and deep (1.8% vs. 0.6%, p < 0.0001) wound infections, pulmonary embolism (0.8% vs. 0.4%, p = 0.004), deep vein thrombosis (1.3% vs. 0.7%, p = 0.01), sepsis/septic shock (4.6% vs. 3.1%, p < 0.0001), unplanned reintubation (1.5% vs. 0.8%, p = 0.003), cardiac complications (1.2% vs. 0.7%, p = 0.03), and transfusion (9.1% vs. 5.9%, p < 0.0001). Postoperative length of stay (LOS) [mean (SD), days: 6.7(6.2) vs. 5(4.5) days, p < 0.0001] was greater for EA. On multivariable analysis, EA had no impact on postoperative ileus for all and laparoscopic cases. However, EA increased the likelihood for ileus (OR 1.34, 95% CI 1.02–1.78) after open colectomy alone. Similarly, EA did not influence prolonged LOS for all and laparoscopic cases but was independently associated with prolonged LOS after open colectomy (OR 1.4, 95% CI 1.1–1.8).

Conclusion

Epidural analgesia was not associated with improved recovery after elective colectomy in the era of ERAS.

King PM, Blazeby JM, Ewings P, Longman RJ, Kipling RM, Franks PJ, Sheffield JP, Evans LB, Soulsby M, Bulley SH, Kennedy RH (2006) The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer. Colorectal Dis 8:506–513CrossRefPubMed

Eskicioglu C, Forbes SS, Aarts MA, Okrainec A, McLeod RS (2009) Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg 13:2321–2329CrossRefPubMed

King PM, Blazeby JM, Ewings P, Franks PJ, Longman RJ, Kendrick AH, Kipling RM, Kennedy RH (2006) Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 93:300–308CrossRefPubMed

Popping DM, Elia N, Van Aken HK, Marret E, Schug SA, Kranke P, Wenk M, Tramer MR (2014) Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg 259:1056–1067CrossRefPubMed

Khan SA, Khokhar HA, Nasr AR, Carton E, El-Masry S (2013) Effect of epidural analgesia on bowel function in laparoscopic colorectal surgery: a systematic review and meta-analysis. Surg Endosc 27:2581–2591CrossRefPubMed

Lai R, Lu Y, Li Q, Guo J, Chen G, Zeng W (2013) Risk factors for anastomotic leakage following anterior resection for colorectal cancer: the effect of epidural analgesia on occurrence. Int J Colorectal Dis 28:485–492CrossRefPubMed

Halabi WJ, Jafari MD, Nguyen VQ, Carmichael JC, Mills S, Stamos MJ, Pigazzi A (2013) A nationwide analysis of the use and outcomes of epidural analgesia in open colorectal surgery. J Gastrointest Surg 17:1130–1137CrossRefPubMed

Halabi WJ, Kang CY, Nguyen VQ, Carmichael JC, Mills S, Stamos MJ, Pigazzi A (2014) Epidural analgesia in laparoscopic colorectal surgery: a nationwide analysis of use and outcomes. JAMA Surg 149:130–136CrossRefPubMed

Hübner M, Blanc C, Roulin D, Winiker M, Gander S, Demartines N (2015) Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Ann Surg 261:648–653CrossRefPubMed

10.

Hanna MH, Jafari MD, Jafari F, Phelan MJ, Rinehart J, Sun C, Carmichael JC, Mills SD, Stamos MJ, Pigazzi A (2017) Randomized clinical trial of epidural compared to conventional analgesia after minimally invasive colorectal surgery. J Am Coll Surg 225:622–630CrossRefPubMed

11.

Neudecker J, Schwenk W, Junghans T, Pietsch S, Böhm B, Müller JM (1999) Randomized controlled trial to examine the influence of thoracic epidural analgesia on postoperative ileus after laparoscopic sigmoid resection. Br J Surg 86:1292–1295CrossRefPubMed

12.

Senagore AJ, Delaney CP, Mekhail N, Dugan A, Fazio VW (2003) Randomized clinical trial comparing epidural anaesthesia and patient-controlled analgesia after laparoscopic segmental colectomy. Br J Surg 90:1195–1199CrossRefPubMed

13.

Khuri SF, Daley J, Henderson W, Hur K, Demakis J, Aust JB, Chong V, Fabri PJ, Gibbs JO, Grover F, Hammermeister K, Irvin G 3rd, McDonald G, Passaro E Jr, Phillips L, Scamman F, Spencer J, Stremple JF (1998) The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg 228:491–507CrossRefPubMedPubMedCentral

14.

