Henshaw Daryl S, Edwards Christopher J, Sellers Austin R, Russell Gregory B, Weller Robert S
J Pain Palliat Care Pharmacother. 2017 Sep-Dec;31(3-4):204-211. doi: 10.1080/15360288.2017.1313354. Epub 2017 May 10.
An open posterior component separation (PCS) is a commonly utilized surgical approach for repair of complex abdominal wall defects and hernias. Although this approach may improve surgical outcomes, significant postoperative pain can be expected given the required laparotomy and extensive abdominal wall manipulation. Both systemic opioids and thoracic epidural analgesia (TEA) are viable postoperative analgesic options, and both are commonly utilized. Although the benefits of TEA have been investigated following a variety of surgeries, there is a paucity of literature related to its efficacy for this particular surgery. The aim of this study was to evaluate the benefits of TEA following open PCS under the hypothesis that the incorporation of TEA into the postoperative analgesic regimen would hasten bowel recovery. Patients who previously underwent an open PCS were identified through an electronic medical record query. A retrospective chart review was then performed, and patients who had TEA, either alone or combined with systemic opioids, were compared with patients who had only systemic opioids. The primary end point was a comparison of the postoperative day (POD) on which a full diet was started. Secondarily, time to liquid diet, postsurgical length of stay (LOS), intensive care unit (ICU) admission rate, ICU LOS, and the rates of several postoperative adverse events were compared. A post hoc analysis was also performed, using the same end points, to compare the subgroup of TEA patients who avoided systemic opioids with all patients who received systemic opioids, whether alone or combined with TEA. One hundred and one patients were ultimately included for analysis. Time to full diet was not significantly different between patients who had TEA, either with or without systemic opioids, and those who received only systemic opioids (TEA 2.6 ± 1.7 vs. systemic opioids 3.1 ± 2.1 [mean POD ± SD], P = .21). Additionally, no statistically significant differences were found for any secondary outcome. In the post hoc analysis, the subgroup of TEA patients who avoided systemic opioids had a significantly faster time to bowel recovery when compared with all patients who received systemic opioids (2.2 ± 1.0 vs. 3.2 ± 2.2, P = .0033). This subgroup also had a significantly shorter time to liquid diet and a decreased postoperative LOS. In conclusion, for patients undergoing an open PCS, the inclusion of TEA in the postoperative analgesic regimen did not by itself hasten the return of bowel function. However, when TEA was utilized and systemic opioids were avoided, bowel recovery occurred significantly sooner and resulted in a shortened hospital LOS.
开放性后入路腹壁分层分离术（PCS）是修复复杂腹壁缺损和疝气常用的手术方法。尽管该方法可能改善手术效果，但鉴于需要开腹和广泛的腹壁操作，术后疼痛可能较为明显。全身使用阿片类药物和胸段硬膜外镇痛（TEA）都是可行的术后镇痛选择，且都被广泛应用。尽管TEA在多种手术后的益处已得到研究，但关于其在该特定手术中的疗效的文献却很少。本研究的目的是在TEA纳入术后镇痛方案可加速肠道恢复这一假设下，评估开放性PCS术后使用TEA的益处。通过电子病历查询确定既往接受过开放性PCS手术的患者。然后进行回顾性病历审查，将单独使用TEA或联合全身阿片类药物的患者与仅使用全身阿片类药物的患者进行比较。主要终点是开始正常饮食的术后天数（POD）的比较。其次，比较流食时间、术后住院时间（LOS）、重症监护病房（ICU）入住率、ICU住院时间以及几种术后不良事件的发生率。还进行了事后分析，使用相同的终点，比较避免使用全身阿片类药物的TEA患者亚组与所有接受全身阿片类药物（单独或联合TEA）的患者。最终纳入101例患者进行分析。使用TEA（无论是否联合全身阿片类药物）的患者与仅接受全身阿片类药物的患者开始正常饮食的时间无显著差异（TEA组为2.6±1.7天，全身阿片类药物组为3.1±2.1天[平均POD±标准差]，P = 0.21）。此外，任何次要结局均未发现统计学上的显著差异。在事后分析中，与所有接受全身阿片类药物的患者相比，避免使用全身阿片类药物的TEA患者亚组肠道恢复明显更快（2.2±1.0天对3.2±2.2天，P = 0.0033）。该亚组流食时间也明显缩短，术后住院时间缩短。总之，对于接受开放性PCS手术的患者，术后镇痛方案中单独使用TEA并不能加速肠道功能恢复。然而，当使用TEA并避免使用全身阿片类药物时，肠道恢复明显更快，住院时间缩短。
