Thoracic Epidural Analgesia: Does It Enhance Recovery?

A randomised comparison of transverse abdominal plane block versus thoracic epidural analgesia on postoperative opioid consumption for colorectal enhanced recovery after surgery programme (OPIATE study)

BACKGROUND

The transverse abdominis plane block is increasingly being used as a less-invasive alternative to thoracic epidural analgesia for effective pain management. This study aimed to compare transverse abdominis plane block with opioid-based thoracic epidural analgesia in terms of postoperative opioid consumption.

METHODS

Patients in the thoracic epidural analgesia group received a continuous infusion of 0.1% levobupivacaine with 2mcg/ml of fentanyl, while those in the transverse abdominis plane group received 6-hourly boluses of 0.4ml/kg of 0.25% levobupivacaine. The primary objective was to compare the average fentanyl consumption, measured as intravenous fentanyl equivalents, over 72 hours.

RESULTS

Data of 35 patients were analysed. Fentanyl consumption at the end of 72 hours was significantly lower in the transverse abdominis plane group (median [interquartile range] 495 mcg (255, 750), and mean (95% confidence interval) 717.35mcg (403.54-1031.16)) compared to the thoracic epidural analgesia group (median [interquartile range] 760mcg (750, 760), and mean (95% confidence interval) 787mcg (746.81-827.19)) with a p value of 0.010. Pain scores at rest and during movement were comparable between the groups (p > 0.05). However, the median pain scores during movement were significantly lower in the thoracic epidural analgesia group at 60 and 72 hours (p ⩽ 0.05).

CONCLUSION

Multimodal analgesia with transverse abdominis plane resulted in lower opioid consumption over 72 hours compared to thoracic epidural analgesia.

Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients

Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.

Acute postoperative pain management techniques, their efficacy and complications after major gastrointestinal and hepato-pancreato-biliary cancer surgeries: An observational study

BACKGROUND

Patients undergoing major gastrointestinal (GI) surgery including hepato-pancreato-biliary (HPB) surgeries have large incisions, which cause severe acute postoperative pain that, if untreated, is associated with a higher incidence of postoperative morbidity and delayed recovery.

METHODOLOGY

Our study included all patients who underwent elective major upper GI and HPB surgeries from 1 January 2018 to 31 December 2018. The patients were divided into two groups: the epidural and the non-epidural group. The average and worst pain scores at rest and movement were compared between both groups. We also studied the effect of pain relief in the two groups and associated postoperative outcomes, resumption of feeding, ambulation, hospital stay and intensive care unit stay.

RESULTS

A total of 566 patients were included in the study, out of which 490 received epidurals, and the rest, 76, belonged to the non-epidural group (transversus abdominis plane, rectus sheath block or no regional analgesia technique). The median average pain score at rest and movement was 2.0 and 3.0, respectively, in the epidural and non-epidural groups. The postoperative outcomes showed no statistical difference.

CONCLUSION

The epidural group and the non-epidural group had similar pain scores, and the postoperative outcomes were also comparable.

The association of regional block with intraoperative opioid consumption in patients undergoing video-assisted thoracoscopic surgery: a single-center, retrospective study

BACKGROUND

Regional block, such as thoracic epidural analgesia (TEA), thoracic paravertebral block (TPVB), or serratus anterior plane block (SAPB) has been recommended to reduce postoperative opioid use in recent guidelines, but the optimal options for intraoperative opioid minimization remain unclear. The aim of this study was to evaluate the intraoperative opioids-sparing effects of three regional blocks (TEA, TPVB, and SAPB) in patients undergoing video-assisted thoracoscopic surgery (VATs).

METHODS

This was a retrospective study of the adults undergoing VATs at a tertiary medical center between January 2020 and February 2022. According to the type of regional block used, patients were classified into 4 groups: GA group (general anesthesia without any regional block), TEA group (general anesthesia combined with TEA), TPVB group (general anesthesia combined with TPVB), and SAPB group (general anesthesia combined with SAPB). Cases were matched with a 1:1:1:1 ratio for analysis by age, sex, ASA physical status, and operation duration. The primary outcome was the total intraoperative opioid consumption standardized to Oral Morphine Equivalents (OME). Multivariable linear regression was used to estimate the association of the three regional blocks with the OME.

