Thoracic versus lumbar epidural anesthesia's effect on pain control and ileus resolution after restorative proctocolectomy

Pathophysiology and Management of Postoperative Ileus in Adults and Neonates: A Review

Postoperative ileus (POI) is caused by enteric neural dysfunction and inflammatory response to the stress of surgery as well as the effect of anesthetics and opioid pain medications. POI results in prolonged hospital stays, increased medical costs, and diminished enteral nutrition, rendering it a problem worth tackling. Many cellular pathways are implicated in this disease process, creating numerous opportunities for targeted management strategies. There is a gap in the literature in studies exploring neonatal POI pathophysiology and treatment options. It is well known that neonatal immune and enteric nervous systems are immature, and this results in gut physiology which is distinct from adults. Neonates undergoing abdominal surgery face similar surgical stressors and exposure to medications that cause POI in adults. In this review, we aim to summarize the existing adult and neonatal literature on POI pathophysiology and management and explore applications in the neonatal population.

Could epidural analgesia be safely used for acute postoperative pain in older adults to enhance recovery?

Epidural analgesia is often considered cornerstone in multimodal analgesia when used in major surgeries. However, its role in managing acute postoperative pain in elderly patients is debatable because of its known potential complications. Furthermore, postoperative pain in elderly patients is under-treated because of complex comorbidities, and they are more prone to adverse events related to pain therapies. All systemic analgesic drugs have pharmacological limitations and precautions in elderly people. Recent meta-analyses showed that epidural analgesia provided better postoperative pain control compared to intravenous opioids. Interestingly, peripheral nerve blocks had no superior control of pain over epidural analgesia. In addition, epidural analgesia has shown to positively affect perioperative morbidities and mortalities, and reduce opioid-related side effects because of its non-analgesic effects on each organ system. When tailored in a specific multimodal approach, it shortens the intensive care and hospital stays. In conclusion, if complications are identified and treated early, and contraindications are ruled out, epidural analgesia can achieve sufficient postoperative pain management with insignificant adverse events in this population.

[The "Big Five" of Invasiveness - the Usefulness of Drains, Probes and Catheters in Colorectal Surgery]

The perioperative management of colorectal resections is often dominated by traditional procedures and a strong focus on safety. Evidence-based measures such as those established in Fast Track or ERAS programs, are rarely applied in a standardised manner. As part of elective colorectal surgery, many patients therefore continue to routinely receive central venous access, peridural catheters, urinary catheters, drains and/or gastric tubes ("Big Five" of invasiveness). This article presents the currently available evidence on these measures in colorectal surgery. In addition, results relating to the "Big Five" from the author's own centre are presented. This review shows that the "Big Five" of invasiveness are clinically unnecessary or supported by evidence. In addition, they often impair the patient's function.

Regional abdominal wall nerve block versus epidural anesthesia after hepatectomy: analysis of the ACS NSQIP database

BACKGROUND

The aim of this study is to determine whether regional abdominal wall nerve block is a superior to epidural anesthesia (EA) after hepatectomy.

METHODS

Patients undergoing open hepatectomy in the NSQIP targeted file (2014-2016) were identified. Those with INR > 1.5, Platelets < 100, bleeding disorders, undergoing liver ablation without resection, and spinal anesthesia were excluded. Patients with regional abdominal wall nerve block (RAB), mostly transversus abdominis plane (TAP) block, were matched (1:1) to those undergoing EA using propensity scores to adjust for baseline differences.

RESULTS

Out of 1727 patients who met our inclusion criteria, 361 (21%) had RAB. Of whom 345 were matched (1:1) to those who underwent EA. The matched cohort was well-balanced regarding preoperative characteristics, extent of hepatectomy, concurrent ablations as well as biliary reconstruction. RAB was associated with shorter hospital stay (median: 6 days vs. 5 days, p = 0.007). Overall morbidity (44.1% vs. 39.4%, p = 0.217), serious morbidity (27% vs. 25.2%, p = 0.603), and mortality (2.6% vs. 2.3%, p = 0.806) were not different between the two groups. Individual complications, readmission rate, and blood transfusion were not different between the two groups.

CONCLUSION

Regional abdominal nerve block is associated with shorter hospital stay than epidural anesthesia without an increase in overall postoperative morbidity or mortality. RAB is a viable alternative anesthesia adjunct to EA in patients undergoing hepatectomy. However, given the retrospective nature of this study further studies comparing the modalities should be considered to definitively define the utility of RAB.

Advantages of Epidural Analgesia on Pulmonary Functions in Liver Transplant Donors

OBJECTIVE

Epidural analgesia (EA) has positive effects on anesthetic requirement, blood loss, postoperative analgesia, and pulmonary function tests (PFTs). The purpose of the present study was to investigate the effect of EA on postoperative PFTs in liver transplant donors (LTDs).