Harrison OJ, Smart NJ, White P, Brigic A, Carlisle ER, Allison AS, Ockrim JB, Francis NK (2014) Operative time and outcome of enhanced recovery after surgery after laparoscopic colorectal surgery. JSLS 18:265–272CrossRefPubMedPubMedCentral

15.

Bailey MB, Davenport DL, Vargas HD, Evers BM, McKenzie SP (2014) Longer operative time: deterioration of clinical outcomes of laparoscopic colectomy versus open colectomy. Dis Colon Rectum 57:616–622CrossRefPubMed

16.

Rencuzogullari A, Benlice C, Costedio M, Remzi FH, Gorgun E (2017) Nomogram-derived prediction of postoperative ileus after colectomy: an assessment from nationwide procedure-targeted cohort. Am Surg 83:564–572PubMed

17.

Kiran RP, Murray AC, Chiuzan C, Estrada D, Forde K (2015) Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg 262:416–425 discussion 423–425 CrossRefPubMed

18.

Althumairi AA, Canner JK, Pawlik TM, Schneider E, Nagarajan N, Safar B, Efron JE (2016) Benefits of bowel preparation beyond surgical site infection: a retrospective study. Ann Surg 264:1051–1057CrossRefPubMed

19.

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

20.

Marret E, Remy C, Bonnet F, Postoperative Pain Forum Group (2007) Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. Br J Surg 94:665–673CrossRefPubMed

21.

Asgeirsson T, El-Badawi KI, Mahmood A, Barletta J, Luchtefeld M, Senagore AJ (2010) Postoperative ileus: it costs more than you expect. J Am Coll Surg 210:228–231CrossRefPubMed

22.

Al-Mazrou AM, Baser O, Kiran RP (2018) Alvimopan, regardless of ileus risk, significantly impacts ileus, length of stay, and readmission after intestinal surgery. J Gastrointest Surg. https://doi.org/10.1007/s11605-018-3846-2 CrossRefPubMed

23.

Carli F, Trudel JL, Belliveau P (2001) The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial. Dis Colon Rectum 44:1083–1089CrossRefPubMed

24.

Bredtmann RD, Herden HN, Teichmann W, Moecke HP, Kniesel B, Baetgen R, Tecklenburg A (1990) Epidural analgesia in colonic surgery: results of a randomized prospective study. Br J Surg 77:638–642CrossRefPubMed

25.

Wu CT, Jao SW, Borel CO, Yeh CC, Li CY, Lu CH, Wong CS (2004) The effect of epidural clonidine on perioperative cytokine response, postoperative pain, and bowel function in patients undergoing colorectal surgery. Anesth Analg 99:502–509CrossRefPubMed

26.

Warschkow R, Steffen T, Lüthi A, Filipovic M, Beutner U, Schmied BM, Müller SA, Tarantino I (2011) Epidural analgesia in open resection of colorectal cancer: is there a clinical benefit? a retrospective study on 1470 patients. J Gastrointest Surg 15:1386–1393CrossRefPubMed

27.

Piccioni F, Mariani L, Negri M, Casiraghi C, Belli F, Leo E, Langer (2015) Epidural analgesia does not influence anastomotic leakage incidence after open colorectal surgery for cancer: a retrospective study on 1474 patients. J Surg Oncol 112:225–230CrossRefPubMed

Title: Epidural analgesia in the era of enhanced recovery: time to rethink its use?
Authors: Ahmed M. Al-Mazrou
James M. Kiely
Ravi P. Kiran
Publication date: 01-07-2019
Publisher: Springer US
Published in: Surgical Endoscopy / Issue 7/2019
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-018-6505-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Epidural analgesia in the era of enhanced recovery: time to rethink its use?

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 7/2019

Underwater polypectomy without submucosal injection for colorectal lesions ≤ 20 mm in size—a multicenter retrospective observational study

Surgical techniques and convalescence recommendations vary greatly in laparoscopic groin hernia repair: a nationwide survey among experienced hernia surgeons

Mesh fixation using novel bio-adhesive coating compared to tack fixation for IPOM hernia repair: in vivo evaluation in a porcine model

Peroral endoscopic myotomy leads to higher rates of abnormal esophageal acid exposure than laparoscopic Heller myotomy in achalasia

Temporary simultaneous two-arterial occlusion for reducing operative blood loss during laparoscopic myomectomy: a randomized controlled trial

Laparoscopic management for aberrant hepatic duct in children with choledochal cysts