RESULTS

A total of 2159 cases met the eligibility criteria. After matching, 168 cases (42 in each group) were included in analysis. Compared with GA without any reginal block, the use of TEA, TPVB, and SAPB reduced the median of intraoperative OME by 78.45 mg (95% confidence interval [CI], -141.34 to -15.56; P = 0.014), 94.92 mg (95% CI, -154.48 to -35.36; P = 0.020), and 11.47 mg (95% CI, -72.07 to 49.14; P = 0.711), respectively.

CONCLUSIONS

The use of TEA or TPVB was associated with an intraoperative opioid-sparing effect in adults undergoing VATs, whereas the intraoperative opioid-sparing effect of SAPB was not yet clear.

Effect of single-shot intrathecal morphine versus continuous epidural analgesia on length of stay after gastrectomy for cancer: a retrospective cohort study

BACKGROUND

Single-dose intrathecal opiates (ITO) could shorten the length of hospital stay compared to thoracic epidural analgesia (TEA). This study aimed to compare TEA with TIO in terms of length of hospital stay, pain control, and parenteral opioid consumption in patients undergoing gastrectomy for cancer.

METHODS

The patients who underwent gastrectomy for cancer in 2007-2018 at the CHU de Québec-Université Laval were included. The patients were grouped as TEA and intrathecal morphine (ITM). The primary outcome was the length of hospital of stay (LOS). The secondary outcomes were numeric rating scales (NRS) for pain and parenteral opioid consumption.

RESULTS

A total of 79 patients were included. There were no differences in preoperative characteristics between the two groups (all P > 0.05). The median LOS was shorter in the ITM group than in the TEA group (median, 7.5 vs. 10 days, P = 0.049). The opioids consumption at 12, 24, and 48 h postoperatively was significantly lower in the TEA group at all time points. The NRS score for pain was lower in the TEA group than in the ITM group at all time points (all P < 0.05).

CONCLUSIONS

Patients with ITM analgesia undergoing gastrectomy presented shorter LOS than those with TEA. ITM had an inferior pain control that did not have a clinical impact on recovery in the cohort studied. Given the limitations of this retrospective study, further trials are warranted.

The clinical impact of the perioperative epidural anesthesia on surgical outcomes after pancreaticoduodenectomy: A retrospective cohort study

Background

Pancreaticoduodenectomy is a highly invasive procedure associated with high morbidity. Several preoperative variables are associated with postoperative complications. The role of perioperative factors is uncertain. The use of perioperative epidural analgesia is potentially associated with fewer postoperative surgical complications. We hypothesize that perioperative epidural analgesia might be associated with fewer surgical complications.

Methods

We reviewed data from 288 cases performed at our institution between 2012 and 2019, classifying patients into 2 groups: perioperative use of epidural analgesia and non-perioperative use of epidural analgesia. The decision to use epidural as an adjunct to general anesthesia was based on the judgment of the attending anesthesiologist. Uni- and multivariate analyses were then performed to determine factors associated with postoperative surgical complications, ie, postoperative pancreatic fistula, delayed gastric emptying, among others, after adjusting for confounders.

Results

Baseline and intraoperative factors were similar between the groups, except for sex and postoperative surgical complications. In the univariate analyses, factors associated with fewer postoperative surgical complications were the diameter of the pancreatic duct ≥ 6 mm, hard pancreatic gland parenchyma texture, younger age (< 65 years), and perioperative use of epidural analgesia. In the multivariate analyses, perioperative use of epidural analgesia was significantly associated with fewer postoperative surgical complications (odds ratio = 0.31; 95% confidence interval: 0.13–0.75; P = .009), even after adjusting for significant covariates.