METHODS

In the present study, 66 LTDs were classified as total intravenous anesthesia (TIVA) and TIVA+EA groups. Patient's age, sex, body mass index, induction and maintenance dose of propofol (IDP and MDP), operation duration, forced expiratory volume in 1 second (FEV₁), forced vital capacity (FVC), FEV₁/FVC ratio, visual analog scale (VAS), atelectasis scores, and lengths of intensive care unit (ICU) and hospital stays were recorded.

RESULTS

In the TIVA+EA group, IPD, MPD, delta-FEV₁ delta-FVC, VAS for all time, atelectasis score and length of hospital stay were significantly lower than in the TIVA group (P < .001 for all). Whereas VAS at the end of the operation was negatively correlated with delta-FEV₁ and delta-FVC (r² = 0.26 P < .001; r² = 0.41 P < .001; respectively), it was positively correlated with atelectasis score and length of ICU stay (r² = 0.49, P < .001; and r² = 0.41, P < .001; respectively). Atelectasis score was positively correlated with length of ICU stay (r² = 0.86, P < .001).

CONCLUSIONS

Reduced anesthetic requirement, better postoperative analgesia, reduced atelectasis score, and preserved PFTs can be provided with the use of EA in LTDs. Positive effects of EA on anesthesia requirement, pain management and pulmonary function are associated with outcomes.

Anesthetic management of intestinal obstruction: A postgraduate educational review

Intestinal obstruction is associated with significant morbidity and mortality. Scientific assessment of the cause, site of obstruction, appropriate correction of the fluid deficit and electrolyte imbalance with preoperative stabilization of blood gases is ideal as a preoperative workup. Placement of a preoperative epidural catheter especially in the thoracic interspace takes care of perioperative pain and stress reduction. Intraoperative management by controlled general anesthesia administering a relative high inspired fraction of oxygen with invasive monitoring in selected sick cases is mandatory. Preoperative monitoring and stabilizing raised intra-abdominal pressure reduces morbidity. Caution should be exercised during opening and closure of abdomen to avoid cardiorespiratory ill effects. There should be an emphasis on avoiding hypothermia. The use of nonsteroidal anti-inflammatory drugs may worsen sick, fragile patients. The use of sugammadex rather than neostigmine will obscure certain controversies in the healing of intestinal anastomotic site. Replacement of blood loss continued correction of fluids and electrolytes with possible postoperative mechanical ventilation in sick cases may improve outcomes in these patients.

Postoperative ileus: mechanisms and future directions for research

Postoperative ileus (POI) is an abnormal pattern of gastrointestinal motility characterized by nausea, vomiting, abdominal distension and/or delayed passage of flatus or stool, which may occur following surgery. Postoperative ileus slows recovery, increases the risk of developing postoperative complications and confers a significant financial load on healthcare institutions. The aim of the present review is to provide a succinct overview of the clinical features and pathophysiological mechanisms of POI, with final comment on selected directions for future research.Terminology used when describing POI is inconsistent, with little differentiation made between the obligatory period of gut dysfunction seen after surgery ('normal POI') and the more clinically and pathologically significant entity of a 'prolonged POI'. Both normal and prolonged POI represent a fundamentally similar pathophysiological phenomenon. The aetiology of POI is postulated to be multifactorial, with principal mediators being inflammatory cell activation, autonomic dysfunction (both primarily and as part of the surgical stress response), agonism at gut opioid receptors, modulation of gastrointestinal hormone activity and electrolyte derangements. A final common pathway for these effectors is impaired contractility and motility and gut wall oedema. There are many potential directions for future research. In particular, there remains scope to accurately characterize the gastrointestinal dysfunction that underscores an ileus, development of an accurate risk stratification tool will facilitate early implementation of preventive measures and clinical appraisal of novel therapeutic strategies that target individual pathways in the pathogenesis of ileus warrant further investigation.

Thoracic Epidural analgesia versus Rectus Sheath Catheters for open midline incisions in major abdominal surgery within an enhanced recovery programme (TERSC): study protocol for a randomised controlled trial

BACKGROUND

Thoracic epidural analgesia (TEA) is recommended for post-operative pain relief in patients undergoing major abdominal surgery via a midline incision. However, the effectiveness of TEA is variable with high failure rates reported post-operatively. Common side effects such as low blood pressure and motor block can reduce mobility and hinder recovery, and a number of rare but serious complications can also occur following their use.Rectus sheath catheters (RSC) may provide a novel alternative approach to somatic analgesia without the associated adverse effects of TEA. The aim of this study is to compare the efficacy of both techniques in terms of pain relief, patient experience, post-operative functional recovery, safety and cost-effectiveness.

METHODS/DESIGN

This is a single-centre randomised controlled non-blinded trial, which also includes a nested qualitative study. Over a two-year period, 132 patients undergoing major abdominal surgery via a midline incision will be randomised to receive either TEA or RSC for post-operative analgesia. The primary outcome measures pain scores on moving from a supine to a sitting position at 24 hours post wound closure, and the patient experience between groups evaluated through in-depth interviews. Secondary outcomes include pain scores at rest and on movement at other time points, opiate consumption, functional recovery, morbidity and cost-effectiveness.

