Epidural Analgesia and Risk of Anastomotic Leakage
Department of Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark. Regional Anesthesia and Pain Medicine
(Impact Factor: 3.09).
03/2001; 26(2):111-7. DOI: 10.1053/rapm.2001.21241
Based on case reports of early anastomotic leakage in patients receiving epidural analgesia with local anesthetic and data to document a stimulatory effect of epidural block on gastrointestinal motility, it has been suggested that continuous infusion of epidural local anesthetic may lead to an increased incidence of anastomotic leakage. Therefore, we examined the association between continuous epidural local anesthetic and anastomotic leakage by reviewing the literature.
Review of controlled, randomized clinical trials aiming to investigate postoperative complications in which continuous postoperative epidural local anesthetic was administered in patients scheduled for colorectal surgery with an anastomosis. Data were obtained from a Medline search (1966-May 2000), previous review articles, references cited in original papers, and personal communication with investigators. Twelve trials including a total of 562 patients met the inclusion criteria.
Sixteen of 266 patients (6.0%, 95% confidence interval [CI]: 3.5% to 9.6%) receiving postoperative epidural local anesthetic or epidural local anesthetic-opioid mixtures developed anastomotic leakage, compared with 10 of 296 patients (3.4%, 95% CI: 1.6% to 6.1%) receiving epidural or systemic opioid-based analgesia (P >.05 between groups, Fisher's test). The risk of overlooking a significant difference (type II error) was approximately 67% (power: 33%). Studies including more than 1,037 patients in each group are needed to demonstrate an increased risk of anastomotic leakage from 3.4% to 6.0% with 80% power and 2alpha = 0.05. There was no significant difference (P >.05 between groups, Fisher's test) between subgroups of study design: Epidural local anesthetic-versus systemic or epidural opioid, or epidural local anesthetic-opioid mixtures versus systemic or epidural opioid.
So far, there is no statistically significant evidence from randomized trials to indicate epidural analgesia with local anesthetic to be associated with an increased risk of anastomotic breakdown. However, relatively few patients have been included in randomized trials, indicating a need for more studies to secure valid conclusions.
Available from: PubMed Central
- "Postoperative ileus is a major gastrointestinal complication of abdominal surgery, leading to increased rates of morbidity and mortality, longer lengths of hospital stay, and higher costs.20 Gastrointestinal hypomotility, caused by surgical reflex via inflammatory cascades, leads to postoperative ileus. TEA could increase gastrointestinal activity and improve postoperative ileus without increasing the risk of anastomotic leakage.21 Additionally, there is evidence that TEA preserves pulmonary function better than other analgesic techniques.22,23,24 "
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Epidural analgesia has been the preferred analgesic technique after major abdominal surgery. On the other hand, the combined use of intrathecal morphine (ITM) and intravenous patient controlled analgesia (IVPCA) has been shown to be a viable alternative approach for analgesia. We hypothesized that ITM combined with IVPCA is as effective as patient controlled thoracic epidural analgesia (PCTEA) with respect to postoperative pain control after conventional open gastrectomy.
Materials and Methods
Sixty-four patients undergoing conventional open gastrectomy due to gastric cancer were randomly allocated into the intrathecal morphine combined with intravenous patient-controlled analgesia (IT) group or patient-controlled thoracic epidural analgesia (EP) group. The IT group received preoperative 0.3 mg of ITM, followed by postoperative IVPCA. The EP group preoperatively underwent epidural catheterization, followed by postoperative PCTEA. Visual analog scale (VAS) scores were assessed until 48 hrs after surgery. Adverse effects related to analgesia, profiles associated with recovery from surgery, and postoperative complications within 30 days after surgery were also evaluated.
This study failed to demonstrate the non-inferiority of ITM-IVPCA (n=29) to PCTEA (n=30) with respect to VAS 24 hrs after surgery. Furthermore, the IT group consumed more fentanyl than the EP group did (1247.2±263.7 µg vs. 1048.9±71.7 µg, p<0.001). The IT group took a longer time to ambulate than the EP group (p=0.021) and had higher incidences of postoperative ileus (p=0.012) and pulmonary complications (p=0.05) compared with the EP group.
