A comparison of thoracic and lumbar epidural techniques for post-thoracoabdominal esophagectomy analgesia

Abstract

A comparison of thoracic and lumbar epidural techniques for postthoracoabdominal esophagectomy analgesiaPurpose: To compare thoracic epidural analgesia (TEA) using a bupivacaine/[entanyl mixture and lumbar epidural analgesia (LEA) with morphine, in respect to the time to extubation and the quality of post-operative analgesia, in patients having thoracoabdominal esophagectomy. Methods: Twenty two patients scheduled for elective thoracoal:x:lominal esophagectomy were randomized to TEA or LEA. Postoperatively, the TEA group received Patient Controlled Epidural Analgesia (PCEA) with bupivacaine 0.12596 and 5/./g'ml Bt fentanyl, and the LEA group received PCEA with 0.2/ag'ml Bl morphine. A blinded observer assessed criteria for tracheal extubation and the time of tracheal extubation was recorded. Early extubation was defined as tracheal extubation within four hours postoperatively. Visual analogue pain scores at rest (Static Visual Analogue Pain Scores, SVAPS) and with movement (Dynamic Visual Analogue Pain Scores, DVAPS) were recorded at I , 6, 12, 18 and 24 hr post-extubation. Failure of the epidural protocol (FEP) was defined as a request for additional analgesia. Results: Tracheal extubation was achieved in 70% of the LEA and 100~ of the TEA at four hours postoperatively (P=NS). However, the TEA group achieved earlier extubation times when assessed with log rank testing (P = 0.01 ). By six hours postextubation FEP had occurred in 50% of the LEA group but in none of the TEA group (P = 0.0 I). Mean SVAPS and DVAPS were lower in the TEA than in the LEA group at all measured times (P < 0.01).Conclusion: This study has demonstrated superior pain control in patients undergoing thoraco-abdominal esophagectomy treated with TEA than with LEA, particularly for pain with movement. Tracheal extubation occurred earlier in the TEA group, but this difference was not significant at four hours postoperatively.

A survey of postoperative epidural and intravenous analgesia in Greece

“…In addition, in all these 10 departments, a sympathetic blockade of the lower extremities was induced, which may contribute to adverse effects, but not to an improvement of the upper abdominal or thoracic analgesia. For thoracic or upper abdominal surgery, thoracic epidural analgesia provides better dynamic analgesia compared to lumbar [18], and also improves gastrointestinal, respiratory and cardiac function [19,20], and decreases the risk of hypotension, urinary retention and limb weakness [21][22][23].…”

Patient-controlled epidural analgesia reduces analgesic requirements compared to continuous epidural infusion after major abdominal surgery

“…There are several means to reduce these drawbacks, e.g., insertion of epidural catheters at the center of the involved segments and the use of low concentrations of LA plus opioids. [3][4][5][6] Patient-controlled epidural analgesia (PCEA) may offer the opportunity to reduce the incidence of side effects associated with CEI, 7 since PCEA provides excellent postoperative analgesia with only minimal side effects when properly used. 8 Both improved analgesia with similar doses of analgesics 7 and dose-sparing effects with comparable analgesia 9 have been shown for PCEA when compared with CEI.…”

Segmental thoracic epidural anaesthesia in a dog undergoing intercostal thoracotomy and lung lobectomy

“…No clear functional benefits have been documented with catheters placed in the lumbar area, which requires the administration of hydrophilic opioids to produce analgesia in the thoracic region 11. Advancing epidural catheters for a long distance has been associated with severe complications, including patchy blocks, missed segments, dural sleeve cannulation, nerve root entrapment, intravascular cannulation and subarachnoid cannulation 1 32.…”

“…Epidural catheter placement at the spinal level corresponding to dermatomes of surgical incision provides catheter incision‐congruent anaesthesia and analgesia 10 11. In human beings segmental TEA may result in a lower incidence of postoperative pain, urinary retention, motor block and hypotension than GA and lumbar epidural analgesia 11 12…”