Effect of epidural analgesia on postoperative complications following pancreaticoduodenectomy

doi:10.1016/j.amjsurg.2012.05.022

The American Journal of Surgery

Volume 204, Issue 6, December 2012, Pages 1000-1006

https://doi.org/10.1016/j.amjsurg.2012.05.022 Get rights and content

Abstract

Background

The purpose of this study was to evaluate the effect of epidural analgesia use on postoperative complications in patients undergoing pancreaticoduodenectomy.

Methods

This retrospective cohort study used the 2009 Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality. Patients who underwent pancreaticoduodenectomy were grouped on the basis of whether they received epidural analgesia. The effect of epidural use on the composite end point of major complications including death was investigated using a generalized linear model.

Results

Overall, 8,610 cases of pancreaticoduodenectomy occurred within the United States in 2009, and 11.0% of these patients received epidural analgesia. After controlling for various potential confounders, results of the multivariate regression indicated that epidural analgesia use was associated with lower odds of composite complications including death (odds ratio, .61; 95% confidence interval, .37–.99; P = .044).

Conclusions

In patients who underwent pancreaticoduodenectomy, epidural analgesia was associated with significantly lower postoperative composite complications.

Section snippets

Study design

This retrospective cohort study used nationally representative inpatient discharge records from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) for 2009.¹³ Sponsored by the Agency for Healthcare Research and Quality, the Healthcare Cost and Utilization Project represents the largest national database in the United States of inpatient-level hospital-care cases, generalizing to >40 million discharges per year. The NIS includes clinical information on episodes of

Results

Overall, 8,610 cases of pancreaticoduodenectomy occurred within the United States in 2009, summing to a national bill of $1.3 billion. The average age across all cases was 63.3 ± .4 years, and 53.9% were men. The average length of stay was 15.4 ± .5 days, and mean charges were $149,353 ± $10,006. Most admissions were elective (77.5%). The mean Deyo-modified Charlson comorbidity index was 4.1 ± .1. The majority race was white (74.3%), followed by Hispanic (10.0%), black (7.4%), Asian (4.4%), and

Comments

The most important finding of this study was that epidural use in patients undergoing pancreaticoduodenectomy was associated with lower risk for composite complications, including death. Epidural analgesia use also resulted in shorter lengths of hospital stay and lower total charges. Our regression models adjusted for relevant confounders that included patient demographics, comorbidities. and hospital characteristics. The finding that epidural analgesia significantly decreases postoperative

Conclusions

Epidural analgesia use in patients undergoing Whipple procedures was associated with decreased postoperative complications, length of hospital stay, and hospital costs. These findings need to be confirmed in a large randomized controlled study. In the interim, unless contraindicated, epidural analgesia should be routinely used for pain control in these patients.

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Cited by (36)

