Macrosson Duncan, Beebeejaun Adam, Odor Peter M
Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, England.
University College London, London, England.
Perioper Med (Lond). 2024 Jul 23;13(1):80. doi: 10.1186/s13741-024-00437-0.
Oesophageal cancer surgery represents a high perioperative risk of complications to patients, such as postoperative pulmonary complications (PPCs). Postoperative analgesia may influence these risks, but the most favourable analgesic technique is debated. This review aims to provide an updated evaluation of whether thoracic epidural analgesia (TEA) has benefits compared to other analgesic techniques in patients undergoing oesophagectomy surgery. Our hypothesis is that TEA reduces pain scores and PPCs compared to intravenous opioid analgesia in patients post-oesophagectomy.
Electronic databases PubMed, Excerpta Medica Database (EMBASE) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomised trials of analgesic interventions in patients undergoing oesophagectomy surgery. Only trials including thoracic epidural analgesia compared with other analgesic techniques were included. The primary outcome was a composite of respiratory infection, atelectasis and respiratory failure (PPCs), with pain scores at rest and on movement as secondary outcomes. Data was pooled using random effect models and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs).
Data from a total of 741 patients in 10 randomised controlled trials (RCTs) from 1993 to 2023 were included. Nine trials were open surgery, and one trial was laparoscopic. Relative to intravenous opioids, TEA significantly reduced a composite of PPCs (risk ratio (RR) 3.88; 95% confidence interval (CI) 1.98-7.61; n = 222; 3 RCTs) and pain scores (0-100-mm visual analogue scale or VAS) at rest at 24 h (MD 9.02; 95% CI 5.88-12.17; n = 685; 10 RCTs) and 48 h (MD 8.64; 95% CI 5.91-11.37; n = 685; 10 RCTs) and pain scores on movement at 24 h (MD 14.96; 95% CI 5.46-24.46; n = 275; 4 RCTs) and 48 h (MD 16.60; 95% CI 8.72-24.47; n = 275; 4 RCTs).
Recent trials of analgesic technique in oesophagectomy surgery are restricted by small sample size and variation of outcome measurement. Despite these limitations, current evidence indicates that thoracic epidural analgesia reduces the risk of PPCs and severe pain, compared to intravenous opioids in patients following oesophageal cancer surgery. Future research should include minimally invasive surgery, non-epidural regional techniques and record morbidity, using core outcome measures with standardised endpoints.
Prospectively registered on PROSPERO (CRD42023484720).
食管癌手术给患者带来较高的围手术期并发症风险，如术后肺部并发症（PPCs）。术后镇痛可能会影响这些风险，但最有利的镇痛技术仍存在争议。本综述旨在对胸段硬膜外镇痛（TEA）与其他镇痛技术相比，在接受食管切除术的患者中是否具有优势进行最新评估。我们的假设是，与静脉注射阿片类药物镇痛相比，TEA可降低食管切除术后患者的疼痛评分和PPCs发生率。
检索电子数据库PubMed、医学文摘数据库（EMBASE）和Cochrane对照试验中心注册库（CENTRAL），查找有关接受食管切除术患者镇痛干预的随机试验。仅纳入将胸段硬膜外镇痛与其他镇痛技术进行比较的试验。主要结局是呼吸道感染、肺不张和呼吸衰竭（PPCs）的综合指标，静息和活动时的疼痛评分作为次要结局。使用随机效应模型汇总数据，并报告为相对风险（RR）或平均差（MD）及95%置信区间（CI）。
纳入了1993年至2023年10项随机对照试验（RCT）中741例患者的数据。9项试验为开放手术，1项试验为腹腔镜手术。与静脉注射阿片类药物相比，TEA显著降低了PPCs的综合发生率（风险比（RR）3.88；95%置信区间（CI）1.98 - 7.61；n = 222；3项RCT），并降低了24小时（MD 9.02；95% CI 5.88 - 12.17；n = 685；10项RCT）和48小时（MD 8.64；95% CI 5.91 - 11.37；n = 685；10项RCT）静息时的疼痛评分（0 - 100毫米视觉模拟量表或VAS），以及24小时（MD 14.96；95% CI 5.46 - 24.46；n = 275；4项RCT）和48小时（MD 16.60；95% CI 8.72 - 24.47；n = 275；4项RCT）活动时的疼痛评分。
近期食管切除术镇痛技术试验受样本量小和结局测量差异的限制。尽管存在这些局限性，但目前证据表明，与静脉注射阿片类药物相比，胸段硬膜外镇痛可降低食管癌手术后患者的PPCs风险和严重疼痛程度。未来研究应纳入微创手术、非硬膜外区域技术，并使用具有标准化终点的核心结局指标记录发病率。
前瞻性注册于PROSPERO（CRD42023484720）。