DISCUSSION

This will be the first randomised controlled trial comparing thoracic epidurals to ultrasound-guided rectus sheath catheters in adults undergoing elective midline laparotomy. The standardised care provided by an Enhanced Recovery Programme makes this a comparison between two complex pain packages and not simply two analgesic techniques, in order to ascertain if RSC is a viable alternative to TEA.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN81223298 (16 January 2014).

The effect of a clinical pathway for enhanced recovery of rectal resections on perioperative quality of care

PURPOSE

There is ample evidence of the benefits of clinical pathways (CPs), but this study is the first to investigate the potential additional benefits of a CP for rectal resections in a setting with an already established policy of enhanced postoperative recovery.

METHODS

We compared 36 patients who underwent rectal resections with ileostomy placement and were treated according to a CP (CP group) with 67 patients treated before CP implementation (prepathway group). Indicators of process quality were placement of central venous line and epidural catheter, day of removal of Foley catheter in relation to removal of the epidural catheter, day of first mobilization, day of resumption of regular diet, day of first passage of stool through the stoma, and length of stay. Outcome quality was assessed by morbidity, mortality, reoperation, and readmission rates.

RESULTS

We found that patients in the CP group resumed regular diet significantly sooner (p = 0.001). There were no significant differences regarding the day of first mobilization (p = 0.69), epidural catheter (p = 0.74), central venous line placement (p = 0.92), and removal of Foley catheter (p = 0.23). The first stool was passed through the stoma earlier (p = 0.04) in the prepathway group. Median length of hospital stay was significantly shorter in the CP group (12.5 vs. 15.0 days; p = 0.008). There were no significant changes in outcome quality, except for a significantly higher need for revisional surgery in the CP group (13.9 vs. 3%, p = 0.05).

CONCLUSIONS

After implementation of a CP for rectal resections, one parameter of process quality improved and length of stay decreased.

A phase II, randomized, controlled trial of acupuncture for reduction of Postcolectomy Ileus

PURPOSE

Postoperative ileus (POI) prolongs hospital stay and increases risk of postoperative complications. We conducted a randomized, sham-controlled trial to evaluate whether acupuncture reduces POI more effectively than sham acupuncture.

METHODS

Colon cancer patients undergoing elective colectomy were randomized to receive 30 min of true or sham acupuncture twice daily during their first 3 postoperative days. GI-3 (the later of the following two events: time that the patient first tolerated solid food, AND time that the patient first passed flatus OR a bowel movement) and GI-2 (the later of the following two events: time patient first tolerated solid food AND time patient first passed a bowel movement) were determined. Pain, nausea, vomiting, and use of pain medications were evaluated daily for the first 3 postoperative days.

RESULTS

Ninety patients were randomized. Eighty-one received the allocated intervention: 39 in the true acupuncture group and 42 in the sham acupuncture group, all evaluated for the primary endpoint. The mean time to GI-3 was 149 h [standard deviation (SD) 71 h] and 146 (SD 62 h) after surgery for the acupuncture group and the sham acupuncture group (difference between means -2 h; 95 % confidence interval -31, 26; p = 0.9). No significant differences were found between groups for secondary endpoints.

CONCLUSIONS

True acupuncture as provided in this study did not reduce POI more significantly than sham acupuncture. The study was limited by a standard deviation much larger than expected, suggesting that a study with a larger sample size might be required.

The Use of Rectus Sheath Catheters as an Analgesic Technique for Patients Undergoing Radical Cystectomy

Introduction:

Despite improvements in peri-operative care and the recent introduction of enhanced recovery protocols, radical cystectomy continues to be associated with a greater morbidity and a more prolonged in-patient stay than other urological procedures. There is significant scope for improvement and it is now well recognised that the analgesic technique used can impact on post-operative recovery. In this paper, we report on our early experience of using bilateral rectus sheath catheters (RSC) and highlight potential benefits of the technique.

Methods:

Over a 12-month period between November 2007 and November 2008, 20 patients underwent a radical cystectomy performed by a single surgeon and anaesthetist. Ten patients had bilateral rectus sheath catheters sited under ultrasound-guidance and they were compared to a preceding group of 10 patients who had epidural catheters inserted. Data were analysed retrospectively and primary outcome measures included pain scores, ileus rates, time to bowel opening and length of stay.

Results:

The demographics of the two groups showed no significant differences. Analgesic effect was equivalent between the groups. The time to passage of flatus and bowel opening was similar between the 2 groups. There was a slightly lower ileus rate and a shorter median length of stay in the RSC group (13 vs. 15 days) though the data are non-randomised and case numbers were small. Practical benefits in the placement and post-operative care of the RSCs were also observed.

Conclusion:

The rectus sheath block is a novel analgesic technique that appears to have an equivalent analgesic effect to epidurals in this early observational case series. RSCs have other potential advantages including earlier mobilisation and reduced burden on nursing and medical staff, thus making it ideally suited to an enhanced recovery protocol. Larger studies are needed to confirm the findings of the current case series.