Conclusion

Perioperative use of epidural analgesia might be associated with fewer postoperative surgical complications after pancreaticoduodenectomy even after adjusting for pancreatic gland parenchyma texture, pancreatic duct size, and age.

Dissecting the Perioperative Care Bundle

Enhanced recovery after surgery (ERAS) protocols are comprehensive perioperative care pathways designed to mitigate the physiologic stressors associated with surgery and, in turn, improve clinical outcomes and lead to health care cost savings. Although individual components may differ, ERAS protocols are typically organized as multimodal care "bundles" that, when followed closely and in their entirety, are meant to generate amplified cumulative benefits. This manuscript examines some of the critical components, describes some areas where the science is weak (but dogma may be strong), and provides some of the evidence or lack thereof behind components of a standard ERAS protocol.

ROUX-IN-Y GASTROJEJUNAL BYPASS: WHICH ANESTHETIC TECHNIQUE HAS BEST RESULTS?

Background:

As the number of bariatric operations increases, there is a greater interest in knowledge, experience and skills in the operative and anesthetic management of obese people. Anesthetic recovery is an important point in the therapeutic approach and less adverse effects delaying discharge of these patients are necessary to be kept in mind by the surgical team.

Aim:

To compare anesthetic-analgesic techniques in the opioid-sparing era through epidural administration of local anesthetic associated with low-dose morphine vs. clonidine and analyze the impact of analgesia on the effectiveness of postoperative recovery by comparing these two techniques.

Methods:

Randomized, double-blind clinical trial with 66 patients candidates for Roux-en-Y gastrojejunal bypass divided into two groups: morphine group and clonidine group. Multimodal analgesia included epidural anesthesia with 0.375% ropivacaine 20 ml at the eighth thoracic vertebra with the association of morphine (morphine group) at a dose of 15 mcg / kg or clonidine (clonidine group) at a dose of 1 mcg / kg.

Results:

The groups were homogeneous and statistical significance was found when analyzing the difference in pain between them in the first postoperative period. The pain was higher in the clonidine group, as in this period, analgesic rescue was also better in this group. In the other times, there was no significance in the differences regarding pain and rescue. The return of intestinal motility in the morphine group was earlier in the first postoperative period. Nausea, vomiting and hospital discharge did not show significant differences between groups.

Conclusion:

Epidural anesthesia with low-dose morphine allowed less pain during the entire hospital stay, with a positive impact on patient recovery.

Feasibility assessment of outpatient colorectal resections at a tertiary referral center

PURPOSE

Enhanced Recovery After Surgery (ERAS) protocols, particularly when paired with advanced laparoscopy, have reduced recovery time following colorectal procedures. The aim of this study was to determine if length of stay (LOS) could be reduced to an overnight observation stay (< 24 h) with comparable perioperative morbidity. The secondary aim was to establish predictive factors contributing to early discharge.

METHODS

This is a retrospective cohort study of all colectomies at a tertiary care center between January 2016 and January 2019. Inclusion criteria included all colorectal resections with varying surgical approaches. Patients underwent a standardized ERAS protocol. A logistical regression model was conducted for predictive factors.

RESULTS

Three hundred sixty patients were included (55.3% female). Of these, 78 (21.7%) patients were discharged within < 24 h and 112 (31.1%) were discharged within 24-48 h. The remainder comprised the > 48 h group. Age differed significantly between the < 24 h and 24-48 h groups (p < 0.0001). Patients discharged within 24 h were younger (59.4 ± 12.3 years), had a lower CCI score (3.1; p = 0.0026), and lower ASA class (p < 0.0001). Emergency department visits (p = 0.3329) and readmissions (p = 0.6453) prior to POD 30 remained comparable among all groups. Younger age, low ASA, and minimally invasive surgical approach all contributed to ultra-fast discharge.

CONCLUSION

ERAS protocols may allow for discharge within 24 h following a major colorectal resection, all with low perioperative morbidity and mortality. The predictive factors for discharge within 24 h include a low ASA (I or II), and a minimally invasive surgical approach.

