Pratt Wande B, Steinbrook Richard A, Maithel Shishir K, Vanounou Tsafrir, Callery Mark P, Vollmer Charles M
Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
J Gastrointest Surg. 2008 Jul;12(7):1207-20. doi: 10.1007/s11605-008-0467-1. Epub 2008 Feb 9.
Epidural analgesia has emerged as a commonly applied method to improve pain management and reduce perioperative complications in major abdominal surgery. However, there is no detailed analysis of its efficacy for pancreatic operations. This study compares clinical and economic outcomes after epidural and intravenous analgesia for pancreatoduodenectomy.
Data for 233 consecutive patients, who underwent pancreatoduodenectomy, were prospectively acquired and retrospectively reviewed at a single institution, pancreato-biliary specialty practice. From October 2001 to February 2007, all patients were offered thoracic epidural analgesia, and those who declined received intravenous analgesia. Perioperative pain management was dictated as an element of a standardized clinical pathway for pancreatic resections. Clinical and economic outcomes were analyzed and compared for epidural analgesia and intravenous analgesia groups.
One hundred eighty-five patients received epidural analgesia, and 48 received intravenous analgesia, with equivalent baseline patient demographics between the groups. Patients administered epidural analgesia had lower pain scores but significantly higher rates of major complications. Pancreatic fistulae and postoperative ileus occurred more frequently, and patients with epidural analgesia more often required discharge to rehabilitation facilities. A trend towards longer hospitalizations was observed among epidural analgesia patients, but total costs were statistically equivalent between the groups. Further analysis demonstrates that 31% of epidural infusions were aborted before anticipated (fourth postoperative day) because of hemodynamic compromise and/or inadequate analgesia. These select patients required more transfusions, aggressive fluid resuscitation, and subsequently suffered even higher rates of gastrointestinal and respiratory complications, all attributing to higher costs. Multivariate analysis demonstrates that preoperative hematocrit concentration less than 36%, elderly age (>75 years), and chronic pancreatitis predict failure of epidural infusions.
Thoracic epidural analgesia after pancreatic resections is associated with hemodynamic instability, which may compromise enteric anastomoses, gastrointestinal recovery, and respiratory function. These outcomes are exacerbated in poorly functioning epidurals and suggest that epidural analgesia may not be the optimal method for perioperative pain control when pancreatoduodenectomy is performed.
硬膜外镇痛已成为改善疼痛管理和减少腹部大手术围手术期并发症的常用方法。然而，对于胰腺手术其疗效尚无详细分析。本研究比较了胰十二指肠切除术后硬膜外镇痛和静脉镇痛的临床及经济结局。
前瞻性收集并回顾性分析了在一家胰腺-胆道专科诊所连续接受胰十二指肠切除术的233例患者的数据。2001年10月至2007年2月期间，所有患者均被建议采用胸段硬膜外镇痛，拒绝者接受静脉镇痛。围手术期疼痛管理是胰腺切除术标准化临床路径的一部分。对硬膜外镇痛组和静脉镇痛组的临床及经济结局进行了分析和比较。
185例患者接受硬膜外镇痛，48例接受静脉镇痛，两组患者的基线人口统计学特征相当。接受硬膜外镇痛的患者疼痛评分较低，但主要并发症发生率显著较高。胰瘘和术后肠梗阻更常见，接受硬膜外镇痛的患者更常需要转至康复机构。硬膜外镇痛患者有住院时间延长的趋势，但两组的总费用在统计学上相当。进一步分析表明，31%的硬膜外输注在预期时间（术后第4天）之前因血流动力学不稳定和/或镇痛不足而中止。这些特定患者需要更多输血、积极的液体复苏，随后胃肠道和呼吸道并发症发生率更高，所有这些都导致费用增加。多因素分析表明，术前血细胞比容浓度低于３６％、老年（>75岁）和慢性胰腺炎预示硬膜外输注失败。
胰腺切除术后胸段硬膜外镇痛与血流动力学不稳定相关，这可能影响肠吻合口、胃肠道恢复及呼吸功能。功能欠佳的硬膜外会使这些结局恶化，提示在进行胰十二指肠切除术时，硬膜外镇痛可能并非围手术期疼痛控制的最佳方法。
