Advertisement

World Journal of Surgery

, Volume 42, Issue 6, pp 1787–1791 | Cite as

A Novel Technique of Paravertebral Thoracic and Preperitoneal Analgesia Enhances Early Recovery After Oesophagectomy

  • Stephanie Phillips
  • Jasmina Dedic-Hagan
  • d’Arcy Ferris Baxter
  • H. Van der Wall
  • G. L. Falk
Original Scientific Report
  • 133 Downloads

Abstract

Background

Excellent analgesia following oesophagectomy facilitates patient comfort, early extubation, physiotherapy and mobilisation, reduces post-operative complications and should enhance recovery. Thoracic epidural analgesia (TEA), the gold standard analgesic regimen for this procedure, is often associated with systemic hypotension treated with inotropes or fluid. This may compromise enhanced recovery and be complicated by anastomotic ischaemia or tissue oedema.

Methods

We report a novel analgesic regimen to reduce post-operative inotrope usage. Infusion of ropivicaine via bilateral preperitoneal and right paravertebral catheters was used. Patient-controlled epidural pethidine provided rescue analgesia (WC) (n = 21). A retrospective audit of inotrope requirement, mean pain scores, episodes of respiratory depression and excessive sedation, need for reintubation, reoperation in the first 5 post-operative days, time to mobilisation, time in intensive care, time in hospital and 30-day mortality were measured. These results were compared with those of an earlier patient group who received a thoracic epidural infusion of low-dose local anaesthetic and fentanyl (TEA) (n = 21).

Results

Inotrope use was reduced by 29% in the WC group (p = 0.03) and the mean intensive care stay reduced by 2.4 days (p = 0.03), as was reintubation rate (p = 0.01) and early mobilisation (p = 0.03). The pain score was comparable in both groups, and there was no difference in the other outcomes examined.

Conclusion

The data demonstrated that it was possible to provide excellent post-oesophagectomy analgesia equivalent to thoracic epidural infusions of local anaesthetic with reduction in inotrope requirements, intensive care stay, more rapid mobilisation, facilitating enhanced recovery.

Notes

Compliance with ethical standards

Conflict of interest

There were no conflicts of interest.

Ethical approval

All ethical requirements were met.