ITM-IVPCA is not as effective as PCTEA in patients undergoing gastrectomy, with respect to pain control, ambulation, postoperative ileus and pulmonary complications.
Yonsei Medical Journal 07/2014; 55(4):1106-14. DOI:10.3349/ymj.2014.55.4.1106 · 1.29 Impact Factor
Available from: Carolyn Nessim
- "Human studies have never been able to show statistically significant results with regard to epidural analgesia/anesthesia and anastomotic dehiscence. The main reason for this is that in order to answer this question in a randomized clinical trial, more than 1037 patients in each group would be needed to demonstrate an increased risk of anastomotic leakage from 3.4% to 6.0% with 80% power and 2alpha ¼ 0.05 . Due to this challenge, multiple animal studies have been performed in an attempt to better understand the physiology and effect of an epidural on the healing of a colorectal anastomosis. "
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Despite the beneficial effects of epidurals in intra-abdominal surgery, the incidence of anastomotic leak remains controversial when used. Moreover, studies have also shown that fluid overload may be deleterious to anastomoses. The purpose of this paper is to evaluate the effects of varying intraoperative fluid protocols, in the presence of an epidural, on the burst pressure strength of colonic anastomoses.
An epidural was installed in 18 rabbits, divided into three groups. Group 1 received 30 mL/kg/h Ringer's lactate, Group 2 received 100 mL/kg/h Ringer's lactate, and Group 3 received 30 mL/kg/h Pentaspan. Two colo-colonic anastomoses were performed per rabbit. On postoperative day 7 the anastomoses were resected and their burst pressures measured as a surrogate for anastomotic leak.
When comparing the average burst pressures of all three groups, there was a significant difference (P = 0.04). The anastomoses in the 100 mL/kg/h Ringer's lactate group were shown to be the weakest, with 64% of the anastomoses having burst under 120 mm Hg. The rabbits hydrated with Pentaspan had the highest strength, with no anastomoses bursting under 120 mm Hg. This translated into significant burst pressure differences (P = 0.02) between Group 2 and Group 3.
These results suggest that fluid overload with a crystalloid, in the presence of an epidural, may be deleterious to the healing of colonic anastomoses, creating a higher risk of anastomotic leak. Intraoperative resuscitation should thus focus on goal-directed euvolemia with appropriate amounts of colloids and/or crystalloids to prevent the risk of weakening anastomoses, especially in patients with epidurals.
Journal of Surgical Research 03/2013; 183(2). DOI:10.1016/j.jss.2013.03.030 · 1.94 Impact Factor
Available from: sassit.co.za
- "In appropriate circumstances, continuous epidural analgesia with local anesthetic, opioids, or clonidine will attenuate the perioperative neuroendocrine response. Single-dose neuraxial anesthetics will reduce the incidence of postoperative pulmonary complications, myocardial infarction, and thromboembolism    . "
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ABSTRACT: A thorough understanding of the anatomy and neurophysiology of the pain response is necessary for the effective treatment of perioperative pain. This article describes the mechanisms that produce pain,including those related to inflammation. Other topics include the pharmacologies of nonopioid and opioid analgesics. Nonopioid analgesics can be separated into two categories: nonsteroidal anti-inflammatory drugs, such as salicylates, and acetaminophen. Opioids include morphine, fentanyl, and meperidine. The pharmacology of local anesthesia is discussed. The six major adverse reactions to local anesthetics are cardiac arrhythmias, hypertension, direct tissue toxicity, central nervous system toxicity, methemoglobinemia and allergic reactions. Methods for measuring pain are described.
Surgical Clinics of North America 01/2006; 85(6):1243-57, xi. DOI:10.1016/j.suc.2005.09.009 · 1.88 Impact Factor
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