Recovery of gastrointestinal function with thoracic epidural vs. systemic analgesia following gastrointestinal surgery

Abstract

The objective of this review was to systematically assess the effect of thoracic epidural analgesia (TEA) vs. systemic analgesia (SA) on the recovery of gastrointestinal (GI) function in patients following GI surgery. We performed a comprehensive literature search to identify randomized controlled trials of adult patients undergoing GI surgery, comparing the effect of two postoperative analgesia regimens. Patients postoperatively receiving local anesthesia-based TEA with or without opioids were compared to patients receiving opioid-based SA. The outcomes considered were times to GI function recovery, GI complications, and specific side effects. Twelve studies with 331 patients in the TEA group and 319 in the SA group were included. Compared to SA, TEA improved the GI recovery after GI procedures by shortening the time to first passage of flatus by 31.3 h, 95% confidence intervals (CIs): -33.2 to -29.4, P < 0.01; and shortening the time to first passage of stool by 24.1 h, 95% CIs: -27.2 to -20.9, P < 0.001. There was no difference between the groups in the incidence of anastomotic leakage and ileus. The occurrence of postoperative hypotension was relatively higher in the TEA group, risk ratio: 7.9, 95% CIs: 2.4 to 26.5, P = 0.001; other side effects (such as pruritus and vomiting) were similar in the two groups. There is evidence that TEA (compared to SA) improves the recovery of GI function after GI procedures without any increased risk of GI complications. To further confirm these effects, larger, better quality randomized controlled trials with standard outcome measurements are needed.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

“…Initiation of neuroaxial blockade before surgery and its maintenance throughout surgery decreases the need for anaesthetic agents, opioids and muscle relaxants . Compared with parenteral opioids, epidural blockade has shown to provide better postoperative static and dynamic analgesia for the first 72 h,, to accelerate the recovery of gastrointestinal function, to reduce insulin resistance and impact positively on cardiovascular and respiratory complications …”

PRO: Epiduralanalgesie – Goldstandard bei abdominalen und thorakalen Eingriffen

“…paralytischem Ileus [12,13]. Dabei führt die früh einsetzende Peristaltik nichtwie befürchtetzu einer gesteigerten Rate an Anastomoseninsuffizienzen [14,15]. Zumindest tierexperimentell konnte bestätigt werden: Die medikamentöse Therapie der Hypotension mit Noradrenalin löste keine Minderperfusion der intestinalen Mikrozirkulation aus [16].…”

Role of regional anesthesia and analgesia in the opioid epidemic

“…Meta-analyses assessing use of transversus abdominis plane (TAP) blocks for laparoscopic procedures demonstrate reduced opioid requirements postoperatively 6 7. Subcostal TAP blocks and thoracic epidural analgesia provide effective analgesia and reduce postoperative opioid use for open abdominal surgery,15 and thoracic epidural analgesia may also improve gastrointestinal recovery versus systemic analgesia possibly related to reduced opioid usage 8. Breast surgery is also amenable to regional anesthesia, and thoracic interfascial plane blocks including paravertebral and pectoralis nerve blocks have both demonstrated opioid-sparing effects 16.…”