Meta‐analysis of epidural analgesia in patients undergoing pancreatoduodenectomy

Groen, Jesse V.; Khawar, Abdullah; Bauer, Pascal; Bonsing, Bert A.; Martini, C.H.; Mungroop, Timothy H.; Vahrmeijer, A.L.; Vuijk, Jaap; Dahan, Albert; Mieog, J. Sven D.

doi:10.1002/bjs5.50171

Cited by 28 publications

(38 citation statements)

References 51 publications

(108 reference statements)

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“…The reported rst postoperative day NRS of 3 in RAPD compared to a NRS of 1 in OPD is of limited clinical relevance and therefore not attributable to major morbidity. Besides, this moderate difference can well be explained by the routine application of additional epidural analgesia in OPD, in accordance with previously reported studies on additional epidural analgesia during pancreatoduodenectomy [25].…”

Section: Discussionsupporting

confidence: 91%

Identifying Perioperative Anesthetic Factors associated with Postoperative Morbidity in Robot-Assisted vs. Open Pancreatoduodenectomy: A Cohort Study

Enden

Koerkamp

Maranus-Vereen

et al. 2021

Preprint

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Background: Robot-assisted pancreatoduodenectomy (RAPD) is a challenging procedure for the perioperative anesthesiologist, e.g. because of prolonged pneumoperitoneum exposure and reversed-Trendelenburg positioning. Purpose of this retrospective cohort study is to identify differences in perioperative anesthesia-related factors between RAPD and open pancreatoduodenectomy (OPD) and to determine perioperative anesthetic factors associated with major morbidity (Clavien Dindo ≥ III) after RAPD. Methods: All consecutive patient undergoing pancreatoduodenectomy were retrospectively included during a two year inclusion period. Anesthesia charts were studied on fluid management details, rates of vasopressor administration and arterial blood gas results. All factors were compared between both surgical approaches. Within RAPD, factors were subsequently compared between patients with major (Clavien Dindo ≥ III) vs. without major postoperative morbidity and between procedures with high and low intraoperative blood loss. Perioperative factors associated with considerable postsurgical morbidity (Clavien Dindo ≥ III) were identified by constructing a logistic regression model.Results: RAPD was associated with higher administration of intraoperative vasopressors (9.5% of operative time vs. 0% in OPD, p=0.005) and a higher net intraoperative fluid balance (2497.6 vs. 1572.3 ml, p<0.001). OPD patients more frequently and quantitatively received colloids compared to RAPD patients (79.0% vs. 51.6%, p<0.001, 1000.0 vs. 500.0 ml, p<0.001). Intraoperative erythrocyte transfusion rate was 6.3% (4/64) for RAPD compared to 30.6% (19/62) for OPD (p<0.001). Colloid administration during surgery and hyperlactatemia after 12 hour postoperative admission were associated with major (Clavien Dindo ≥ III) morbidity after RAPD (OR 5.06 with 95% CI 1.49-17.20, p=0.009 and OR 3.18 with 95% CI 1.01-9.91, p=0.047, respectively).Conclusions: RAPD is a challenging procedure for the perioperative anesthesiologist e.g. considering a higher perioperative demand for vasopressors. Perioperative anesthetic factors, including hemodynamics and fluid strategy might alter postoperative morbidity. However, current data is insufficient to make specific recommendations.

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Section: Discussionsupporting

confidence: 91%

Identifying Perioperative Anesthetic Factors associated with Postoperative Morbidity in Robot-Assisted vs. Open Pancreatoduodenectomy: A Cohort Study

Enden

Koerkamp

Maranus-Vereen

et al. 2021

Preprint

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“…Besides, this moderate difference can well be explained by the routine application of additional epidural analgesia in OPD, in accordance with previously reported studies on additional epidural analgesia during pancreatoduodenectomy [25].…”

Section: Discussionsupporting

confidence: 91%

Robot-Assisted versus Open Pancreatoduodenectomy: Identifying Perioperative Anesthetic Factors associated with Postoperative Morbidity. A retrospective cohort study.