Narcotic sparing postoperative analgesic strategies after pancreatoduodenectomy: analysis of practice patterns for 1004 patients
2022, HPB
Citation Excerpt :
One study found that EPI use was associated with lower pain scores, but increased rates of major surgical complications, attributed to rapid fluid shifts causing hemodynamic instability.20 In contrast another study reported decreased postoperative complications, length of stay and hospital costs in patients who received EPI compared to conventional analgesia.25 Another institutional study reported decreased rates of infectious and pulmonary complications as well as superior analgesia with EPI compared to non-EPI modalities.26
Improved post-operative outcomes have been demonstrated in gastrointestinal procedures where a narcotic sparing strategy has been utilized. Data for pancreaticoduodenectomy (PD) patients is limited. This study reviews an institutional database for outcomes based on initial analgesic strategy.
1004 consecutive patients who underwent PD at Emory University between 2010 and 2017, were included in the analysis. Patients were divided into groups based on primary analgesic strategy employed: epidural alone (EPI), patient controlled opiate analgesia (PCA), dual (dual-PCA/EPI) and other (non-PCA/EPI). Postoperative outcomes for each group were analyzed utilizing univariate and multivariate linear regression.
448 (44.6%) patients were treated with EPI, 300 (29.9%) were given a PCA, 78 (7.8%) had dual-PCA/EPI and 178 (17.7%) had non-PCA/EPI analgesia. On univariate analysis, increased BMI (p = 0.030), PCA use (p < 0.001), venous thromboembolism (VTE) (p < 0.001), post-operative pancreatic fistula (POPF) (p < 0.001) and Ileus/delayed gastric emptying (DGE) (p < 0.001) were all correlated with increased LOS. On multivariate linear regression, VTE (b-coefficient 9.07, p = 0.004) POPF (8.846, p = 0.001), Ileus/DGE (4.464, p = 0.004) and PCA use (1.75, p = 0.003) were associated with significantly increased LOS.
A primary narcotic sparing strategy is associated with a significantly reduced LOS and lower rates of Ileus/DGE. Mean opiate usage was significantly lower in the EPI and non-EPI/PCA groups.
Epidural Versus Transabdominal Wall Catheters: A Comparative Study of Outcomes After Pancreatic Resection
2021, Journal of Surgical Research
This study compared epidural analgesia with local anesthetic administration via transabdominal wall catheters (TAWC), to determine the effect on perioperative outcomes in pancreatic surgery.
A retrospective review of patients undergoing open pancreatic surgery at Auckland City Hospital from 2015 to 2018 was undertaken. Data collected included patient demographics, type of perioperative analgesia, intravenous fluid and vasopressor use, length of high dependency unit stay, postoperative complications, and length of hospital stay.
Seventy-two patients underwent pancreatic surgery, of which 47 had epidural analgesia and 25 TAWC. The median age was 64 y (range 29-85). Failure of analgesia method occurred in 45% of epidural patients and 28% of TAWC patients (P = 0.209). There was no significant difference in volume of intravenous fluid given or need for vasopressors in the first 3 postoperative days, length of high dependency unit stay (median 1 d, P = 0.2836), rates of postoperative pancreatic fistula (32% versus 40%, P = 0.6046), postoperative complications (38% versus 20%, P = 0.183), or mortality (0.04% versus 0.04%, P = 1.0).
Epidural analgesia and TAWC may have comparable perioperative outcomes in patients undergoing pancreatic surgery. Further randomized studies with a larger cohort of patients are warranted to identify the best postoperative analgesic method in patients undergoing pancreatic resection.
Use of perioperative epidural analgesia among Medicare patients undergoing hepatic and pancreatic surgery
2019, HPB
Citation Excerpt :
Data in the literature regarding the influence of EA use on the costs of the surgical episode are largely lacking. Amini et al. compared hospital charges - rather than costs incurred by payers - among patients who underwent a Whipple procedure who received EA versus conventional analgesia and reported that hospital charges were lower when EA was utilized.37 In the present study, despite the slightly longer LOS observed for patients who received EA (8 days vs. 7 days), when risk-adjusted Medicare payments were analyzed, EA was associated with increased expenditures only among patients undergoing an open pancreatic resection, with the difference in median Medicare payments for EA versus conventional analgesia totaling $1600 (p = 0.013) (Table 5).
We sought to characterize epidural analgesia (EA) use among Medicare patients undergoing hepatopancreatic (HP) procedures, identify factors associated with EA use and asses perioperative outcomes.
Patients undergoing HP surgery were identified using the Inpatient Standard Analytic Files. Logistic regression was utilized to identify factors associated with EA receipt, and assess associations of EA with in-hospital outcomes and Medicare expenditures.
Among 20,562 patients included in the study, 6.7% (n =1362) had EA. There was no difference in the odds of complications (OR 1.05, 95% CI 0.93–1.19) or blood transfusions (OR 0.90, 95% CI 0.79–1.03) with EA versus conventional analgesia (CA). The odds of prolonged LOS (OR 1.16, 95% CI 1.03–1.30) were higher with EA; the odds of in-hospital mortality were higher with conventional analgesia (OR 1.90, 95% CI 1.28–2.83). Medicare payments for liver surgery were comparable among EA ($19,500) versus conventional analgesia ($19,300, p = 0.85) and slightly higher for EA ($23,600) versus conventional analgesia ($22,000, p < 0.001) for pancreatic procedures.