Impact of an enhanced recovery programme in colorectal surgery

Surgery is undergoing revolutionary change as a result of newer approaches to pain control, the introduction of techniques that reduce the post-operative stress response, and the use of minimally invasive operations, such as laparoscopic surgery. As demand for hospital beds continues to escalate, it is paramount that patients recover from surgery quickly and safely; the use of evidence-based interventions to hasten recovery within an enhanced recovery programme (ERP) can play a vital role in achieving this, as well as reducing costs by shortening hospital stay. This article outlines the principles and key elements of an ERP, and discusses how it can help to achieve an improved and safe recovery and shorter hospital stay for patients, thereby reducing the cost to the NHS of inpatient treatment and recovery. The literature surrounding the development of 'enhanced recovery' (also called 'fast-track') surgery is reviewed to determine whether it is appropriate for patients undergoing elective colorectal surgery.

Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life

BACKGROUND

Perioperative epidural analgesia provides continuous pain control and may have advantages over parenteral opiate administration. This study assessed the impact of epidural analgesia on quality of life (QOL) of patients undergoing major surgery.

METHODS

Sixty patients undergoing thoracic or thoraco-abdominal surgery were studied prospectively. Patients were randomly assigned to receive either thoracic epidural analgesia or patient-controlled i.v. opiate analgesia (PCA) after operation. Visual analogue pain and sedation scores were recorded for the period of the study. QOL health surveys at 24 h (SF-8 acute form) and at 1 week (SF-36) were recorded. Results were examined by uni- and multivariate analyses corrected for the effect of multiple comparisons.

RESULTS

Mean pain scores were significantly lower in the epidural group at most time points. Physical and mental scores in the epidural group were significantly better than the PCA group for both SF-8 and SF-36 QOL health surveys (P<0.001).

CONCLUSIONS

Epidural analgesia with local anaesthetic and opioid improves QOL and delivers better analgesia compared with PCA in patients undergoing major thoraco-abdominal surgery.

Thoracic epidural anesthesia reverses sepsis-induced hepatic hyperperfusion and reduces leukocyte adhesion in septic rats

INTRODUCTION

Liver dysfunction is a common feature of severe sepsis and is associated with a poor outcome. Both liver perfusion and hepatic inflammatory response in sepsis might be affected by sympathetic nerve activity. However, the effects of thoracic epidural anesthesia (TEA), which is associated with regional sympathetic block, on septic liver injury are unknown. Therefore, we investigated hepatic microcirculation and inflammatory response during TEA in septic rats.

METHODS

Forty-five male Sprague-Dawley-rats were instrumented with thoracic epidural catheters and randomized to receive a sham procedure (Sham), cecal ligation and puncture (CLP) without epidural anesthesia (Sepsis) and CLP with epidural infusion of 15 ul/h bupivacaine 0.5% (Sepsis + TEA). All animals received 2 ml/100 g/h NaCl 0.9%. In 24 (n = 8 in each group) rats, sinusoidal diameter, loss of sinusoidal perfusion and sinusoidal blood flow as well as temporary and permanent leukocyte adhesion to sinusoidal and venolar endothelium were recorded by intravital microscopy after 24 hours. In 21 (n = 7 in each group) separate rats, cardiac output was measured by thermodilution. Blood pressure, heart rate, serum transaminase activity, serum TNF-alpha concentration and histologic signs of tissue injury were recorded.

RESULTS

Whereas cardiac output remained constant in all groups, sinusoidal blood flow increased in the Sepsis group and was normalized in rats subjected to sepsis and TEA. Sepsis-induced sinusoidal vasoconstriction was not ameliorated by TEA. In the Sepsis + TEA group, the increase in temporary venolar leukocyte adherence was blunted. In contrast to this, sinusoidal leukocyte adherence was not ameliorated in the Sepsis + TEA group. Sepsis-related release of TNF-alpha and liver tissue injury were not affected by Sepsis + TEA.

CONCLUSIONS

This study demonstrates that TEA reverses sepsis-induced alterations in hepatic perfusion and ameliorates hepatic leukocyte recruitment in sepsis.

Effect of spinal cord stimulation in a rodent model of post-operative ileus

Post-operative ileus (POI) is a transient impairment of gastrointestinal (GI) transit that develops after abdominal surgery. The goal of this study was to investigate the effect of spinal cord stimulation (SCS) on gastric emptying and upper GI transit in a rat model of POI. All rats had an electrode placed on the dorsal surface of the spinal cord between the T(5) and T(8) segments. After recovery, gastric emptying and upper GI transit (geometric centre and head of meal) were assessed using a radiolabelled meal fed to each rat via oral gavage. In unanaesthetized rats, SCS (15, 25, 50, 100, 200 Hz, 0.2 ms at 90% motor threshold for 15 min) was performed immediately after the meal. The sham control group had no current applied. The naïve group was without POI or SCS. Gastric emptying was significantly delayed in sham-stimulated rats with POI compared with naïve controls (39.8 +/- 6.2%vs 76.5 +/- 4.9%, P < 0.001). In rats with POI that underwent SCS, there was a significant acceleration of gastric emptying to levels that resembled those of naïve controls (65.1 +/- 7.4%, P < 0.05). However, while SCS did not normalize the geometric centre and head of the meal when compared with the naïve group, it did significantly improve both parameters compared with the sham stimulation group. In summary, SCS normalizes gastric emptying and improves upper GI transit in a rodent model of POI. Further experiments are required to address the mechanism(s) by which SCS exhibits prokinetic activity.

