Scientific papers
Randomized 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

Presented at the 47th Annual Meeting of the Midwest Surgical Association, Mackinac Island, Michigan, August 15–18, 2004
https://doi.org/10.1016/j.amjsurg.2004.11.012Get rights and content

Abstract

Background

Multimodal postoperative care regimens accelerate recovery after abdominal surgery. The benefit of thoracic epidural (TE) analgesia over patient-controlled analgesia (PCA) remains unproven when used with a fast-track postoperative care plan.

Methods

Fifty-six patients undergoing major intestinal resection, and on a fast-track postoperative care plan, were randomized to preemptive TE or PCA. Patients were evaluated at standard time points for pain score, quality of life (Short Form-36), and complications. Oral analgesia was substituted for TE and PCA on the second postoperative day. Discharge criteria were identical for both groups.

Results

Six patients (20.6%) had a failed epidural. There was no difference in length of stay (5.8 versus 6.2 days, TE versus PCA, P = .55), total length of stay (including readmissions), pain scores, quality of life, complications, or hospital costs at any time point.

Conclusion

TE offers no advantage over PCA for patients undergoing major intestinal resections who are on a fast-track postoperative care plan using PCA.

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.

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