Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland.
JAMA Surg. 2014 Dec;149(12):1224-30. doi: 10.1001/jamasurg.2014.210.
The optimal analgesic technique following open abdominal surgery within an enhanced recovery protocol remains controversial. Thoracic epidural is often recommended; however, its role is increasingly being challenged and alternative techniques are being suggested as suitable replacements.
To determine by meta-analysis whether epidurals are superior to alternative analgesic techniques following open abdominal surgery within an enhanced recovery setting in terms of postoperative morbidity and other markers of recovery.
A literature search was performed of EMBASE, Medline, PubMed, and the Cochrane databases from 1966 through May 2013.
All randomized clinical trials comparing epidurals with an alternative analgesic technique following open abdominal surgery within an enhanced recovery protocol were included.
All studies were assessed by 2 independent reviewers. Study quality was assessed using the Cochrane bias assessment tool and the Jadad and Chalmers modified bias risk assessment tools. Dichotomous data were analyzed by random or fixed-effects odds ratios. Qualitative analysis was performed where appropriate.
Seven trials with a total of 378 patients were identified. No significant difference in complication rate was detected between epidurals and alternative analgesic methods (odds ratio, 1.14; 95% CI, 0.49-2.64; P = .76). Subgroup analysis showed fewer complications in the patient-controlled analgesia group compared with epidural analgesia (odds ratio, 1.97; 95% CI, 1.10-3.53; P = .02). Following qualitative assessment, epidural analgesia was associated with faster return of gut function and reduced pain scores; however, no difference was observed in length of stay.
Epidurals may be associated with superior pain control but this does not translate into improved recovery or reduced morbidity when compared with alternative analgesic techniques when used within an enhanced recovery protocol.
在强化康复方案中，开腹手术后的最佳镇痛技术仍存在争议。胸椎硬膜外通常被推荐；然而，其作用正越来越受到质疑，并且有替代技术被建议作为合适的替代品。
通过荟萃分析确定在强化康复环境中，与替代镇痛技术相比，硬膜外在开腹手术后的术后发病率和其他恢复标志物方面是否更优。
从 1966 年到 2013 年 5 月，对 EMBASE、Medline、PubMed 和 Cochrane 数据库进行了文献检索。
所有将硬膜外与强化康复方案中开腹手术后的替代镇痛技术进行比较的随机临床试验均被纳入。
所有研究均由 2 名独立评审员进行评估。使用 Cochrane 偏倚评估工具和 Jadad 和 Chalmers 改良偏倚风险评估工具评估研究质量。二项数据通过随机或固定效应比值比进行分析。在适当的情况下进行定性分析。
共确定了 7 项包含 378 名患者的试验。硬膜外与替代镇痛方法之间的并发症发生率无显著差异（比值比，1.14；95%CI，0.49-2.64；P=.76）。亚组分析显示，患者自控镇痛组的并发症少于硬膜外镇痛组（比值比，1.97；95%CI，1.10-3.53；P=.02）。经过定性评估，硬膜外镇痛与更快的肠道功能恢复和降低的疼痛评分相关；然而，在住院时间方面没有差异。
与替代镇痛技术相比，硬膜外可能与更好的疼痛控制相关，但在强化康复方案中使用时，这并不意味着恢复更好或发病率降低。
