Short and Long-Term Outcomes of Epidural or Intravenous Analgesia after Esophagectomy: A Propensity-Matched Cohort Study

Abstract

Background and ObjectivesAs a well-established technique for postoperative pain relief, the benefits of epidural analgesia (EDA) have been under debate recently. This study aimed to determine whether EDA could improve perioperative outcomes and survival in patients undergoing esophagectomy.MethodsFrom January 2010 to December 2012, 587 consecutive cases undergoing McKeown-type esohpageactomy were retrospectively identified from a prospectively maintained database.ResultsAfter propensity-matching, incorporating baseline characteristics, 178 cases were included in each group, and patients characteristics distributions were well-balanced between two groups. Compared with intravenous analgesia, the use of EDA significantly decreased the incidence of pneumonia from 32% to 19.7% (P = 0.008), and anastomotic leakage from 23.0% to 14.0% (P = 0.029). The change in CRP level of EDA group was significantly decreased (preoperative, 6.2 vs. 6.2; POD 1, 108.1 vs. 121.3; POD 3, 131.5 vs. 137.8; POD 7, 69.3 vs. 82.1 mg/L; P = 0.044). EDA patients had a significantly longer duration of indwelling urinary catheter (P<0.001), and lower levels in both systolic (P = 0.001) and diastolic blood pressure (P<0.001). There weren't significant differences in overall survival (log-rank P = 0.47) and recurrence (Gray-test P = 0.46) between two groups.ConclusionsThese findings revealed that EDA could attenuate inflammatory response and reduce the incidence of pneumonia and anastomotic leakage after esophagectomy, at the price of delayed urinary catheter removal and lower blood pressure. EDA remains an important component of multimodal perioperative management after esophagectomy.

Epidural analgesia and avoidance of blood transfusion are associated with reduced mortality in patients with postoperative pulmonary complications following thoracotomic esophagectomy: a retrospective cohort study of 335 patients

“…Data on the use of TEA to reduce the incidence of PPCs after esophagectomy are inconsistent [2, 14, 16–18, 20]. The current meta-analysis by Visser and colleagues shows no significant benefit for TEA compared to systemic analgesia with respect to PPCs or postoperative pain scores at 24 and 48 h after esophagectomy.…”

“…TEA is another procedural and anesthesia-related factor potentially reducing the incidence of PPCs after esophagectomy. Results on this topic appear contradictory [2, 14–20]. Although it has been shown that perioperative TEA in patients after esophagectomy significantly decreases time on ICU, there is no study that provides data on superior oncological results and mortality decrease among patients with PPCs due to TEA [19].…”

Effect of restrictive fluid therapy with hydroxyethyl starch during esophagectomy on postoperative outcomes: a retrospective cohort study

“…Furthermore, we could not consider perioperative analgesic methods such as intravenous or thoracic epidural analgesia. Thoracic epidural analgesia can reduce the incidence of pneumonia and anastomotic leak and the systemic proinflammatory response [28, 29]. Simultaneously, prolonged hypotension due to excess epidural bolus doses is associated with a higher rate of anastomotic leakages [30].…”

Reply

“…The last word on TEA for esophagectomy may not yet have been said, but the conclusion made by Levy and colleagues [1], who compared two different analgesic regimens in two different kinds of surgical procedures, is certainly premature. Therefore, epidural analgesia for patients undergoing esophagectomy remains the standard for perioperative pain control [4,5].…”