Surgical Endoscopy

, Volume 27, Issue 7, pp 2581–2591 | Cite as

Effect of epidural analgesia on bowel function in laparoscopic colorectal surgery: a systematic review and meta-analysis

  • Suhail A. Khan
  • Haseeb A. Khokhar
  • A. R. H. Nasr
  • Eleanor Carton
  • Sherif El-Masry
Article

Abstract

Purpose

Use of thoracic epidural analgesia (TEA) with local anesthetic and adjuncts, such as opioids, are cornerstones of ERAS (Enhanced Recovery After Surgery) and are considered to play a key role in recovery after colorectal surgery. However, its effect on bowel function may lead to prolong hospital stay and is still a matter of debate. The purpose of this systemic review was to assess whether epidural analgesia could have a detrimental effect on bowel function in laparoscopic colorectal surgery with a subsequent effect on hospital stay duration, leading to failure of ERAS in colorectal surgery.

Methods

A systematic review of randomized, controlled trials for the effect of epidural analgesia on laparoscopic colorectal surgery was performed. The effect on postoperative recovery was evaluated in terms of return of bowel function as the primary outcome, whereas length of stay (LOS), pain score on visual analogue scale, operative time, and incidence of postoperative complications and side-effects of analgesia were recorded as secondary outcomes.

Results

Six trials published between 1999 and 2011 were included in the final analysis. TEA significantly improves return of bowel function assessed by time to first bowel motion [WMD −0.62 (−1.11, −0.12) with Z = 2.43; P = 0.02, 95 % confidence interval (CI)], and pain scores [WMD −1.23 (−2.4, −0.07)] with Z = 2.07; P = 0.04, 95 % CI]. TEA did not influence duration of hospital stay [WMD −0.47 (−1.55, 0.61)] with Z = 0.85 (P = 0.39, 95 % CI). No significant increase in operative time or side effects was associated with TEA.

Conclusions

Despite of some beneficial effect of epidural analgesia on return of bowel function and pain in laparoscopic surgery, it does not affect LOS, which is multifactorial.

Keywords

Abdominal Anaesthesia Bowel Colorectal < cancer GI < cancer Clinical papers/trials/research 