Gum chewing reduces postoperative ileus? A systematic review and meta-analysis

BACKGROUND

An important cause of delayed recovery from intestinal surgery is postoperative ileus. Gum chewing is a form of sham feeding, which could encourage gastrointestinal motility through cephalic-vagal stimulation.

METHODS

We sought to identify all randomized controlled trials comparing gum chewing with standard care after elective intestinal surgery. We searched electronic databases (Cochrane, Embase, and PubMed), reference lists and contacted authors to obtain further data. We assessed the identified trials for quality and performed a meta-analysis and systematic review. The main outcome measures examined were time to flatus and stool postoperatively and length of hospital stay, which were analysed using random effect models. We also examined clinical complication rates.

RESULTS

We identified nine eligible trials that had enrolled a total of 437 patients. The intervention was well tolerated and complication rates were low. There was statistical evidence of heterogeneity for the three main outcomes. Pooled estimates showed a reduction in time to flatus by 14 h (95% CI: -20 to -8h, p=0.001), time to bowel movement by 23 h (95% CI: -32 to -15 h, p<0.001) and a reduction in length of hospital stay by 1.1 days (95% CI: -1.9 to -0.2 days, p=0.016).

CONCLUSIONS

Chewing sugarless gum following elective intestinal resection is associated with improved outcomes. Insufficient data were available to demonstrate a reduced rate of clinical complications or reduced cost. An adequately powered, methodologically rigorous trial of gum chewing is required to confirm if there are any benefits and if these result in differences in clinical outcomes such as infection.

Audit of motor weakness and premature catheter dislodgement after epidural analgesia in major abdominal surgery

In a quality improvement audit on epidural analgesia in 300 patients after major abdominal surgery, we identified postoperative lower leg weakness and premature catheter dislodgement as the most frequent causes of premature discontinuation of postoperative epidural infusion. Lower limb motor weakness occurred in more than half of the patients with lumbar epidural analgesia. In a second period monitoring 177 patients, lumbar catheter insertion was abandoned in favour of exclusive thoracic placement for epidural catheters. Additionally, to prevent outward movement, the catheters were inserted deeper into the epidural space (mean (SD) 5.2 (1.5) cm in Period Two vs 4.6 (1.3) cm in Period One). Lower leg motor weakness declined from 14.7% to 5.1% (odds ratio 0.35; 95% confidence interval 0.16-0.74) between the two periods. Similarly, the frequency of premature catheter dislodgement was reduced from 14.5% to 5.7% (odds ratio 0.35; 95% confidence interval 0.17-0.72). With a stepwise logistic regression model we demonstrated that the odds of premature catheter dislodgement was reduced by 43% for each centimetre of additional catheter advancement in Period Two. We conclude that careful audit of specific complications can usefully guide changes in practice that improve success of epidural analgesia regimens.

Programas de rehabilitación multimodal (fast-track) en cirugía laparoscópica colorrectal

For the last two decades, general and digestive surgeons have attempted to improve the postoperative course of surgical patients. Classical perioperative treatment can be described as a period of preoperative dehydration caused by fasting and intensive colon preparation followed by fluid overload generally due to excessively prolonged serum therapy. There is also perioperative surgical stress, the trauma of surgery itself, and a long period of drainage and nasogastric tubes. The patient is thus literally confined to bed and mobilization is, at the very least, difficult. Moreover, the use of opiates delays intestinal peristalsis and consequently oral nutrition. All together, these factors prolong the length of hospital stay and hamper recovery. All these perioperative treatment modalities have been questioned by Kehlet, resulting in a set of new, more realistic and evidence-based modalities, currently known as the fast-track program. The aim of this program is to decrease perioperative stress, reduce organ involvement produced by surgical trauma and hasten the patient's general recovery. Major advantages of this program consist not only of shorter length of hospital stay but also of a concurrent improvement in patients' quality of life and a reduction in mortality. The present review article analyzes all these modalities, with special emphasis on laparoscopic colorectal surgery. This approach is presented as one of the elements of the fast-track program.

