Original Contribution
Epidural compared with non-epidural analgesia and cardiopulmonary complications after colectomy: A retrospective cohort study of 20,880 patients using a national quality database

https://doi.org/10.1016/j.jclinane.2018.03.005Get rights and content

Highlights

  • Overall, epidural analgesia showed no difference in postoperative complications.

  • In open colectomy, epidural analgesia is associated with fewer complications.

  • Epidural analgesia may improve outcomes and speed recovery after open colectomy.

Abstract

Study objective

Epidural analgesia may be associated with fewer postoperative complications and is associated with improved survival after colon cancer resection. This study used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to assess any association between epidural analgesia (versus non-epidural) and complications after colectomy.

Setting

603 hospitals in the United States reporting data to NSQIP.

Patients

From 2014–15 data, 4176 patients undergoing colectomy with records indicating epidural analgesia were matched 1:4 via propensity scores to 16,704 patients without.

Interventions

None (observational study).

Measurements

Primarily, we assessed the association between epidural analgesia and a composite of cardiopulmonary complications using an average relative effect generalized estimating equations model. Secondary outcomes included neurologic, renal, and surgical complications and length of hospitalization. Sensitivity analyses repeated the analyses on a subgroup of only open colectomies.

Main results

We found no association between epidural analgesia and the primary outcome: average relative effect (95% CI) 0.87 (0.68, 1.11); P = 0.25. We found no significant associations with any secondary outcomes. In the 8005 open colectomies, however, there was a significant association between epidural analgesia and fewer cardiopulmonary complications (average relative effect odds ratio [95% CI] of 0.58 [0.35, 0.95]; P = 0.03) and shortened hospital stay (HR for time to discharge [98.75% CI] of 1.10 [1.02, 1.18]; P < 0.001).

Conclusions

We found no overall association between epidural analgesia and reduced complications after colectomy. In open colectomies, however, epidural analgesia was associated with fewer cardiopulmonary complications and shorter hospitalization. This may inform analgesic choice when planning open colectomy.

Introduction

In recent years, there has been much interest in the potential effects of regional anesthesia or analgesia on outcomes after surgery. We previously used the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database to assess the impact of epidural analgesia use on recurrence and survival after colon cancer resection and found that epidural analgesia was associated with improved survival but not recurrence [1].

Although our previous analysis was unable to find a difference in cancer recurrence, there was an early and persistent survival advantage among patients receiving epidural analgesia, even adjusting for multiple covariates. A decrease in perioperative adverse events could explain much of the observed mortality difference. Indeed, recent analysis of Cochrane Database systematic reviews suggests that epidural anesthesia may confer a mortality benefit in some patients [2]. There is also evidence showing epidural analgesia reduces postoperative pain and reduces a number of postoperative complications in various settings [[3], [4], [5], [6], [7], [8], [9]]. Our previous analysis, however, was unable to address the specific reasons for the mortality difference because the SEER-Medicare database has limited clinical detail to reliably capture many postoperative complications.

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) provides a rich, validated data source concerning perioperative care and postoperative complications from 603 participating hospitals (in 2015) in the United States, both academic and private (https://www.facs.org/quality-programs/acs-nsqip) [10]. Each participating site has a trained Surgical Clinical Reviewer and a “Surgeon Champion” responsible for auditing cases to ensure data quality. Cases from each site are randomly sampled on a risk-adjusted basis, so the NSQIP data only provide a sample of the overall case volume at each center. Starting in 2014, an additional variable was added to capture additional anesthetic techniques such as epidural analgesia, providing the ability to evaluate the impact of epidural analgesia on perioperative outcomes. We therefore used the 2014–15 ACS NSQIP Colectomy Procedure-Targeted and standard Participant Use Data Files (PUFs) to identify patients undergoing non-emergent colectomy and evaluate the primary hypothesis that patients with epidural analgesia (as defined below) would have a lower composite risk of 30-day mortality and cardiopulmonary complications than those without epidural analgesia. Secondary analyses tested the hypotheses that epidural analgesia is associated with fewer renal, neurologic, and surgical complications as well as shorter length of hospital stay than systemic analgesia. Because of the significant clinical differences between open and laparoscopic procedures, a subgroup analysis of only open colectomies was performed to evaluate whether the associations of epidural analgesia with the composite outcomes differ by procedure type.

Section snippets

Materials and methods

This study using de-identified data was determined by the Cleveland Clinic Institutional Review Board to be exempt from review. We assessed the association between epidural analgesia around the time of colectomy (versus no epidural analgesia) on postoperative complications and hospital length of stay using the 2014 and 2015 NSQIP standard and colectomy procedure-targeted data. Patients undergoing colectomy for all indications were included. Patients were excluded from the analysis if they had

Results

The 2014 and 2015 NSQIP data included 56,569 colectomy cases. Among those, 4329 colectomy patients who received epidural analgesia and 33,127 patients who did not were eligible for this analysis (Fig. 1). 4176 colectomy patients who received epidural analgesia were successfully matched 1:4 to 16,704 who did not (99% matched). Balance of groups on potentially confounding patient characteristics are presented before and after matching in Table 1. Virtually all patients received general anesthesia

Discussion

In this analysis, despite adequate post-hoc power, we found no overall significant association between epidural analgesia and the primary composite outcome. There was also no association with other complications or length of stay after colectomy. When looking specifically at open procedures, however, there was a significant association between epidural analgesia and a reduction in the primary composite outcome as well as shorter hospital length of stay.

There is ample reason to expect that

Declarations of interest

None.

Funding

L.C.C. was supported by an American College of Gastroenterology Junior Faculty Development Grant. G.S.C. was supported by National Institutes of Health grant P50 CA150964 (Case GI SPORE), UL1 TR000439 (Case Clinical & Translational Science Collaborative), P30 CA043703 (Case Comprehensive Cancer Center), and P30 DK097948 (Cleveland Digestive Diseases Research Core Center).

The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS

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    Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery

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    1

    Cleveland Clinic, 9500 Euclid Ave/E-31, Cleveland, OH 44195.

    2

    University Hospitals Cleveland Medical Center, 11,100 Euclid Avenue, Mail Stop 5066, Cleveland, OH 44106–5066.

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