Comparison of multimodal analgesia with thoracic epidural after transthoracic oesophagectomy

Abstract

Background Thoracic epidural analgesia (TEA) has been regarded as the standard of care after oesophagectomy for pain control, but has several side-effects. Multimodal (intrathecal diamorphine, paravertebral and rectus sheath catheters) analgesia (MA) may facilitate postoperative mobilization by reducing hypotensive episodes and the need for vasopressors, but uncertainty exists about whether it provides comparable analgesia. This study aimed to determine whether MA provides comparable analgesia to TEA following transthoracic oesophagectomy. Methods Consecutive patients undergoing oesophagectomy for cancer between January 2015 and December 2018 were grouped according to postoperative analgesia regimen. Propensity score matching (PSM) was used to account for treatment selection bias. Pain scores at rest and on movement, graded from 0 to 10, were used. The incidence of hypotensive episodes and the requirement for vasopressors were evaluated. Results The study included 293 patients; 142 (48.5 per cent) received TEA and 151 (51.5 per cent) MA. After PSM, 100 patients remained in each group. Mean pain scores were significantly higher at rest in the MA group (day 1: 1.5 versus 0.8 in the TEA group, P = 0.017; day 2: 1.7 versus 0.9 respectively, P = 0.014; day 3: 1.2 versus 0.6, P = 0.047). Fewer patients receiving MA had a hypotensive episode (25 per cent versus 45 per cent in the TEA group; P = 0.003) and fewer required vasopressors (36 versus 53 per cent respectively; P = 0.016). There was no significant difference in the overall complication rate (71.0 versus 61.0 per cent; P = 0.136). Conclusion MA is less effective than TEA at controlling pain, but this difference may not be clinically significant. However, fewer patients experienced hypotension or required vasopressor support with MA; this may be beneficial within an enhanced recovery programme.

Epidural analgesia and mortality after colorectal cancer surgery: A retrospective cohort study

“…Several studies have shown comparable postoperative pain management in MIS procedures and open abdominal surgery using the transversus abdominal plane block [ [22] , [23] , [24] ]. Recently, Ng Cheong Chung et al have shown that a multimodal approach including intrathecal morphine, paravertebral and rectus sheath block provides comparable analgesia to thoracic EA in transthoracic oesophagectomy [ 25 ]. A meta-analysis of 29 randomized controlled trials, including 2059 patients, demonstrated that postoperative pain control after abdominal surgery is comparable to epidural analgesia when pre-peritoneal wound catheters are used.…”

Improved management of grade B biliary leaks after complex liver resections using gadoxetic acid disodium–enhanced magnetic resonance cholangiography

“…There are several factors that may have contributed toward improved outcomes, although it is impossible to establish a direct cause and effect relationship. The integration of a standardized enhanced recovery pathway, may have served to ensure uniform care for patients, with a standardized analgesic regime (which has dispensed with epidurals and now favors rectus sheath catheters, and patient controlled analgesia as well as intrathecal diamorphine at induction), 22,23 early mobilization and a uniform approach to nutrition. This multimodal analgesic regime, without epidural, reduces the incidence hypotension, which can limit a patients' ability to mobilize, and may have contributed toward the reduction in pulmonary complications.…”