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Thoracic epidural analgesia as part of an enhanced recovery program in gynecologic oncology: a prospective cohort study
  1. Anastasios Pandraklakis1,
  2. Dimitrios Haidopoulos1,
  3. Theodoros Lappas2,
  4. Emmanouil Stamatakis2,
  5. Dimitrios Valsamidis2,
  6. Maria D Oikonomou3,
  7. Dimitrios Loutradis1,
  8. Alexandros Rodolakis1,
  9. Steven P Bisch4,
  10. Gregg Nelson4 and
  11. Nikolaos Thomakos1
  1. 1 Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, "Alexandra" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
  2. 2 Department of Anesthesiology and Pain Management, "Alexandra" General Hospital, Athens, Greece
  3. 3 The Fertility Centre, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
  4. 4 Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr Anastasios Pandraklakis, Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece; tasospandraklakis{at}


Objective To evaluate the safety and the effectiveness of thoracic epidural analgesia as part of the enhanced recovery after surgery (ERAS) multimodal analgesic protocol in patients with gynecologic oncology who have undergone laparotomy for suspected or confirmed malignancy.

Methods We conducted a prospective cohort study, following an enhanced recovery after surgery pathway, among patients who had undergone laparotomy for confirmed or suspected gynecological malignancy between January 2020 and September 2021. All patients who underwent laparotomy at the gynecologic oncology department for the aforementioned reason during that time were considered eligible. Patients (n=217) were divided into two groups: epidural (n=118) and non-epidural (n=99) group. Both groups were treated with the standard ERAS departmental analgesic protocol. The primary outcomes were length of hospital stay, complications, and readmission rates.

Results Data from 217 patients (epidural group, n=118 vs non-epidural group, n=99) with median age of 61 years (IQR 53–68) were analyzed. The most common type of cancer was of ovarian origin (85/217, 39.2%, p=0.055) and median (Aletti) surgical complexity score was 3 (p=0.42). No differences were observed in the patients’ demographics, clinical, and surgical characteristics. Primarily, median length of stay was 4 days in both groups with statistically significant lower IQR in the epidural group (3–5 vs 4–5, p=0.021). Complication rates were more common in the non-epidural group (38/99, 38.3% vs 36/118, 30.5%, p<0.001) with similar rates of grade III (p=0.51) and IV (0%) complications and readmission rates (p=0.51) between the two groups. Secondarily, the epidural group showed lower pain scores (p<0.001) on the day of surgery and in the first post-operative day (p<0.001), higher mobilization rates on the day of surgery (94.1% vs 57.6%, p<0.001), faster removal of urinary catheter (p<0.001), shorter time to flatus (p<0.001), and less nausea on the day of surgery (p<0.001).

Conclusion In this study we showed that thoracic epidural analgesia, when used as part of an ERAS protocol, is safe and offers more favorable pain relief along with a number of additional benefits, improving the peri-operative experience of patients with gynecologic cancer.

  • Anesthesia, General
  • Postoperative Period
  • Preoperative Period
  • Postoperative complications
  • Operative Time

Data availability statement

Data are available upon reasonable request.

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  • Twitter @StevenBischMD, @GreggNelsonERAS

  • Contributors All authors meaningfully contributed to the study. AP: conceptualization; data acquisition; statistical analysis; writing; review and editing. DH: data acquisition; visualization, project administration. TL, ES, DV: data acquisition; visualization; review and editing. MDO, SPB, GN: visualization; review and editing. DL, AR: supervision. NT: supervision; project administration, review, editing, and is responsible for the overall content as the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests SPB has reported research funding from Pharmacosmos, Pfizer and personal fees from Merck, Johnson & Johnson, Ethicon; all outside the submitted work. GN has reported personal fees from AstraZeneca, outside the submitted work. He is the treasurer of the ERAS Society and co-chair of Enhanced Recovery Canada. AP, DH, TL, ES, DV, MDO, DL, AR, NT have reported no conflicts of interest.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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