References

  1. 1.
    Hongo M, Nagasaki Y, Shoji T (2009) Epidemiology of esophageal cancer: orient to occident. Effects of chronology, geography and ethnicity. J Gastroenterol Hepatol 24(5):729–735CrossRefPubMedGoogle Scholar
  2. 2.
    Chandrashekar MV, Irving M, Wayman J et al (2003) Immediate extubation and epidural analgesia allow safe management in a high-dependency unit after two-stage oesophagectomy. Results of eight years of experience in a specialized upper gastrointestinal unit in a district general hospital. Br J Anaesth 90(4):474–479CrossRefPubMedGoogle Scholar
  3. 3.
    Chang AC, Ji H, Birkmeyer NJ, Orringer MB et al (2008) Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg 85(2):424–429CrossRefPubMedGoogle Scholar
  4. 4.
    Ng J-M (2011) Update on anesthetic management for esophagectomy. Curr Opin Anaesthesiol 24(1):37–43CrossRefPubMedGoogle Scholar
  5. 5.
    Jaeger JM, Collins SR, Blank RS (2012) Anesthetic management for esophageal resection. Anesthesiol Clin 30(4):731–747CrossRefPubMedGoogle Scholar
  6. 6.
    Preston SR, Markar SR, Baker CR et al (2013) Impact of a multidisciplinary standardized clinical pathway on perioperative outcomes in patients with oesophageal cancer. Br J Surg 100(1):105–112CrossRefPubMedGoogle Scholar
  7. 7.
    Ali M, Winter DC, Hanly AM et al (2010) Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life. Br J Anaesth 104(3):292–297CrossRefPubMedGoogle Scholar
  8. 8.
    Rigg JRA, Jamrozik K, Myles PS et al (2002) Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 359(9314):1276–1282CrossRefPubMedGoogle Scholar
  9. 9.
    Flisberg P, Törnebrandt K, Walther B et al (2001) Pain relief after esophagectomy: thoracic epidural analgesia is better than parenteral opioids. J Cardiothorac Vasc Anesth 15(3):282–287CrossRefPubMedGoogle Scholar
  10. 10.
    Wenk M, Schug SA (2011) Perioperative pain management after thoracotomy. Curr Opin Anaesthesiol. 24(1):8–12CrossRefPubMedGoogle Scholar
  11. 11.
    Al-Rawi OY, Pennefather SH, Page RD et al (2008) The effect of thoracic epidural bupivacaine and an intravenous adrenaline infusion on gastric tube blood flow during esophagectomy. Anesth Analg 106(3):884–887CrossRefPubMedGoogle Scholar
  12. 12.
    Freise H, Van Aken HK (2011) Risks and benefits of thoracic epidural anaesthesia. Br J Anaesth 107(6):859–868CrossRefPubMedGoogle Scholar
  13. 13.
    Joshi GP, Bonnet F, Shah R et al (2008) A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 107(3):1026–1040CrossRefPubMedGoogle Scholar
  14. 14.
    Dango S, Harris S, Offner K et al (2013) Combined paravertebral and intrathecal vs thoracic epidural analgesia for post-thoracotomy pain relief. Br J Anaesth 110(3):443–449CrossRefPubMedGoogle Scholar
  15. 15.
    Wheatley GH, Rosenbaum DH, Paul MC et al (2005) Improved pain management outcomes with continuous infusion of a local anesthetic after thoracotomy. J Thorac Cardiovasc Surg 130(2):464–468CrossRefPubMedGoogle Scholar
  16. 16.
    Davies RG, Myles PS, Graham JM (2006) A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth 96(4):418–426CrossRefPubMedGoogle Scholar
  17. 17.
    Beaussier M, El’Ayoubi H, Schiffer E et al (2007) Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery: a randomized, double-blind, placebo-controlled study. Anesthesiology 107(3):461–468CrossRefPubMedGoogle Scholar
  18. 18.
    Bertoglio S, Fabiani F, De Negri P et al (2012) The postoperative analgesic efficacy of preperitoneal continuous wound infusion compared to epidural continuous infusion with local anesthetics after colorectal cancer surgery: a randomized controlled multicenter study. Anesth Analg 115(6):1442–1450CrossRefPubMedGoogle Scholar
  19. 19.
    Liu SS, Richman JM, Thirlby RC et al (2006) Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized controlled trials. J Am Coll Surg 203(6):914–932CrossRefPubMedGoogle Scholar
  20. 20.
    Levene H (1960) Robust test for equality of variance. In: Okin H (ed) Contributions to probability and statistics: essays in honor of harold hotelling. Stanford University Press, Palo Alto, pp 278–292Google Scholar
  21. 21.
    Mann V, Mann S, Hecker A et al (2011) Continuous local wound infusion with local anesthetics. Der Chir 82(10):906–912CrossRefGoogle Scholar
  22. 22.
    Leslie K, Myles P, Devereaux P et al (2013) Neuraxial block, death and serious cardiovascular morbidity in the POISE trial. Br J Anaesth 111(3):382–390CrossRefPubMedGoogle Scholar
  23. 23.
    Low DE, Kunz S, Schembre D et al (2007) Esophagectomy-it’s not just about mortality anymore: Standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer. J Gastrointest Surg 11(11):1395–1402CrossRefPubMedGoogle Scholar
  24. 24.
    Tomaszek SC, Cassivi SD, Allen MS et al (2010) An alternative postoperative pathway reduces length of hospitalisation following oesophagectomy. Eur J Cardio Thorac Surg 37(4):807–813CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2017

Authors and Affiliations

  1. 1.Sydney Adventist HospitalWahroonga, SydneyAustralia
  2. 2.University of SydneySydneyAustralia
  3. 3.Sydney Medical SchoolUniversity of SydneySydneyAustralia
  4. 4.Concord Nuclear ImagingSydneyAustralia
  5. 5.Macquarie UniversitySydneyAustralia
  6. 6.LindfieldAustralia

Personalised recommendations