References

  1. 1.
    Basse L, Hjort Jakobsen D, Billesbolle P, Werner M, Kehlet H (2000) A clinical pathway to accelerate recovery after colonic resection. Ann Surg 232(1):51–57PubMedCrossRefGoogle Scholar
  2. 2.
    Basse L, Raskov HH, Hjort Jakobsen D et al (2002) Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg 89(4):446–453PubMedCrossRefGoogle Scholar
  3. 3.
    Wind J, Polle SW, Fung Kon Jin PH et al (2006) Laparoscopy and/or Fast Track Multimodal Management Versus Standard Care (LAFA) Study Group; Enhanced Recovery after Surgery (ERAS) Group. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93(7):800–809PubMedCrossRefGoogle Scholar
  4. 4.
    Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA (2007) A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 245(6):867–872PubMedCrossRefGoogle Scholar
  5. 5.
    Holte K, Kehlet H (2000) Postoperative ileus—a preventable event? Br J Surg 87:1480–1493CrossRefGoogle Scholar
  6. 6.
    Liu S, Carpenter RL, Neal JM (1995) Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 82:1474–1506PubMedCrossRefGoogle Scholar
  7. 7.
    Kehlet H (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78:606–617PubMedCrossRefGoogle Scholar
  8. 8.
    Jørgensen H, Wetterslev J, Møiniche S, Dahl JB (2000) Epidural local anaesthetics vs opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev (4):CD001893Google Scholar
  9. 9.
    Marret E, Remy C, Bonnet F, Postoperative Pain Forum Group (2007) Meta-analysis of epidural analgesia vs parenteral opioid analgesia after colorectal surgery. Br J Surg 94(6):665–673PubMedCrossRefGoogle Scholar
  10. 10.
    Levy BF, Tilney HS, Dowsen HMP, Rockall TA (2010) A systematic review of postoperative analgesia following laparoscopic colorectal surgery. Colorectal Dis 12(1):5–15CrossRefGoogle Scholar
  11. 11.
    Neudecker J, Schwenk W, Junghans T, Pietsch S, Bohm B, Muller JM (1999) Randomized controlled trial to examine the influence of thoracic epidural analgesia on postoperative ileus after laparoscopic sigmoid resection. Br J Surg 86:1292–1295PubMedCrossRefGoogle Scholar
  12. 12.
    Taqi A, Hong X, Mistraletti G, Stein B, Charlebois P, Carli F (2007) Thoracic epidural analgesia facilitates the restoration of bowel function and dietary intake in patients undergoing laparoscopic colon resection using a traditional, nonaccelerated, perioperative care program. Surg Endosc 21:247–252PubMedCrossRefGoogle Scholar
  13. 13.
    Zingg U, Miskovic D, Hamel CT, Erni L, Oertli D, Metzger U (2008) Influence of thoracic epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal resection: benefit with epidural analgesia. Surg Endosc 23:276–282PubMedCrossRefGoogle Scholar
  14. 14.
    Cooperman AM, Katz V, Zimmon D, Botero G (1991) Laparoscopic colon resection: a case report. J Laparoendosc Surg 1:221–224PubMedCrossRefGoogle Scholar
  15. 15.
    Fowler DL, White SA (1991) Laparoscopy-assisted sigmoid resection. Surg Laparosc Endosc 1:183–188PubMedCrossRefGoogle Scholar
  16. 16.
    Jacobs M, Verdeja JC, Goldstein HS (1991) Minimally invasive colon resection (laparoscopic resection). Surg Laparosc Endosc 1:144–150PubMedGoogle Scholar
  17. 17.
    Higgins JPT, Green S (2009) Cochrane handbook for systematic reviews of interventions Version 5.0.1 (updated September 2009). The Cochrane CollaborationGoogle Scholar
  18. 18.
    Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12PubMedCrossRefGoogle Scholar
  19. 19.
    Dennis RJ, Mills P (2008) Thoracic epidural versus morphine patient controlled analgesia after laparoscopic colectomy. World J Laparosc Surg 1(3):49–52CrossRefGoogle Scholar
  20. 20.
    Ali M, Winter DC, Hanly AM, O’Hagan C, Keaveny J, Broe P (2010) Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life. Br J Anaesth 104(3):292–297PubMedCrossRefGoogle Scholar
  21. 21.
    Warschkow R, Steffen T, Lüthi A, Filipovic M, Beutner U, Schmied BM, Müller SA, Tarantino I (2011) Epidural analgesia in open resection of colorectal cancer: is there a clinical benefit? A retrospective study on 1,470 patients. J Gastrointest Surg 15(8):1386–1393PubMedCrossRefGoogle Scholar
