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Epidural analgesia in the era of enhanced recovery: time to rethink its use?

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Abstract

Background

Previous assessments of the impact of epidural analgesia (EA) on outcomes after colorectal surgery were related to the period before widespread implementation of the enhanced recovery after surgery (ERAS) protocols. This study evaluates the impact of EA on postoperative recovery after colectomy using recent multicenter data.

Methods

Patients who underwent elective colectomy from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) data (2014–2015) were identified. Demographics, comorbidities, diagnosis, procedure type and approach, and postoperative complications associated with EA were assessed. Impact of EA on postoperative ileus, length of stay (LOS), and prolonged LOS (defined as LOS > 75 percentile) was evaluated for all, open, and laparoscopic cases using univariable and multivariable analyses.

Results

Of 9045 elective colectomy procedures, 3081 (34.1%) received EA. Epidural analgesia was associated with greater rates of postoperative ileus (15.9% vs. 10.8%, p < 0.0001), superficial (5.5% vs. 4%, p = 0.001) and deep (1.8% vs. 0.6%, p < 0.0001) wound infections, pulmonary embolism (0.8% vs. 0.4%, p = 0.004), deep vein thrombosis (1.3% vs. 0.7%, p = 0.01), sepsis/septic shock (4.6% vs. 3.1%, p < 0.0001), unplanned reintubation (1.5% vs. 0.8%, p = 0.003), cardiac complications (1.2% vs. 0.7%, p = 0.03), and transfusion (9.1% vs. 5.9%, p < 0.0001). Postoperative length of stay (LOS) [mean (SD), days: 6.7(6.2) vs. 5(4.5) days, p < 0.0001] was greater for EA. On multivariable analysis, EA had no impact on postoperative ileus for all and laparoscopic cases. However, EA increased the likelihood for ileus (OR 1.34, 95% CI 1.02–1.78) after open colectomy alone. Similarly, EA did not influence prolonged LOS for all and laparoscopic cases but was independently associated with prolonged LOS after open colectomy (OR 1.4, 95% CI 1.1–1.8).

Conclusion

Epidural analgesia was not associated with improved recovery after elective colectomy in the era of ERAS.

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Authors and Affiliations

  1. Division of Colorectal Surgery, NewYork-Presbyterian Hospital, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA

    Ahmed M. Al-Mazrou, James M. Kiely & Ravi P. Kiran

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  1. Ahmed M. Al-Mazrou
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  2. James M. Kiely
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  3. Ravi P. Kiran
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Correspondence to Ahmed M. Al-Mazrou or Ravi P. Kiran.

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Disclosures

Ahmed M. Al-Mazrou, James M. Kiely, and Ravi P. Kiran declare no conflict of interest.

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Al-Mazrou, A.M., Kiely, J.M. & Kiran, R.P. Epidural analgesia in the era of enhanced recovery: time to rethink its use?. Surg Endosc 33, 2197–2205 (2019). https://doi.org/10.1007/s00464-018-6505-5

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  • DOI: https://doi.org/10.1007/s00464-018-6505-5

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