Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
Department of Anaesthesia and Critical Care Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
Br J Surg. 2021 Jan 27;108(1):58-65. doi: 10.1093/bjs/znaa013.
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.
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.
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).
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.
胸椎硬膜外镇痛（TEA）一直被认为是开胸食管癌手术后控制疼痛的标准治疗方法，但它有几个副作用。多模式（鞘内吗啡、椎旁和腹直肌鞘导管）镇痛（MA）可以通过减少低血压发作和对血管加压药的需求来促进术后活动，但对于它是否提供可比的镇痛效果存在不确定性。本研究旨在确定 MA 在开胸食管癌手术后是否提供与 TEA 相当的镇痛效果。
根据术后镇痛方案将 2015 年 1 月至 2018 年 12 月期间接受食管癌手术的连续患者分为两组。采用倾向评分匹配（PSM）来考虑治疗选择偏差。使用从 0 到 10 的等级评估休息和运动时的疼痛评分。评估低血压发作的发生率和对血管加压药的需求。
该研究纳入了 293 例患者；142 例（48.5%）接受 TEA，151 例（51.5%）接受 MA。PSM 后，每组各有 100 例患者。在 MA 组，休息时的平均疼痛评分显著较高（第 1 天：TEA 组 0.8，MA 组 1.5，P=0.017；第 2 天：0.9，1.7，P=0.014；第 3 天：0.6，1.2，P=0.047）。接受 MA 的患者发生低血压发作的比例较低（TEA 组为 45%，MA 组为 25%，P=0.003），需要血管加压药的比例也较低（TEA 组为 53%，MA 组为 36%，P=0.016）。总的并发症发生率无显著差异（71.0%与 61.0%，P=0.136）。
MA 在控制疼痛方面不如 TEA 有效，但这种差异可能没有临床意义。然而，MA 组发生低血压或需要血管加压药支持的患者较少；这在强化康复计划中可能是有益的。
