Epidural Analgesia Improves Postoperative Pain Control but Impedes Early Discharge in Patients Undergoing Pancreatic Surgery

National trends in perioperative epidural analgesia use for surgical patients

STUDY OBJECTIVE

Newer regional anesthesia techniques and minimally invasive surgeries have yielded decreased postoperative pain scores, potentially leading to decreased need for perioperative epidural analgesia. Limited literature is available on trends in usage rates of epidurals. The objective of this study was to identify trends in perioperative epidural analgesia rates among multiple fields of surgery.

METHODS

All patients undergoing general, thoracic, urologic, plastic, vascular, orthopedic, or gynecological surgery in 2014-2020 were included from the National Surgical Quality Improvement Program database of over 700 hospitals in the U.S. and 11 different countries. Annual trends in epidural analgesia for all surgeries and each surgical specialty were assessed by mixed effects multivariable logistic regression. The odds ratios (OR) and 99 % confidence intervals (CI) were reported.

RESULTS

There were 3,111,435 patients from 2014 to 2020 that were included in the final analysis, in which 107,209 (3.4 %) received perioperative epidural analgesia. Among all surgeries combined, epidural use throughout the study period decreased (OR 0.98 per year, 99 % CI 0.97-0.98, P < 0.001). When only analyzing the surgeries with the top 5 most frequent epidural use per specialty, there was no statistically significant trend in epidural utilization (OR 0.99 per year, 99 % CI 0.99-1.00, P = 0.09). However, there was an increasing trend in epidural utilization in general surgery (OR 1.05 per year, 99 % CI 1.03-1.07, P < 0.001) and vascular surgery (OR 1.08 per year, 99 % CI 1.05-1.10, P < 0.001).

CONCLUSION

Rates of perioperative epidural analgesia use has decreased in recent years overall, however, among surgeries within the general surgery and vascular surgery specialty, utilization has increased for procedures that have the highest rates of usage.

The Impact of Transcutaneous Electrical Nerve Stimulation (TENS) on Acute Pain and Other Postoperative Outcomes: A Systematic Review with Meta-Analysis

This study aimed to investigate the efficacy and safety of transcutaneous electrical nerve stimulation (TENS) in postoperative acute pain control. PubMed, Scopus, and Cochrane Library were searched on 1-8 December 2022, for randomized controlled trials on the analgesic effects of TENS. The outcomes were pain intensity and opioid use (primary), and postoperative (PO) adverse events, blood pressure, and the duration of hospital stay (secondary); PROSPERO CRD42022333335. A total of 40 articles were included in the meta-analysis. Pain intensity at rest and during coughing for all types of surgeries combined was lower in the TENS group (standardized mean difference (SMD) = -0.51 [-0.61, -0.41], p < 0.00001, 29 studies, and -1.28 [-2.46, -0.09], p-value = 0.03, six studies, respectively). There was a statistically significant decrease in morphine requirements, as well as in the incidence of postoperative nausea and vomiting, dizziness, and pruritus. There was no difference between the groups in postoperative pain intensity during walking, in blood pressure, and only a borderline difference in the length of hospital stay. The subgroup analysis by surgery type did not show significant differences between the groups in pain severity at rest. Thus, TENS has a potential for pain control and postoperative recovery outcomes.

Regional anesthesia for transplantation surgery - A White Paper Part 2: Abdominal transplantation surgery

Transplantation surgery continues to evolve and improve through advancements in transplant technique and technology. With the increased availability of ultrasound machines as well as the continued development of Enhanced Recovery after Surgery (ERAS) protocols, regional anesthesia has become an essential component of providing analgesia and minimizing opioid use perioperatively. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures. To date, no formal guidelines or recommendations exist which address the use of regional anesthesia in transplantation surgery. In response, the Society for the Advancement of Transplant Anesthesia (SATA) identified experts in both transplantation surgery and regional anesthesia to review available literature concerning these topics. The goal of this task force was to provide an overview of these publications to help guide transplantation anesthesiologists in utilizing regional anesthesia. The literature search encompassed most transplantation surgeries currently performed and the multitude of associated regional anesthetic techniques. Outcomes analyzed included analgesic effectiveness of the blocks, reduction in other analgesic modalities-particularly opioid use, improvement in patient hemodynamics, as well as associated complications. The findings summarized in this systemic review support the use of regional anesthesia for postoperative pain control after transplantation surgeries. Part 1 of the manuscript focused on regional anesthesia performed in thoracic transplantation surgeries, and part 2 in abdominal transplantations. Specifically, regional anesthesia in liver, kidney, pancreas, intestinal, and uterus transplants or applicable surgeries are discussed.