An Analysis of Postoperative Epidural Analgesia Failure by Computed Tomography Epidurography

In this prospective study involving 125 patients, we analyzed epidural analgesia failure after major abdominal surgery using computed tomography (CT) epidurographies to compare the incidence of dislodgement of epidural catheters and leakage of solution from the epidural space between two groups of patients: patients with successful or failed epidural analgesia. Our hypothesis was that the incidence of dislodgement and leakage should be low when epidural analgesia is successful. A thoracic epidural catheter was inserted before general anesthesia and secured by subcutaneous tunneling. Bupivacaine (0.25%) was administered during surgery followed by continuous epidural analgesia with 0.125% bupivacaine (10 mL/h) and morphine (0.25 mg/h) for 48 h. Failure was defined as a visual analog scale pain score at rest more than 30 mm and/or interruption of epidural analgesia before 48 h for any reason. When failure was not due to unintentionally withdrawn, kinked catheters or adverse events (n = 11), a CT scan with contrast injection was performed. Control CT scans were also performed in patients with adequate analgesia (i.e., the success group). The incidence of failure was 24.8% (n = 31). CT scans in the failure group (n = 20) showed seven patients with catheters outside the epidural space, nine with normal distribution, one with unilateral spread, and three with leakage of solution outside the epidural space. In the success group, CT scans (n = 19) showed 11 patients with normal distribution, five with unilateral spread, and three with leakage. We conclude that the major cause of epidural analgesia failure was dislodgment of the catheter. CT scans were mostly useful for detecting leakage of injectate, which may be the early phase of dislodgment.

Randomized controlled trial comparing the controlled rehabilitation with early ambulation and diet pathway versus the controlled rehabilitation with early ambulation and diet with preemptive epidural anesthesia/analgesia after laparotomy and intestinal resection

BACKGROUND

Multimodal postoperative care regimens accelerate recovery after abdominal surgery. The benefit of thoracic epidural (TE) analgesia over patient-controlled analgesia (PCA) remains unproven when used with a fast-track postoperative care plan.

METHODS

Fifty-six patients undergoing major intestinal resection, and on a fast-track postoperative care plan, were randomized to preemptive TE or PCA. Patients were evaluated at standard time points for pain score, quality of life (Short Form-36), and complications. Oral analgesia was substituted for TE and PCA on the second postoperative day. Discharge criteria were identical for both groups.

RESULTS

Six patients (20.6%) had a failed epidural. There was no difference in length of stay (5.8 versus 6.2 days, TE versus PCA, P = .55), total length of stay (including readmissions), pain scores, quality of life, complications, or hospital costs at any time point.

CONCLUSION

TE offers no advantage over PCA for patients undergoing major intestinal resections who are on a fast-track postoperative care plan using PCA.

Epidural analgesia in gastrointestinal surgery

BACKGROUND

The ideal perioperative analgesia should provide effective pain relief, avoid the detrimental effects of the stress response, be simple to administer without the need for intensive monitoring, and have a low risk of complications.

METHODS

This review defines the physiological effects of epidural analgesia and assesses whether the available evidence supports its preferential use in gastrointestinal surgery. All papers studied were identified from a Medline search or selected by cross-referencing.

RESULTS

Epidural analgesia is associated with a shorter duration of postoperative ileus, attenuation of the stress response, fewer pulmonary complications, and improved postoperative pain control and recovery. It does not reduce anastomotic leakage, intraoperative blood loss, transfusion requirement, risk of thromboembolism or cardiac morbidity, or hospital stay compared with that after conventional analgesia in unselected patients undergoing gastrointestinal surgery. Thoracic epidural analgesia reduces hospital costs and stay in patients at high risk of cardiac or pulmonary complications.

CONCLUSIONS

Epidural analgesia enhances recovery after gastrointestinal surgery. The results support the development of structured regimens of early postoperative feeding and mobilization to exploit the potential for thoracic epidural analgesia to reduce hospital stay after gastrointestinal surgery.

Factors affecting intravenous analgesic requirements after colectomy

BACKGROUND

The purpose of this study was to determine factors that influence postoperative IV analgesic use after colectomy.

STUDY DESIGN

We retrospectively evaluated patients who underwent colectomy between January 1997 and December 2000 at our medical center and calculated the amount of postoperative IV narcotics needed in morphine equivalents. Statistical differences (p < 0.05 considered significant) were measured using the Wilcoxon rank-sum test. Correlations were performed using Spearman correlation coefficients, and linear regression analysis was also performed.

RESULTS

Four hundred eighty-one patients (235 men, 246 women) underwent colectomy; patients had a mean age of 60.6 years (range, 17 to 96 years). Procedures performed included total/subtotal colectomy (10%, n = 49), right colectomy (42%, n = 200), transverse colectomy (3%, n = 12), left/sigmoid colectomy (40%, n = 195), and low anterior resection (4%, n = 17). Laparoscopic colectomy was performed in 53 (11%) patients. Mean postoperative morphine equivalent use was 160.2 mg. Narcotic analgesic use was significantly less for women (p = 0.02), diagnosis of cancer (p = 0.02), and laparoscopic colectomy (p = 0.0001). Patients undergoing a right colectomy required less postoperative narcotics than patients having other types of colectomies (p < 0.02). There was a positive correlation between postoperative narcotic use and operative time (r = 0.14, p = 0.007) and a negative correlation with patient age (r = -0.37, p = 0.0001). Linear regression analysis demonstrated that age (p = 0.0001), female gender (p = 0.04), and laparoscopy (p = 0.001) were independent predictors for decreased narcotic use.