EA utilization among Medicare patients undergoing HP was low. While EA was not associated with morbidity, it resulted in an average additional one day LOS and slightly higher expenditures in pancreatic surgery.
Post-Pancreaticoduodenectomy Outcomes and Epidural Analgesia: A 5-year Single-Institution Experience
2019, Journal of the American College of Surgeons
Citation Excerpt :
However, there was no significant difference in the rate of any individual component included in this aggregate analysis, including sepsis or wound infection.38 Another study examining PD alone revealed a higher rate of overall wound complications with the use of EDA, defined as internal or external disruption; it is unclear whether this definition includes wound infections, making comparison with the current study results difficult.42 Mechanistically, there is support in the literature for a reduced rate of infectious complications with the use of EDA through dampening of the stress response to the operation and its associated attenuation of the immune system.14,23,24
Optimal pain control post pancreaticoduodenectomy is a challenge. Epidural analgesia (EDA) is used increasingly, despite inherent risks and unclear effects on outcomes.
All pancreaticoduodenectomies (PDs) performed from January 2013 through December 2017 were included. Clinical parameters were obtained from a retrospective review of a prospective clinical database, the American College of Surgeons NSQIP prospective institutional database, and medical record review. Chi-square, Fisher's exact test, and independent-samples t-tests were used for univariable analyses. Multivariable regression was performed.
Six hundred and seventy-one consecutive PDs from a single institution were included (429 EDA, 242 non-EDA). On univariable analysis, EDA patients experienced significantly less wound disruption (0.2% vs 2.1%), unplanned intubation (3.0% vs 7.9%), pulmonary embolism (0.5% vs 2.5%), mechanical ventilation longer than 48 hours (2.1% vs 7.9%), septic shock (2.6% vs 5.8%), and lower pain scores. On multivariable regression (accounting for baseline group differences (ie sex, hypertension, preoperative transfusion, laboratory results, approach, and pancreatic duct size), EDA was associated with less superficial wound infections (odds ratio [OR] 0.34; 95% CI 0.14 to 0.83; p = 0.017), unplanned intubations (OR 0.36; 95% CI 0.14 to 0.88; p = 0.024), mechanical ventilation longer than 48 hours (OR 0.22; 95% CI 0.08 to 0.62; p = 0.004), and septic shock (OR 0.39; 95% CI 0.15 to 1.00; p = 0.050). Epidural analgesia improved pain scores post-PD days 1 to 3 (p < 0.001). No differences were seen in cardiac or renal complications; pancreatic fistula (B+C) or delayed gastric emptying, 30-/90-day mortality, length of stay, readmission, discharge destination, or unplanned reoperation.
Based on the largest single-institution series published to date, our data support the use of EDA for optimization of pain control. More importantly, our data document that EDA improved infectious and pulmonary complications significantly.
What Is the Best Pain Control After Major Hepatopancreatobiliary Surgery?
2018, Advances in Surgery
Thoracic paravertebral block versus thoracic epidural analgesia for post-operative pain control in open pancreatic surgery: A randomized controlled trial
2018, Journal of Clinical Anesthesia
The purpose of this study was to compare the efficacy of bilateral ultrasound guided thoracic paravertebral catheters to a thoracic epidural after open pancreatic surgery.
This was a prospective non-blinded randomized controlled trial.
Academic hospital operating room, postoperative recovery area, and ward.
53 patients aged 18 and above who had open pancreatic surgery.
Patients received either bilateral thoracic paravertebral block at T8 with an infusion of 0.2% ropivacaine or thoracic epidural analgesia at T7/8 with an infusion of 0.125% bupivacaine with hydromorphone 6 μg/mL.
Pain scores, opioid use, length of recovery room and hospital stay, adverse events, and incidence of nausea and vomiting.
There was no difference in baseline demographics between the two groups. There were no significant differences in pain scores between the two groups in each of the first five days after surgery. There was no difference in length of stay nor nausea and vomiting. There was significantly less modality related adverse events in the paravertebral group compared to the epidural group (p = 0.02).
The use of thoracic paravertebral catheters provided comparable analgesia and less modality related adverse events when compared to a thoracic epidural in patients undergoing open pancreaticoduodenectomy.

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The Southwestern Surgical CongressEffect of epidural analgesia on postoperative complications following pancreaticoduodenectomy

Abstract

Background

Methods

Results

Conclusions

Section snippets

Study design

Results

Comments

Conclusions

Lancet

Surg Clin North Am

J Clin Epidemiol

J Gastrointest Surg

Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study

Ann Surg

Epidural analgesia enhances functional exercise capacity and health related quality of life after colonic surgery

Anesthesiology

The role of epidural anesthesia and analgesia in postoperative outcome

Anesthesiol Clin North Am

The role of epidural anesthesia and analgesia in surgical practice

Ann Surg

The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials

Anesth Analg

The Southwestern Surgical Congress
Effect of epidural analgesia on postoperative complications following pancreaticoduodenectomy