Analgesic Modalities in Patients Undergoing Open Pancreatoduodenectomy-A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review explored the efficacy of different analgesic modalities and the impact on perioperative outcome in patients undergoing pancreatoduodenectomy.

METHODS

A systematic literature search was performed on PubMed, Embase, Web of Science, Scopus, and Cochrane Library Database using the PRISMA framework. The primary outcome was pain scores on postoperative day one (POD1) and postoperative day two (POD2). The secondary outcomes included length of hospital stay (LOS) and specific procedure-related complications.

RESULTS

Five randomized controlled trials and ten retrospective cohort studies were included in the systematic review. Studies compared epidural analgesia (EA), patient-controlled analgesia (PCA), continuous wound infiltration (CWI), continuous bilateral thoracic paravertebral infusion (CTPVI), intrathecal morphine (ITM), and sublingual sufentanil. The pain scores on POD1 (p < 0.001) and POD2 (p = 0.05) were higher in the PCA group compared with the EA group. Pain scores were comparable between EA and CWI plus PCA or CTPVI on POD1 and POD2. Pain scores were comparable between EA and ITM on POD1. The procedure-related complications and length of hospital stay were not significantly different according to the type of analgesia.

CONCLUSIONS

EA provided lower pain scores compared with PCA on the first postoperative day after pancreatoduodenectomy; the length of hospital stay and procedure-related complications were similar between EA and PCA. CWI and CTPVI provided similar pain relief to EA.

Analgesic effects of combined transversus abdominis plane block and intramuscular electrical stimulation in patients undergoing cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy: a randomized controlled trial

BACKGROUND

To evaluate the analgesic efficacy of a four-quadrant transversus abdominis plane (4QTAP) block and a combination of 4QTAP block with needle electrical twitch and intramuscular electrical stimulation (NETOIMS) in patients undergoing cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC).

MATERIALS AND METHODS

Eighty-one patients who underwent CRS followed by HIPEC were included in this study. Patients were randomly assigned to one of three groups: group 1 (intravenous patient-controlled analgesia, control group), group 2 (preoperative 4QTAP block), and group 3 (preoperative 4QTAP block and postoperative NETOIMS). The primary study endpoint was the pain score assessed by the visual analog scale (VAS: 0, no pain; 10, worst imaginable pain) on postoperative day (POD) 1.

RESULTS

The VAS pain score on POD 1 was significantly lower in group 2 than in group 1 (6.0±1.7 and 7.6±1.9, P =0.004), whereas that in group 3 was significantly lower than that in groups 1 and 2 ( P <0.001 and P =0.004, respectively). Opioid consumption and nausea and vomiting incidence during POD 7 were significantly lower in group 3 than in groups 1 and 2. Gait speed and peak cough flow on POD 4 and 7, as well as the quality of recovery (QoR)-40 score on POD 4, were significantly higher in group 3 than in groups 1 and 2.

CONCLUSIONS

The combination of a 4QTAP block with NETOIMS provided more effective analgesia than a 4QTAP block alone after CRS, followed by HIPEC, and enhanced functional restoration and quality of recovery.

Ultrasound-Guided Anterior Quadratus Lumborum Block at Lateral Supra-Arcuate Ligament vs Thoracic Epidural Analgesia after Open Liver Surgery: A Randomized, Controlled, Noninferiority Trial

BACKGROUND

Thoracic epidural analgesia (TEA) has demonstrated great analgesic benefits in open liver surgery. However, the increased risk of postoperative coagulopathy after open liver surgery has promoted interest in alternate analgesic research. We aimed to explore whether ultrasound-guided anterior quadratus lumborum block at the lateral supra-arcuate ligament (LAL-QLB) with intravenous analgesia was noninferior to TEA under multimodal analgesia after open liver surgery.

STUDY DESIGN

Seventy-four patients undergoing open liver surgery were randomized (1:1) to the LAL-QLB or TEA group in this open-label study. The primary outcome was the numeric rating scale during coughing at 24 hours postoperatively with a noninferiority limit of 1.