CONCLUSIONS

Postoperative IV narcotic analgesic use is affected by gender, patient age, indication for colectomy, operative time, type of procedure, and operative technique.

Pre- and intraoperative epidural ropivacaine have no early preemptive analgesic effect in major gynecological tumour surgery

PURPOSE

Thoracic epidural analgesia (TEA) is an established technique for postoperative pain relief after major abdominal surgery. However it is still under discussion whether pre-incisional TEA can reduce postoperative pain perception or postoperative analgesic consumption.

METHODS

The present prospective, randomized, double-blind study was performed to investigate the effects of intra- and postoperative TEA vs only postoperative TEA using ropivacaine 0.375% in 30 women scheduled for major abdominal tumour surgery. Prior to induction of general anesthesia patients received an epidural bolus of 10 mL saline in Group I (GI) and 10 mL ropivacaine 0.375% in Group II (GII) followed by an infusion of 6 mL x hr(-1) of the respective solution during surgery. Postoperatively all patients received an epidural infusion of 6 mL x hr(-1) ropivacaine 0.375% during 24 hr followed by patient controlled epidural analgesia for the next 72 hr. Operative data, dynamic pain scores, consumption of local anesthetics and standardized supplemental analgesics were analyzed.

RESULTS

No difference was seen between groups with respect to the amount of required postoperative local anesthetics and supplemental analgesics, pain scores and side effects during the first 96 hr following surgery except a reduction of intraoperative sufentanil consumption (GI: 143.2 +/- 52.6 vs GII: 73.3 +/- 32.6 microg, P < 0.001).

CONCLUSION

Intraoperative TEA with ropivacaine 0.375% did not significantly reduce the amount of analgesics required after major abdominal gynecological tumour surgery.

Postoperative ileus: etiologies and interventions

This article will review the pathophysiology of postoperative ileus, with emphasis on potential therapeutic targets, and examine the efficacy of pharmacologic and nonpharmacologic interventions. Proposed mechanisms include actuation of spinal and local sympathetic neural reflexes, inflammatory mediation, and exacerbation by anesthetic or surgical procedures. Some procedures or agents have shown clinical benefit, and these include use of laparoscopic surgery, thoracic epidurals, nonsteroidal anti-inflammatory drugs, and opiate antagonists. Other procedures may be helpful with low risk of adverse effects. These include early feeding and ambulation, laxatives, and possibly neostigmine.

Effect of post-operative analgesia on patient morbidity

The pathophysiology that commonly follows surgery results in detrimental physiological effects and may be associated with post-operative mortality and morbidity. The use of post-operative epidural analgesia, but not systemic opioids, may attenuate some of these adverse physiological effects and result in a decrease in patient-related morbidity post-operatively. Randomized trials suggest that the perioperative use of epidural analgesia may facilitate return of gastrointestinal function, attenuate hypercoagulable events and diminish post-operative pulmonary complications. A multimodal approach incorporating the use of epidural analgesia to control perioperative pathophysiology will facilitate the patient's recovery.

The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery: a prospective, randomized trial

PURPOSE

Colorectal surgery is associated with postoperative ileus, which contributes to delayed discharge. This study was designed to investigate the effect of thoracic epidural anesthesia and analgesia on gastrointestinal function after colorectal surgery under standardized controlled postoperative care.

METHODS

Forty-two patients diagnosed with either colonic cancer, diverticulitis, polyps, or adenoma, and scheduled for elective colorectal surgery, were randomly assigned to either postoperative patient-controlled analgesia (PCA) with intravenous morphine (n = 21) or epidural analgesia with a mixture of bupivacaine and fentanyl (n = 21). Postoperative early oral feeding and assistance to mobilization were offered to all patients. Pain visual analog scale (1-100 mm), passage of flatus and bowel movements, length of hospital stay, and readiness for discharge were recorded.

RESULTS

Pain visual analog scale (visual analog scale, 1-100 mm) at rest, on coughing, and daily on mobilization was significantly lower in the epidural group compared with the patient-controlled analgesia group. Median values for the visual analog scale group were 7 (95 percent confidence interval, 2-18) mm, 19 (95 percent confidence interval, 4-38) mm, and 10 (95 percent confidence interval, 5-33) mm, respectively, and, for the patient-controlled analgesia group, were 24 (95 percent confidence interval, 18-51) mm, 59 (95 percent confidence interval, 33-74) mm, and 40 (95 percent confidence interval, 29-79) mm, respectively (P < 0.01). Intake of protein and calories and time out of bed were similar in both groups. Mean time intervals +/- standard deviation from surgery to first flatus and first bowel movement occurred earlier in the epidural group, 1.9 +/- 0.6 days and 3.1 +/- 1.7 days, respectively, compared with patient-controlled analgesia, 3.6 +/- 1.5 days and 4.6 +/- 1.6 days, respectively (P < 0.01). Postoperative complications occurred in 33 percent of the patient-controlled analgesia group and 28 percent of the epidural group. There was no significant difference in length of hospital stay between the two groups with a mean of 7.3 +/- 3.7 days in the patient-controlled analgesia group and 8.5 +/- 4.2 days in the epidural group. Readiness for discharge was similar in both groups.

