Scientific papersRandomized controlled trial comparing the controlled rehabilitation with early ambulation and diet pathway versus the controlled rehabilitation with early ambulation and diet with preemptive epidural anesthesia/analgesia after laparotomy and intestinal resection
Section snippets
Inclusion and exclusion criteria
Patients undergoing elective segmental intestinal resection by laparotomy were suitable for enrollment in the trial. Reoperative cases and patients with comorbidities were included. Patients were considered to be undergoing their first operation if they had not undergone prior intestinal resection.
Recruitment and randomization
After institutional review board approval, consenting patients were given detailed information and full informed consent was obtained. Randomization was performed using sealed envelopes.
Preoperative education and the CREAD protocol
All patients
Demographics
Figure 1 shows the distribution of patients recruited to the study, according to the CONSORT statement [14]. Fifty-nine patients were randomized and analyzed by intention-to-treat principles; one patient did not meet randomization criteria and was excluded. There were 31 TE and 28 PCA patients. There was no difference between groups for any of the demographic or operative variables described in Table 1.
Length of stay
There was no difference in length of stay in the hospital, whether for primary stay or
Discussion
The role of epidural analgesia in major abdominal surgery has been widely debated. Liu et al [15] have suggested that bupivacaine with morphine provides the optimum analgesic effect with the minimum side effects. This superior effect has been attributed to preemptive analgesia and the synergy with opioids. Epidural analgesia may also be associated with a reduction in respiratory depression and a lower overall serious complication rate [16]. A recent Cochrane report has supported many of these
Conclusion
TE offered no significant improvement in length of stay, recovery of gastrointestinal function, quality of life, or patient satisfaction when compared with intravenous PCA. Pain control was slightly and significantly better but only at 48 hours after surgery. This study shows that patients on a fast-track postoperative care pathway with intravenous PCA analgesia do not get further benefits with use of a preemptive thoracic epidural.
References (24)
- et al.
Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis
Surgery
(1997) Multimodal approach to control postoperative pathophysiology and rehabilitation
Br J Anaesth
(1997)- et al.
Measurement of pain
Surg Clin North Am
(1999) - et al.
Critical pathways as a strategy for improving patient care
Ann Intern Med
(1995) - et al.
Thoracic versus lumbar epidural anesthesia’s effect on pain control and ileus resolution after restorative proctocolectomy
Surgery
(1996) - et al.
Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme
Br J Surg
(1999) - et al.
A clinical pathway to accelerate recovery after colonic resection
Ann Surg
(2000) - et al.
“Fast track” post-operative management protocol for patients with high comorbidity undergoing complex abdominal and pelvic colorectal surgery
Br J Surg
(2000) - et al.
Prospective randomized controlled trial between a pathway of controlled rehabilitation with early ambulation and diet (CREAD) and traditional postoperative care after laparotomy and intestinal resection
Dis Colon Rectum
(2003) - et al.
Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery
Cochrane Database Syst Rev
(2000)