09 Jan 12

Reduction in mortality after epidural anaesthesia and analgesia in patients undergoing rectal but not colonic cancer surgery

Posted in Anesthesia, Neuraxial block at 1:41 by Laci

By A Gupta, A Björnsson, M Fredriksson, O Hallböök and C Eintrei

Br. J. Anaesth 2011;107:164-170

There is some evidence that epidural analgesia (EDA) reduces tumour recurrence after breast and prostatic cancer surgery. We assessed whether EDA reduces long-term mortality after colorectal cancer surgery.

Methods
All patients having colorectal cancer surgery between January 2004 and January 2008 at Linköping and Örebro were included. Exclusion criteria were: emergency operations, laparoscopic-assisted colorectal resection, and stage 4 cancer. Statistical information was obtained from the Swedish National Register for Deaths. Patients were analysed in two groups: EDA group or patient-controlled analgesia (PCA group) as the primary method of analgesia.

Results
A total of 655 patients could be included. All-cause mortality for colorectal cancer (stages 1–3) was 22.7% (colon: 20%, rectal: 26%) after 1–5 yr of surgery. Multivariate regression analysis identified the following statistically significant factors for death after colon cancer (P<0.05): age (>72 yr) and cancer stage 3 (compared with stage 1). A similar model for rectal cancer found that age (>72 yr) and the use of PCA rather than EDA and cancer stages 2 and 3 (compared with stage 1) were associated with a higher risk for death. No significant risk of death was found for colon cancer when comparing EDA with PCA (P=0.23), but a significantly increased risk of death was seen after rectal cancer when PCA was used compared with EDA (P=0.049) [hazards ratio: 0.52 (0.27–1.00)].

Conclusions
We found a reduction in all-cause mortality after rectal but not colon cancer in patients having EDA compared with PCA technique.

03 Feb 08

Epidural analgesia: first do no harm

Posted in Anesthesia, Neuraxial block at 15:00 by Laci

By J. Low, N. Johnston and C. Morris

Anaethesia 2008;63:1-3

The use of epidural analgesia in patients undergoing major abdominal gastrointestinal (GIT) surgery has become routine practice. Multiple, non-randomised, small trials comparing epidural analgesia to ‘older’ opioid analgesia regimens have produced results that shaped modern practice but are rarely appropriate for modern anaesthesia. Well-structured, randomised controlled trials are few and far between and those that have been performed must be used to guide modern practice. Perceived best practice, influenced by how good the patients look in recovery, is not supported by the evidence to date. Compounding this is a lack of good evidence to accurately assess the complication rate of epidurals. The number needed to treat (NNT) and the number needed to harm (NNH) may be far closer than we think. There is a significant lack of evidence supporting the use of epidural analgesia and we question the routine use of this mode of analgesia in the postoperative period for patients having abdominal surgery. Decisions regarding the use of an epidural in any individual patient, and what we should and should not tell our patients, need to be framed from the best evidence available and not the most evidence available.

Epidural anaesthesia and analgesia and outcome of major surgery

Posted in Anesthesia, Neuraxial block at 14:55 by Laci

By J R A Rigg, K Jamrozik, P S Myles, B S Silbert, et al.

The Lancet 2002;359:1276-1282

Epidural block is widely used to manage major abdominal surgery and postoperative analgesia, but its risks and benefits are uncertain. We compared adverse outcomes in high-risk patients managed for major surgery with epidural block or alternative analgesic regimens with general anaesthesia in a multicentre randomised trial.

Methods
915 patients undergoing major abdominal surgery with one of nine defined comorbid states to identify high-risk status were randomly assigned intraoperative epidural anaesthesia and postoperative epidural analgesia for 72 h with general anaesthesia (site of epidural selected to provide optimum block) or control. The primary endpoint was death at 30 days or major postsurgical morbidity. Analysis by intention to treat involved 447 patients assigned epidural and 441 control.

Findings
255 patients (57.1%) in the epidural group and 268 (60.7%) in the control group had at least one morbidity endpoint or died (p=0.29). Mortality at 30 days was low in both groups (epidural 23 [5.1%], control 19 [4.3%], p=0.67). Only one of eight categories of morbid endpoints in individual systems (respiratory failure) occurred less frequently in patients managed with epidural techniques (23% vs 30%, p=0.02). Postoperative epidural analgesia was associated with lower pain scores during the first 3 postoperative days. There were no major adverse consequences of epidural-catheter insertion.

Interpretation
Most adverse morbid outcomes in high-risk patients undergoing major abdominal surgery are not reduced by use of combined epidural and general anaesthesia and postoperative epidural analgesia. However, the improvement in analgesia, reduction in respiratory failure, and the low risk of serious adverse consequences suggest that many high-risk patients undergoing major intra-abdominal surgery will receive substantial benefit from combined general and epidural anaesthesia intraoperatively with continuing postoperative epidural analgesia.

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