CONCLUSION

Thoracic epidural analgesia has distinct advantages over patient-controlled analgesia morphine in providing superior quality of analgesia and shortening the duration of postoperative ileus. However, discharge home was not faster, indicating that other perioperative factors influence the length of hospital stay.

Acute Intestinal Pseudo-obstruction

Acute pseudo-obstruction may manifest clinically in one of three forms--acute gastroparesis, ileus, and acute colonic pseudo-obstruction (Ogilvie's syndrome). Though formerly associated primarily with the postoperative state, these entities are increasingly recognized in association with a wide variety of major medical problems. There are few controlled studies to guide the clinician in the management of these disorders. Treatment remains largely empirical, and time-honored, based primarily on "bowel rest," nasogastric decompression, and supportive care. While a wide variety of pharmacologic approaches have been advocated, few have been subjected to, or survived, the rigors of a properly controlled trial. Neostigmine is a notable exception, and has been shown to be effective in Ogilvie's syndrome. Perforation is a significant threat in megacolon; colonoscopic, or surgical decompression may, therefore, be indicated. Both are associated with significant risks in this context, but may prevent progression to perforation with its attendant mortality. New approaches seek to exploit current concepts in the pathophysiology of ileus and megacolon but have not, as yet, achieved efficacy in human studies.

Improved bowel function after gynecological surgery with epidural bupivacaine-fentanyl than bupivacaine-morphine infusion

PURPOSE

To compare postoperative gastrointestinal recovery between continuous epidural bupivacaine-fentanyl and bupivacaine-morphine.

METHODS

In a blinded, randomized, prospective trial, 60 women undergoing surgery for gynecologic cancer were studied. Anesthesia was provided by a combined general/epidural (L2-3 catheter) technique without epidural opioids. Postoperative epidural analgesia was by continuous infusion of bupivacaine 0.1% with either morphine 0.05 mg x ml(-1) (BM) or fentanyl 5 microg x ml(-1) (BF). Visual Analogue Scale (VAS) scores for pain at rest and during movement, and the return of bowel function were collected for three days and the duration of hospitalization were noted.

RESULTS

On POD-1, 18.5% of patients in the BM group had emesis compared with none in the BF group (P = 0.038) and fewer patients in the BM group tolerated clear oral fluids (11.1% BM vs 40.6% BF, P = 0.025). These differences became insignificant on POD-2 and 3. Median pain scores were comparable at rest and ranged from 10-20 in the BM group vs 0-20 in the BF group over the three days. Similarly, median pain scores with movement respectively ranged from 20-25 and 20-30 in the BF and BM groups. The mean duration of hospitalization was longer in the BM group (5.7 +/- 2.4) vs BF (4.5 +/- 1.2 days), P = 0.017.

CONCLUSION

Epidural BM and BF provided equally effective postoperative analgesia at rest and during movement. Compared with BM, epidural BF is associated with less emesis and an increased ability to tolerate oral fluids on POD-1 and an overall shorter hospital stay.

Randomized controlled trial to examine the influence of thoracic epidural analgesia on postoperative ileus after laparoscopic sigmoid resection

BACKGROUND

The aim of the study was to evaluate whether perioperative epidural analgesia had any effect on the duration of postoperative ileus after laparoscopic sigmoid resection.

METHODS

Twenty patients were randomized to surgery either with (group 1; n = 10) or without (group 2; n = 10) thoracic epidural analgesia. The major endpoint of the study was the time to the first postoperative bowel movement. Secondary endpoints were the interval until oral feeding was tolerated, incidence of postoperative vomiting, postoperative analgesic consumption use of patient-controlled analgesia (PCA) until the fourth day after operation, subjective pain perception and the incidence of epidural-related side-effects.

RESULTS

Age, sex and American Society of Anesthesiologists classification were similar in the two groups. The first bowel movement was documented after a median of 54 (95 per cent confidence interval 32-127) h in group 1 and 77 (31-99) h in group 2 (P = 0.8). Oral feeding without additional parenteral therapy was tolerated after 48 (40-64) h in group 1 and after 56 (48-64) h in group 2 (P = 0.6). Postoperative vomiting occurred in two patients from each group. During epidural therapy the use of PCA was lower in group 1 (0.30 (0.19-0.96) mg morphine per kg) than in group 2 (0.56 (0.37-0. 80) mg/kg) (P < 0.05). Postoperative pain perception during rest and while coughing was similar in both groups. Three patients experienced reversible side-effects of epidural therapy (motor deficit, two patients; bladder dysfunction, one).

CONCLUSION

Perioperative thoracic epidural analgesia did not have a clinically relevant effect on the duration of postoperative ileus after laparoscopic sigmoid resection.