Perioperative outcomes comparing patient controlled epidural versus intravenous analgesia in 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.
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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.
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