RESULTS

The mean difference of numeric rating scale during coughing at 24 hours postoperatively was 0.32 (95% CI -0.03 to 0.68), showing noninferiority. The TEA group had better pain scores at 1 and 6 hours, and the early postoperative pain of the LAL-QLB group was within the clinically acceptable limit with no differences at other time points. The LAL-QLB group received more opioids within 24 hours postoperatively. There were no differences in analgesia-related adverse reactions or rescue analgesia. Postoperative coagulopathy was responsible with 19.4% of delayed epidural removal. TEA outperformed LAL-QLB in terms of ambulation and bowel recovery. There were no differences in hospital stay or 30-day postoperative complications.

CONCLUSIONS

LAL-QLB provided noninferior analgesia at 24 hours postoperatively. Despite regarding coagulopathy and delayed epidural removal, TEA was found to be better than LAL-QLB for pain management after open liver surgery. Epidural removal required close coagulation test.

Analgesic effects of ultrasound-guided four-quadrant transabdominal plane block in patients with cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a prospective, randomized, controlled study

Background

Postoperative pain occurring after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is difficult to control because of extensive surgical injuries and long incisions. We assessed whether the addition of a four-quadrant transabdominal plane (4Q-TAP) block could help in analgesic control.

Methods

Seventy-two patients scheduled to undergo elective CRS with HIPEC and intravenous patient-controlled analgesia (IV PCA) were enrolled. The patients received 4Q-TAP blocks in a 10 ml mixture of 2% lidocaine and 0.75% ropivacaine per site (4Q-TAP group, n = 36) or normal saline (control group, n = 33). Oxycodone in the post-anesthesia care unit (PACU) and pethidine or tramadol in the ward were used as rescue analgesics. The primary outcome was less than 3 times of rescue analgesic administration (%) in the ward for 5 postoperative days. Secondary endpoints included oxycodone requirement in PACU, fentanyl doses of IV PCA, morphine milligram equivalent (MME) of total opioid use, hospital stay, and postoperative complications.

Results

During 5 postoperative days, there was no difference in pain scores and total rescue analgesic administration between two groups. However, the use of oxycodone in PACU (P = 0.011), fentanyl requirement in IV PCA (P = 0.029), and MME/kg of total opioid use (median, 2.35 vs. 3.21 mg/kg, P = 0.009) were significantly smaller in the 4Q-TAP group. Hospital stay and incidence of postoperative morbidity were similar in both groups.

Conclusions

The 4Q-TAP block enhanced multimodal analgesia and decreased opioid requirements in patients with CRS with HIPEC, but did not change postoperative recovery outcomes.

Use of Erector Spinae Fascial Plane Blocks in Enhanced Recovery for Open Abdominal Surgery

BACKGROUND

Bilateral erector spinae fascial plane blocks (ESPB) offers a novel, alternative method of regional post-operative pain control to thoracic epidural analgesia (TEA). The aim of this study was to compare rates of postoperative hypotension, and other standard enhanced recovery after surgery (ERAS) endpoints, in patients receiving ESPB versus TEA for open hepatopancreaticobiliary (HPB) surgery.

MATERIALS AND METHODS

This retrospective analysis compared historical controls of ERAS patients undergoing open HPB surgery with TEA versus ESPB. The incidence of postoperative hypotension and clinical outcomes, including opioid requirements, were compared.

RESULTS

Forty patients receiving TEA were compared to 27 ESPB patients. Return of bowel function and length of stay (mean 7.2 versus7.4 days; P = 0.83) were similar. ESPB patients received less intraoperative colloid (142cc versus 340cc; P = 0.01) and had less postoperative hypotension versus TEA (22% versus 55%; P = 0.03). No ESPB patient required patient-controlled analgesia (versus 32.5% TEA; P< 0.001). ESPB MME requirements decreased over time, while TEA MME requirements increased over 72 hours (P = 0.019).

CONCLUSIONS

ESPB is a novel method that shows promising outcomes in improving enhanced recovery parameters and minimizing opioid administration in open HPB surgery.

Postoperative Pain Relief after Pancreatic Resection: Systematic Review and Meta-Analysis of Analgesic Modalities

Background

This systematic review explored the efficacy of different pain relief modalities used in the management of postoperative pain following pancreatoduodenectomy (PD) and distal pancreatectomy (DP) and impact on perioperative outcomes.

Methods

MEDLINE (OVID), Embase, Pubmed, Web of Science and CENTRAL databases were searched using PRISMA framework. Primary outcomes included pain on postoperative day 2 and 4 and respiratory morbidity. Secondary outcomes included operation time, bile leak, delayed gastric emptying, postoperative pancreatic fistula, length of stay, and opioid use.