Enden

Vereen

Koerkamp

et al. 2021

Preprint

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BackgroundRobot-assisted pancreatoduodenectomy (RAPD) poses several challenges concerning perioperative anesthetic guidance compared to open pancreatoduodenectomy (OPD), e.g. combined pneumoperiotoneum with reversed-Trendelenburg positioning. The primary objective of this observational study is to specify these anesthetic differences of RAPD versus OPD and secondly to identify independent anesthetic factors associated with patient morbidity following RAPD.MethodsAll consecutive patients who underwent either RAPD or OPD between 2017 and 2018 were included for analysis. Patient records were screened for intraoperative vasopressor and fluid administration as well as for results of perioperative arterial blood gas analysis. Variables were compared for the groups RAPD versus OPD, major morbidity following RAPD versus non-major morbidity following RAPD (resp. Clavien-Dindo score ≥ III vs. < III) and high versus low intraoperative blood loss during RAPD. Perioperative factors associated with major postoperative morbidity (Clavien-Dindo ≥ III ) were identified using a logistic regression model.ResultsN=64 RAPD and n=62 OPD patients were included for retrospective analysis. RAPD was associated with higher administration of intraoperative norepinephrine (9.5% of operative time vs. 0% in OPD, p=0.005) and a higher net intraoperative fluid balance (2497.6 vs. 1572.3 ml, p<0.001). During OPD, patients received more frequent and higher doses of colloid fluids compared to RAPD (79.0% vs. 51.6%, p<0.001, median 1000.0 vs. 500.0 ml, p<0.001). Colloid administration during surgery and hyperlactatemia 12 hours postoperatively were associated with major morbidity after RAPD (OR 5.06, 95% CI 1.49-17.20, p=0.009 and OR 3.18, 95% CI 1.01-9.91, p=0.047, respectively).ConclusionsRAPD is a challenging procedure for the anesthesiologist, e.g. considering a higher demand for vasopressors. Inotropic/vasopressor administration as well as the intraoperative fluid balance are associated with (major) morbidity following RAPD. However, it remains unclear whether and in which direction a causal relationship exists.Trial registration: Not applicable.

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“…Based on a large body of evidence, EDA with thoracic approach remains the first-line therapy to control pain after major abdominal and thoracic surgery (44)(45)(46), whereas lumbar catheters are suitable in obstetrics and for patients with artery occlusive disease of the lower limb. Concerns about outcome deterioration due to delayed bowel function return, hypotension, and urinary retention caused by EDA are not substantiated; EDA does not lead to an increased risk of any major complications or relevant side effects (47,48).…”

Section: Neuraxial Blocks-epidural Cathetersmentioning

confidence: 99%

“…Complications after epidural puncture are rare but may have dramatic effects including paraplegia (68). However, the currently available literature suggests that the benefits of EDA outweigh its risks and side effects (44,46,49,50,69,70). Thoracic epidurals are inserted in close vicinity to the spinal cord; the procedure has to be performed by experienced professionals (71).…”

Section: Complicationsmentioning

confidence: 99%

Regional Catheters for Postoperative Pain Control: Review and Observational Data

Suksompong

Bormann

2020

Anesth Pain Med

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Context: Perioperative analgesia is an essential but frequently underrated component of medical care. The purpose of this work is to describe the actual situation of surgical patients focusing on effective pain control by discarding prejudice against 'aggressive' measures. Evidence Acquisition: This is a narrative review about continuous regional pain therapy with catheters in the postoperative period. Included are the most-relevant literature as well as own experiences. Results: As evidenced by an abundance of studies, continuous regional/neuraxial blocks are the most effective approach for relief of severe postoperative pain. Catheters have to be placed in adequate anatomical positions and meticulously maintained as long as they remain in situ. Peripheral catheters in interscalene, femoral, and sciatic positions are effective in patients with surgery of upper and lower limbs. Epidural catheters are effective in abdominal and thoracic surgery, birth pain, and artery occlusive disease, whereas paravertebral analgesia may be beneficial in patients with unilateral approach of the truncus. However, failure rates are high, especially for epidural catheter analgesia. Unfortunately, many reports lack a comprehensive description of catheter application, management, failure rates and complications and thus cannot be compared with each other. Conclusions: Effective control of postoperative pain is possible by the application of regional/neuraxial catheters, measures requiring dedication, skill, effort, and funds. Standard operating procedures contribute to minimizing complications and adverse side effects. Nevertheless, these methods are still not widely accepted by therapists, although more than 50% of postoperative patients suffer from 'moderate, severe or worst' pain.

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Meta‐analysis of epidural analgesia in patients undergoing pancreatoduodenectomy

Cited by 28 publications

References 51 publications

Identifying Perioperative Anesthetic Factors associated with Postoperative Morbidity in Robot-Assisted vs. Open Pancreatoduodenectomy: A Cohort Study

Identifying Perioperative Anesthetic Factors associated with Postoperative Morbidity in Robot-Assisted vs. Open Pancreatoduodenectomy: A Cohort Study

Robot-Assisted versus Open Pancreatoduodenectomy: Identifying Perioperative Anesthetic Factors associated with Postoperative Morbidity. A retrospective cohort study.

Regional Catheters for Postoperative Pain Control: Review and Observational Data

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