Elsevier

Gynecologic Oncology

Volume 115, Issue 3, December 2009, Pages 357-361
Gynecologic Oncology

Perioperative outcomes comparing patient controlled epidural versus intravenous analgesia in gynecologic oncology surgery

https://doi.org/10.1016/j.ygyno.2009.08.015Get rights and content

Abstract

Objectives

Our aim was to compare perioperative patient controlled epidural analgesia (PCEA) versus patient controlled intravenous analgesia (PCA) after gynecologic oncology laparotomy.

Methods

This was a prospective cohort study where perioperative pain management was decided through patient-centered discussion by anesthesia and surgical teams. The study was designed to accrue 224 patients, to test for equivalence in pain control on postoperative day 1, defined as less than a 10% difference in the proportion of patients with a visual analog scale pain score of < 2 (0–10 scale).

Results

Two hundred forty patients were enrolled, with 205 patients evaluable for outcomes: 98 received PCA, while 107 received a thoracic level PCEA. Utilization of PCEA was associated with longer anesthesia time pre-op (means: 60 vs. 44 min, p < 0.0001), as well as more likely use of pressors during surgery (78% vs. 57%, p = 0.002). Pain control was comparable between groups on postoperative day 1 (mean VAS: 2.4 vs. 2.5, p = 0.56), but patients with PCEA tended to require more supplemental pain medications. Time to first ambulation was longer in the PCEA patients (means: 49 vs. 36 h post-op, p = 0.03), with no difference in time to tolerating regular diet (means: 89 vs. 77 h post-op, 0.17) and no difference in readiness for discharge (means: 144 vs. 145 h post-op, p = 0.95).

Conclusions

In this nonrandomized prospective study, selection of a PCEA for perioperative pain management did not improve pain management for patients undergoing gynecologic oncology surgery.

Introduction

Epidural analgesia is an effective therapy for the management of pain after major abdominal surgery. Opiates administered by the epidural route improve the potency of analgesia while minimizing opiate-related side effects. Meta-analyses of randomized trials of epidural analgesia after laparotomy have shown that epidurals improve postoperative analgesia [1], [2]. Reduced doses of epidural opiates allow for sooner return of and potentially quicker hospital discharge, but are associated with increased pain [3]. Adding a local anesthetic allows for the reduction of both medications, but also increases the incidence of motor and sympathetic block. Thoracic level neuraxial blockade has also been associated with decreased intraoperative blood loss, fewer thromboembolic events, improved pulmonary toilet, and overall reduction of morbidity [4]. In contrast, a recent Cochrane review combining thoracic and lumbar epidurals concludes that there is insufficient evidence to draw comparisons about other outcomes besides pain relief [5].

Gynecologic cancer surgery encompasses a wide variety of surgical procedures including radical pelvic dissection, upper abdominal exploration, tumor cytoreduction, and bowel resection, which are associated with potential complications of blood loss, thromboembolic events, and delayed return of bowel function. Epidural analgesia may be considered a standard approach to postoperative pain management, but this approach requires a greater level of expertise from both anesthesia and nursing staff. Because gynecologic cancer surgery can extensively involve both the abdomen and pelvis, there may be a greater risk for complications such as bleeding, hypotension, thromboembolic events, and postoperative ileus. While some have suggested improved return of bowel function and time to discharge for gynecologic oncology patients, these findings have not been confirmed in those patients undergoing radical debulking surgery, who are at highest risk for postoperative ileus [6], [7]. The optimal drug combination for epidural infusion also has not yet been defined.

Our goal for this study was to prospectively study a cohort of gynecologic oncology patients receiving perioperative epidural analgesia. A concurrently accrued group of patients receiving standard patient controlled analgesia is used for comparison.

Section snippets

Materials and methods

This was a prospective cohort study approved by the Committee on Human Research and conducted by the Gynecologic Oncology Division at the University of California, San Francisco. All gynecologic oncology patients undergoing laparotomy were considered eligible. Written informed consent was obtained at the time of the preoperative appointment. Women chronically taking opiate pain medications in the month prior to surgery were excluded. The decision for postoperative patient controlled epidural

Results

Two hundred and forty patients were enrolled into the study between March 2005 and April 2008. Seven patients were excluded for having a non-abdominal surgery or chronic opiate use, nine patients were excluded for having a lumbar epidural placed, 18 charts were missing or unavailable for complete review, and one patient withdrew from the study. In total, 205 patients were evaluable for outcomes—107 receiving PCEA and 98 receiving PCA. The PCEA arm reached accrual 2 months before the PCA arm.

Discussion

Our study suggests that the selection of a PCEA for perioperative pain management provides good pain control but does not improve pain management for women undergoing gynecologic oncology surgery. Patients with cancer, and particularly those with ovarian cancer, were more likely to be offered a PCEA. Intraoperative anesthesia technique varied based on attending anesthesiologists' preferences. In all cases, there was a goal of optimal pain management in the recovery room before transfer of the

Conflict of interest statement

The authors declare that there are no conflicts of interest.

Acknowledgment

The authors would like to acknowledge Kelly Crowe, M.A., for her assistance in data collection for this study.

References (18)

There are more references available in the full text version of this article.

Cited by (45)

  • Continuous epidural infusion in gynecologic oncology patients undergoing exploratory laparotomy: The new standard for decreased postoperative pain and opioid use

    2019, Gynecologic Oncology
    Citation Excerpt :

    Perioperative epidural anesthesia has become an important aspect of enhanced recovery after surgery (ERAS) protocols based on studies in surgical literature demonstrating a significant decrease in postoperative pain in patients who received a perioperative epidural compared to those who relied on patient-controlled analgesia with intravenous opioids alone [10–14]. Although the data on epidural use and postoperative pain control in the gynecologic oncology population was initially mixed [15–17], it has more recently been shown to be an important intervention that can decrease postoperative opioid use in this population [18,19]. Because of this, perioperative epidural anesthesia has been proposed as a tool to address the opioid epidemic in gynecologic oncology patients [18,20,21].

View all citing articles on Scopus
View full text