Results

Five randomized controlled trials and seven retrospective cohort studies (1313 patients) were included in the systematic review. Studies compared epidural analgesia (EDA) (n = 845), patient controlled analgesia (PCA) (n = 425) and transabdominal wound catheters (TAWC) (n = 43). EDA versus PCA following PD was compared in eight studies (1004 patients) in the quantitative meta-analysis. Pain scores on day 2 (p = 0.19) and 4 (p = 0.18) and respiratory morbidity (p = 0.42) were comparable between EDA and PCA. Operative times, bile leak, delayed gastric emptying, pancreatic fistula, opioid use, and length of stay also were comparable between EDA and PCA. Pain scores and perioperative outcomes were comparable between EDA and PCA following DP and EDA and TAWC following PD.

Conclusions

EDA, PCA and TAWC are the most frequently used analgesic modalities in pancreatic surgery. Pain relief and other perioperative outcomes are comparable between them. Further larger randomized controlled trials are warranted to explore the relative merits of each analgesic modality on postoperative outcomes with emphasis on postoperative complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06217-x.

Epidural analgesia for reduction of postoperative systemic opioid use following selective dorsal rhizotomy in children

OBJECTIVE

Selective dorsal rhizotomy (SDR) requires significant postoperative pain management, traditionally relying heavily on systemic opioids. Concern for short- and long-term effects of these agents has generated interest in reducing systemic opioid administration without sacrificing analgesia. Epidural analgesia has been applied in pediatric patients undergoing SDR; however, whether this reduces systemic opioid use has not been established. In this retrospective cohort study, the authors compared postoperative opioid use and clinical measures between patients treated with SDR who received postoperative epidural analgesia and those who received systemic analgesia only.

METHODS

All patients who underwent SDR at Boston Children's Hospital between June 2013 and November 2019 were reviewed. Treatment used the same surgical technique. Postoperative systemic opioid dosage (in morphine milligram equivalents per kilogram [MME/kg]), pain scores, need for respiratory support, vomiting, bowel movements, and length of hospital and ICU stay were compared between patients who received postoperative epidural analgesia and those who did not, by using the Wilcoxon rank-sum test or Fisher's exact test.

RESULTS

A total of 35 patients were identified, including 18 females (51.4%), with a median age at surgery of 6.1 years. Thirteen patients received postoperative epidural and systemic analgesia and 22 patients received systemic analgesia only. Groups were otherwise similar, with treatment selection based solely on surgeon routine. Patients who received epidural analgesia required less systemic morphine milligram equivalents/kg on postoperative days (PODs) 0-4 (p ≤ 0.042). Patients who did not receive epidural analgesia were more likely to require respiratory support on POD 1 (45% vs 8%; p = 0.027). Reported pain scores did not differ between groups, although patients receiving epidural analgesia trended toward less severe pain on PODs 1 and 2. Groups did not differ with respect to postoperative vomiting or time to first bowel movement, although epidural analgesia use was associated with a longer hospital stay (median 7 vs 5 days; p < 0.001).

CONCLUSIONS

Patients who received postoperative epidural analgesia required less systemic opioid use and had at least equivalent reported pain scores on PODs 1-4, and they required less respiratory support on POD 1, although they remained in the hospital longer when compared to patients who received systemic analgesia only. A larger prospective study is needed to confirm whether epidural analgesia lowers systemic opioid use in children, contributes to a safer postoperative hospital stay, and results in better pain control following SDR.

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.

The Impact of Thoracic Epidural Analgesia Versus Four Quadrant Transversus Abdominis Plane Block on Quality of Recovery After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Surgery: A Single-Center, Noninferiority, Randomized, Controlled Trial

BACKGROUND

Recovery after CRS-HIPEC influenced by several factors, including pain and opioid consumption. We hypothesized that 4Q-TAP blocks provide not inferior quality of recovery compared with TEA after CRS-HIPEC. We conducted a randomized, controlled trial to determine whether 4-quadrant transversus abdominis plane (4Q-TAP) block analgesia was noninferior to thoracic epidural (TEA) among patients who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS HIPEC).

METHODS

Patients 18 years or older who underwent a CRS-HIPEC surgery were randomly assigned to have either TEA or 4Q-TAP blocks. The primary outcome of this study was the change in quality of recovery 2 days after surgery. Secondary outcomes included quality of recovery on Days 1, 3, 5, 7, 10, and 30 postoperatively, opioid consumption, pain intensity, length of stay, and postoperative complications. Analyses were performed on a per-protocol basis.

