Epidural Analgesia Improves Postoperative Pain Control but Impedes Early Discharge in Patients Undergoing Pancreatic Surgery

Abstract

Objectives: Aim of this study was to evaluate the impact of epidural analgesia on postoperative length of stay, expeditious discharge, and pain relief after pancreaticoduodenectomy and distal pancreatectomy.Methods: Retrospective reviews of 2014-2015 American College of Surgeons National Surgical Quality Improvement Program databases and our institutional pancreas surgery database were conducted.Results: On univariate analysis, epidural analgesia was associated with statistically significant longer lengths of stay for both pancreaticoduodenectomy and distal pancreatectomy. On comparative analysis at mode length of stay, discharged before vs. after 7 days for pancreaticoduodenectomy and 6 days for distal pancreatectomy, epidural analgesia was a significant predictor for the longer groups for both procedures on multivariable analysis (pancreaticoduodenectomy: odds ratio 1.465; P < 0.001, distal pancreatectomy: odds ratio 1.471; P = 0.004). On review of our institution's pancreas surgery database, patient-reported pain scores were significantly lower in the epidural analgesia groups than intravenous narcotics groups on the day of surgery only for both pancreaticoduodenectomy and distal pancreatectomy.Conclusions: Epidural analgesia was associated with longer length of stay with a most pronounced effect on early discharge after surgery for patients undergoing open pancreaticoduodenectomy and distal pancreatectomy. It only resulted in superior pain control on the day of surgery.

Postoperative Pain Relief after Pancreatic Resection: Systematic Review and Meta‐Analysis of Analgesic Modalities

“…Four studies [ 5 , 13 , 20 , 37 ] reported comparable pain scores on POD2 including a total of 565 patients (EDA: n =358, PCA: n =207) and found no significant difference in pain scores between EDA and PCA (SMD 0.29, 95% CI 0.83 to 0.24, p =0.19). Subgroup analysis of non-randomised studies also found no significant difference in pain scores (SMD 0.33, 95% CI 1.36 to 0.69, p =0.3) (Fig.…”

“…Subgroup analysis of randomised studies was not possible. Three studies [ 5 , 13 , 20 ] reported pain scores on POD4 including a total of 463 patients (EDA: n =271, PCA: n =192). There was no significant difference in pain scores between EDA and PCA (SMD 0.08, 95% CI 0.26 to 0.06, p =0.18) (Fig.…”

“…Although a variety of pain modalities have been explored for the management of postoperative pain after pancreatic surgery, the literature is generally limited to pair-wise comparisons, small study sizes and heterogeneity in their study population [2,5,8,9,[11][12][13][14][15][16][17][18][19][20][21][22][23] making it difficult to justify routine use of one pain modality over the other. This is reflected in the recently published ERAS guidance [6] which recommends EDA for postoperative pain relief and TAWC as an alternative, however the majority of evidence for this recommendation was extrapolated from non-pancreatic surgery.…”

Analgesic effects of ultrasound-guided four-quadrant transabdominal plane block in patients with cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a prospective, randomized, controlled study

“…Poorer analgesia compared to a well-controlled IV PCA may also reduce patient satisfaction [ 3 ]. Some studies have shown that thoracic epidural analgesia increased the complexity of recovery and rather increased the total hospital stay [ 20 ]. These studies explained that if epidural analgesia were performed in surgeries with short recovery periods, the start of anticoagulation after surgery was delayed, and the voiding rehabilitation period due to Foley catheter placement would be also required, which in turn delayed the recovery.…”

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review

“…Pancreas transplant recipients often require increased anticoagulation due to the risk of allograft thrombosis, sometimes limiting the epidural options available [ 102 , 103 , 104 ]. Epidural analgesia is also known to increase the LOS while only providing superior pain control on the day of surgery in pancreatic surgery [ 105 ].…”