Carli F, Trudel J L, Belliveau P
Department of Anesthesia, McGill University Health Centre, Montreal, Canada.
Dis Colon Rectum. 2001 Aug;44(8):1083-9. doi: 10.1007/BF02234626.
Colorectal surgery is associated with postoperative ileus, which contributes to delayed discharge. This study was designed to investigate the effect of thoracic epidural anesthesia and analgesia on gastrointestinal function after colorectal surgery under standardized controlled postoperative care.
Forty-two patients diagnosed with either colonic cancer, diverticulitis, polyps, or adenoma, and scheduled for elective colorectal surgery, were randomly assigned to either postoperative patient-controlled analgesia (PCA) with intravenous morphine (n = 21) or epidural analgesia with a mixture of bupivacaine and fentanyl (n = 21). Postoperative early oral feeding and assistance to mobilization were offered to all patients. Pain visual analog scale (1-100 mm), passage of flatus and bowel movements, length of hospital stay, and readiness for discharge were recorded.
Pain visual analog scale (visual analog scale, 1-100 mm) at rest, on coughing, and daily on mobilization was significantly lower in the epidural group compared with the patient-controlled analgesia group. Median values for the visual analog scale group were 7 (95 percent confidence interval, 2-18) mm, 19 (95 percent confidence interval, 4-38) mm, and 10 (95 percent confidence interval, 5-33) mm, respectively, and, for the patient-controlled analgesia group, were 24 (95 percent confidence interval, 18-51) mm, 59 (95 percent confidence interval, 33-74) mm, and 40 (95 percent confidence interval, 29-79) mm, respectively (P < 0.01). Intake of protein and calories and time out of bed were similar in both groups. Mean time intervals +/- standard deviation from surgery to first flatus and first bowel movement occurred earlier in the epidural group, 1.9 +/- 0.6 days and 3.1 +/- 1.7 days, respectively, compared with patient-controlled analgesia, 3.6 +/- 1.5 days and 4.6 +/- 1.6 days, respectively (P < 0.01). Postoperative complications occurred in 33 percent of the patient-controlled analgesia group and 28 percent of the epidural group. There was no significant difference in length of hospital stay between the two groups with a mean of 7.3 +/- 3.7 days in the patient-controlled analgesia group and 8.5 +/- 4.2 days in the epidural group. Readiness for discharge was similar in both groups.
Thoracic epidural analgesia has distinct advantages over patient-controlled analgesia morphine in providing superior quality of analgesia and shortening the duration of postoperative ileus. However, discharge home was not faster, indicating that other perioperative factors influence the length of hospital stay.
结直肠手术常伴有术后肠梗阻，这会导致出院延迟。本研究旨在探讨在标准化的术后护理控制下，胸段硬膜外麻醉和镇痛对结直肠手术后胃肠功能的影响。
42例被诊断为结肠癌、憩室炎、息肉或腺瘤且计划进行择期结直肠手术的患者，被随机分为两组，一组接受静脉注射吗啡的术后患者自控镇痛（PCA）（n = 21），另一组接受布比卡因和芬太尼混合液的硬膜外镇痛（n = 21）。所有患者术后均尽早给予口服喂养并协助活动。记录疼痛视觉模拟评分（1 - 100 mm）、排气和排便情况、住院时间以及出院准备情况。
与患者自控镇痛组相比，硬膜外组静息时、咳嗽时以及每日活动时的疼痛视觉模拟评分（视觉模拟评分，1 - 100 mm）显著更低。视觉模拟评分组的中位数分别为7（95%置信区间，2 - 18）mm、19（95%置信区间，4 - 38）mm和10（95%置信区间，5 - 33）mm，而患者自控镇痛组分别为24（95%置信区间，18 - 51）mm、59（95%置信区间，33 - 74）mm和40（95%置信区间，29 - 79）mm（P < 0.01）。两组的蛋白质和热量摄入量以及下床时间相似。与患者自控镇痛组相比，硬膜外组从手术到首次排气和首次排便的平均时间间隔更早，分别为1.9 ± 0.6天和3.1 ± 1.7天，而患者自控镇痛组分别为3.6 ± 1.5天和4.6 ± 1.6天（P < 0.01）。患者自控镇痛组术后并发症发生率为33%，硬膜外组为28%。两组住院时间无显著差异，患者自控镇痛组平均为7.3 ± 3.7天，硬膜外组为8.5 ± 4.2天。两组出院准备情况相似。
在提供更高质量的镇痛和缩短术后肠梗阻持续时间方面，胸段硬膜外镇痛比患者自控吗啡镇痛具有明显优势。然而，出院回家的速度并未更快，这表明其他围手术期因素会影响住院时间。