RESULTS

Sixty-eight patients were included in the analysis. The difference between 4Q-TAP and TEA in the mean QoR-15 change from surgery at postoperative Days 1, 2, and 3 was 0.80 (P = 0.004), -4.5 (P = 0.134), and 3.4 (P = 0.003), respectively. All differences through postoperative day 30 were significantly within the noninferiority boundary of -10 except at postoperative Day 2 (P = 0.134). Length of stay, opioid-related adverse events, and frequency and grade of complications were not significantly different between TEA and 4Q-TAP patients.

CONCLUSIONS

Despite the significantly higher use of opioids after CRS-HIPEC in patients with 4Q-TAP blocks, their short-term quality of recovery was not inferior to those treated with TEA. Patients undergoing CRS-HIPEC can be effectively managed with 4Q-TAP blocks.

Epidural analgesia for postoperative pain: Improving outcomes or adding risks?

Current evidence shows that the benefits of epidural analgesia (EA) are not as impressive as believed in the past, while the risks of adverse effects and serious complications are greater than previously estimated. There are many reasons for the decreasing role of epidural technique in clinical practice (table). Indeed, EA can cause harm and hinder early mobilization in enhanced recovery after surgery (ERAS) programmes. Some ERAS interventions are complex, confusing, sometimes contradictory and apparently unimplementable. In spite of much hype and after almost 25 years, the originator of the concept has described the current status of ERAS as 'far from good'. Outpatient surgery setup has been a remarkable success for many major surgical procedures, and it predates ERAS and appears to be a simpler and better model for reducing postoperative morbidity and hospitalization times. Systematic reviews of comparative studies have shown that less invasive and safer but equally effective alternatives to EA are available for almost all major surgical procedures. These include: paravertebral block, peripheral nerve blocks, catheter wound infusion, periarticular local infiltration analgesia, preperitoneal catheters and transversus abdominis plane block. Increasingly, these non-EA methods are being used as surgeon-delivered regional analgesia (RA) techniques. This encouraging trend of active surgeon participation, with anaesthesiologist collaboration, will undoubtedly improve the decades-old twin problems of underused RA techniques and undertreated postoperative pain. The continued use of EA at any institution can only be justified by results from its own audits; however, regrettably only very few institutions perform such regular audits.

[Efficacy of local infiltration of ropivacaine combined with multimodal analgesia with parecoxib for perioperative analgesia in patients undergoing pancreaticoduodenectomy]

OBJECTIVE

To explore the effect of local infiltration of ropivacaine combined with multimodal analgesia with parecoxib for perioperative pain management in patients undergoing pancreaticoduodenectomy.

METHODS

This randomized controlled trial was conducted among 98 patients undergoing pancreaticoduodenectomy in the Department of Biliary Surgery of West China Hospital between March, 2017 and August, 2018. The patients were randomized to receive perioperative analgesia with local infiltration anesthesia with ropivacaine combined with multimodal analgesia with parecoxib (experimental group, n=50) or postoperative analgesia with dizosin (control group, n=48). The regimens for intraoperative anesthesia and postoperative pain relief were identical in the two groups. The differences in NRS pain score, use of pain relief agents, the incidences of adverse reactions to analgesia and wound infection, and the time to first ambulation and first flatus passage after the operation were compared between the two groups.

RESULTS

At 12, 24 h, 48 h, 72 h and 7 days after the operation, the patients in the experimental group had significantly lower NRS scores (P < 0.05) than those in the control group. The rate of use of rescue analgesics was significantly lower in the experimental group than in the control group (32% vs 66.67%, P < 0.05); the rate of tramadol hydrochloride use was also significantly lower in the experimental group (P < 0.05). Compared with those in the control group, the patients in the experimental group showed a significantly lower total incidence of adverse reactions (22% vs 54.17%, P < 0.05) as well as a lower incidence of nausea and vomiting (P < 0.05), an earlier time of first ambulation and first flatus passage after the operation (P < 0.05), and a shorter postoperative hospital stay (P < 0.05).

CONCLUSIONS

In patients undergoing pancreaticoduodenectomy, local infiltration of ropivacaine combined with multimodal analgesia with ropivacaine can effectively relieve perioperative pain, reduce the use of relief analgesics, lower the incidence of adverse reactions, and promote the recovery after the surgery.