  22. 22.
    Gendall KA, Kennedy RR, Watson AJ, Frizelle FA (2007) The effect of epidural analgesia on postoperative outcome after colorectal surgery. Colorectal Dis 9(7):584–598PubMedCrossRefGoogle Scholar
  23. 23.
    Lassen K et al (2009) Consensus review of optimal perioperative care in colorectal surgery. Arch Surg 144(10):961–969PubMedCrossRefGoogle Scholar
  24. 24.
    Turunen P, Holmstrom M, Kairaluoma P, Wikstrom H, Kruuna O, Pere P, Bachmann M, Sarna S, Schenin T (2009) Epidural analgesia diminished pain but did not otherwise improve enhanced recovery after laparoscopic sigmoidectomy: a prospective randomized study. Surg Endosc 23:31–37PubMedCrossRefGoogle Scholar
  25. 25.
    Wongyingsinn M, Baldini G, Charlebois P, Liberman S, Stein B, Carli F (2011) A randomized controlled trial in patients undergoing laparoscopic colorectal surgery using an enhanced recovery program. Reg Anesth Pain Med 36(3):241–248PubMedCrossRefGoogle Scholar
  26. 26.
    Levy BF, Tilney HS, Dowsen HMP, Rockall TA (2011) Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. Br J Surg 98:1068–1078PubMedCrossRefGoogle Scholar
  27. 27.
    Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL (2003) Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA 290:2455–2463PubMedCrossRefGoogle Scholar
  28. 28.
    Liu SS, Carpenter RL, Mackey DC et al (1995) Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 83:757–765PubMedCrossRefGoogle Scholar
  29. 29.
    Seeling W, Bruckmooser KP, Hufner C et al (1990) No reduction in postoperative complications by use of catheterized epidural analgesia following major abdominal surgery. Anaesthesist 39:33–40PubMedGoogle Scholar
  30. 30.
    Jayr C, Thomas H, Rey A et al (1993) Postoperative pulmonary complications: epidural analgesia using bupivacaine and opioids versus parenteral opioids. Anesthesiology 78:666–676PubMedCrossRefGoogle Scholar
  31. 31.
    Ahn H, Bronge A, Johansson K et al (1988) Effect of continuous postoperative epidural analgesia on intestinal motility. Br J Surg 75:1176–1178PubMedCrossRefGoogle Scholar
  32. 32.
    Scheinin B, Asantila R, Orko R (1987) The effect of bupivacaine and morphine on pain and bowel function after colonic surgery. Acta Anaesthesiol Scand 31:161–164PubMedCrossRefGoogle Scholar
  33. 33.
    Wattwil M, Thoren T, Hennerdal S, Garvill JE (1989) Epidural analgesia with bupivacaine reduces postoperative paralytic ileus after hysterectomy. Anesth Analg 68:353–358PubMedCrossRefGoogle Scholar
  34. 34.
    Bredtmann RD, Herden HN, Teichmann W et al (1990) Epidural analgesia in colonic surgery: results of a randomized prospective study. Br J Surg 77:638–642PubMedCrossRefGoogle Scholar
  35. 35.
    Ballantyne JC, Kupelnick B, McPeek B, Lau J (2005) Does the evidence support the use of spinal and epidural anesthesia for surgery? J Clin Anesth 17:382–391PubMedCrossRefGoogle Scholar
  36. 36.
    Zutshi M, Delaney CP, Senagore AJ et al (2005) 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. Am J Surg 189:268–272PubMedCrossRefGoogle Scholar
  37. 37.
    Smith G, Power I, Cousins MJ (1999) Acute pain—is there scientific evidence on which to base treatment? Br J Anaesth 82:817–819PubMedCrossRefGoogle Scholar
  38. 38.
    Kehlet H, Wilmore DW (2008) Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 248:189–198PubMedCrossRefGoogle Scholar
  39. 39.
    Kuo CP, Jao SW, Chen KM et al (2006) Comparison of the effects of thoracic epidural analgesia and i.v. infusion with lidocaine on cytokine response, postoperative pain and bowel function in patients undergoing colonic surgery. Br J Anaesth 97:640–646PubMedCrossRefGoogle Scholar
  40. 40.
    Nygren J, Hausel J, Kehlet H et al (2005) A comparison in five European Centres of case mix, clinical management and outcomes following either conventional or fast-track perioperative care in colorectal surgery. Clin Nutr 24(3):455–461PubMedCrossRefGoogle Scholar
  41. 41.