State-of-the-art colorectal disease: postoperative ileus

PURPOSE

Postoperative Ileus (POI) remains an important complication for patients after abdominal surgery with an incidence of 10-27% representing an everyday issue for abdominal surgeons. It accounts for patients' discomfort, increased morbidity, prolonged hospital stays, and a high economic burden. This review outlines the current understanding of POI pathophysiology and focuses on preventive treatments that have proven to be effective or at least show promising effects.

METHODS

Pathophysiology and recommendations for POI treatment are summarized on the basis of a selective literature review.

RESULTS

While a lot of therapies have been researched over the past decades, many of them failed to prove successful in meta-analyses. To date, there is no evidence-based treatment once POI has manifested. In the era of enhanced recovery after surgery or fast track regimes, a few approaches show a beneficial effect in preventing POI: multimodal, opioid-sparing analgesia with placement of epidural catheters or transverse abdominis plane block; μ-opioid-receptor antagonists; and goal-directed fluid therapy and in general the use of minimally invasive surgery.

CONCLUSION

The results of different studies are often contradictory, as a concise definition of POI and reliable surrogate endpoints are still absent. These will be needed to advance POI research and provide clinicians with consistent data to improve the treatment strategies.

Postoperative Thoracic Epidural Analgesia: Adverse Events from a Single-Center Series of 3126 Patients

Purpose

Thoracic epidural analgesia (TEA) has been shown to reduce postsurgical morbidity and mortality; nevertheless, major and minor complications can occur. We report our 10-year experience with TEA and incidence of complications.

Patients and Methods

Patients received continuous infusion TEA (0.2% ropivacaine and 2 µg ml⁻¹ fentanyl) to control postoperative pain. Every 8 hours, the acute pain service recorded the analgesia regimen and occurrence of side effects. The initial infusion rate was tapered daily in response to improvement in pain symptoms or occurrence of side effects.

Results

A total of 3126 patients received TEA. The median age was 65 years (range, 18–94) and the duration of catheter placement was 3.5 days (range, 2–8). Three major complications were identified (1:1042): two subarachnoid blocks and one epidural abscess which led to permanent sequela (1:3126). Minor complications were hypotension (4.8%), pruritus (4.4%), accidental catheter removal (3.7%), insertion site inflammation (2.5%), motor weakness (2.0%), postoperative nausea and vomiting (1.8%), catheter disconnection (1.9%), catheter occlusion (0.3%), post-dural puncture headache (0.5%), and catheter fragment retention (0.06%), which were the reasons for a 7.4% rate of early discontinuation of epidural analgesia. No occurrence of epidural hematoma, local anesthetic systemic toxicity, and cardiovascular/respiratory depression was recorded.

Conclusion

Postoperative TEA is an advanced technique that poses certain difficulties that can subvert its great potential. While serious complications were rare, minor complications occurred more often and affected the postoperative course negatively. A risk/benefit evaluation of each patient should be done before employing the technique.

Postoperative Complications After Colorectal Surgery: Where Are We in the Era of Enhanced Recovery?

PURPOSE OF REVIEW

Individual elements in enhanced recovery pathways may be associated with specific complication risks. In this review, we highlight three areas of controversy surrounding complications in enhanced recovery: (1) whether enhanced recovery is associated with increased rates of acute kidney injury, (2) whether NSAID use is associated with anastomotic leaks, and (3) whether early urinary catheter removal is justified following colorectal surgery.

RECENT FINDINGS

Acute kidney injury has been reported at several institutions following implementation of enhanced recovery pathways highlighting the importance of institutional data tracking. NSAID use has been implicated in anastomotic leak rates for non-elective colorectal procedures, and criteria for its use should be implemented. Early urinary catheter removal has been supported despite increased urinary retention rates in order to decrease urinary tract infections. Enhanced recovery protocols will continue to evolve, and risk profiles associated with individual elements should continue to be evaluated.