    Fearon KC, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24(3):466–477PubMedCrossRefGoogle Scholar
  42. 42.
    Holte K, Kehlet H (2002) Epidural anaesthesia and analgesia: effects on surgical stress responses and implications for postoperative nutrition. Clin Nutr 21:199–206PubMedCrossRefGoogle Scholar
  43. 43.
    Liu SS, Allen HW, Olsson GL (1998) Patient-controlled epidural analgesia with bupivacaine and fentanyl on hospital wards: prospective experience with 1030 surgical patients. Anesthesiology 88:688–695PubMedCrossRefGoogle Scholar
  44. 44.
    Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P (2002) Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 97:540–549PubMedCrossRefGoogle Scholar
  45. 45.
    Holte K, Kehlet H (2001) Epidural anesthesia and risk of anastomotic leakage. Reg Anesth Pain Med 26:111–117PubMedGoogle Scholar
  46. 46.
    Miedema BW, Johnson JO (2003) Methods for decreasing postoperative gut dysmotility. Lancet Oncol 4(6):365–372PubMedCrossRefGoogle Scholar
  47. 47.
    Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I (2005) Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 103(1):25–32PubMedCrossRefGoogle Scholar
  48. 48.
    Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP (2002) Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet 359(9320):1812–1818PubMedCrossRefGoogle Scholar
  49. 49.
    Abraham-Nordling M, Hjern F, Pollack J, Prytz M, Borg T, Kressner U (2012) Randomized clinical trial of fluid restriction in colorectal surgery. Br J Surg 99:186–191PubMedCrossRefGoogle Scholar
  50. 50.
    Hansen CT, Sorensen M, Moller C, Ottesen B, Kehlet H (2007) Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double-blind, placebo-controlled randomized study. Am J Obstet Gynecol 196(4):311.e1–311.e7CrossRefGoogle Scholar
  51. 51.
    Basse L, Madsen JL, Kehlet H (2001) Normal gastrointestinal transit after colonic resection using epidural analgesia, enforced oral nutrition and laxative. Br J Surg 88(11):1498–1500PubMedCrossRefGoogle Scholar
  52. 52.
    Tjandra JJ, Chan MK (2006) Systematic review on the short-term outcome of laparoscopic resection for colon and rectosigmoid cancer. Colorectal Dis 8(5):375–388PubMedCrossRefGoogle Scholar
  53. 53.
    Delaney CP, Wolff BG, Viscusi ER et al (2007) Alvimopan, for postoperative ileus following bowel resection: a pooled analysis of phase III studies. Ann Surg 245(3):355–363PubMedCrossRefGoogle Scholar
  54. 54.
    Lewis SJ, Andersen HK, Thomas S (2009) Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. J Gastrointest Surg 13:569–575PubMedCrossRefGoogle Scholar
  55. 55.
    Purkayastha S, Tilney HS, Darzy AW, Tekkis PP (2008) Meta-analysis of studies evaluating chewing gum to enhance postoperative recovery following colectomy. Arch Surg 143:788–793PubMedCrossRefGoogle Scholar
  56. 56.
    Kong SK, Onsiong SM, Chiu WK, Li MK (2002) Use of intrathecal morphine for postoperative pain relief after elective laparoscopic colorectal surgery. Anaesthesia 57:1168–1173PubMedCrossRefGoogle Scholar
  57. 57.
    Schlachta CM, Burpee SE, Fernandez C, Chan B, Mamazza J, Poulin EC (2007) Optimizing recovery after laparoscopic colon surgery (ORAL-CS): effect of intravenous Ketorolac on length of hospital stay. Surg Endosc 21:2212–2219PubMedCrossRefGoogle Scholar
  58. 58.
    Kaba A, Laurent SR, Detroz BJ, Sessler DI, Durieux ME, Lamy ML, Joris JL (2007) Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy. Anesthesiology 106:11–18PubMedCrossRefGoogle Scholar
  59. 59.
    Virlos I, Clements D, Beynon J, Ratnalikar V, Khot U (2010) Short-term outcomes with intrathecal versus epidural analgesia in laparoscopic colorectal surgery. Br J Surg 97:1401–1406PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Suhail A. Khan
    • 1
  • Haseeb A. Khokhar
    • 1
  • A. R. H. Nasr
    • 1
  • Eleanor Carton
    • 1
  • Sherif El-Masry
    • 1
  1. 1.Colorectal Unit Surgical DepartmentOur Lady of Lourdes Hospital Drogheda Co.LouthIreland

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